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1.  Do Clinicians Tell Patients They Have Prehypertension? 
Journal of the American Board of Family Medicine : JABFM  2011;24(1):10.3122/jabfm.2011.01.100206.
doi:10.3122/jabfm.2011.01.100206
PMCID: PMC3814021  PMID: 21209353
2.  A non-experimental study of oral anticoagulation therapy initiation before and after national patient safety goals 
BMJ Open  2014;4(2):e003960.
Objectives
The Joint Commission revised its National Patient Safety Goals (NPSGs) to include oral anticoagulation therapy (OAT) in 2008. We sought to examine the effect of including OAT in The Joint Commission's NPSGs on historically low rates of OAT initiation for individuals with incident atrial fibrillation (AF).
Setting
Southeastern state in the USA.
Participants
North Carolina State Health Plan claims data from 944 500 individuals enrolled between 1 January 2006 and 31 December 2010, supplemented with data from the Area Resource File and Online Survey, Certification and Reporting data network. We evaluated OAT initiation before and after the 2008 NPSGs revisions in a retrospective cohort new user design with an AF intervention group and two control groups: a positive control—patients estimated to be at very high risk of thromboembolism (mechanical heart valve and pulmonary embolism); and a negative control—patients with very low perceived risk of thromboembolism (paroxysmal AF). We developed multivariable models using a difference-in-difference parameterisation. Effects were estimated with generalised estimating equations.
Primary outcome measure
OAT initiation, a binary outcome defined as having a prescription drug claim for warfarin within 30 days of the index claim.
Results
OAT initiation was low (26.8%) for eligible individuals with incident AF in 2006–2008 but increased after NPSGs implementation (31.7%, p=0.022). OAT initiation was high but decreased in the positive control group (67.5% vs 62.0%, p=0.003). Multivariate analysis resulted in a relative 11% (95% CI (4% to 18%), p<0.01) increase in OAT initiation for incident AF patients.
Conclusions
We document a substantial increase in guideline concordant OAT initiation in incident AF after the establishment of NPSGs, suggesting that regulatory healthcare agency initiatives can influence clinical practice.
doi:10.1136/bmjopen-2013-003960
PMCID: PMC3927813  PMID: 24525389
3.  NIGHTTIME BLOOD PRESSURE DIPPING IN YOUNG ADULTS AND CORONARY ARTERY CALCIUM 10-15 YEARS LATER: THE CARDIA STUDY 
Hypertension  2012;59(6):1157-1163.
Nighttime blood pressure (BP) dipping can be quantified as the ratio of mean nighttime (sleep) BP to mean daytime (awake) BP. People whose dipping ratio is 0.90 have been referred to as nondippers, and nondipping is associated with cardiovascular disease events. We examined the relationship between systolic nighttime BP dipping in young adults and presence of coronary artery calcium (CAC) 10-15 years later using data from the ambulatory BP monitoring substudy of the Coronary Artery Risk Development in Young Adults (CARDIA) study. Among 239 participants with adequate measures of both nighttime and daytime readings and coronary artery calcium, the systolic BP dipping ratio ranged from 0.72 to 1.24 (mean 0.88, SD 0.06), and CAC was present 10 to 15 years later in 54 participants (22.6%). Compared to those whose systolic BP dipping ratio ranged from 0.88 to 0.92 (Quartile 3), the 57 participants (23.9%) with less pronounced or absent dipping (ratio 0.92 to 1.24, Quartile 4) had an unadjusted odds ratio of 4.08 (95% CI 1.48-11.2) for presence of CAC. The 60 participants (25.1%) with a more pronounced dipping (ratio 0.72 to 0.85, Quartile 1) also had greater odds for presence of CAC (OR 4.76; 95% CI 1.76-12.9). When modeled as a continuous predictor, a U-shaped relationship between systolic BP dipping ratio and future CAC was apparent, and persisted after adjustment for multiple potential confounders (p<0.001 for quadratic term). Both failure of systolic BP to dip sufficiently and “overdipping” during nighttime may be associated with future subclinical coronary atherosclerosis.
