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opportunities to improve quality & cost-effectiveness of health-care

Management: - general - identify financial incentives associated with clinical guidelines - HIV1 infection - 13% of the 1.2 million people with HIV1 infection in the U.S. have undiagnosed infection [1] - 30-40% of patients with known HIV1 infection are not getting regular care [2] - diabetes mellitus type 2 - 25% of patients with diabetes have not been diagnosed [3] - disease often present for 5-10 years prior to diagnosis - retinopathy, neuropathy & nephropathy are commonly seen at clinical presentation - diet is the most important management strategy, but for many patients, diet control is more optimism than science [4] - Mediterranean diet - improves glycemic control in new onset type-2 diabetes [5] - reduces cardiovascular complications in patients with type-2 diabetes, including those with 'TT' variant of the TCF7L2 gene (high-risk polymorphism) [6] - regular exercise - exercise capacity is associated with increased survival [7] - exercise may be less important than diet [8] - limit sitting to < 90 minutes a stretch [9] - cancer prevention - > 85% of adults in the U.S. do not eat the recommended amounts of fruits & vegetables [10] - cardiovascular risk reduction - diet & lifestyle modifications are the cornerstone of management [11] - 4 of 5 MIs in men are preventable through healthy diet & lifetyle; NNT of 20 for 10 years to prevent 1 MI [12] - Alzheimer's disease - there is no good evidence that anything prevents the pathology of Alzheimer's disease [13] - participation in new stimulating activities contributes to cognitive fitness & might delay cognitive decline [14] - exercise & computer classes seem to generate equivalent beneficial effects [14] - Mediterranean diet in combination with exercise reduces the risk of dementia & Alzheimer's disease [15] - evaluate financial incentives associated with implementation of clinical guidelines

Related

cost effectiveness; high-value care; cost-conscious care quality indicator (QI); quality measure

References

  1. Hall IH Prevalence of Diagnosed and Undiagnosed HIV Infection - United States, 2008-2012. MMWR. Weekly. June 26, 2015 / 64(24);657-662 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6424a2.htm - Seth P et al Identifying New Positives and Linkage to HIV Medical Care - 23 Testing Site Types, United States, 2013 MMWR. Weekly. June 26, 2015 / 64(24);663-667 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6424a3.htm
  2. Sax PE HIV and ID Observations (Blog). July 7, 2105 For HIV in the USA, Not in Care Exceeds the Undiagnosed - Solutions Welcome. http://blogs.jwatch.org/hiv-id-observations/index.php/for-hiv-in-the-usa-not-in-care-exceeds-the-undiagnosed-solutions-welcome/2015/07/07/
  3. Ali MK et al A Cascade of Care for Diabetes in the United States: Visualizing the Gaps. Ann Intern Med. 2014;161(10):681-689. PMID: 25402511 http://annals.org/article.aspx?articleid=1935052
  4. Journal Watch 24(18):145, 2004 - Hippisley-Cox J, Pringle M. Prevalence, care, and outcomes for patients with diet- controlled diabetes in general practice: cross sectional survey. Lancet. 2004 Jul 31;364(9432):423-8. PMID: 15288740
  5. Esposito K et al Effects of a Mediterranean-style diet on the need for antihyperglycemic drug therapy in patients with newly diagnosed type 2 diabetes: A randomized trial. Ann Intern Med 2009 Sep 1; 151:306. PMID: 19721018
  6. Corella D et al Mediterranean Diet Reduces the Adverse Effect of the TCF7L2- rs7903146 Polymorphism on Cardiovascular Risk Factors and Stroke Incidence. A randomized controlled trial in a high- cardiovascular-risk population. PMID: 23942586 http://care.diabetesjournals.org/content/early/2013/08/06/dc13-0955.abstract
  7. Nylen ES, Kokkinos P, Myers J, Faselis C Prognostic effect of exercise capacity on mortality in older adults with diabetes mellitus. J Am Geriatr Soc. 2010 Oct;58(10):1850-4. PMID: 20929462
  8. Andrews RC et al. Diet or diet plus physical activity versus usual care in patients with newly diagnosed type 2 diabetes: The Early ACTID randomised controlled trial. Lancet 2011 Jun 25 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60442-X/fulltext - Hu FB. Diet and exercise for new-onset type 2 diabetes? Lancet 2011 Jun 25; http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60692-2/fulltext
  9. American Diabetes Association Standards of Medical Care in Diabetes-2015: Summary of Revisions Diabetes Care. Jan 2015. 38:S1-S2 http://care.diabetesjournals.org/content/38/Supplement_1
  10. Moore LV, Thompson FE Adults Meeting Fruit and Vegetable Intake Recommendations - United States, 2013 MMWR Weekly. July 10, 2015 / 64(26);709-713 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6426a1.htm - USDA: How Many Vegetables Are Needed Daily or Weekly? http://www.choosemyplate.gov/printpages/MyPlateFoodGroups/Vegetables/food-groups.vegetables-amount.pdf - USDA: How Much Fruit Is Needed Daily? http://www.choosemyplate.gov/printpages/MyPlateFoodGroups/Fruits/food-groups.fruits-amount.pdf
  11. Djousse L et al Relation between modifiable lifestyle factors and lifetime risk of heart failure. JAMA 2009 Jul 22/29; 302:394. PMID: 19622818
  12. Akesson A, Larsson SC, Discacciati A, Wolk A. Low-risk diet and lifestyle habits in the primary prevention of myocardial infarction in men. J Am Coll Cardiol 2014; PMID: 25257629 http://content.onlinejacc.org/article.aspx?articleID=1909605 - Mozaffarian D. The promise of lifestyle for cardiovascular health. J Am Coll Cardiol 2014 PMID: 25257630
  13. NATIONAL INSTITUTES OF HEALTH STATE-OF-THE-SCIENCE CONFERENCE STATEMENT NIH State-of-the-Science Conference: Preventing Alzheimer's Disease and Cognitive Decline April 26-28, 2010 PMID: 20547888 http://consensus.nih.gov/2010/docs/alz/alz_stmt.pdf
  14. Klusmann V, Evers A, Schwarzer R Complex mental and physical activity in older women and cognitive performance: a 6-month randomized controlled trial. J Gerontol A Biol Sci Med Sci. 2010 Jun;65(6):680-8 PMID: 20418350
  15. Scarmeas N et al, Mediterranean diet and Alzheimer's disease mortality. Neurology 2007, 69:1084 PMID: 17846408 - Galvin JE Pass the grain; spare the brain. Neurology 2007, 69:1072 PMID: 17846407 - Scarmeas N et al. Physical activity, diet, and risk of Alzheimer disease. JAMA 2009 Aug 12; 302:627. PMID: 19671904 - Feart C et al. Adherence to a Mediterranean diet, cognitive decline, and risk of dementia. JAMA 2009 Aug 12; 302:638. PMID: 19671905 - Knopman DS. Mediterranean diet and late-life cognitive impairment: A taste of benefit. JAMA 2009 Aug 12; 302:686. PMID: 19671912