PURPOSEThe Seventh Report of the Joint National Commission (JNC 7) on High Blood Pressure established prehypertension (120 to 139 mm Hg systolic or 80 to 89 mm Hg diastolic) as a new risk category. We aim to determine the risk of major cardiovascular events associated with blood pressure in the prehypertensive range in a longitudinal, population-based cohort.METHODS Analyses were conducted on participants in the National Health and Nutrition Examination Survey I (1971Survey I ( -1975 observed for 18 years for major cardiovascular disease events. Cox proportional hazard ratios were calculated to assess relative risk of cardiovascular disease, including stroke, myocardial infarction, and heart failure, in participants with prehypertension and normal blood pressure (<120/80 mm Hg). CONCLUSIONS In a longitudinal, population-based, US cohort, prehypertension was associated with increased risk of major cardiovascular events independently of other cardiovascular risk factors. These fi ndings, along with the presence of cardiovascular risk factors in the majority of participant sample with prehypertension, support recommendations for physicians to actively target lifestyle modifi cations and multiple risk reduction in their prehypertensive patients. RESULTS

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Resting heart rate is an easily accessible tool that may be helpful for stratifying CHD and mortality risk in people with prehypertension.

PURPOSE Nearly one third of diabetes cases in the United States is undiagnosed, with mounting evidence that complications accrue even before clinical diagnosis. We wanted to determine whether persons with undiagnosed diabetes have signs of nephropathy and peripheral neuropathy METHODS We examined the prevalence of positive screening tests for nephropathy and peripheral neuropathy in adults aged ≥40 years with undiagnosed diabetes using secondary analysis of survey and examination data from the population-based United States National Health and Nutrition Examination Survey 1999-2002. We defi ned a positive screening test for nephropathy as a spot urine albumin-creatinine ratio >30.0 mg/g, representing at least microalbuminuria. We defi ned ≥1 insensate area on Semmes-Weinstein monofi lament testing as a positive fi nding for neuropathy. Undiagnosed diabetes was defi ned as a combination of no history of diagnosed diabetes and a measured fasting glucose ≥126 mg/dL. We used SUDAAN for χ 2 and regression analyses. RESULTSThe prevalence of a positive test when screening for nephropathy among those with undiagnosed diabetes was 26.5% compared with 7.1% in those with no diabetes (χ 2 , P <.01). After adjusting for age and diagnosed or undiagnosed hypertension, the association of undiagnosed diabetes with nephropathy persisted (odds ratio = 2.35; 95% confi dence interval, 1.38-4.01). For peripheral neuropathy, 21.5% with undiagnosed diabetes had positive screening tests compared with 10.1% with no diabetes (χ 2 , P <.01); however, this effect was not signifi cant after adjustment for age. There was no signifi cant difference in positive screening tests for nephropathy or neuropathy when comparing those with undiagnosed and diagnosed diabetes.CONCLUSIONS A signifi cant proportion of adults with undiagnosed diabetes have signs of nephropathy and peripheral neuropathy. These fi ndings may infl uence policies about early screening for diabetes. INTRODUCTIONT he prevalence of undiagnosed diabetes for US adults has been estimated at 2.4%, representing 4.9 million adults and nearly 30% of all cases of diabetes in the United States in 1999-2000.1 Type 2 diabetes is especially likely to be undiagnosed for years because of its insidious clinical prodrome; projections based on extrapolation of time to development of complications of diabetes estimate that the average time from the onset of disease to clinical diagnosis of diabetes in the US population is as much as 12 years. 428NEUROPAT HY A ND UNDIAGNOSED DIA BE T ES nephropathy and neuropathy, were found to be highly prevalent at the time of diagnosis of diabetes in United Kingdom and Dutch populations. 4,5 Peripheral sensory neuropathy is an important complication of diabetes and a major contributor to diabetic foot ulcers. 6 In the United States in 1999-2000, the prevalence of peripheral neuropathy, as measured by at least 1 insensate area on monofi lament testing, has been found to be 28.5% in those aged 40 years and older with diagnosed diabetes. 7Diabetes is the l...

