A taxa de controle da hipertensão arterial permanece subótima apesar dos amplos e intensos programas institucionais e o número das novas medicações. A combinação de drogas de diferentes mecanismos de ação vem se tornando uma alternativa para aumentar a redução na pressão arterial (PA) e aumentar seu controle, aumentar aderência ao tratamento e reduzir os eventos adversos. Um estudo fatorial 4X4 foi desenhado para determinar a eficácia e a segurança de telmisartana (T) mais anlodipino (A) em pacientes hipertensos estágios I e II. Pacientes hipertensos adultos (N=1461) estágios I e II (pressão arterial basal 153,212,1 &#8260;101,74,3 mm Hg) foram randomizados para 1 de 16 grupos de tratamento com T 0, 20, 40, 80 mg e A 0, 2.5, 5, 10 mg por oito semanas. A maior redução na média das pressões sistólica e diastólica foram observadas com T 80 mg mais A10 mg (- 26,4 &#8260;20,1 mm Hg; p<0,05 comparados com as monoterapias). A taxa de controle da PA foi também maior no grupo T 80mg mais A 10mg (76,5% [controle total] e 85,3% [controle da PA diastólica ]), e taxa de controle da PA >90% com esta combinação. O edema periférico maleolar foi o evento adverso mais frequente e ocorreu no grupo A 10mg (17,8%), porém, esta taxa foi marcadamente menor quando A foi usada associada com T: 11,4% (T20+A10), 6,2% (T40+ A10), e 11,3% (T80+A10). Um subestudo utilizando a monitorização ambulatorial da pressão arterial (MAPA) foi realizado na fase basal e após oito semanas de tratamento. A maior redução média das pressões nas 24 horas a partir do período basal foi registrada para a combinação de telmisartana 80 mg e anlodipino 10 mg e encontrou-se queda de 22,4/14,6 mmHg, de 11,9/6,9 mmHg para anlodipino 10 mg monoterapia e de 11,0/6,9 mmHg para telmisartana 80 mg (p< 0,001). Além disso, resultados relevantes foram também constatados numa análise post hoc de subgrupos incluindo idosos, obesos, diabéticos tipo 2 e hipertensão sistólica. A resposta anti-hipertensiva da combinação foi semelhante, independente de qualquer característica de cada subgrupo. Estes dados demonstram que telmisartana e anlodipino em combinação oferecem substancial redução e controle nas 24 horas superior às respectivas monoterapias em hipertensos estágios I e II. / The rate of control of hypertension remains suboptimal despite widespread educational programs and the increasing number of novel medications. The combination of drugs with different mechanism of action has become an alternative to improve blood pressure reduction and control, enhance adherence to the treatment and reduce adverse events. This randomized 4X4 factorial study determined the efficacy and safety of telmisartan (T) plus amlodipine (A) in hypertensive patients. Adults (N=1461) with stage 1 or 2 hypertension (baseline blood pressure (BP) 153.212.1 &#8260;101.74.3 mm Hg) were randomized to 1 of 16 treatment groups with T 0, 20, 40, 80 mg and A 0, 2.5, 5, 10 mg for 8 weeks. The greatest leastsquare mean systolic &#8260; diastolic BP reductions were observed with T80 mg plus A10 mg (- 26.4 &#8260;20.1 mm Hg; P<.05 compared with both monotherapies). BP control was also greater in the T80-mg plus A10-mg group (76.5% [overall control] and 85.3% [diastolic BP control]), and BP response rates >90% with this combination. Peripheral edema was most common in the A10-mg group (17.8%); however, this rate was notably lower when A was used in combination with T: 11.4% (T20 &#8260; A10), 6.2% (T40 &#8260; A10), and 11.3% (T80 &#8260; A10). Ambulatory BP monitoring (ABPM) was performed, at baseline and after 8 weeks of treatment; the endpoints of interest were the changes from baseline in 24-hour systolic and diastolic BP. Mean reductions from baseline in 24-hour BP for the combination of the highest doses of telmisartan 80 mg and amlodipine 10 mg were -22.4/-14.6 mmHg versus -11.9/-6.9 mmHg for amlodipine 10 mg and -11.0/-6.9 mmHg for telmisartan 80 mg (p< 0.001 for each comparison. This study also presents most of the relevant results in hypertensive patients and a post hoc analysis of subgroups including elderly, diabetics type 2, systolic hypertension and obese patients. These findings demonstrate that telmisartan and amlodipine in combination provide substantial 24 hour BP efficacy that is superior to either monotherapy in patients with stages 1 and 2 hypertension.

