Risk Reduction Clinic Research Articles

Does having a patient attend a postpartum vascular risk reduction clinic improve physician knowledge and management of preeclampsia as a cardiovascular risk factor?

Background Preeclampsia is an independent risk factor for vascular diseases. The Postpartum Preeclampsia Clinic (PPPC) intervenes in the first year postpartum to address these risks. This study aims to characterize physicians’ understanding and management of the cardiovascular risk associated with preeclampsia and whether this differs in physicians who had a patient attend the PPPC. Methods Family physicians, obstetricians, internists, obstetric internists, and cardiologists in Edmonton were anonymously surveyed. Results were analyzed using SPSS. Results Sixty-four surveys were returned, with physicians correctly identifying preeclampsia as a vascular risk factor 73% of the time. Physicians who had a patient attend the PPPC were more likely to counsel patients on their increased cardiovascular risk, although increased knowledge did not reach statistical significance. Conclusion Vascular risk reduction clinics may benefit the long-term management of patients with a history of preeclampsia by improving counseling by physicians, which may reduce the disproportionate vascular morbidity these patients face.

Effectiveness of a postpartum vascular risk reduction clinic on behavioral change and long-term cardiovascular outcomes in women who had preeclampsia: a case-control study

Effectiveness of a postpartum vascular risk reduction clinic on behavioral change and long-term cardiovascular outcomes in women who had preeclampsia: a case-control study

P 025: A real-world evaluation of the cardiovascular risk reduction clinic (CRRC) at Hospital Pulau Pinang: A comprehensive analysis

P 025: A real-world evaluation of the cardiovascular risk reduction clinic (CRRC) at Hospital Pulau Pinang: A comprehensive analysis

Cardiovascular risk reduction clinic (CRRC) proof of concept study experience in penang general hospital

Cardiovascular risk reduction clinic (CRRC) proof of concept study experience in penang general hospital

Observational analysis of cardiovascular risk reduction clinic (CRRC) – a single centre experience

Observational analysis of cardiovascular risk reduction clinic (CRRC) – a single centre experience

Impact of Pharmacist-Led Health Initiatives in Rural Alabama

Perry County is a predominantly African American community in rural Alabama. The prevalence of cardiovascular risk factors such as obesity, diabetes, and hypertension is higher than average in the Perry County population. The Cardiovascular Risk Reduction Clinic, a collaboration between Samford University McWhorter School of Pharmacy, Sowing Seeds of Hope, and the Perry County Health Department, partnered with the Perry County Department of Transportation (DOT) to offer DOT employees, mostly African American men, health screenings and education delivered at times and locations convenient to their work schedules. The objective of the present study was to evaluate the impact of a community partnership with pharmacist-led health interventions on modifiable cardiovascular risk factors in participants lacking access to other community health initiatives due to work obligations. This study was a retrospective chart review evaluating changes in blood pressure and body mass index (BMI). Participants included DOT employees 18 years of age and older who participated in at least two health screenings 12 weeks apart. Over the course of the intervention, the average systolic blood pressure decreased by 6 mmHg, and the average diastolic blood pressure decreased by 4 mmHg. The baseline BMI average of 35.1 kg/m2 had dropped to 34.5 kg/m2 at 12 weeks. Although modest, the reductions in blood pressure and BMI indicate a potential for cardiovascular disease risk reduction. Lessons learned from this pilot project can inform the initiation of similar programs intended to decrease cardiovascular risk. Pharmacist-led interventions combined with community support can lead to positive cardiovascular results among rural communities.

Understanding Patient Perspectives on Specialized, Longitudinal, Postpartum, Cardiovascular Risk-Reduction Clinics