doi:10.1161/HYPERTENSIONAHA.112.191536
PMCID: PMC3369268  PMID: 22547435
ambulatory blood pressure; diurnal blood pressure; blood pressure dipping; coronary artery calcium; subclinical atherosclerosis
4.  Diurnal blood pressure pattern and development of prehypertension or hypertension in young adults: the CARDIA study 
Nondippers (people whose sleep systolic blood pressure (SBP) fails to decrease >10% from daytime SBP) have increased risk of cardiovascular disease. The prevalence of nondipping in younger adults has not been well-studied, nor has its value for predicting hypertension. We examined the prevalence of nondipping in a sub-study of the Coronary Artery Risk Development in Young Adults (CARDIA) Study. We used Cox regression to estimate the hazard ratio (HR) conferred by nondipping for incident prehypertension or hypertension (preHTN/HTN) over 15 years. Of the 264 non-hypertensive participants at baseline, 118 (45%) were nondippers. Blacks were more likely than Whites to be nondippers (52% vs 33%, p=0.004). The incidence rate of preHTN/HTN was 29.2/1000 person-years among dippers and 36.2/1000 person-years among nondippers. Compared to those in the lowest quartile of nighttime to daytime SBP, those in the highest quartile were more likely to develop preHTN/HTN (HR 1.61; p =0.06), but this relationship was attenuated after adjustment (HR 1.34; p =0.27). Our results demonstrate that nondipping is common in young, nonhypertensive adults, and is more common in Blacks than Whites. Nondipping might predate a meaningful clinically detected increase in BP in some people, but more research in larger study samples is needed.
doi:10.1016/j.jash.2010.12.002
PMCID: PMC3061433  PMID: 21269909
diurnal blood pressure; blood pressure dipping; hypertension
5.  A Hypertension Risk Score for Middle-Aged and Older Adults 
Determining which demographic and medical variables predict the development of hypertension could help clinicians stratify risk in both prehypertensive and nonhypertensive persons. Subject-level data from 2 community-based biracial cohorts were combined to ascertain the relationship between baseline characteristics and incident hypertension. Hypertension, defined as diastolic blood pressure ≥90 mm Hg, systolic blood pressure ≥140 mm Hg, or reported use of medication known to treat hypertension, was assessed prospectively at 3, 6, and 9 years. Internal validation was performed by the split-sample method with a 2:1 ratio for training and testing samples, respectively. A scoring algorithm was developed by converting the multivariable regression coefficients to integer values. Age, level of systolic or diastolic blood pressure, smoking, family history of hypertension, diabetes mellitus, high body mass index, female sex, and lack of exercise were associated with the development of hypertension in the training sample. Regression models showed moderate to high capabilities of discrimination between hypertension vs nonhypertension (area under the receiver operating characteristic curve 0.75–0.78) in the testing sample at 3, 6, and 9 years of follow-up. This risk calculator may aide health care providers in guiding discussions with patients about the risk for progression to hypertension.
doi:10.1111/j.1751-7176.2010.00343.x
PMCID: PMC3683833  PMID: 21029343
6.  Simplifying healthful choices: a qualitative study of a physical activity based nutrition label format 
Nutrition Journal  2013;12:72.
Background
This study used focus groups to pilot and evaluate a new nutrition label format and refine the label design. Physical activity equivalent labels present calorie information in terms of the amount of physical activity that would be required to expend the calories in a specified food item.
Methods
Three focus groups with a total of twenty participants discussed food choices and nutrition labeling. They provided information on comprehension, usability and acceptability of the label. A systematic coding process was used to apply descriptive codes to the data and to identify emerging themes and attitudes.