Objectives: 1) To determine 2010 pharmacy-related ambulatory care sensitive condition (ACSC) hospital discharges by Tennessee (TN) county; 2) To explore pharmacy-related ACSC hospital discharges across county characteristics for Tennessee counties, including community pharmacies per county, age, and county rurality; 3) To explore pharmacy-related ACSC hospital discharges across age for northeastern Tennessee counties. Methods: Data were obtained from the TN Department of Health Statistics (hospital discharge data), TN Board of Pharmacy (licensed community pharmacies), the United States (US) Census Bureau (county-level populations), the Office of Rural Health Policy (rural designations), and the US Health Resources and Services Administration (health professional shortage area designations). ACSC discharges were determined using the Agency for Healthcare Research & Quality's (AHRQ's) Prevention Quality Indictors (PQIs) for asthma, bacterial pneumonia, congestive heart failure, chronic obstructive pulmonary disease, hypertension, uncontrolled diabetes, and short-term and long-term diabetes complications. County-level analyses were population adjusted and analyzed across age. Analyses were conducted using SPSS and ArcGIS software. Results: In 2010, 79,683 hospital discharges were noted for pharmacy-related ACSCs, 55% of which were for residents 65 and over. For northeast Tennessee counties, 8,538 were documented accounting for 11% of Tennessee pharmacy-related ACSCs discharges. Bacterial pneumonia, heart failure, and COPD accounted for nearly 65% of discharges in northeastern Tennessee counties. The number of community pharmacies per Tennessee county was statistically significantly negatively correlated with county-level bacterial pneumonia (r=-0.339; p=0.001), CHF (r=-0.215; p=0.036), and COPD (r=-0.403; p<0.001) hospital discharges. Implications/Conclusions: Community pharmacies have the potential to positively impact the health needs of Tennesseans by targeting services (e.g., MTM, immunizations, adherence assistance) based on ambulatory care sensitive conditions. Future research is warranted to quantify current services and determine the capacity to provide such services.

In the modern society, chronic diseases have become the leading causes of death. With early recognition and proper management, however, many of the complications from chronic diseases could be prevented or delayed. Taking such a proactive approach in managing a population often requires the use of team-based approaches and delegation of certain clinical and nonclinical tasks to nonphysician team members. This three-study dissertation used a combination of methods to explore contextual factors that influence primary care teamwork and physician-pharmacist collaboration. The first study quantitatively examined baseline barriers and facilitators of physician-pharmacist collaboration in clinics participating in the Collaboration Among Pharmacists and Physicians To Improve Outcomes Now (CAPTION) Trial. Pharmacist expertise and clinic staff support were found to be the most important facilitators for physicians, while insurance reimbursement and task design factors were important for pharmacists. The second study characterized clinic personnel experience participating in the CAPTION trial and explored determinants of disease state control. Higher proportions of indigent and minority populations and higher baseline pharmacy structure scores were found to be associated with lower blood pressure control. The third study qualitatively examined organizational influences on primary care team effectiveness and the roles of pharmacists in a separate sample of primary care clinics. A lack of organizational rewards for teamwork in primary care was identified and pharmacists were integrated into clinic workflow in various degrees. These findings will be informative for practice managers and health care professionals seeking to redesign their practice to meet increasing needs of patients with chronic diseases.

This study presented an empirical analysis of the key market, regulatory, organizational, operational and financial factors associated with hospital entry into joint venture (JV) arrangements with Ambulatory Surgery Centers (ASCs) as examined through the framework of resource dependency theory complimented with neo-institutional theory. This study used a cross sectional design to examine hospitals that entered into a joint venture arrangement with ASCs in 2006 and 2007. The data for this study were drawn from five main sources: the American Hospital Association Annual Survey (AHA), the Area Resource File (ARF), the CMS (Center for Medicare and Medicaid Services) minimum dataset, the National Legislative Assembly Website and the CM case-mix files. Descriptive analysis and multivariate logistic regression were performed to examine the association of various factors in this study. The study found that market factors such as unemployment rate and percentage of elderly were strongly associated with the hospitals decision to joint venture with ASCs. Also organizational size (measured by bed size) was a significant factor in these decisions. Other factors which showed a marginal significance were Herfindahl-Hirschman Index, number of ASCs, certificate of need laws, ownership status, and operating expense per adjusted discharge of the hospital. This research project sheds light on joint venture arrangements between hospitals and ASCs at a very opportune time. In light of the new Health Reform Legislation, studying hospital-ASC joint ventures is very important. For hospitals and ASCs, and their collaborative interests such as joint ventures, Accountable Care Organizations (ACO’s) could either provide incentives to help improve quality of care to patients or stint on needed care by making them focus narrowly on higher margin services (Fisher and Shortell 2010; Shortell and Casalino 2010). Since policy measures should encourage the first and not the second outcome, it is important to have a transparent performance measurement system that can win the confidence of the provider organizations such as hospitals and ASCs. Lacking which, it may discourage joint venture arrangements between hospitals and ASCs in future.

