Electronic communications and home blood pressure monitoring (e-BP) study: design, delivery, and evaluation framework

Improved semi-parametric inference for a mixture model of responses from a control versus treatment group trial

The mixture of a distribution of responses from untreated patients and a shift of that distribution is a useful model for the responses from a group of treated patients. The mixture model accounts for the fact that not all the patients in the treated group will respond to the treatment and consequently their responses follow the same distribution as the responses from untreated patients. The treatment effect in this context consists of both the fraction of the treated patients that are responders and the magnitude of the shift in the distribution for the responders. In this article, we introduce inference based on a pseudo-likelihood approach and compare it with an existing method of moment approach. An extensive simulation study is used to compare robust performance of the two approaches regarding point estimation, confidence regions, and confidence intervals. The methods are demonstrated on an illustrative blood pressure data set.

Systematic Review of Self-Measured Blood Pressure Monitoring With Support: Intervention Effectiveness and Cost

INTRODUCTION

Self-measured blood pressure monitoring with support is an evidence-based intervention that helps patients control their blood pressure. This systematic economic review describes how certain intervention aspects contribute to effectiveness, intervention cost, and intervention cost per unit of the effectiveness of self-measured blood pressure monitoring with support.

METHODS

Papers published between data inception and March 2021 were identified from a database search and manual searches. Papers were included if they focused on self-measured blood pressure monitoring with support and reported blood pressure change and intervention cost. Papers focused on preeclampsia, kidney disease, or drug efficacy were excluded. Quality of estimates was assessed for effectiveness, cost, and cost per unit of effectiveness. Patient characteristics and intervention features were analyzed in 2021 to determine how they impacted effectiveness, intervention cost, and intervention cost per unit of effectiveness.

RESULTS

A total of 22 studies were included in this review from papers identified in the search. Type of support was not associated with differences in cost and cost per unit of effectiveness. Lower cost and cost per unit of effectiveness were achieved with simple technologies such as interactive phone systems, smartphones, and websites and where providers interacted with patients only as needed.

DISCUSSION

Some of the included studies provided only limited information on key outcomes of interest to this review. However, the strength of this review is the systematic collection and synthesis of evidence that revealed the associations between the characteristics of implemented interventions and their patients and the interventions' effectiveness and cost, a useful contribution to the fields of both research and implementation.

Adult patient access to electronic health records

BACKGROUND

To support patient-centred care, healthcare organisations increasingly offer patients access to data stored in the institutional electronic health record (EHR).

OBJECTIVES

Primary objective 1. To assess the effects of providing adult patients with access to electronic health records (EHRs) alone or with additional functionalities on a range of patient, patient-provider, and health resource consumption outcomes, including patient knowledge and understanding, patient empowerment, patient adherence, patient satisfaction with care, adverse events, health-related quality of life, health-related outcomes, psychosocial health outcomes, health resource consumption, and patient-provider communication. Secondary objective 1. To assess whether effects of providing adult patients with EHR access alone versus EHR access with additional functionalities differ among patient groups according to age, educational level, or different status of disease (chronic or acute).

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, and Scopus in June 2017 and in April 2020.

SELECTION CRITERIA

Randomised controlled trials and cluster-randomised trials of EHR access with or without additional functionalities for adults with any medical condition.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures.

MAIN RESULTS

We included 10 studies with 78 to 4500 participants and follow-up from 3 to 24 months. Nine studies assessed the effects of EHR with additional functionalities, each addressing a subset of outcomes sought by this review. Five studies focused on patients with diabetes mellitus, four on patients with specific diseases, and one on all patients. All studies compared EHR access alone or with additional functionalities plus usual care versus usual care only. No studies assessing the effects of EHR access alone versus EHR access with additional functionalities were identified. Interventions required a variety of data within the EHR, such as patient history, problem list, medication, allergies, and lab results. In addition to EHR access, eight studies allowed patients to share self-documented data, seven offered individualised disease management functions, seven offered educational disease-related information, six supported secure communication, and one offered preventive reminders. Only two studies were at low or unclear risk of bias across domains. Meta-analysis could not be performed, as participants, interventions, and outcomes were too heterogeneous, and most studies presented results based on different adjustment methods or variables. The quality of evidence was rated as low or very low across outcomes. Overall differences between intervention and control groups, if any, were small. The relevance of any small effects remains unclear for most outcomes because in most cases, trial authors did not define a minimal clinically important difference. Overall, results suggest that the effects of EHR access alone and with additional functionalities are mostly uncertain when compared with usual care. Patient knowledge and understanding: very low-quality evidence is available from one study, so we are uncertain about effects of the intervention on patient knowledge about diabetes and blood glucose testing. Patient empowerment: low-quality evidence from three studies suggests that the intervention may have little or no effect on patient empowerment measures. Patient adherence: low-quality evidence from two studies suggests that the intervention may slightly improve adherence to the process of monitoring risk factors and preventive services. Effects on medication adherence are conflicting in two studies; this may or may not improve to a clinically relevant degree. Patient satisfaction with care: low-quality evidence from three studies suggests that the intervention may have little or no effect on patient satisfaction, with conflicting results. Adverse events: two small studies reported on mortality; one of these also reported on serious and other adverse events, but sample sizes were too small for small differences to be detected. Therefore, low-quality evidence suggests that the intervention may have little to no effect on mortality and other adverse events. Health-related quality of life: only very low-quality evidence from one study is available. We are uncertain whether the intervention improves disease-specific quality of life of patients with asthma. Health-related outcomes: low-quality evidence from eight studies suggests that the intervention may have little to no effect on asthma control, glycosylated haemoglobin (HbA1c) levels, blood pressure, low-density lipoprotein or total cholesterol levels, body mass index or weight, or 10-year Framingham risk scores. Low-quality evidence from one study suggests that the composite scores of risk factors for diabetes mellitus may improve slightly with the intervention, but there is uncertainty about effects on ophthalmic medications or intraocular pressure. Psychosocial health outcomes: no study investigated psychosocial health outcomes in a more than anecdotal way. Health resource consumption: low-quality evidence for adult patients in three studies suggests that there may be little to no effect of the intervention on different measures of healthcare use. Patient-provider communication: very low-quality evidence is available from a single small study, and we are uncertain whether the intervention improves communication measures, such as the number of messages sent.

