Puerto Rico Heart Attack Study (PRHAS)
Principal Investigator: Juan Carlos Zevallos, MD
This collaborative study proposes to adapt the successful methodology of the Worcester Heart Attack Study (WHAS). The methodology examines time trends in the incidence, in-hospital and long-term survival rates of acute myocardial infarction (AMI) and out-of hospital deaths due to ischemic heart disease (IHD) into a Hispanic community residing in the San Juan, Puerto Rico Statistical Metropolitan Area (SMA).
During this pilot study we are examining the quality of care for patients hospitalized with the diagnosis of AMI in selected hospitals located in the San Juan SMA by characterizing and describing differences in, and relationships between, patient demographics, treatment practices, and in-hospital and post-discharge outcomes. Investigators from the University of Massachusetts Medical School (UMASS) have committed to assist their counterparts from the University of Puerto Rico Medical School in the development, planning and implementation of this pilot study.
The proposed pilot study is being carried out in five hospitals located within the San Juan, Puerto Rico SMA from December 2007 to May 2008. All hospitals have acute care capabilities and were selected because the majority of AMI cases in the San Juan SMA during 2000-2005 were seen at these facilities. Characteristics of participating hospitals include: teaching status (participation in an accredited fellowship or residency training program), hospital ownership type (government, not-for-profit, profit), and cardiac facilities (availability of cardiac catheterization laboratory, cardiac surgery capability, procedure volume). By ascertaining specific hospital characteristics, we will be able to further adjust for patient and hospital-level factors in examining the impact of hospital features in the management of patients hospitalized with AMI and various clinical outcomes.
At the conclusion of this pilot study, we estimate that there will be approximately 120 Hispanic Puerto Rican patients hospitalized with independently validated AMI during January 1 to March 31 of 2001, 2003 and 2005. The data collected in this pilot study will set up the basis for the submission of an investigator-initiated research project grant applications to external sources such as the National Institute of Health or other federal and non-federal agencies.
This initial pilot phase was completed and the results were presented in several national and international forums and conferences (See results below). The subsequent phase is being carried out in all the 14 hospitals within the San Juan Metropolitan Statistical Area.
Puerto Rico Heart Failure Pilot Study
Principal Investigator: Héctor Banchs, MD
Co-Investigators: Juan C. Zevallos, MD, Juan A. González, MD, FACEP
This pilot study proposes to adapt the successful methodology of the University of Massachusetts Medical Center (UMASS) Heart Failure Study in examining time trends in the incidence, in-hospital and long-term survival rates of HF and out-of hospital deaths due to HF to a pilot study to be conducted among patients from two hospitals (UPR-Hospital at Carolina and Medical Center at San Juan, Puerto Rico) Statistical Metropolitan Area (SMA) (Goldberg, 2008).
During this pilot study we will also examine the quality of care for patients hospitalized with the diagnosis of HF in the two participating hospitals by characterizing and describing differences in, and relationships between, patient demographics, treatment practices, and in-hospital and post-discharge outcomes.
The pilot phase was completed with 150 cases with a validated heart failure diagnoses in the three participant’s hospital. The recompilation of information about the disease will be continuing as part of the core study titled Cardiovascular Surveillance.
The specific aims of this pilot study are to examine the following:
Among residents living in the San Juan SMA
• Incidence and rates of HF;
• Community death rates from HF;
Among patients admitted to selected hospitals
• Pre-hospital phase: duration of pre-hospital delay in seeking medical care due to decompensate heart failure;
• In-hospital phase: use of evidence-based therapeutic management, no-pharmacology intervention: smoking cessation, sodium restriction;
• Post-discharge phase: processes of care: ambulatory/ER/hospital between at 6 and 12 months.
• Incidence rates of, and survival from, the major clinical complications associated with HF: death, cardiac arrest, stroke, AMI, pneumonia, pulmonary embolus
• Twelve-month survival of patients discharged after HF
Puerto Rico Stroke Registry (PRSR)
Principal Investigator: Juan Carlos Zevallos, MD
Our pilot study proposes to examine the feasibility of establishing a population-based stroke registry in Puerto Rico utilizing a non-concurrent prospective review of hospital medical records as well as collection and analysis of routinely collected vital statistics and hospital discharge data. This passive (cold pursuit) approach to population-based surveillance has been successfully used for the past twenty five years in other community-wide settings (e.g., The Worcester Heart Attack Study, Minnesota Heart Survey). Through the establishment of population-based surveillance for stroke in metropolitan San Juan residents, information will be provided about recent trends in the incidence rates, in-hospital and long-term survival rates of stroke, contemporary management practices, and out-of hospital deaths due to acute cerebrovascular disease (CBVD) in a large Hispanic community residing in the San Juan, Puerto Rico, Statistical Metropolitan Area (SMA).
During this pilot study we will also examine the quality of care delivered to patients hospitalized with a diagnosis of recent onset stroke in seven selected hospitals located in the San Juan SMA by characterizing and describing differences in, and relationships between, patient demographics, treatment practices, and in-hospital and post-discharge outcomes. The specific aims of this pilot study are to examine changing trends in the following outcomes among residents of the San Juan SMA:
• Incidence and attack rates of acute stroke based on hospital discharge diagnoses of patients with a Principal Discharge Diagnosis of acute stroke (9th International Classification of Diseases (ICD-9) Codes 430.00 – 438.53) for the years 2000 – 2005
• Community death rates from stroke for 2000 – 2005 based on ICD-9 Codes 430.00 – 438.53. Because most of the Death Registries and statistics use the 10th version of the ICD (ICD-10), we will include the ICD-10 I60 – I69 codes to calculate community death rates.