Urinary tract infections are diagnosed in female populations primarily in ambulatory care settings in the United States. Yet, published evidence documents that many of the antibiotics prescribed in these settings are unnecessary, erroneous, or, inappropriately prescribed. Improper management of uncomplicated urinary tract infections in nonpregnant women has resulted in higher morbidity rates due to antibiotic resistance. The purpose of this retrospective observational cohort study was to explore a current national database for associations between nonpregnant American female patients who were exposed to poverty and at risk for urinary tract infection antibiotic resistance in an ambulatory care setting. Krieger's ecosocial theory was utilized as the study's theoretical foundation to complement current public health social change priorities. Data from the National Ambulatory Medical Care Survey were analyzed to explore potential associations with urinary tract infections and antibiotic resistance. The sample consisted of ambulatory patients with urinary tract infection symptoms (n=45). The independent variables selected were antibiotics prescribed initially in 3 months or less after the onset of urinary tract infection symptoms, the continuation of antibiotics prescribed in 12 months or less after recurrence, and three classes of antibiotics prescribed for urinary tract infection symptoms known as broad-spectrum, narrow-spectrum, and combined broad- and narrow-spectrum antibiotics, while the dependent variable was urinary tract infection antibiotic resistance. Relationships between the variables were analyzed using binary logistic regression, however, there were no statistically significant outcomes. Promoting antibiotic stewardship programs in all health care settings in the U.S. can effect positive social changes that will prevent further antibiotic resistance.

<p>This study examined relationships between 24-hour ambulatory BP and components of the insulin resistance syndrome, and investigated the prognostic significance of 24-hour BP for cardiovascular morbidity in a longitudinal population-based study of 70-year-old men. The findings indicated, that a reduced nocturnal BP fall, nondipping, was a marker of increased risk primarily in subjects with diabetes. A low body mass index and a more favourable serum fatty acid composition at age 50 predicted the development of white-coat as opposed to sustained hypertension over 20 years. Furthermore, cross-sectionally determined hypertensive organ damage at age 70 was detected in sustained hypertensive but not in white-coat hypertensive subjects. In a prospective analysis, 24-hour ambulatory pulse pressure and systolic BP variability at age 70 were strong predictors of subsequent cardiovascular morbidity, independently of office BP and other established risk factors. Isolated ambulatory hypertension, defined as having a normal office BP but increased daytime ambulatory BP, was associated with a significantly increased incidence of cardiovascular events during follow-up. </p><p>Hypertension constitutes part of the insulin resistance syndrome, and is a common and powerful risk factor for cardiovascular disease in elderly. Blood pressure (BP) measured with 24-hour ambulatory monitoring gives however more detailed information and may be a better estimate of the true BP than conventional office BP. </p><p>In summary, these data provide further knowledge of 24-hour ambulatory BP and associated metabolic risk profile, and suggest that the prognostic value of 24-hour ambulatory BP is superior to conventional BP in an elderly population.</p>

Thesis (Ph. D.)--University of Florida, 2003. / Title from title page of source document. Includes vita. Includes bibliographical references.