BackgroundFemales who experience hypertensive disorders of pregnancy (HDP) have an increased lifelong risk of cardiovascular disease. Thus, Canadian clinical practice guidelines recommend cardiovascular risk reduction follow-up after a patient has HDP. This study examined the experiences of patients with HDP who attended a specialized, longitudinal general internal medicine postpartum cardiovascular risk reduction clinic called PreVASC. PreVASC focuses on comprehensive cardiovascular risk reduction through cardiovascular risk factor screening and management tailored specifically for female patients after they have HDP. MethodsThis multimethod study examined the experiences of female patients with HDP via the following: (i) a quantitative survey (summarized with descriptive statistics); (ii) semistructured qualitative patient phone interviews (results grouped thematically); and (iii) triangulation of qualitative themes with quantitative survey results. ResultsOverall, 37% of eligible clinic patients (42 of 115) participated; 79% of participants (n = 33) reported being “very satisfied” with the PreVASC clinic’s specialized longitudinal model of care, and 95% (n = 40) reported making at least one preventive health behaviour change after receiving individualized counselling on cardiovascular risk reduction. Qualitative results found improvements in patient-reported cardiovascular health knowledge, health behaviours, and health-related anxiety. A preference for in-person vs phone clinic visits was reported by participants. ConclusionsAn in-person, general internal medicine specialist–led, longitudinal model of cardiovascular disease preventive care focused specifically on cardiovascular risk reduction after HDP had positive impacts on patient experience, health knowledge, and preventive health behaviours. This novel knowledge on patient preferences for a longitudinal, specialized model of care advances cardiovascular risk reduction tailored specifically for high-risk people after HDP.

Hereditary ovarian cancer risk reduction: a retrospective evaluation of patient perspectives and service provision at a regional hereditary gynaecologic cancer clinic 2006–2016

BackgroundGermline pathogenic variants in BRCA1/2 have been established in hereditary breast and ovarian cancer (HBOC) syndrome and result in significantly elevated lifetime risk of ovarian cancer. Risk reduction interventions are presently the only effective means of improving survival and specialized counselling clinics have been established as an effective means of aiding this population in navigating complex decisions surrounding these interventions. This study sought to evaluate patient perceptions of a specialized counselling clinic for patients with HBOC Syndrome and referral patterns to this clinic.MethodsWe completed a retrospective review of 200 patients with HBOC in Nova Scotia, Canada seen through Maritime Medical Genetics Services between 2006 and 2016. Data were collected on referral pattern to the Hereditary Gynaecologic Risk Reduction Clinic (HGRRC), demographics, health history, and uptake of risk-reducing interventions. Participants were invited to complete a questionnaire about their experience.Results156/200(78%) women were referred to HGRCC and 135/156 (85.9%) of those referred attended their appointment. 124/200 (62%) were over age 40 at the time of testing. The mean time from referral to HGRCC appointment was 134.68 days (SD 85.78). 85/135 (63%) underwent risk-reducing bilateral salpingo-oophorectomy following their HGRCC appointment. The questionnaire was completed by 94/188 (50.3%) women. Most participants found information received from genetics clinics (81/94; 91%) and genetic counsellors (87/94; 95%) most helpful in making choices around risk-reduction strategies. 83/94 (88%) participants felt they had sufficient information to make an informed decision.ConclusionThe majority of women with HBOC in Nova Scotia during the study period were referred to and counselled through HGRRC. Genetic counselling was found most valuable in risk-reduction decision making, which highlights the importance of a multidisciplinary team. Patients viewed this clinic as an effective care model to support informed choice about risk-reducing intervention.

Creation and Implementation of a Large-Scale Geriatric Interprofessional Education Experience.

The care of the older adult requires an interprofessional approach to solve complex medical and social problems, but this approach is difficult to teach in our educational silos. We developed an interprofessional educational session in response to national requests for innovative practice models that use collaborative interprofessional teams. We chose geriatric fall prevention as our area of focus as our development of the educational session coincided with the development of an interprofessional Fall Risk Reduction Clinic. Our aim of this study was to evaluate the number and type of students who attended a pilot and 10 subsequent educational sessions. We also documented the changes that occurred due to a Plan-Do-Study-Act (PDSA) rapid-cycle improvement model to modify our educational session. The educational session evolved into an online presession self-study didactic and in-person educational session with a poster/skill section, an interprofessional team simulation, and simulated patient experience. The simulated patient experience included an interprofessional fall evaluation, team meeting, and presentation to an expert panel. The pilot session had 83 students from the three sponsoring institutions (hospital system, university, and medical university). Students were from undergraduate nursing, nurse practitioner graduate program, pharmacy, medicine, social work, physical therapy, nutrition, and pastoral care. Since the pilot, 719 students have participated in various manifestations of the online didactic plus in-person training sessions. Ten separate educational sessions have been given at three different institutions. Survey data with demographic information were available on 524 participants. Students came from ten different schools and represented thirteen different health care disciplines. A large-scale interprofessional educational session is possible with rapid-cycle improvement, inclusion of educators from a variety of learning institutions, and flexibility with curriculum to accommodate learners in various stages of training.

