WIHI - A Podcast from the Institute for Healthcare Improvement

Gazing into the Crystal Ball: US Health Care in 2013

Diamond Pass

How a Simple Checklist can Dramatically Reduce Medical Errors

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

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.