This study examined relationships between 24-hour ambulatory BP and components of the insulin resistance syndrome, and investigated the prognostic significance of 24-hour BP for cardiovascular morbidity in a longitudinal population-based study of 70-year-old men. The findings indicated, that a reduced nocturnal BP fall, nondipping, was a marker of increased risk primarily in subjects with diabetes. A low body mass index and a more favourable serum fatty acid composition at age 50 predicted the development of white-coat as opposed to sustained hypertension over 20 years. Furthermore, cross-sectionally determined hypertensive organ damage at age 70 was detected in sustained hypertensive but not in white-coat hypertensive subjects. In a prospective analysis, 24-hour ambulatory pulse pressure and systolic BP variability at age 70 were strong predictors of subsequent cardiovascular morbidity, independently of office BP and other established risk factors. Isolated ambulatory hypertension, defined as having a normal office BP but increased daytime ambulatory BP, was associated with a significantly increased incidence of cardiovascular events during follow-up. Hypertension constitutes part of the insulin resistance syndrome, and is a common and powerful risk factor for cardiovascular disease in elderly. Blood pressure (BP) measured with 24-hour ambulatory monitoring gives however more detailed information and may be a better estimate of the true BP than conventional office BP. In summary, these data provide further knowledge of 24-hour ambulatory BP and associated metabolic risk profile, and suggest that the prognostic value of 24-hour ambulatory BP is superior to conventional BP in an elderly population.

Enhancing primary care is key to the Canadian health care reform. Considered as an indicator of primary care access and quality, hospitalisations for ambulatory care sensitive (ACS) conditions are commonly reported by Canadian organisations as sentinel events signaling problems with the delivery of primary care. However, the literature calls for further research to identify what lies behind ACS hospitalisation rates in regions with a predominantly urban population benefiting from universal access to health care. A theoretical model was built and, using an ecological design, multiple regressions were implemented to identify which neighbourhood characteristics explained the socio-economic gradient in ACS hospitalisation rates observed in Ottawa. Among these neighbourhoods, healthy behaviour and - to a certain extent - health status were significantly associated with ACS hospitalisation rates. Evidence of an association with primary care accessibility was also signaled for the more rural neighbourhoods. Smoking prevention and cessation campaigns may be the most relevant health care strategies to push forward by policy makers hoping to prevent ACS hospitalisations in Ottawa. From a health care equity perspective, targeting these campaigns to neighbourhoods of low socio-economic status may contribute to closing the gap in ACS hospitalisations described in this current study. Reducing the socio-economic inequalities of neighbourhoods would also contribute to health equity.

Dagkirurgi blir allt vanligare. Då det genomförs under generell anestesi förekommer ofta oro och postoperativa komplikationer som smärta och illamående. Patienters tillfredsställelse med dagkirurgi och anestesi har tidigare studerats, men ofta med enkäter av låg kvalité. Syftet med denna studie var därför att med hjälp av intervjuer studera dagkirurgiska patienters upplevelse av anestesi och kirurgi. Sju patienter intervjuades. Intervjuerna var kvalitativa och analyserades med innehållsanalys. Resultatet kan sammanfattas i ett övergripande tema: förberedda patienter ser dagkirurgi som en positiv upplevelse. Domänen före operation beskrevs av kategorierna: viktigt med information, mycket tankar inför operation, smidigt insomnande och vissa obehagliga moment. Domänen efter operation beskrevs av kategorin: lugnt uppvaknande. Domänen total upplevelse beskrevs av kategorierna: kommunikation med personal ger lugn samt dagkirurgi en positiv upplevelse. Patienter som med hjälp av förberedande information och personalens goda bemötande och som genomgår dagkirurgi under generell anestesi, ser upplevelsen som positiv. De kommer in till sjukhuset med mer förhoppningar än oroskänslor. Informationen som ges behöver anpassas individuellt. Förekomsten av smärta och illamående är låg den närmsta tiden efter dagkirurgi. / Day surgery is becoming more common and with general anesthesia, anxiety and postoperative complications such as pain and nausea has been described. Patient satisfaction with day surgery and anesthesia are previously studied, but often with surveys of low quality. The purpose of this study was therefore with interviews study patients’ experience of anesthesia and surgery in day surgery. Seven patients were interviewed. The interviews were qualitative and analyzed using content analysis. The result can be summarized in a theme: prepared patients describe day surgery as a positive experience. The domain before surgery was described by the categories: importance of information, many thoughts before surgery, fell asleep easily and some uncomfortable moments. The domain after surgery was described by the category: peacefully awakening. The domain total experience was described by the categories: communication with nursing staff reduces anxiety and day surgery a positive experience. Patients with the help of preparatory information and good interactions with the nursing staff and who are undergoing day surgery with general anesthesia, describe the experience as positive. They come to the hospital with more hope than anxiety. The information needs to be individually adjusted. The presence of pain and nausea is low immediately after day surgery.