Results
Participants in all three groups were able to comprehend the label format. Discussion about label format focused on issues including gender of the depicted figure, physical fitness of the figure, preference for walking or running labels, and preference for information in miles or minutes. Feedback from earlier focus groups was used to refine the labels in an iterative process.
Conclusions
In contrast to calorie labels, participants shown physical activity labels asked and answered, “How does this label apply to me?” This shift toward personalized understanding may indicate that physical activity labels offer an advantage over currently available nutrition labels.
doi:10.1186/1475-2891-12-72
PMCID: PMC3681646  PMID: 23742678
Calorie label; Menu label; Nutrition information; Restaurant label; Patient protection and affordable care act; Obesity; Food away from home; Fast food
7.  Level of Blood Pressure above Goal and Clinical Inertia in a Medicaid Population 
Failure to adjust hypertension therapy despite elevated blood pressure (BP) levels is an important contributor to lack of BP control. One possible explanation is that small elevations above goal BP are not concerning to clinicians. BP levels farther above goal, however, should be more likely to prompt clinical action. We reviewed one year’s worth of primary care records of 3,742 North Carolina Medicaid recipients 21 years and older with hypertension (a total of 15,516 office visits) to examine variations in hypertension management stratified by level of BP above goal and the association of BP level above goal with documented anti-hypertensive medication change. Among the 53% of patients not at goal BP, 42% were within 10/5 mm Hg of goal; 11% had a BP ≥40/20 mm Hg above goal. Higher level of BP above goal was independently associated with anti-hypertensive medication change. Compared to visits at which BP was <10/5 mm Hg above goal, the adjusted odds of medication change were 7.9 (95% CI 6.2-10.2) times greater at visits when patients’ BP was ≥ 40/20 mm Hg above goal. However, even when BP was above goal at this level, treatment change occurred only 46% (95% CI 40.2-51.8) of the time.
doi:10.1016/j.jash.2010.07.003
PMCID: PMC3124129  PMID: 20728422
8.  Patient safety and quality improvement education: a cross-sectional study of medical students’ preferences and attitudes 
BMC Medical Education  2013;13:16.
Background
Recent educational initiatives by both the World Health Organization and the American Association of Medical Colleges have endorsed integrating teaching of patient safety and quality improvement (QI) to medical students. Curriculum development should take into account learners’ attitudes and preferences. We surveyed students to assess preferences and attitudes about QI and patient safety education.
Methods
An electronic survey was developed through focus groups, literature review, and local expert opinion and distributed via email to all medical students at a single medical school in the spring of 2012.
Results
A greater proportion of students reported previous exposure to patient safety than to quality improvement topics (79% vs. 47%). More than 80% of students thought patient safety was of the same or greater importance than basic science or clinical skills whereas quality improvement was rated as the same or more important by about 70% of students. Students rated real life examples of quality improvement projects and participation in these projects with actual patients as potentially the most helpful (mean scores 4.2/5 and 3.9/5 respectively). For learning about patient safety, real life examples of mistakes were again rated most highly (mean scores 4.5/5 for MD presented mistakes and 4.1/5 for patient presented mistakes). Students rated QI as very important to their future career regardless of intended specialty (mean score 4.5/5).
Conclusions
Teaching of patient safety and quality improvement to medical students will be best received if it is integrated into clinical education rather than solely taught in pre-clinical lectures or through independent computer modules. Students recognize that these topics are important to their careers as future physicians regardless of intended specialty.
doi:10.1186/1472-6920-13-16
PMCID: PMC3570358  PMID: 23379673
Medical education; Quality improvement; Patient safety; Curriculum development
9.  Long-term prognosis associated with J-point elevation in a large middle-aged biracial cohort: the ARIC study 
European Heart Journal  2011;32(24):3098-3106.
Aims
An association has been described between death from arrhythmia and early repolarization, an electrocardiogram pattern characterized by elevation of the QRS–ST junction (J-point). Little is known about this relationship in non-white populations. This study examines the relationship between J-point elevation (JPE) and sudden cardiac death (SCD) and whether this relationship differs by race or sex.