AUTHORS' CONCLUSIONS

The effects of EHR access with additional functionalities in comparison with usual care for the most part are uncertain. Only adherence to the process of monitoring risk factors and providing preventive services as well as a composite score of risk factors for diabetes mellitus may improve slightly with EHR access with additional functionalities. Due to inconsistent terminology in this area, our search may have missed relevant studies. As the overall quality of evidence is very low to low, future research is likely to change these results. Further trials should investigate the impact of EHR access in a broader range of countries and clinical settings, including more patients over a longer period of follow-up, as this may increase the likelihood of detecting effects of the intervention, should these exist. More studies should focus on assessing outcomes such as patient empowerment and behavioural outcomes, rather than concentrating on health-related outcomes alone. Future studies should distinguish between effects of EHR access only and effects of additional functionalities, and investigate the impact of mobile EHR tools. Future studies should include information on usage patterns, and consider the potential for widening health inequalities with implementation of EHR access. A taxonomy for EHR access and additional functionalities should be developed to promote consistency and comparability of outcome measures, and facilitate future reviews by better enabling cross-study comparisons.

Interventions for improving medication-taking ability and adherence in older adults prescribed multiple medications

BACKGROUND

Older people taking multiple medications represent a large and growing proportion of the population. Managing multiple medications can be challenging, and this is especially the case for older people, who have higher rates of comorbidity and physical and cognitive impairment than younger adults. Good medication-taking ability and medication adherence are necessary to ensure safe and effective use of medications.

OBJECTIVES

To evaluate the effectiveness of interventions designed to improve medication-taking ability and/or medication adherence in older community-dwelling adults prescribed multiple long-term medications.

SEARCH METHODS

We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, CINAHL Plus, and International Pharmaceutical Abstracts from inception until June 2019. We also searched grey literature, online trial registries, and reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs. Eligible studies tested interventions aimed at improving medication-taking ability and/or medication adherence among people aged ≥ 65 years (or of mean/median age > 65 years), living in the community or being discharged from hospital back into the community, and taking four or more regular prescription medications (or with group mean/median of more than four medications). Interventions targeting carers of older people who met these criteria were also included.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed abstracts and full texts of eligible studies, extracted data, and assessed risk of bias of included studies. We conducted meta-analyses when possible and used a random-effects model to yield summary estimates of effect, risk ratios (RRs) for dichotomous outcomes, and mean differences (MDs) or standardised mean differences (SMDs) for continuous outcomes, along with 95% confidence intervals (CIs). Narrative synthesis was performed when meta-analysis was not possible. We assessed overall certainty of evidence for each outcome using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). Primary outcomes were medication-taking ability and medication adherence. Secondary outcomes included health-related quality of life (HRQoL), emergency department (ED)/hospital admissions, and mortality.

MAIN RESULTS

We identified 50 studies (14,269 participants) comprising 40 RCTs, six cluster-RCTs, and four quasi-RCTs. All included studies evaluated interventions versus usual care; six studies also reported a comparison between two interventions as part of a three-arm RCT design. Interventions were grouped on the basis of their educational and/or behavioural components: 14 involved educational components only, 7 used behavioural strategies only, and 29 provided mixed educational and behavioural interventions. Overall, our confidence in results regarding the effectiveness of interventions was low to very low due to a high degree of heterogeneity of included studies and high or unclear risk of bias across multiple domains in most studies. Five studies evaluated interventions for improving medication-taking ability, and 48 evaluated interventions for improving medication adherence (three studies evaluated both outcomes). No studies involved educational or behavioural interventions alone for improving medication-taking ability. Low-quality evidence from five studies, each using a different measure of medication-taking ability, meant that we were unable to determine the effects of mixed interventions on medication-taking ability. Low-quality evidence suggests that behavioural only interventions (RR 1.22, 95% CI 1.07 to 1.38; 4 studies) and mixed interventions (RR 1.22, 95% CI 1.08 to 1.37; 12 studies) may increase the proportions of people who are adherent compared with usual care. We could not include in the meta-analysis results from two studies involving mixed interventions: one had a positive effect on adherence, and the other had little or no effect. Very low-quality evidence means that we are uncertain of the effects of educational only interventions (5 studies) on the proportions of people who are adherent. Low-quality evidence suggests that educational only interventions (SMD 0.16, 95% CI -0.12 to 0.43; 5 studies) and mixed interventions (SMD 0.47, 95% CI -0.08 to 1.02; 7 studies) may have little or no impact on medication adherence assessed through continuous measures of adherence. We excluded 10 studies (4 educational only and 6 mixed interventions) from the meta-analysis including four studies with unclear or no available results. Very low-quality evidence means that we are uncertain of the effects of behavioural only interventions (3 studies) on medication adherence when assessed through continuous outcomes. Low-quality evidence suggests that mixed interventions may reduce the number of ED/hospital admissions (RR 0.67, 95% CI 0.50 to 0.90; 11 studies) compared with usual care, although results from six further studies that we were unable to include in meta-analyses indicate that the intervention may have a smaller, or even no, effect on these outcomes. Similarly, low-quality evidence suggests that mixed interventions may lead to little or no change in HRQoL (7 studies), and very low-quality evidence means that we are uncertain of the effects on mortality (RR 0.93, 95% CI 0.67 to 1.30; 7 studies). Moderate-quality evidence shows that educational interventions alone probably have little or no effect on HRQoL (6 studies) or on ED/hospital admissions (4 studies) when compared with usual care. Very low-quality evidence means that we are uncertain of the effects of behavioural interventions on HRQoL (1 study) or on ED/hospital admissions (2 studies). We identified no studies evaluating effects of educational or behavioural interventions alone on mortality. Six studies reported a comparison between two interventions; however due to the limited number of studies assessing the same types of interventions and comparisons, we are unable to draw firm conclusions for any outcomes.

AUTHORS' CONCLUSIONS

Behavioural only or mixed educational and behavioural interventions may improve the proportion of people who satisfactorily adhere to their prescribed medications, but we are uncertain of the effects of educational only interventions. No type of intervention was found to improve adherence when it was measured as a continuous variable, with educational only and mixed interventions having little or no impact and evidence of insufficient quality to determine the effects of behavioural only interventions. We were unable to determine the impact of interventions on medication-taking ability. The quality of evidence for these findings is low due to heterogeneity and methodological limitations of studies included in the review. Further well-designed RCTs are needed to investigate the effects of interventions for improving medication-taking ability and medication adherence in older adults prescribed multiple medications.