Assessment of clinical inertia in people with diabetes within primary care.

Clinical inertia, defined as a delay in treatment intensification, is prevalent in people with diabetes. Treatment intensification rates are as low as 37.1% in people with haemoglobin A1c (HbA1c) values >7%. Intensification by addition of medication therapy may take 1.6 to more than 7 years. Clinical inertia increases the risk of cardiovascular events. The primary objective was to evaluate rates of clinical inertia in people whose diabetes is managed by both pharmacists and primary care providers (PCPs). Secondary objectives included characterizing types of treatment intensification, HbA1c reduction, and time between treatment intensifications. Retrospective chart review of persons with diabetes managed by pharmacists at an academic, safety-net institution. Eligible subjects were referred to a pharmacist-managed cardiovascular risk reduction clinic while continuing to see their PCP between October 1, 2016 and June 30, 2018. All progress notes were evaluated for treatment intensification, HbA1c value, and type of medication intensification. Three hundred sixty-three eligible patients were identified; baseline HbA1c 9.6% (7.9, 11.6) (median interquartile range [IQR]). One thousand one hundred ninety-two pharmacist and 1739 PCP visits were included in data analysis. Therapy was intensified at 60.5% (n = 721) pharmacist visits and 39.3% (n = 684) PCP visits (P < .001). The median (IQR) time between interventions was 49 (28, 92) days for pharmacists and 105 (38, 182) days for PCPs (P < .001). Pharmacists more frequently intensified treatment with glucagon-like peptide-1 agonists and sodium glucose cotransporter-2 inhibitors. Pharmacist involvement in diabetes management may reduce the clinical inertia patients may otherwise experience in the primary care setting.

Is there an association between perceived social support and cardiovascular health behaviours in people with severe mental illnesses?

PurposePeople with severe mental illnesses (SMI) have an increased risk of cardiovascular disease (CVD). Research in the general population suggests that social support may protect against increased CVD morbidity and mortality; however, this may not apply to those with SMI. We aimed to explore the association between perceived social support and attendance at primary care nurse CVD risk reduction clinic appointments and CVD risk-reducing behaviours in an SMI population with elevated CVD risk factors.MethodsWe used longitudinal and cross-sectional data from a randomised controlled trial on 326 adults with SMI recruited via 76 general practices in England. Multilevel regression analysis estimated the effect of perceived social support on attendance at CVD risk reduction clinic appointments over 6 months, and adherence to CVD medication, physical activity, diet, smoking and alcohol use at baseline, adjusted by age, sex, ethnicity, deprivation, psychiatric diagnosis and employment.ResultsPerceived social support predicted greater appointment attendance in unadjusted (IRR = 1.005; 1.000–1.010; p = 0.05) but not adjusted analysis (IRR = 1.003; 0.998–1.009; p = 0.25). Perceived social support was associated with greater adherence to medication; for each 1% increase in social support, there was a 4.2% increase in medication adherence (OR = 1.042; 1.015–1.070; p = 0.002). No association was found between greater perceived social support and greater physical activity, lower sedentary behaviour, healthier diet, lower alcohol use or being a non-smoker.ConclusionsSocial support may be an important facilitator for CVD medication adherence and is potentially important for primary care appointment attendance; however, alternative strategies might be needed to help people with SMI engage in physical activity, healthier diets and to reduce their smoking and alcohol use.

A pharmacist-managed cardiovascular risk-reduction clinic for individuals experiencing serious mental illness