An increasing percentage of Internet users are seeking health information online. The purpose of our study was to determine the extent of Internet access and online health-seeking and the feasibility of implementing Internet services for our urban, residency-based practice. Using a self-administered survey, we obtained information on use of the Internet, demographics and socioeconomic profile, presence of a chronic medical condition and self-rated health from 300 consecutive patients. Complete surveys were obtained by 203 (68 percent). Responses were compared based on demographic, socioeconomic, and medical variables using Chi-square analysis. Results showed that our sample population tended to be under age 50, female, non-Hispanic Black, low income, and healthy. Seventy-seven percent of respondents had accessed the Internet at least once, 79 percent had used the Internet to find health-related information, 73 percent used the online information to make a health-related decision, 50 percent shared the information with their provider. In conclusion, we confirmed a high rate of Internet usage in our specific patient population, characterized by low socioeconomic status, low education level, and high minority percentages. Our patients not only access online health information, but also make changes based on this information, with only about half of all patients sharing this information with their physicians. It is unclear how this system of 'virtual medical care' influences overall patient health.

The gap between evidence-based guidelines for clinical care and their application in medical settings is well established and widely discussed. Effective interventions are needed to help health care providers reduce this gap. Whereas the development of clinical practice guidelines from biomedical and clinical research is an example of Type 1 translation, Type 2 translation involves successful implementation of guidelines in clinical practice. This article describes a multimethod intervention that is part of a Type 2 translation project aimed at increasing adherence to clinical practice guidelines in a nationwide network of primary care practices that use a common electronic medical record (EMR). Practice performance reports, site visits, and network meetings are intervention methods designed to stimulate improvement in practices by addressing personal and organizational factors. Theories and evidence supporting these interventions are described and could prove useful to others trying to translate medical research into practice. Additional theory development is needed to support translation in medical offices.

Many medical conditions are caused or exacerbated by heavy drinking, necessitating alcohol screening and discussion in primary care practices. This is particularly true of hypertension, the most common primary diagnosis in the United States, which has been linked to the regular consumption of 3 or more standard alcoholic beverages a day. The Accelerating Alcohol Screening-Translating Research into Practice (AA-TRIP) project was designed to improve detection and management of alcohol problems in primary care patients with hypertension. Medical providers are being trained using the Practice Partner Research Network's- Translating Research into Practice (PPRNet-TRIP) quality improvement model. This includes a multi-method intervention (electronic medical records, on-site academic detailing, practice feedback reports and annual network meetings) to help practices increase adherence to clinical guidelines. Qualitative analyses of initial steps taken by nine primary care practices toward the routine implementation of alcohol screening guidelines are presented. Organizational factors and provider and patient characteristics all influenced the method and consistency of alcohol screening and intervention. Perceived time constraints, patient sensitivity to questions about alcohol, and possible stigma associated with a diagnosis of alcoholism were also relevant barriers requiring problem solving.

A number of sources publish health care quality reports in the United States, but there is limited information about achievable performance in primary care settings. The objective of this article is to report Achievable Benchmarks of Care (ABCs) for 54 quality indicators. Eighty-seven practices participating in a demonstration project in the Practice Partner Research Network (PPRNet), representing 35 US states and 711 969 patients, were included in the analyses. PPRNet practices use a common electronic medical record (Practice Partner, Seattle, Washington). ABCs ranged from 25% to 99%. High ABCs (> or =90%) were achieved for blood pressure screening, lipid screening, and avoiding antibiotics in upper respiratory infection. Some calculated ABCs may be lower than the actual ABCs due to incomplete data recording or abstracting. Primary care practices can achieve high performance across a number of quality indicators, and PPRNet ABCs can serve as benchmarks for primary care practitioners and payers.