How Behavior Change Strategies are Used to Design Digital Interventions to Improve Medication Adherence and Blood Pressure Among Patients With Hypertension: Systematic Review

BACKGROUND

Information on how behavior change strategies have been used to design digital interventions (DIs) to improve blood pressure (BP) control or medication adherence (MA) for patients with hypertension is currently limited.

OBJECTIVE

Hypertension is a major modifiable risk factor for cardiovascular diseases and can be controlled with appropriate medication. Many interventions that target MA to improve BP are increasingly using modern digital technologies. This systematic review was conducted to discover how DIs have been designed to improve MA and BP control among patients with hypertension in the recent 10 years. Results were mapped into a matrix of change objectives using the Intervention Mapping framework to guide future development of technologies to improve MA and BP control.

METHODS

We included all the studies regarding DI development to improve MA or BP control for patients with hypertension published in PubMed from 2008 to 2018. All the DI components were mapped into a matrix of change objectives using the Intervention Mapping technique by eliciting the key determinant factors (from patient and health care team and system levels) and targeted patient behaviors.

RESULTS

The analysis included 54 eligible studies. The determinants were considered at two levels: patient and health care team and system. The most commonly described determinants at the patient level were lack of education, lack of self-awareness, lack of self-efficacy, and forgetfulness. Clinical inertia and an inadequate health workforce were the most commonly targeted determinants at the health care team and system level. Taking medication, interactive patient-provider communication, self-measurement, and lifestyle management were the most cited patient behaviors at both levels. Most of the DIs did not include support from peers or family members, despite its reported effectiveness and the rate of social media penetration.

CONCLUSIONS

This review highlights the need to design a multifaceted DI that can be personalized according to patient behavior(s) that need to be changed to overcome the key determinant(s) of low adherence to medication or uncontrolled BP among patients with hypertension, considering different levels including patient and healthcare team and system involvement.

Self-monitoring of Blood Pressure in Patients With Hypertension-Related Multi-morbidity: Systematic Review and Individual Patient Data Meta-analysis

BACKGROUND

Studies have shown that self-monitoring of blood pressure (BP) is effective when combined with co-interventions, but its efficacy varies in the presence of some co-morbidities. This study examined whether self-monitoring can reduce clinic BP in patients with hypertension-related co-morbidity.

METHODS

A systematic review was conducted of articles published in Medline, Embase, and the Cochrane Library up to January 2018. Randomized controlled trials of self-monitoring of BP were selected and individual patient data (IPD) were requested. Contributing studies were prospectively categorized by whether they examined a low/high-intensity co-intervention. Change in BP and likelihood of uncontrolled BP at 12 months were examined according to number and type of hypertension-related co-morbidity in a one-stage IPD meta-analysis.

RESULTS

A total of 22 trials were eligible, 16 of which were able to provide IPD for the primary outcome, including 6,522 (89%) participants with follow-up data. Self-monitoring was associated with reduced clinic systolic BP compared to usual care at 12-month follow-up, regardless of the number of hypertension-related co-morbidities (−3.12 mm Hg, [95% confidence intervals −4.78, −1.46 mm Hg]; P value for interaction with number of morbidities = 0.260). Intense interventions were more effective than low-intensity interventions in patients with obesity (P < 0.001 for all outcomes), and possibly stroke (P < 0.004 for BP control outcome only), but this effect was not observed in patients with coronary heart disease, diabetes, or chronic kidney disease.

CONCLUSIONS

Self-monitoring lowers BP regardless of the number of hypertension-related co-morbidities, but may only be effective in conditions such obesity or stroke when combined with high-intensity co-interventions.

Self-monitoring of blood pressure in hypertension: A systematic review and individual patient data meta-analysis

BACKGROUND

Self-monitoring of blood pressure (BP) appears to reduce BP in hypertension but important questions remain regarding effective implementation and which groups may benefit most. This individual patient data (IPD) meta-analysis was performed to better understand the effectiveness of BP self-monitoring to lower BP and control hypertension.

METHODS AND FINDINGS

Medline, Embase, and the Cochrane Library were searched for randomised trials comparing self-monitoring to no self-monitoring in hypertensive patients (June 2016). Two reviewers independently assessed articles for eligibility and the authors of eligible trials were approached requesting IPD. Of 2,846 articles in the initial search, 36 were eligible. IPD were provided from 25 trials, including 1 unpublished study. Data for the primary outcomes-change in mean clinic or ambulatory BP and proportion controlled below target at 12 months-were available from 15/19 possible studies (7,138/8,292 [86%] of randomised participants). Overall, self-monitoring was associated with reduced clinic systolic blood pressure (sBP) compared to usual care at 12 months (-3.2 mmHg, [95% CI -4.9, -1.6 mmHg]). However, this effect was strongly influenced by the intensity of co-intervention ranging from no effect with self-monitoring alone (-1.0 mmHg [-3.3, 1.2]), to a 6.1 mmHg (-9.0, -3.2) reduction when monitoring was combined with intensive support. Self-monitoring was most effective in those with fewer antihypertensive medications and higher baseline sBP up to 170 mmHg. No differences in efficacy were seen by sex or by most comorbidities. Ambulatory BP data at 12 months were available from 4 trials (1,478 patients), which assessed self-monitoring with little or no co-intervention. There was no association between self-monitoring and either lower clinic or ambulatory sBP in this group (clinic -0.2 mmHg [-2.2, 1.8]; ambulatory 1.1 mmHg [-0.3, 2.5]). Results for diastolic blood pressure (dBP) were similar. The main limitation of this work was that significant heterogeneity remained. This was at least in part due to different inclusion criteria, self-monitoring regimes, and target BPs in included studies.

CONCLUSIONS

Self-monitoring alone is not associated with lower BP or better control, but in conjunction with co-interventions (including systematic medication titration by doctors, pharmacists, or patients; education; or lifestyle counselling) leads to clinically significant BP reduction which persists for at least 12 months. The implementation of self-monitoring in hypertension should be accompanied by such co-interventions.

