The prevalence of cardiovascular disease (CVD) in American women is staggering. In 2008, the Amer... more The prevalence of cardiovascular disease (CVD) in American women is staggering. In 2008, the American Heart Association reported that one in three women had some form of CVD. An estimated 7.3 million women alive today have had a heart attack or are living with angina pectoris. This year, almost 500,000 new and recurrent myocardial infarctions are expected in women. Education and counseling focusing on the acquisition of healthy lifestyle behaviors will help to protect women against the development of atherosclerosis. It is the responsibility of health care professionals to develop skills to facilitate lifestyle change and CVD risk reduction. This change can be accomplished only through a partnership with women that is based on careful risk evaluation, trust, open communication, skill building for behavioral change, and follow-up care. This article identifies educational and counseling approaches that have been shown to effect behavioral change in women.
The benefits of regular physical activity in older persons are numerous and well established. Reg... more The benefits of regular physical activity in older persons are numerous and well established. Regular physical activity in older adults is associated with an overall improvement in health, functional capacity, quality of life, and independence. Many questions arise for healthcare providers regarding an older person’s ability and motivation to be physically active. The healthcare provider has a unique opportunity to assess the older client’s incentives, preferences, and abilities for physical activities, as well as to prescribe a safe, appropriate, and enjoyable exercise plan. The exercise precription can be simple yet thorough enough to ensure benefits in an older person’s health and functional capacity.
Few data exist on the effectiveness of cardiovascular disease (CVD) risk-reduction programs in pa... more Few data exist on the effectiveness of cardiovascular disease (CVD) risk-reduction programs in patients with limited access to health care. The objective of this project was to evaluate a disease management approach to multifactor CVD risk reduction in patients with limited or no health insurance and low family income. Patients (n = 148) were recruited from not-for-profit or free clinics and hospitals and randomized to usual care or usual care plus team case management. Mean age was 59.3 years, 57% were women, 50% had less than a high school education, 57% were Hispanic, and 64% had no health insurance. All had > or =1 increased risk factor for CVD, and 24.5% had documented coronary artery disease. Follow-up measurements were obtained at 6 and 12 months. Primary outcomes were low-density lipoprotein cholesterol and systolic blood pressure. The disease management program was supervised by a physician, delivered by nurses and dietitians, and included comprehensive lifestyle changes and medications. Data were collected on 91% of patients at 12 months. Disease management produced clinically important decreases in selected risk factors compared with usual care, including systolic blood pressure (p <0.01) and low-density lipoprotein cholesterol (p <0.03). More patients with disease management than those with usual care moved from "high" and "very-high" risk to lower risk categories for selected risk factors. In conclusion, the disease management program had excellent retention and lower CVD risk factors and demonstrated the potential of such approaches for decreasing long-term disease burden in selected medically underserved populations.
Seniors comprise the largest population of adults over the age of 18 years. It is expected that b... more Seniors comprise the largest population of adults over the age of 18 years. It is expected that by 2030, 74 million Americans will be over the age of 65 years, with a substantial number of these over age 85. Seniors experience more chronic illnesses, are responsible for the majority of outpatient clinic visits, take significantly more medications, and are more often hospitalized compared to younger adults. Managing chronic illness in seniors involves lifestyle change and medical therapies/interventions. As time constraints increase for providers and the population of seniors requiring additional medical attention grows, the capacity of providers to comprehensively address these needs will decrease. It is imperative that we find new, innovative, and better ways to provide the level of health care that is needed and deserved by seniors. This article reviews options for the management of chronic illness, with a focus on cardiovascular diseases, for seniors.
Critical Pathways in Cardiology: A Journal of Evidence-based Medicine, 2007
Case-management (CM) can positively influence chronic disease care by facilitating guideline-conc... more Case-management (CM) can positively influence chronic disease care by facilitating guideline-concordant interventions that improve outcomes through intensive, individualized, longitudinal care. Implementation of CM, however, is difficult. We have identified lessons learned from a cardiovascular risk reduction CM program that may aid future CM implementation. Heart to Heart is both a clinical trial and program dissemination project implementing CM for persons at elevated risk of coronary heart disease (CHD) events in a multiethnic, low-income population in a county health system. Patients were randomized to CM plus usual primary care (N = 212) or primary care alone (N = 207). CM patients received face-to-face nurse and dietitian visits (mean of 14 hours) over 17 months. Visits emphasized behavior change, risk-factor monitoring, and guideline-based pharmacotherapy. A total of 341 patients (81%) were available for follow-up. This CM model is currently transitioning to a County-run program. Findings demonstrated statistically significant reductions in mean Framingham Risk for CM versus usual primary care (1.56% absolute decrease in 10-year CHD risk, P = 0.007). Favorable changes were noted across most major CHD risk factors. Lessons learned are the need for the following: (1) Strategies for implementing CM in low-income, ethnically-diverse populations, (2) Methods for developing clinically more effective CM, and (3) Approaches to increase the efficiency of cardiovascular CM. CM for cardiac risk factors faces notable implementation barriers, particularly in County health systems. Specific implementation solutions recommended may help confront these barriers and improve diffusion of this evidence-based and patient centered model of care.