ObjectivesThis retrospective analysis sought to: (1) characterize a cardiovascular risk-reduction clinic (CVRRC) patient population with serious mental illness (SMI); (2) analyze clinical outcomes of CVRRC patients over a 2-year period; and (3) compare outcomes for individuals prescribed different antipsychotic treatments in the CVRRC patient population over a 2-year period. Evaluation methodsIn 2016, A pharmacist-managed CVRRC was implemented within a primary care clinic for patients with SMI. The CVRRC operates under a collaborative practice agreement allowing the pharmacist to initiate and change medications and order laboratory tests. Baseline data collected included demographic information, referring provider, tobacco use, and 10-year atherosclerotic cardiovascular disease risk. Data collected at subsequent visits included date of visit, A1C, estimated average glucose (eAG), blood pressure, weight, body mass index, low-density lipoprotein cholesterol, non–high-density lipoprotein cholesterol, statin and dose, tobacco use, amount smoked, and current antipsychotic treatment. Number of times that treatment for diabetes was initiated or intensified by the pharmacist or primary care provider was also collected. Impact of innovationA total of 101 patients were referred to the CVRRC over the 2-year period. Of these, 81 (80.2%) had at least 1 subsequent visit and were included in the A1C analysis. CVRRC patients had a statistically significant improvement in A1C over time. Mean A1C decreased by an increment of 0.06% for each month increase in follow-up time (P < 0.0001). There was no significant difference in A1C values between patients on different antipsychotic treatments (P = 0.74). ConclusionThe pharmacist-managed CVRRC demonstrated beneficial outcomes for individuals diagnosed with diabetes and SMI. Results provide promising evidence supporting future larger studies to confirm these findings. Considering the morbidity and mortality disparities for individuals with SMI, health care organizations should consider similar models to improve diabetes outcomes.

A Focused Ethnography of Baccalaureate Nursing Students Who Are Using Motivational Interviewing.

The purpose of this article is to describe how nursing students learned and used motivational interviewing (MI) in a community-based clinical context at a primary care vascular risk reduction clinic focused on health promotion. A focused ethnography was used to access a sample of 20 undergraduate nursing students, 16 patients, and 2 instructors. Data were generated from participant observations, field notes, student journals, and interviews (one-on-one and focus group). Central to the students' experience was their transformation because of learning and using MI. Three sub themes describe the social processes that shaped the student experience: learning a relational skill, engaging patients, and collaborating as partners. It is feasible for nursing students to learn MI and use this approach to enhance collaborative care in a primary care setting. The experience can be transformative for students. Supporting patients to adopt healthy lifestyles is a significant role for nurses in practice. The findings provide key insights and strategies for nurse educators teaching students a collaborative communication approach, such as MI, to engage patients in health behavior change.

Maintenance of Clinical Endpoints After Discharge from a Pharmacist-Managed Risk Reduction Clinic at a Veterans Affairs Medical Center.