Outcomes of a multi-community hypertension implementation study: the American Heart Association's Check. Change. Control. program

Single-site, intensive, community-based blood pressure (BP) intervention programs have led to BP improvements. The authors examined the American Heart Association's Check. Change.

CONTROL

(CCC) program (4069 patients/18 cities) to determine whether BP interventions can effectively be scaled to multiple communities, using a simplified template and local customization. Effectiveness was evaluated at each site via site percent enrollment goals, participant engagement, and BP change from first to last measurement. High-enrolling sites frequently recruited at senior residential institutions and service organizations held hypertension management classes and utilized established and new community partners. High-engagement sites regularly held hypertension education classes and followed up with participants. Top-performing sites commonly distributed BP cuffs, checked BP at engagement activities, and trained volunteers. CCC demonstrated that simplified community-based hypertension intervention programs may lead to BP improvements, but there was high outcomes variability among programs. Several factors were associated with BP improvement that may guide future program development.

Family member-based supervision of patients with hypertension: a cluster randomized trial in rural China

Empirical evidence has suggested that social support from family can help patients take their medicines correctly. This study aims to evaluate the role of a family member-based supervision package in the management of hypertension using a cluster randomized trial in rural China. We recruited patients with hypertension from four villages in Yangzhong and randomly allocated them to the control group (n=288) and the intervention group (n=266). A family member-based supervision package was applied to the intervention group, while the usual service was applied to the controls. Patients were followed for 12 months and completed face-to-face interviews at the end of 6 and 12 months. The primary outcomes were patients' medication adherence and frequency of blood pressure measurement. Secondary outcomes included changes in blood pressure, altered risk behaviours and occurrence of hypertension-related complications. To control for the effects of cluster randomization, multilevel mixed-effects regression models were used to compare group changes. We observed that the intervention improved patients' blood pressure measurement frequency (OR: 9.00, 95% CI: 4.52-17.91) and adherence to antihypertensive treatment (OR: 1.74, 95% CI: 0.91-3.32). Its effect on the blood pressure control rate was significant at the mid-term investigation (OR: 0.67, 95% CI: 0.40-0.93), but the long-term effect was not significant (OR: 0.89, 95% CI: 0.64-1.26). After 6 months of intervention, either systolic or diastolic blood pressure was significantly decreased in the intervention group. However, this difference was not significant at the final investigation. Findings from this study revealed that the family member-based supervised therapy may have positive effects on patients' adherence to blood monitoring and hypertensive medications.

Telemedicine and M-Health in Hypertension Management: Technologies, Applications and Clinical Evidence

Electronic processes and communication technologies are more and more often employed to provide healthcare services to caregivers and their patients. Such solutions are currently referred as e-health, the most popular and widely distributed being those based on telemedicine and mobile health (m-health). A specific application of telemedicine for hypertension management is blood pressure telemonitoring (BPT), which allows remote data transmission of BP and additional information on patients' health status from their living site or from a community setting to the doctor's office or the hospital. Several randomized studies have documented a significant BP reduction with regular BPT compared to usual care, particularly in high risk hypertensive patients. Additional benefits are observed when BPT is offered under the supervision of a team of healthcare professionals, including a community pharmacist. BPT may also be provided in the context of m-health solutions, which commonly include wireless diagnostic and clinical decision support tools. M-health has the potential to promote patient's self-management, as a complement to the doctor's intervention, and encourage greater participation in medical decision making. Current statistics show that half of smartphone owners gather health information through their phone and 19 % use a health app. In case of hypertensive patients the most popular apps are those with tracking function, including BPT. Thus, e-health, and in particular BPT and m-health, are progressively gaining a key role in the management of hypertensive patients, having the potential to improve the quality of the delivered care and to more effectively prevent cardiovascular consequences of high BP.

The evaluation of diabetic patients' use of a telehealth program

Diabetes is a metabolic disorder that, if not treated promptly and appropriately, can cause complex health complications and mortality. Care models that apply technology, such as telehealth, may be useful in working with diabetes patients. The development and application of wireless communication telehealth have significantly affected healthcare in recent years. Thus, the purpose of this study was to evaluate diabetic patients' use of a telehealth program by using questionnaire survey and laboratory data results. A quantitative study, 1-group pretest-posttest design, was conducted. This study recruited 20 diabetic patients who received telehealth service to measure their glucose, heart rate, and blood pressure, with data uploaded back to the hospital daily. A questionnaire survey was conducted in May 2012 and between August and January 2013 with 20 participants. The test values (blood pressure, heart rate, and blood glucose) of subjects were obtained from the hospital telecare platform and the outpatient monthly reporting system. Study findings showed an overall satisfaction rating of 91% by telehealth participants. Nonparametric statistical analysis demonstrated a significant difference (P < .01) in participants' glycosylated hemoglobin and resultant effective control. These findings indicated that participants accepted this care model, and telehealth could improve participants' glucose control.

A Cluster-Randomized Trial of a Centralized Clinical Pharmacy Cardiovascular Risk Service to Improve Guideline Adherence

BACKGROUND

Numerous studies have demonstrated the value of including pharmacists in team-based care to improve adherence to cardiovascular (CV) guidelines, medication adherence, and risk factor control. However, there is limited information on whether these models can be successfully implemented more widely in diverse settings and populations. The purpose of this study is to evaluate whether a centralized, web-based cardiovascular risk service (CVRS) managed by clinical pharmacists will improve guideline adherence in multiple primary care medical offices with diverse geographic and patient characteristics.

METHODS

This study is a prospective trial in 20 primary care offices stratified by the percent of under-represented minorities and then randomized to either the CVRS intervention or usual care. The intervention will last for 12 months and all subjects will have research visits at baseline and 12 months. The primary outcome is the difference in guideline adherence between groups. Data will also be abstracted from the medical record at 24 months to determine if the intervention effect is sustained after it is discontinued.

CONCLUSIONS

Patient enrollment will continue through 2016, with results expected in 2019. This study will provide information on whether a distant, centralized CVRS can be implemented in large numbers of medical offices, if it is effective in diverse populations, and if there is a long-term sustained effect.

A centralized cardiovascular risk service to improve guideline adherence in private primary care offices

BACKGROUND

Many large health systems now employ clinical pharmacists in team-based care to assist patients and physicians with management of cardiovascular (CV) diseases. However, small private offices often lack the resources to hire a clinical pharmacist for their office. The purpose of this study is to evaluate whether a centralized, web-based CV risk service (CVRS) managed by clinical pharmacists will improve guideline adherence in primary care medical offices in rural and small communities.