The prevalence of cardiovascular disease (CVD) in American women is staggering. In 2008, the Amer... more The prevalence of cardiovascular disease (CVD) in American women is staggering. In 2008, the American Heart Association reported that one in three women had some form of CVD. An estimated 7.3 million women alive today have had a heart attack or are living with angina pectoris. This year, almost 500,000 new and recurrent myocardial infarctions are expected in women. Education and counseling focusing on the acquisition of healthy lifestyle behaviors will help to protect women against the development of atherosclerosis. It is the responsibility of health care professionals to develop skills to facilitate lifestyle change and CVD risk reduction. This change can be accomplished only through a partnership with women that is based on careful risk evaluation, trust, open communication, skill building for behavioral change, and follow-up care. This article identifies educational and counseling approaches that have been shown to effect behavioral change in women.
The benefits of regular physical activity in older persons are numerous and well established. Reg... more The benefits of regular physical activity in older persons are numerous and well established. Regular physical activity in older adults is associated with an overall improvement in health, functional capacity, quality of life, and independence. Many questions arise for healthcare providers regarding an older person’s ability and motivation to be physically active. The healthcare provider has a unique opportunity to assess the older client’s incentives, preferences, and abilities for physical activities, as well as to prescribe a safe, appropriate, and enjoyable exercise plan. The exercise precription can be simple yet thorough enough to ensure benefits in an older person’s health and functional capacity.
Few data exist on the effectiveness of cardiovascular disease (CVD) risk-reduction programs in pa... more Few data exist on the effectiveness of cardiovascular disease (CVD) risk-reduction programs in patients with limited access to health care. The objective of this project was to evaluate a disease management approach to multifactor CVD risk reduction in patients with limited or no health insurance and low family income. Patients (n = 148) were recruited from not-for-profit or free clinics and hospitals and randomized to usual care or usual care plus team case management. Mean age was 59.3 years, 57% were women, 50% had less than a high school education, 57% were Hispanic, and 64% had no health insurance. All had > or =1 increased risk factor for CVD, and 24.5% had documented coronary artery disease. Follow-up measurements were obtained at 6 and 12 months. Primary outcomes were low-density lipoprotein cholesterol and systolic blood pressure. The disease management program was supervised by a physician, delivered by nurses and dietitians, and included comprehensive lifestyle changes and medications. Data were collected on 91% of patients at 12 months. Disease management produced clinically important decreases in selected risk factors compared with usual care, including systolic blood pressure (p <0.01) and low-density lipoprotein cholesterol (p <0.03). More patients with disease management than those with usual care moved from "high" and "very-high" risk to lower risk categories for selected risk factors. In conclusion, the disease management program had excellent retention and lower CVD risk factors and demonstrated the potential of such approaches for decreasing long-term disease burden in selected medically underserved populations.
Seniors comprise the largest population of adults over the age of 18 years. It is expected that b... more Seniors comprise the largest population of adults over the age of 18 years. It is expected that by 2030, 74 million Americans will be over the age of 65 years, with a substantial number of these over age 85. Seniors experience more chronic illnesses, are responsible for the majority of outpatient clinic visits, take significantly more medications, and are more often hospitalized compared to younger adults. Managing chronic illness in seniors involves lifestyle change and medical therapies/interventions. As time constraints increase for providers and the population of seniors requiring additional medical attention grows, the capacity of providers to comprehensively address these needs will decrease. It is imperative that we find new, innovative, and better ways to provide the level of health care that is needed and deserved by seniors. This article reviews options for the management of chronic illness, with a focus on cardiovascular diseases, for seniors.
Critical Pathways in Cardiology: A Journal of Evidence-based Medicine, 2007
Case-management (CM) can positively influence chronic disease care by facilitating guideline-conc... more Case-management (CM) can positively influence chronic disease care by facilitating guideline-concordant interventions that improve outcomes through intensive, individualized, longitudinal care. Implementation of CM, however, is difficult. We have identified lessons learned from a cardiovascular risk reduction CM program that may aid future CM implementation. Heart to Heart is both a clinical trial and program dissemination project implementing CM for persons at elevated risk of coronary heart disease (CHD) events in a multiethnic, low-income population in a county health system. Patients were randomized to CM plus usual primary care (N = 212) or primary care alone (N = 207). CM patients received face-to-face nurse and dietitian visits (mean of 14 hours) over 17 months. Visits emphasized behavior change, risk-factor monitoring, and guideline-based pharmacotherapy. A total of 341 patients (81%) were available for follow-up. This CM model is currently transitioning to a County-run program. Findings demonstrated statistically significant reductions in mean Framingham Risk for CM versus usual primary care (1.56% absolute decrease in 10-year CHD risk, P = 0.007). Favorable changes were noted across most major CHD risk factors. Lessons learned are the need for the following: (1) Strategies for implementing CM in low-income, ethnically-diverse populations, (2) Methods for developing clinically more effective CM, and (3) Approaches to increase the efficiency of cardiovascular CM. CM for cardiac risk factors faces notable implementation barriers, particularly in County health systems. Specific implementation solutions recommended may help confront these barriers and improve diffusion of this evidence-based and patient centered model of care.
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Papers by Linda Klieman