Diabetes, dyslipidemia, and hypertension are complex chronic disease states that often require close monitoring and frequent follow-up to achieve and maintain therapeutic control as determined by hemoglobin A1c (A1c), low-density lipoprotein (LDL), and blood pressure (BP). At the Charles George Veterans Affairs Medical Center (CGVAMC), physicians may refer their patients to the on-site pharmacist-managed Risk Reduction Clinic (RRC). Patients are discharged from the RRC once patient-specific therapeutic goals have been met for diabetes, dyslipidemia, and/or hypertension. This study investigated the change in A1c, LDL, and systolic blood pressure (SBP) after discharge from the CGVAMC RRC. To investigate (a) how clinical endpoints for diabetes, dyslipidemia, and hypertension change after discharge from the pharmacist-managed RRC at the CGVAMC; (b) the factors associated with worsening of monitoring parameters; and (c) the frequency of reconsultation to the RRC. In this single-center retrospective quality management study, patients were included if they had a completed consultation to the CGVAMC RRC between August 11, 2008, and January 1, 2011, for the management of type 2 diabetes, dyslipidemia, and/or hypertension. Patients were included if they were discharged from the RRC prior to October 1, 2011, due to goal attainment. Furthermore, it was required that patients have A1c, LDL, and SBP measurements, as applicable based on diagnoses, at least yearly during the first 2 years following discharge. Patients were excluded if they were discharged for any reason other than goal attainment or if they were followed by a specialty clinic related to the RRC, including the Diabetes PharmD, Diabetes MD, MIDAS (group diabetes), or MAGIC (group dyslipidemia) clinics. Data collection included patient demographics; date of and indication for consultation to the RRC; date of first RRC visit; date of discharge from the RRC; number of visits to the RRC; A1c, LDL, SBP, and weight at consultation to the RRC, at discharge, and during the 2 years following discharge from the RRC; and date of and indication for reconsultation to the RRC, as applicable. Two-tailed paired t-tests were used to compare A1c, LDL, and SBP at discharge from the RRC to A1c, LDL, and SBP during the follow-up period. Two-tailed unpaired t-tests were performed to determine which variables were associated with changes in the monitoring parameters after discharge from the RRC. One hundred forty-nine patients were included in this study. For all patients with a diagnosis of diabetes (N = 82), A1c rose from 6.49% to 6.79% (P < 0.001) during the first year and to 7.04% (P < 0.001) during the second year following discharge. For patients diagnosed with dyslipidemia (N = 137), LDL rose after discharge from 81.5 mg/dL to 90.8 mg/dL (P < 0.001) and to 90.9 mg/dL (P < 0.001), respectively. For patients diagnosed with hypertension (N = 132), SBP rose from 126.2 mm Hg to 131.5 mm Hg (P < 0.001) and to 133.9 mm Hg (P < 0.001), respectively. An increase in A1c after discharge was associated with lower discharge A1c (P = 0.014), higher consultation weight (P = 0.009), and higher discharge weight (P = 0.042). A rise in LDL was correlated to higher consultation LDL (P = 0.006), while higher SBP was associated with lower discharge SBP (P < 0.001). Twelve percent of patients were reconsulted to the RRC. A1c, LDL, and SBP rose after discharge from the pharmacist-managed risk reduction clinic, but these changes may not have been clinically significant based on the low reconsultation rate and values remaining close to generally accepted therapeutic goals. Patients likely to benefit from extending RRC services past goal attainment include those with higher A1c and LDL at the time of consultation and those with higher weight. As a result of this study, recommendations have been made to consider following up every 3-4 months for 2-3 additional visits for patients with baseline A1c > 8% and LDL > 115 mg/dL and those with weight > 220 pounds prior to discharging them from the CGVAMC RRC. Furthermore, we believe that all patients could benefit from extending follow-up to 6 months for 1-2 additional visits or as needed after their therapeutic goals have been reached.

Effectiveness of a Pharmacist-Led Cardiovascular Risk Reduction Clinic in Rural Perry County, Alabama.

Background. The Cardiovascular Risk Reduction Clinic (CRRC) in Perry County, Alabama, provides free pharmacist-led services. Clinic goals include improving health outcomes and reducing cardiovascular risk factors. Objective. To investigate the effectiveness of the CRRC in rural Perry County, Alabama. The reduction of the modifiable cardiovascular risk factors, blood pressure and body mass index, was evaluated to measure a decrease from baseline to last clinic date. Methods. This retrospective chart review identified 130 patients with at least two blood pressure and BMI measurements from baseline to June 30, 2010. The patients' paper files were used to collect baseline data and most recent measurements, which were recorded on a data collection sheet. Results. There was a statistically significant reduction in systolic blood pressure of 4.08 mmHg, 3.25 mmHg reduction in diastolic blood pressure, and 0.42 kg/m2 reduction in mean BMI. At their last visit prior to June 30, 2010, 59% of hypertensive patients and 35% of diabetic patients were meeting their blood pressure goals. Conclusion. Pharmacist-led management of patients with cardiovascular risk factors significantly reduced blood pressure and allowed more patients to meet their hypertension treatment goals. Despite being modest, reductions in blood pressure and BMI help reduce overall cardiovascular risks.

Pharmacist managed diabetes and cardiovascular risk reduction clinic in kidney transplant recipients: Bridging the gap in care transition

The purpose was to assess the feasibility of a care transition intervention for kidney transplant recipients (KTRs) with diabetes. Results document improved quality indicators and reduced resource utilization. These findings imply that a care transition intervention for KTRs with diabetes is feasible and associated with improved patient outcomes.

