WIHI - A Podcast from the Institute for Healthcare Improvement

Health Care Reform in Massachusetts: A Model for the Nation?

Gazing into the Crystal Ball: US Health Care in 2013

Supervised treadmill exercise improves walking performance for patients with peripheral arterial disease (PAD), whether or not the patient has classic symptoms of intermittent claudication. Supervised lower extremity strength training improves quality of life, stair climbing ability, and treadmill walking performance for PAD patients with and without intermittent claudication. Supervised treadmill walking exercise improves brachial arterial flow mediated dilation in patients with PAD, suggesting a global cardiovascular health benefit.

Drugs such as the alpha glucosidase inhibitor, acarbose, which reduce the rate of digestion and absorption of carbohydrate and so flatten the post-prandial glycemic response have been shown to improve diabetes control, reduce the risk of developing hypertension and lower the risk for cardiovascular disease. Can a selection of more slowly digested carbohydrate foods achieve qualitatively similar benefits to drugs? Current data suggest that selection of diets containing low glycemic intake foods have modest benefits in reducing HbA1C even in type 2 diabetes patients treated with one to three antihyperglycemic medications. Foods with a low glycemic index include many traditional study foods such as dried peas, beans, lentils, intact grain breads, pasta, oats, barley, parboiled rice, and temperate climate fruits and berries. Low glycemic index starchy foods are digested less readily in vitro. Other effects include a tendency for higher HDL, lower CRP values and greater weight loss in the per protocol completers ie. those who completed the study with no change in medications.

Depression is a common and serious condition in patients with heart disease; therefore health care workers should inquire about symptoms of depression in their heart disease patients. Our recent systematic review shows that there is not sufficient evidence at this time to call for routine screening for depression in patients with heart disease. Additional research is needed to determine the optimal model(s) of care that will allow depression to be appropriately diagnosed and treated in patients with heart disease, particularly at times when these patients are being cared for primarily by heart disease experts rather than by experts in depression diagnosis and treatment.

A majority (55.5% ) of Medicare patients with stable coronary artery disease who underwent an elective percutaneous coronary intervention (PCI) did not have a recommended stress test performed to document ischemia. The rate of stress testing before elective PCI shows significant geographic variation, from a low of 22% in Fresno, CA to a high of 71% in Rochester, MN. Patient characteristics (female sex, age of 85 years or older, and having co-existing illnesses) and physician characteristics (physicians who performed a higher volume of PCI procedures) were associated with lower rates of stress testing.

The three primary pelvic floor disorders include urinary and fecal incontinence, and pelvic organ prolapse. In a national population-based sample, nearly one-quarter of U.S. women reported at least one symptomatic pelvic floor disorder: overall, 15.7 percent experienced moderate to severe urinary incontinence, 9.0 percent experienced fecal incontinence at least monthly and 2.9 percent experienced symptomatic pelvic organ prolapse (a bulge in the vagina they could see or feel). Older women, overweight and obese women and multiparous women were more likely to report a pelvic floor disorder.

Emergent sexual dysfunction (SD) is a principal reason for a three-fold increased risk of non-adherence that leads to increased relapse, recurrence, and poor disease management outcomes. Selective phosphodiesterase-type 5 inhibitors (PDE5Is), limited to studies in men, have demonstrated evidence based data to support broad based and clinically meaningful treatment efficacy. In an intention-to-treat analysis, women treated with sildenafil showed significant improvement in adverse sexual effects compared with those taking placebo. Evidence shows that selective phosphodiesterase type 5 inhibitors are effective in both sexes for patients who have been effectively treated for depression but need to continue on their medication to avoid relapse or recurrence.

If blood pressure (BP) control could be improved, many deaths from cardiovascular and renal disease could be prevented. The Chronic Care Model was used to design an intervention that empowered patients to be more involved in their own care using home BP monitoring, a patient shared electronic medical record, and Web-based pharmacist assistance. The group of patients that received BP monitors and training to use an existing patient website (with encouragement to send their BP numbers to their physician) had a modest decrease in systolic blood pressure, but BP control did not significantly improve. The group that received BP monitors, web training, and web-based pharmacy assistance had greater decreases in BP and were almost two times as likely to have controlled BP.

People with symptoms of depression are more likely to engage in diabetes-producing health behaviors, including eating more, exercising less, and smoking more. As a consequence, they were more obese. People with elevated symptoms of depression had a 42 percent increased risk of developing type 2 diabetes over 3 years. This was partially explained by unhealthy behaviors. People with treated type 2 diabetes had a 52 percent increased risk of developing depressive symptoms over 3 years. This suggests that individuals with diabetes should be monitored for development of depression.

Which way forward for the quality improvement and patient safety movements? Join IHI's President and CEO, Donald Berwick, for a series of conversations with Senior Communications Strategist, Madge Kaplan. Each monthly installment offers Dr. Berwick's latest thinking on the major issues of the day and how health care professionals, health care leaders, and patients and families can bring about significant reform.

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Adding a single screening ultrasound examination to screening mammography in women at increased risk of breast cancer with at least heterogeneously dense breasts increases the cancer detection rate from 50% to 78%. The risk of a biopsy for a benign lesion in our series was 1 in 40 for women undergoing mammography vs. 1 in 10 for women undergoing mammography combined with ultrasound screening. Using the standardized technique and interpretive criteria developed for this study, other radiologists and facilities with similar equipment and experience should expect similar results.

Which way forward for the quality improvement and patient safety movements? Join IHI's President and CEO, Donald Berwick, for a series of conversations with Senior Communications Strategist, Madge Kaplan. Each monthly installment offers Dr. Berwick's latest thinking on the major issues of the day and how health care professionals, health care leaders, and patients and families can bring about significant reform.