METHODS

This study is a cluster randomized prospective trial in 12 primary care offices. Medical offices were randomized to either the CVRS intervention or usual care. The intervention will last for 12 months and all subjects will have research visits at baseline and 12 months. Primary outcomes will include adherence to treatment guidelines and control of key CV risk factors. Data will also be abstracted from the medical record at 30 months to determine if the intervention effect is sustained after it is discontinued.

CONCLUSIONS

This study will enroll subjects through 2015 and results will be available in 2018. This study will provide information on whether a distant, centralized CV risk service can improve guideline adherence in medical offices that lack the resources to employ clinical pharmacists.

Team-based care and improved blood pressure control: a community guide systematic review

CONTEXT

Uncontrolled hypertension remains a widely prevalent cardiovascular risk factor in the U.S. team-based care, established by adding new staff or changing the roles of existing staff such as nurses and pharmacists to work with a primary care provider and the patient. Team-based care has the potential to improve the quality of hypertension management. The goal of this Community Guide systematic review was to examine the effectiveness of team-based care in improving blood pressure (BP) outcomes.

EVIDENCE ACQUISITION

An existing systematic review (search period, January 1980-July 2003) assessing team-based care for BP control was supplemented with a Community Guide update (January 2003-May 2012). For the Community Guide update, two reviewers independently abstracted data and assessed quality of eligible studies.

EVIDENCE SYNTHESIS

Twenty-eight studies in the prior review (1980-2003) and an additional 52 studies from the Community Guide update (2003-2012) qualified for inclusion. Results from both bodies of evidence suggest that team-based care is effective in improving BP outcomes. From the update, the proportion of patients with controlled BP improved (median increase=12 percentage points); systolic BP decreased (median reduction=5.4 mmHg); and diastolic BP also decreased (median reduction=1.8 mmHg).

CONCLUSIONS

Team-based care increased the proportion of people with controlled BP and reduced both systolic and diastolic BP, especially when pharmacists and nurses were part of the team. Findings are applicable to a range of U.S. settings and population groups. Implementation of this multidisciplinary approach will require health system-level organizational changes and could be an important element of the medical home.

Home blood pressure monitoring, secure electronic messaging and medication intensification for improving hypertension control: a mediation analysis

OBJECTIVE

We evaluated the role of home monitoring, communication with pharmacists, medication intensification, medication adherence and lifestyle factors in contributing to the effectiveness of an intervention to improve blood pressure control in patients with uncontrolled essential hypertension.

METHODS

We performed a mediation analysis of a published randomized trial based on the Chronic Care Model delivered over a secure patient website from June 2005 to December 2007. Study arms analyzed included usual care with a home blood pressure monitor and usual care with home blood pressure monitor and web-based pharmacist care. Mediator measures included secure messaging and telephone encounters; home blood pressure monitoring; medications intensification and adherence and lifestyle factors. Overall fidelity to the Chronic Care Model was assessed with the Patient Assessment of Chronic Care (PACIC) instrument. The primary outcome was percent of participants with blood pressure (BP) <140/90 mm Hg.

RESULTS

At 12 months follow-up, patients in the web-based pharmacist care group were more likely to have BP <140/90 mm Hg (55%) compared to patients in the group with home blood pressure monitors only (37%) (p = 0.001). Home blood pressure monitoring accounted for 30.3% of the intervention effect, secure electronic messaging accounted for 96%, and medication intensification for 29.3%. Medication adherence and self-report of fruit and vegetable intake and weight change were not different between the two study groups. The PACIC score accounted for 22.0 % of the main intervention effect.

CONCLUSIONS

The effect of web-based pharmacist care on improved blood pressure control was explained in part through a combination of home blood pressure monitoring, secure messaging, and antihypertensive medication intensification.

Use of family member-based supervision in the management of patients with hypertension in rural China

Medication nonadherence is a major problem in the management of hypertension. The aim of this study was to develop a family member-based supportive therapy for patients with hypertension to provide an affordable way to access essential health services and to ensure adequate control of blood pressure. This study applied a mixed methods approach using qualitative and quantitative study designs in Yangzhong County, a rural area in the People's Republic of China. Findings from indepth interviews demonstrated that the limited effects of traditional health education, a lack of professional advice regarding antihypertensive treatment, and age were related to a patient's adherence with regular blood pressure measurement and taking medication. We also performed a quantitative study, selecting two villages in Yangzhong County as study sites. A total of 188 patients with hypertension were invited to participate in a 6-month family member-based intervention trial. The primary outcomes were the acceptability and feasibility of the intervention strategy. Secondary outcomes included medication adherence and changes in blood pressure. More than 75% of patients expressed a wish for external reminders, and 93.5% responded that they would accept the family member-based supervision. The patients preferred their spouse or a child as the supervisor. After the 6-month intervention, the proportion of patients with uncontrolled blood pressure decreased from 87.2% to 45.7%. This pilot study shows that external supervision by family members is acceptable and feasible for patients with hypertension; it also shows favorable effects with regard to improved treatment adherence and blood pressure control. Future randomized controlled trials with modified intervention measures are needed to validate this finding.

Improving BP control through electronic communications: an economic evaluation

BACKGROUND

Web-based collaborative approaches to managing chronic illness show promise for both improving health outcomes and increasing the efficiency of the healthcare system.

OBJECTIVE

Analyze the cost-effectiveness of the Electronic Communications and Home Blood Pressure Monitoring to Improve Blood Pressure Control (e-BP) study, a randomized controlled trial that used a patient-shared electronic medical record, home blood pressure (BP) monitoring, and web-based pharmacist care to improve BP control (<140/90 mm Hg).

STUDY DESIGN

Incremental cost-effectiveness analysis conducted from a health plan perspective.

METHODS

Cost-effectiveness of home BP monitoring and web-based pharmacist care estimated for percent change in patients with controlled BP and cost per mm Hg in diastolic and systolic BP relative to usual care and home BP monitoring alone.