Methods and results
A total of 15 141 middle-aged subjects from the prospective, population-based Atherosclerosis Risk in Communities (ARIC) study were included in this analysis. The primary endpoint was physician-adjudicated SCD occurring from baseline (1987–1989) through December 2002, secondary endpoints were fatal and non-fatal coronary events and all-cause mortality occurring through December 2007. J-point elevation was defined as J-point amplitude ≥0.1 mV. Pre-specified subgroup analyses by sex and race were conducted. J-point elevation in any lead was present in 1866 subjects (12.3%). After adjustment for demographic, clinical, lifestyle, and laboratory variables, JPE was not significantly related to SCD in the overall sample [adjusted hazard ratio (HR), 1.23; 95% confidence interval (CI), 0.87–1.75]. However, significant interactions were present between race and JPE (P = 0.006) and between sex and JPE (P = 0.020). J-point elevation was significantly predictive of SCD in whites (adjusted HR, 2.03; 95% CI, 1.28–3.21) and in females (adjusted HR, 2.54; 95% CI, 1.34–4.82).
Conclusion
Our results suggest that JPE is associated with an increased risk of SCD in whites and in females, but not in blacks or males. Further studies are needed to clarify which subgroups of individuals with JPE are at increased risk for adverse cardiac events.
doi:10.1093/eurheartj/ehr264
PMCID: PMC3236999  PMID: 21785106
Electrocardiography; Sudden cardiac death; J-point elevation; Epidemiology
10.  Medication documentation in a primary care network serving North Carolina medicaid patients: results of a cross-sectional chart review 
BMC Family Practice  2012;13:83.
Background
Medical records that do not accurately reflect the patient’s current medication list are an open invitation to errors and may compromise patient safety.
Methods
This cross-sectional study compares primary care provider (PCP) medication lists and pharmacy claims for 100 patients seen in 8 primary care practices and examines the association of congruence with demographic, clinical, and practice characteristics. Medication list congruence was measured as agreement of pharmacy claims with the entire PCP chart, including current medication list, visit notes, and correspondence sections.
Results
Congruence between pharmacy claims and the PCP chart was 65%. Congruence was associated with large chronic disease burden, frequent PCP visits, group practice, and patient age ≥45 years.
Conclusion
Agreement of medication lists between the PCP chart and pharmacy records is low. Medication documentation was more accurate among patients who have more chronic conditions, those who have frequent PCP visits, those whose practice has multiple providers, and those at least 45 years of age. Improved congruence among patients with multiple chronic conditions and in group practices may reflect more frequent visits and reviews by providers.
doi:10.1186/1471-2296-13-83
PMCID: PMC3515456  PMID: 22889327
Congruence; Medication documentation; Medical record; Patient safety; Medication discrepancy; Community Care of North Carolina; Community network
11.  Effect of hawthorn standardized extract on flow mediated dilation in prehypertensive and mildly hypertensive adults: a randomized, controlled cross-over trial 
Background
Hawthorn extract has been used for cardiovascular diseases for centuries. Recent trials have demonstrated its efficacy for the treatment of heart failure, and the results of several small trials suggest it may lower blood pressure. However, there is little published evidence to guide its dosing. The blood pressure lowering effect of hawthorn has been linked to nitric oxide-mediated vasodilation. The aim of this study was to investigate the relationship between hawthorn extract dose and brachial artery flow mediated dilation (FMD), an indirect measure of nitric oxide release.
Methods
We used a four-period cross-over design to evaluate brachial artery FMD in response to placebo or hawthorn extract (standardized to 50 mg oligomeric procyanidin per 250 mg extract). Randomly sequenced doses of hawthorn extract (1000 mg, 1500 mg, and 2500 mg) and placebo were assigned to each participant. Doses were taken twice daily for 3 1/2 days followed by FMD and a 4-day washout before proceeding to the next dosing period.