• Among patients admitted to the seven selected teaching and community hospitals during the first three months of study years 2001, 2003, 2005 and 2007, we intend to examine changing trends in the following endpoints based on the review of hospital medical records:
▪ Pre-hospital and transfer phase: duration of pre-hospital delay after the onset of acute stroke related symptoms and the relationship between extent of pre-hospital delay to the receipt of various medical therapies and cerebral reperfusion strategies. Emergency Medical Services (EMS) data, including mode of transportation and pre-hospital medication.
▪ In-hospital phase: use of evidence-based therapeutic management, initiation of risk factor/behavioral interventions during hospitalization for stroke, and factors associated with use of secondary prevention measures. Emergency Room (ER)/admission findings, including first Glasgow Coma Scale score assessment, will be collected. In addition, information will be obtained about the use of oral medications and the administration of thrombolytic therapy as well as utilization of various hospital procedures.
▪ Post-discharge phase: processes of care (hospital and ambulatory) after hospital discharge and the 1 year survival of patients discharged from all area hospitals after an acute stroke.
The initial phase was completed and the preliminary results were published in the Boletín Asociación Médica de Puerto Rico.
Ponte Guillao con Buena Salud
Principal investigator: Juan Carlos Zevallos, MD
This is a collaborative study with the Puerto Rico Department of Health, the UPR Graduate School of Public Health, UPR School of Medicine and the Municipalities of Caguas, Dorado and Loíza, conducting to examine the population of overweight children of three Puerto Rican municipalities.
The overall purpose of this pilot study is to assess the feasibility of conducting a physical activity, nutrition and self-esteem intervention program among elementary school students, and their parents/guardians, enrolled in open schools programs in one municipality of Puerto Rico: Loíza. This process will help us identifying the barriers, strengths and possible solutions for a similar program to be implemented Island-wide.
The specific aims are the following:
1. Identify two elementary schools with open school programs in the municipality of Loíza.
2. Asses the knowledge and behaviors on physical activity and food intake among students between 8 and 12 years old from the six identified open schools of Loíza.
3. Conduct standard measurements of height, weight and body fat distribution among the same group of children attending the six open schools and calculate their body mass index (BMI) adjusted by age and gender.
4. Perform an environmental assessment of the participating open schools with an emphasis on the observation of the availability of fast foods, vending machines, independent vendors in an area of 500 feet around the school.
5. Randomly select one of the two schools in each municipality for a ten-week intervention program aimed to increase physical activity, healthier eating and enhancement of self-esteem utilizing a parent-student approach.
6. Evaluate changes on knowledge and behaviors on physical activity, food intake and BMI among students participating in the intervention school, as compared to those students who were not selected for the ten-week intervention.
7. Assess the effect of the presence of fast food, vending machines and independent vendors near the school on the knowledge, and behaviors, as well as age and gender adjusted BMI.
The hypotheses to be tested at the end of the 10-week intervention program are the following:
1. Children participating in the intervention site will have better knowledge about healthy foods, importance of physical activity and self-esteem, as compared to those in the control group.
2. Children participating in the intervention site will increase their consumption of healthy foods, and will increase their physical activity, as compared to those in the control group.
3. Children participating in the intervention site will increase their self-esteem, as compared to those in the control group.
The project will offer education through games, recreation, display and practice of dexterity in three main areas: physical activity, healthy eating and self-esteem. The pilot study will be conducted in two elementary schools participating in the open school program called Escuela Abierta located at the municipality Loíza. A total of 30 students will be participating in each one of the identified schools. Those schools will be randomly assigned as control or intervention sites. In the schools selected as intervention sites, the students will participate in a variety of activities related with healthy eating, nutrition, physical activity, and self esteem. In the schools selected as control sites, no special activities will be offer.
The project is planned to be developed in 10 school weeks and will consist of 4 sessions per week, divided as follows: 1 session about nutrition, 2 sessions about physical activity (recreational activities and cardiovascular exercises), and 1 session of self- esteem. The study will also have a nutrition education workshop for parents focusing on the food group pyramid, nutritional label interpretation and alternatives to select when eating out of home.
The interventions and data collection were completed and the results were presented in two national forums. The results will be submitted for publication (For details See the Preliminary Report).
Cardiovascular diseases (CVD) have been the leading cause of death and disability in Puerto Rico for approximately four decades. Unfortunately, there are no reliable up-to-date data on the impact of this group of diseases in the Puerto Rican population.
The success achieved in the pilot studies of the Puerto Rico Heart Attack Study, Puerto Rico Heart Failure Study and Puerto Rico Stroke Study conducted in the metropolitan San Juan area, has allowed to expand the research for years 2007, 2009 and 2011 throughout the island using the same methodology. In order to merge the studies in a core project to enlarge the scope of the results, we proposed to develop the Cardiovascular Surveillance Study, a project that is based in three cardiovascular diseases: Acute Myocardial Infarction (AMI), Heart Failure (HF) and Cerebrovascular Disease (CBVD).
The overall aim of the proposed study is to characterize and describe the incidence of AMI, HF and CBVD, hospital and long term case-fatality rates associated with the mentioned diagnosis, current hospital and post discharge management practices, and deaths due to cardiovascular diseases in Puerto Ricans. The proposed project will examine a variety of different outcomes of contemporary clinical and public health importance in residents from Puerto Rico hospitalized from medical centers located across the Island with validated AMI, HF & CBVD diagnoses during years 2007, 2009 and 2011.In the study will participate approximately 24 hospitals through Puerto Rico. Approximately, a total of 6,000 cases will be reviewed and analyzed.