RESULTS

A 1% improvement in number of patients with controlled BP using home BP monitoring and web-based pharmacist care-the e-BP program-costs $16.65 (95% confidence interval: 15.37- 17.94) relative to home BP monitoring and web training alone. Each mm HG reduction in systolic and diastolic BP achieved through the e-BP program costs $65.29 (59.91-70.67) relativeto home BP monitoring and web tools only. Life expectancy was increased at an incremental cost of $1850 (1635-2064) and $2220 (1745-2694) per year of life saved for men and women, respectively.

CONCLUSIONS

Web-based collaborative care can be used to achieve BP control at a relatively low cost. Future research should examine the cost impact of potential long-term clinical improvements.

The role of home blood pressure telemonitoring in managing hypertensive populations

Hypertension is a common chronic disease affecting nearly one-third of the United States population. Many interventions have been designed to help patients manage their hypertension. With the evolving climate of healthcare, rapidly developing technology, and emphasis on delivering patient-centered care, home-based blood pressure telemonitoring is a promising tool to help patients achieve optimal blood pressure (BP) control. Home-based blood pressure telemonitoring is associated with reductions in blood pressure values and increased patient satisfaction. However, additional research is needed to understand cost-effectiveness and long-term clinical outcomes of home-based BP monitoring. We review key interventional trials involving home based BP monitoring, with special emphasis placed on studies involving additionally behavioral modification and/or medication management. Furthermore, we discuss the role of home-based blood pressure telemonitoring within the context of the patient-centered medical home and the evolving role of technology.

A telehealth strategy for increasing adherence in the treatment of hypertension in primary care

OBJECTIVE

This study describes and analyzes a telehealth strategy for Family Health Teams (FHTs) providing primary care services. This strategy aimed to increase the adherence to the treatment of hypertension.

SUBJECTS AND METHODS

We conducted a before-after study that enrolled 21 professionals and 502 hypertensive patients in two of the Family Health Units connected to our Telehealth Center Network. Seminars addressing the treatment adherence of hypertension were offered by Web conferences, for a period of 6 months, to the FHTs. The adherence to antihypertensive drugs, low salt diet, and physical activity was measured by specific questionnaires. The rates of adherence were assessed before and after a continuing education program (CEP). After the telehealth intervention, 17 professionals and 465 patients were re-evaluated.

RESULTS

The participation in the question and answer session, after the seminar, was significant. The qualitative evaluation of the sessions by FHTs showed 87.5% of great/good. There was a trend toward a greater critical understanding of the results and targets set for the team, although at insignificant levels. The rates of adherence to antihypertensive medication, physical activity, and sodium control, before and after the CEP, were 37.8% versus 46.7% (p<0.004), 90.3% versus 89.9% (p=0.90), and 92.2% versus 96.3% (p<0.001), respectively.

CONCLUSIONS

The adherence to antihypertensive drugs and low salt diet improved after the CEP. Preliminarily, this telehealth strategy suggests a positive impact on hypertensive patients.

Adherence to blood pressure telemonitoring in a cluster-randomized clinical trial

Hypertension is a leading cause of cardiovascular disease and death worldwide. Advances in technology have added telemedicine as a tool for managing hypertension. The effectiveness of telemedicine depends on patients' ability to adhere to schedules of home monitoring and case management. Participants with uncontrolled hypertension in the intervention arm of a randomized trial who completed 6 months of follow-up were included in this analysis. They were asked to measure their blood pressure (BP) a minimum of 6 times per week using a telemonitor that transmitted the readings to their pharmacist case manager. Hypertensive patients in this study had high adherence to telemonitoring (73% took at least 6 BP readings per week) and phone visits (88% of expected visits were attended). In a multivariate analysis, older age, male sex, and some college education predicted better telemonitoring adherence. White non-Hispanic race/ethnicity predicted better adherence to phone visits with pharmacist case managers. Telemonitoring adherence and phone adherence were highly correlated; participants who did not send readings on schedule were more likely to skip at least one phone visit with their pharmacist case manager. The findings from this analysis indicate that hypertensive patients in this study were able to achieve and maintain high adherence to both the telemonitoring and the phone case management visits.

Design and rationale for Home Blood Pressure Telemonitoring and Case Management to Control Hypertension (HyperLink): a cluster randomized trial

BACKGROUND

Patients with high blood pressure (BP) visit a physician an average of 4 times or more per year in the U.S., yet BP is controlled in fewer than half. Practical, robust and sustainable models are needed to improve BP in patients with uncontrolled hypertension.

OBJECTIVES

The Home Blood Pressure Telemonitoring and Case Management to Control Hypertension study (HyperLink) is a cluster-randomized trial designed to determine whether an intervention that combines home BP telemonitoring with pharmacist case management improves BP control compared to usual care at 6 and 12 months in patients with uncontrolled hypertension. Secondary outcomes are maintenance of BP control at 18 months, patient satisfaction with their health care, and costs of care.

METHODS

HyperLink enrolled 450 hypertensive patients with uncontrolled BP from 16 primary care clinics. Eight clinics were randomized to provide usual care (UC) to their patients (n=222) and 8 were randomized to provide the telemonitoring intervention (TI) (n=228). TI patients received home BP telemonitors that internally store and electronically transmit BP data to a secure database. Pharmacist case managers adjust antihypertensive therapy based on the home BP data under a collaborative practice agreement with the clinics' primary care teams. The length of the intervention is 12 months, with follow-up to 18 months to determine the durability of the intervention.

CONCLUSIONS

We will test in a real primary care setting whether combining BP telemonitoring and pharmacist case management can achieve and maintain high rates of BP control compared to usual care.

Commentary: opportunities for innovation and improvement in advance care planning using a tethered patient portal in the electronic health record

In the last 20 years, progress has been made to develop resources for advance care planning (ACP). Several ACP delivery tools have demonstrated progress, but more are needed to improve ACP delivery systems. Providers continue to indicate that increasing patient volume, increasing patient complexity, and an increasing paperwork burden have adversely affected quality ACP delivery. An increasing and ubiquitous use of health information technology, such as electronic health records and electronic health record-tethered patient portals, affords opportunities for innovation to streamline communication methods between providers and patients. In a medical culture that provides only limited time for physician and patient interactions, physician-patient communication using electronic health record-tethered patient portals may provide a time-efficient, low-cost mechanism for effective ACP.