Results
Twenty-one prehypertensive or mildly hypertensive adults completed the study. There was no evidence of a dose-response effect for our main outcome (FMD percent) or any of our secondary outcomes (absolute change in brachial artery diameter and blood pressure). Most participants indicated that if given evidence that hawthorn could lower their blood pressure, they would be likely to use it either in conjunction with or instead of lifestyle modification or anti-hypertensive medications.
Conclusion
We found no evidence of a dose-response effect of hawthorn extract on FMD. If hawthorn has a blood pressure lowering effect, it is likely to be mediated via an NO-independent mechanism.
Trial Registration
This trial has been registered with ClinicalTrials.gov, a service of the U.S. National Institutes of Health: NCT01331486.
doi:10.1186/1472-6882-12-26
PMCID: PMC3350435  PMID: 22458601
Hawthorn; Crataegus; hypertension; prehypertension; flow mediated dilation; Phase I
12.  Does an offer for a free on-line continuing medical education (CME) activity increase physician survey response rate? A randomized trial 
BMC Research Notes  2012;5:129.
Background
Achieving a high response rate in a physician survey is challenging. Monetary incentives increase response rates but obviously add cost to a survey project. We wondered whether an offer of a free continuing medical education (CME) activity would be effective in improving survey response rate.
Results
As part of a survey of a national sample of physicians, we randomized half to an offer for a free on-line CME activity upon completion of a web-based survey and the other half to no such offer. We compared response rates between the groups. A total of 1214 out of 8477 potentially eligible physicians responded to our survey, for an overall response rate of 14.3%. The response rate among the control group (no offer of CME credit) was 16.6%, while among those offered the CME opportunity, the response rate was 12.0% (p < 0.0001).
Conclusions
An offer for a free on-line CME activity did not improve physician survey response rate. On the contrary, the offer for a free CME activity actually appeared to worsen the response rate.
doi:10.1186/1756-0500-5-129
PMCID: PMC3327628  PMID: 22397624
13.  Use of global coronary heart disease risk assessment in practice: a cross-sectional survey of a sample of U.S. physicians 
Background
Global coronary heart disease (CHD) risk assessment is recommended to guide primary preventive pharmacotherapy. However, little is known about physicians' understanding and use of global CHD risk assessment. Our objective was to examine US physicians' awareness, use, and attitudes regarding global CHD risk assessment in clinical practice, and how these vary by provider specialty.
Methods
Using a web-based survey of US family physicians, general internists, and cardiologists, we examined awareness of tools available to calculate CHD risk, method and use of CHD risk assessment, attitudes towards CHD risk assessment, and frequency of using CHD risk assessment to guide recommendations of aspirin, lipid-lowering and blood pressure (BP) lowering therapies for primary prevention. Characteristics of physicians indicating they use CHD risk assessments were compared in unadjusted and adjusted analyses.
Results
A total of 952 physicians completed the questionnaire, with 92% reporting awareness of tools available to calculate CHD global risk. Among those aware of such tools, over 80% agreed that CHD risk calculation is useful, improves patient care, and leads to better decisions about recommending preventive therapies. However, only 41% use CHD risk assessment in practice. The most commonly reported barrier to CHD risk assessment is that it is too time consuming. Among respondents who calculate global CHD risk, 69% indicated they use it to guide lipid lowering therapy recommendations; 54% use it to guide aspirin therapy recommendations; and 48% use it to guide BP lowering therapy. Only 40% of respondents who use global CHD risk routinely tell patients their risk. Use of a personal digital assistant or smart phone was associated with reported use of CHD risk assessment (adjusted OR 1.58; 95% CI 1.17-2.12).