Abstract 205: Potential Cardiovascular Risk Reduction in High-Risk Uninsured Patients: An Analysis of the Heart Improvement Project

Background: The Heart Improvement Project (HIP) is a cardiovascular (CV) risk reduction clinic targeting high-risk, uninsured patients. Using coronary heart disease prediction models from the Framingham Heart Study, it is possible to project an individual’s 10-year CV disease risk based on status of the following risk factors: sex, age, LDL-Cholesterol (LDL-C), HDL-Cholesterol (HDL-C), blood pressure (BP), diabetes, and smoking status. Objective: To project the reduction in CV risk associated with two levels of intervention: first-line therapy (designed to decrease the systolic BP by 15 mm Hg and LDL-C by 30%) and maximal therapy to optimally control all modifiable risk factors. Methods: Data on 251 patients (52% male, mean age 51 yrs; 48% with Diabetes, 45% smokers) from HIP were analyzed. For each patient, their Framingham Risk Scores (FRS) and 10-year Coronary Heart Disease Risk (CHDR) were calculated in three different conditions: their actual risk assessment, and that projected under first-line, and maximal therapy. The three sets of FRS and CHDR were summarized using descriptive statistics. Pairwise differences between the three sets of FRS and CHDR were tested using two-sample t-test and 95% confidence intervals for the differences were computed. Results: Table 1 shows that the mean FRSs were 7.33, 4.90, and 3.51 (under initial, first-line, and maximal conditions, respectively). The corresponding CHDRs were 13%, 8%, and 6% respectively. All comparisons were statistically significant at the p&lt;0.001 level. Conclusions: First-line interventions for BP and lipid management can yield significant improvement in CHD risk in a population of high-risk uninsured patients.

Language Concordance as a Determinant of Patient Outcomes in a Pharmacist-Managed Cardiovascular Risk Reduction Clinic

Background: Published literature reveals that health care disparities exist due to race, gender, and language, although this has not been confirmed in a pharmacist-managed patient population. Objective: The objective of this study is to examine the association of language concordance and clinical outcomes in a comparison of English-speaking (ES) and Spanish-speaking (SS) patients in a pharmacist-managed cardiovascular risk reduction clinic (CVRRC). Methods: A retrospective chart review was undertaken to collect hemoglobin A1C, blood pressure, and low-density lipoprotein cholesterol (LDL-C) for patients enrolled in the CVRRC from July 2010 and August 2012. A 2-sample t-test was utilized to compare these outcomes between ES and SS patients. Results: A total of 9 SS patients and 62 ES patients were included. No statistically significant differences were found between ES and SS patients in this language-concordant, pharmacist-managed clinic setting. Conclusions: These results suggest that similar clinical outcomes between ES and SS patients may be achieved with the ability of pharmacists to speak the same language as their patients.

Interventions to maintain cardiac risk control after discharge from a cardiovascular risk reduction clinic: A randomized controlled trial

AimsTo evaluate the efficacy of two maintenance strategies compared to usual care after discharge from a pharmacist-led cardiovascular risk reduction clinic (CRRC). MethodsOpen-label, randomized-controlled trial of 200 consecutive CRRC patients that met clinic discharge criteria (HbA1c ≤7% (53mmol/mol); blood pressure ≤140/80mmHg for those with diabetes and ≤140/90mmHg for those without diabetes; and an LDL-cholesterol ≤2.59mmol/l). Participants were randomized to either [1] quarterly group medical visits or [2] quarterly CRRC individual clinic visits, or [3] a usual care control arm with the standard primary care alone first in a 1:1:1 ratio, followed by a 2:2:1 ratio after first 100 patients. Primary outcome measures were time to failure for guideline recommended goals of HbA1c and blood pressure over 12-months. ResultsOf the 200 participants randomized, 89% had diabetes and were similar in other cardiovascular risk factors. After 1-year, the HbA1c failure rate was 0.36 [95% CI, 0.28–0.47] per quarter for the group medical visit arm, 0.24 [95% CI, 0.18–0.33] per quarter for the quarterly CRRC individual arm and, 0.82 [95% CI, 0.69–0.96] per quarter for the usual care control arm, p<0.001. The rate of failure for blood pressure was 0.31 [95% CI, 0.23–0.41] per quarter for the group medical visit arm, 0.22 [95% CI, 0.16–0.30] per quarter for the CRRC individual arm and, 0.53 [95% CI, 0.40–0.71] per quarter the control arm, p<0.001. ConclusionAfter discharge from a CRRC program, both individual and group interventions are more effective in maintaining glycemia and blood pressure control for patients with diabetes than usual care after 1-year of follow-up.

Challenges in Implementing an Interdisciplinary Cardiometabolic Risk Reduction Clinic†

Challenges in Implementing an Interdisciplinary Cardiometabolic Risk Reduction Clinic†