Connected health care: the future of health care and the role of the pharmacist

The population of the world is ageing. As a result, the incidence of chronic disease is projected to increase, there are predicted shortages in health care workforce and budget restraints; implications for future health care provision are serious. The current model of health care is not equipped to deal with these changes. Connected health care, via the use of health informatics, disease management and home telehealth technologies, has been suggested as an approach to ease the projected strain on future health care. Evidence to date suggests a positive impact of the use of connected health care model; however, the majority of studies have overlooked the involvement of the community pharmacist. As the most common point of contact with primary health services for most of the population, the community pharmacist may be well placed to provide connected health care. The research to date is promising with improvements in outcomes for cardiovascular patients noted; however, further work is required to investigate the potential role the community pharmacist can play in the future of connected health care.

Development of a home-based telehealthcare model for improving the effectiveness of the chronic care of stroke patients

This study describes the development of an information technology (IT)-mediated home-based healthcare model designed to improve the effectiveness of caring for stroke patients who require chronic, home care. This model was evaluated at Kaohsiung Medical Hospital in Taiwan between 2005 and 2008; 84 newly diagnosed stroke patients diagnosed as the chronic covalence stage were enrolled for preliminary testing of this model. These patients required 24-hour in-home monitoring of their health status and emergency call service. Over the course of the study, 15 emergency transfers were carried out, and the acute stroke patients were sent to the emergency care within 26 minutes, on average. This system helped physicians, patients, and their families to more efficiently detect the occurrence of recurrent stroke. In addition, we found a statistically significant finding (p < 0.001) that daily blood pressure (BP) monitoring increased from 45.5% in the initial month of the study to 76% after 3-10 months of intervention. Meanwhile, the proportion of patients with an abnormal BP rate decreased from 20.5% in the initial month of the study to 10.9% after 3-10 months of intervention. This suggests that this model helped to improve patient behavior and their ability to care for themselves. This is the first study to develop an IT-mediated, home-based healthcare model in Taiwan. This model integrates both healthcare and clinical services and is capable of enhancing the effectiveness of the care provided to patients with chronic diseases, especially those in situations where self-care is essential for disease management.

Electronic health records and personal health records

OBJECTIVES

To provide an overview of electronic personal health information technology.

DATA SOURCES

Peer reviewed research studies, review articles, and web resources.

CONCLUSION

As technology develops and electronic health records become more common, patients and clinicians are working toward a safer, more personal form of health care delivery.

IMPLICATIONS FOR NURSING PRACTICE

Improving access and input to personal health information is still in its infancy, but with government funding, development of patient health records will continue to grow. Patients are the consumers of health care and are witness to the paradigm shift of access to health information and changes in information communication technology (ICT). For the oncology nurse, the transformation of health care and ICT will require nurses to educate patients and family members on available online resources for self management and health promotion.

Attending rounds: a patient with drug-resistant hypertension

Drug-resistant hypertension is present in about one in eight patients with high BP. It can be a frustrating and expensive condition to pursue from an office-based perspective. In this review, utilizing the American Heart Association scientific statement on drug-resistant hypertension as a guide, a case of drug-resistant hypertension is presented and walked through exactly as encountered by the author. Woven into the discussion is a combination of insights from the literature on this topic, blended with the experience of the author. This is not intended as an exhaustive review of each step in the evaluation and management process but, rather, as an overview incorporating a few carefully chosen references and, hopefully, a logical and useful approach to a common clinical challenge.

The impact of pharmaceutical care on patients with hypertension and their pharmacists

Objective

The purpose of the study was to assess the influence of pharmaceutical care on patients’ knowledge, quality of life and blood pressure and to determine whether new type of pharmaceutical services changes the pharmacists’ satisfaction and knowledge.

Methods

Community pharmacies were randomly assigned to study and control group and pharmacists from both groups included patients with hypertension, who meet inclusion and exclusion criteria. Study group provided the pharmaceutical care (education, pharmacotherapy monitoring, detecting and solving drug related problems) for their patients, while the control group provided the standard pharmaceutical services (dispensing medicines with or without counseling). At the beginning and the end of the study pharmacists and patients filled in the knowledge test. Pharmacists fulfilled also satisfaction questionnaire.

Results

Survey data were collected from 28 and 56 patients from community pharmacies in study and control group respectively. At the last meeting the normal blood pressure achieved 79% and 55% patients in study and control group, respectively (p>0,05). The pharmaceutical care improved patients’ knowledge about disease. Pharmacists from study group, who provided pharmaceutical care, had higher level of pharmacotherapy knowledge and professional satisfaction than the control group.

Conclusions

Implementation of pharmaceutical care into the pharmacy practice benefits both, patients and pharmacists.

Pharmacist interventions to enhance blood pressure control and adherence to antihypertensive therapy: Review and meta-analysis

PURPOSE

Pharmacist interventions to enhance blood pressure (BP) control and adherence to antihypertensive therapy in adults with essential hypertension were reviewed.

METHODS

A literature search was conducted to identify relevant articles describing pharmacist interventions intended to improve adherence to antihypertensive medications. Studies were included if they described a pharmacist intervention to improve medication adherence and analyzed adherence to therapy and BP control as outcomes. A fixed-effects model was used to combine data from randomized controlled trials.

RESULTS

A total of 15 studies were identified, testing 16 different interventions and containing data on 3280 enrolled patients. Although 87.5% of the interventions resulted in significant improvements in treatment outcomes, only 43.8% of the interventions were associated with significant increases in medication adherence. All interventions that increased antihypertensive medication adherence also significantly reduced BP. Almost all the interventions that were effective in increasing adherence to medication were complex, including combinations of different strategies. Meta-analysis of 2619 patients in 8 studies found that pharmacist interventions significantly reduced systolic blood pressure (SBP) (p < 0.001) and diastolic blood pressure (DBP) (p = 0.002) and that the meta-analytic differences in SBP and DBP changes from baseline to endpoint in intervention and control groups were -4.9 ± 0.9 mm Hg (p < 0.001) and -2.6 ± 0.9 mm Hg (p < 0.001), respectively.

CONCLUSION

A literature review and meta-analysis showed that pharmacist interventions can significantly improve medication adherence, SBP, DBP, and BP control in patients with essential hypertension. Interventions were complex and multifaceted and included medication management in all analyzed studies.