Conclusions
Reported awareness of tools to calculate global CHD risk appears high, but the majority of physicians in this sample do not use CHD risk assessments in practice. A minority of physicians in this sample use global CHD risk to guide prescription decisions or to motivate patients. Educational interventions and system improvements to improve physicians' effective use of global CHD risk assessment should be developed and tested.
doi:10.1186/1472-6963-12-20
PMCID: PMC3292915  PMID: 22273080
14.  Acceptance of a Polypill Approach to Prevent Cardiovascular Disease Among a Sample of U.S. Physicians 
Preventive medicine  2010;52(1):10-15.
Objective
Toex amine US physicians’ self-reported knowledge about the Polypill, factors considered in deciding whether to prescribe it, and acceptance of prescribing it for cardiovascular disease (CVD)prevention.
Methods
Numerical scales of 0 (lowest) to 5 (highest) were used to assess self -reported knowledge and importance of factors relevant to making a decision to prescribe a Polypill. Characteristics of physicians indicating they would prescribe a Polypill were compared.
Results
Among 952 physicians surveyed February through March 2010, mean self-rated knowledge about the Polypill was 2.0±1.5. Importance of degree of CVD event reduction, cost, and side effects were rated with means of 4.4, 4.3, and 4.3, respectively. 83% of respondents indicated they would “definitely” or “probably” prescribe it for high-risk patients; 62% would do so for moderate risk patients. Physicians with self-rated knowledge at ≥75th percentile were more likely to indicate they would prescribe a Polypill for moderate risk ( adjusted OR 2.16; 95% CI 1.60–2.93) and high-risk (adjusted OR 1.57; 95% CI 1.07–2.32) patients.
Conclusion
Among this sample of physicians, there is relatively high acceptance of prescribing a Polypill for CVD prevention despite relatively modest knowledge about it.
doi:10.1016/j.ypmed.2010.09.016
PMCID: PMC3014398  PMID: 20933538
15.  Assessing and Promoting Physical Activity in African American Barbershops: Results of the FITStop Pilot Study 
This study assessed the feasibility of recruiting African American men in barbershops, assessing their physical activity, conducting physical measurements, and gauging their interest in barbershop-based health research. The authors recruited African American shop owners (n = 4), barbers (n = 6), and customers (n = 90) from four barbershops in Raleigh and Durham, North Carolina, during 2009. The participation levels were high among owners (100%), barbers (67%), and customers (81%). In addition to completing a self-administered survey, 57% (51/90) of the customers completed physical measurements. According to self-reported data, 34% (30/88) of the customers met national physical activity recommendations within the last week. Customers expressed moderately high interest in learning more about health at barbershops and joining a barbershop-based physical activity contest. The estimated recruiting cost per customer was $105.92. Barbershops offer an effective setting for recruiting African American men and conducting physical measurements as well as an interesting possible location for conducting future interventions.
doi:10.1177/1557988309360569
PMCID: PMC3031660  PMID: 20413387
African American men; barbershops; physical activity
16.  Calorie menu labeling on quick-service restaurant menus: an updated systematic review of the literature 
Nutrition labels are one strategy being used to combat the increasing prevalence of overweight and obesity in the United States. The Patient Protection and Affordable Care Act of 2010 mandates that calorie labels be added to menu boards of chain restaurants with 20 or more locations. This systematic review includes seven studies published since the last review on the topic in 2008. Authors searched for peer-reviewed studies using PUBMED and Google Scholar. Included studies used an experimental or quasi-experimental design comparing a calorie-labeled menu with a no-calorie menu and were conducted in laboratories, college cafeterias, and fast food restaurants. Two of the included studies were judged to be of good quality, and five of were judged to be of fair quality. Observational studies conducted in cities after implementation of calorie labeling were imprecise in their measure of the isolated effects of calorie labels. Experimental studies conducted in laboratory settings were difficult to generalize to real world behavior. Only two of the seven studies reported a statistically significant reduction in calories purchased among consumers using calorie-labeled menus. The current evidence suggests that calorie labeling does not have the intended effect of decreasing calorie purchasing or consumption.
doi:10.1186/1479-5868-8-135
PMCID: PMC3254594  PMID: 22152038
Calorie label; menu label; nutrition information; restaurant label; Patient Protection and Affordable Care Act; obesity; food away from home; fast food
17.  ENDOTHELIAL DYSFUNCTION AND THE RISK OF HYPERTENSION: THE MULTI-ETHNIC STUDY OF ATHEROSCLEROSIS 
Hypertension  2010;55(5):1210-1216.
Hypertension is associated with impaired endothelial function in cross-sectional studies. However, few longitudinal data exist on whether endothelial dysfunction precedes the development of hypertension. We examined the cross-sectional and longitudinal relationships between endothelial-dependent brachial artery flow-mediated dilation (FMD) and hypertension prevalence and incidence in 3,500 participants from the Multi-Ethnic Study of Atherosclerosis (MESA), an ethnically diverse, community-based cohort study. At baseline, the prevalence ratios (95% CI) of hypertension from the highest to the lowest quartile of FMD were 1.00 (referent), 1.26 (1.12 – 1.40), 1.35 (1.21 – 1.52), and 1.68 (1.50 – 1.87) (linear trend P < 0.001). This association remained (P = 0.017) after adjustment for demographics (age, gender, ethnicity), MESA site, and other risk factors. Of the 1,869 participants without hypertension at baseline, 584 (31.3%) developed hypertension over a median follow-up of 4.8 years. The unadjusted relative risks (95% CI) of incident hypertension from the highest to the lowest quartile of FMD were 1.00 (referent), 1.38 (1.14 – 1.67), 1.44 (1.19 – 1.74), and 1.64 (1.36 – 1.97) (linear trend P < 0.001). However, after adjustment for demographics and MESA site, the relationship between FMD and incident hypertension was attenuated and not statistically significant: 1.00 (referent), 1.26 (1.04 – 1.52), 1.19 (0.98 – 1.44), and 1.18 (0.97 – 1.44). The longitudinal results also did not appreciably change after adjustment for additional risk factors and baseline blood pressure levels. In this sample, reduced FMD was not an independent predictor of hypertension incidence, suggesting that impaired endothelial function does not play a major role in the development of hypertension.
doi:10.1161/HYPERTENSIONAHA.109.143123
PMCID: PMC2896877  PMID: 20308612
hypertension; blood pressure; endothelium; atherosclerosis; epidemiology
18.  Tolerability of the Oscar 2 ambulatory blood pressure monitor among research participants: a cross-sectional repeated measures study 
Background
Ambulatory blood pressure monitoring (ABPM) is increasingly used to measure blood pressure (BP) in research studies. We examined ease of use, comfort, degree of disturbance, reported adverse effects, factors associated with poor tolerability, and association of poor tolerability with data acquisition of 24-hour ABPM using the Oscar 2 monitor in the research setting.
Methods
Sixty adults participating in a research study of people with a history of borderline clinic BP reported on their experience with ABPM on two occasions one week apart. Poor tolerability was operationalized as an overall score at or above the 75th percentile using responses to questions adapted from a previously developed questionnaire. In addition to descriptive statistics (means for responses to Likert-scaled "0 to 10" questions and proportions for Yes/No questions), we examined reproducibility of poor tolerability as well as associations with poor tolerability and whether poor tolerability was associated with removal of the monitor or inadequate number of BP measurements.
Results
The mean ambulatory BP of participants by an initial ABPM session was 148/87 mm Hg. After wearing the monitor the first time, the degree to which the monitor was felt to be cumbersome ranged from a mean of 3.0 to 3.8, depending on whether at work, home, driving, or other times. The most bother was interference with normal sleeping pattern (mean 4.2). Wearers found the monitor straightforward to use (mean 7.5). Nearly 67% reported that the monitor woke them after falling asleep, and 8.6% removed it at some point during the night. Reported adverse effects included pain (32%), skin irritation (37%), and bruising (7%). Those categorized as having poor tolerability (kappa = 0.5 between sessions, p = 0.0003) were more likely to report being in fair/poor health (75% vs 22%, p = 0.01) and have elevated 24-hour BP average (systolic: 28% vs 17%, p = 0.56; diastolic: 30% vs 17%, p = 0.37). They were also more likely to remove the monitor and have inadequate numbers of measurements.
Conclusions
The Oscar 2 ABPM device is straightforward to use but can interfere with sleep. Commonly reported adverse effects include pain, skin irritation, and bruising. Those who tolerate the monitor poorly are more likely to report being in fair or poor health and to remove it, particularly at night.
doi:10.1186/1471-2288-11-59
PMCID: PMC3097008  PMID: 21524301
19.  Hypertensive patients' use of blood pressure monitors stationed in pharmacies and other locations: a cross-sectional mail survey 
Background
Blood pressure (BP) monitors are commonly stationed in public places such as pharmacies, but it is uncertain how many people with hypertension currently use them. We sought to estimate the proportion of hypertensive patients who use these types of monitors and examine whether use varies by demographic or health characteristics.
Methods
We conducted a cross-sectional mail survey of hypertensive adults enrolled in a practice based research network of 24 primary care practices throughout the state of North Carolina. We analyzed results using descriptive statistics and examined bivariate associations using chi-square and independent associations using logistic regression.
Results
We received 530 questionnaires (76% response rate). Of 333 respondents (63%) who reported checking their BP in locations other than their doctor's office or home, 66% reported using a monitor stationed in a pharmacy. Younger patients more commonly reported using pharmacy monitors (48% among those < 45 years vs 35% of those over 65, p = 0.04). Blacks reported using them more commonly than whites (48% vs 39%, p = 0.03); and high school graduates more often than those with at least some college (50% vs 37%, p = 0.02). In multivariate analysis, younger age (aOR 1.49; 95% CI 1.00–2.21 for those age 45 to 65 years vs those > 65 years old) and high school education (aOR 1.74; 95% CI 1.13–2.58) were associated with use of pharmacy-stationed monitors, but Black race was not. Patients with diabetes, heart disease, or stroke were not more likely to use pharmacy-stationed monitors.
Conclusion
Hypertensive patients' use of BP monitors located in pharmacies is common. Younger patients, Blacks, and those with high school education were slightly more likely to report using them. Because use of these monitors is so common, efforts to ensure their accuracy are important.
doi:10.1186/1472-6963-8-216
PMCID: PMC2577653  PMID: 18945355
20.  Effects of sex, age, and visits on receipt of preventive healthcare services: a secondary analysis of national data 
Background
Sex and age may exert a combined influence on receipt of preventive services with differences due to number of ambulatory care visits.
Methods
We used nationally representative data to determine weighted percentages and adjusted odds ratios of men and women stratified by age group who received selected preventive services. The presence of interaction between sex and age group was tested using adjusted models and retested after adding number of visits.
Results
Men were less likely than women to have received blood pressure screening (aOR 0.44;0.40–0.50), cholesterol screening (aOR 0.72;0.65–0.79), tobacco cessation counseling (aOR 0.66;0.55–0.78), and checkups (aOR 0.53;0.49–0.57). In younger age groups, men were particularly less likely than women to have received these services. In adjusted models, this observed interaction between sex and age group persisted only for blood pressure measurement (p = .016) and routine checkups (p < .001). When adjusting for number of visits, the interaction of age on receipt of blood pressure checks was mitigated but men were still overall less likely to receive the service.
Conclusion
Men are significantly less likely than women to receive certain preventive services, and younger men even more so. Some of this discrepancy is secondary to a difference in number of ambulatory care visits.
doi:10.1186/1472-6963-6-15
PMCID: PMC1402283  PMID: 16504097

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