Patient ability and willingness to participate in a web-based intervention to improve hypertension control

BACKGROUND

Patient-shared electronic health records provide opportunities for care outside of office visits. However, those who might benefit may be unable to or choose not to use these resources, while others might not need them.

OBJECTIVE

Electronic Communications and Home Blood Pressure Monitoring (e-BP) was a randomized trial that demonstrated that Web-based pharmacist care led to improved blood pressure (BP) control. During recruitment we attempted to contact all patients with hypertension from 10 clinics to determine whether they were eligible and willing to participate. We wanted to know whether particular subgroups, particularly those from vulnerable populations, were less willing to participate or unable to because they lacked computer access.

METHODS

From 2005 to 2006, we sent invitation letters to and attempted to recruit 9298 patients with hypertension. Eligibility to participate in the trial included access to a computer and the Internet, an email address, and uncontrolled BP (BP ≥ 140/90 mmHg). Generalized linear models within a modified Poisson regression framework were used to estimate the relative risk (RR) of ineligibility due to lack of computer access and of having uncontrolled BP.

RESULTS

We were able to contact 95.1% (8840/9298) of patients. Those refusing participation (3032/8840, 34.3%) were significantly more likely (P < .05) to be female, be nonwhite, have lower levels of education, and have Medicaid insurance. Among patients who answered survey questions, 22.8% (1673/7354) did not have computer access. Older age, minority race, and lower levels of education were risk factors for lack of computer access, with education as the strongest predictor (RR 2.63, 95% CI 2.30-3.01 for those with a high school degree compared to a college education). Among hypertensive patients with computer access who were willing to participate, African American race (RR 1.22, 95% CI 1.06-1.40), male sex (RR 1.28, 95% CI 1.18-1.38), and obesity (RR 1.53, 95% CI 1.31-1.79) were risk factors for uncontrolled BP.

CONCLUSION

Older age, lower socioeconomic status, and lower levels of education were associated with decreased access to and willingness to participate in a Web-based intervention to improve hypertension control. Failure to ameliorate this may worsen health care disparities.

TRIAL REGISTRATION

Clinicaltrials.gov NCT00158639; http://www.clinicaltrials.gov/ct2/show/NCT00158639 (Archived by WebCite at http://www.webcitation.org/5v1jnHaeo).

Home-based monitoring and assessment of Parkinson's disease

As a clinically complex neurodegenerative disease, Parkinson's disease (PD) requires regular assessment and close monitoring. In our current study, we have developed a home-based tool designed to monitor and assess peripheral motor symptoms. An evaluation of the tool was carried out over a period of ten weeks on ten people with idiopathic PD. Participants were asked to use the tool twice daily over four days, once when their medication was working at its best ("on" state) and once when it had worn off ("off" state). Results showed the ability of the data collected to distinguish the "on" and "off" state and also demonstrated statistically significant differences in timed assessments. It is anticipated that this tool could be used in the home environment as an early alert to a change in clinical condition or to monitor the effects of changes in prescribed medications used to manage PD.

Health technology assessment review: remote monitoring of vital signs--current status and future challenges

Recent developments in communications technologies and associated computing and digital electronics now permit patient data, including routine vital signs, to be surveyed at a distance. Remote monitoring, or telemonitoring, can be regarded as a subdivision of telemedicine - the use of electronic and telecommunications technologies to provide and support health care when distance separates the participants. Depending on environment and purpose, the patient and the carer/system surveying, analysing or interpreting the data could be separated by as little as a few feet or be on different continents. Most telemonitoring systems will incorporate five components: data acquisition using an appropriate sensor; transmission of data from patient to clinician; integration of data with other data describing the state of the patient; synthesis of an appropriate action, or response or escalation in the care of the patient, and associated decision support; and storage of data. Telemonitoring is currently being used in community-based healthcare, at the scene of medical emergencies, by ambulance services and in hospitals. Current challenges in telemonitoring include: the lack of a full range of appropriate sensors, the bulk weight and size of the whole system or its components, battery life, available bandwidth, network coverage, and the costs of data transmission via public networks. Telemonitoring also has the ability to produce a mass of data - but this requires interpretation to be of clinical use and much necessary research work remains to be done.

Pilot study of providing online care in a primary care setting

OBJECTIVE

To study the use of e-visits in a primary care setting.

PATIENTS AND METHODS

A pilot study of using the Internet for online care ("e-visits") was conducted in the Department of Family Medicine at Mayo Clinic in Rochester, MN. Patients in the department preregistered for the service, and then were able to use the online portal for consultations with their primary care physician. Use of the online portal was monitored and data were collected from November 1, 2007, through October 31, 2009.

RESULTS

During the 2-year period, 4282 patients were registered for the service. Patients made 2531 online visits, and billings were made for 1159 patients. E-visits were submitted primarily by women during working hours and involved 294 different conditions. Of the 2531 e-visits, 62 (2%) included uploaded photographs, and 411 (16%) replaced nonbillable telephone protocols with billable encounters. The e-visits made office visits unnecessary in 1012 cases (40%); in 324 cases (13%), the patient was asked to schedule an appointment for a face-to-face encounter.

CONCLUSION

Although limited in scope, to our knowledge this is the largest study of online visits in primary care using a structured history, allowing the patient to enter any problem, and billing the patient when appropriate. The extent of conditions possible for treatment by online care was far-ranging and was managed with a minimum of message exchanges by using structured histories. Processes previously given as a free service or by nurse triage and subject to malpractice (protocols) were now documented and billed.

Effects of education on self-monitoring of blood pressure based on BASNEF model in hypertensive patients

BACKGROUND

Hypertension is one of the most important health problems. Self-monitoring may be an effective method for controlling this disease. The aim of this study is to determine the effectiveness of education on blood pressure self-monitoring in patients with hypertension based on BASNEF model.

METHODS

In this clinical trial, 150 outpatients with hypertension were randomly selected from those referred to private clinics in Yazd, Iran, during 2008. They were divided in two groups. The data were collected by a validated and reliable questionnaire. The implementing educational program was continued for 2 months and the pre-test and post-test had an interval of 2-months. BASNEF model was applied to explain the motivation of a behavior. Descriptive analysis, correlation test and also regression analysis were used to analyze data.

RESULTS

The respondents acquired 17.72% of total score for self-monitoring behavior, 47.03% of attitude, 12.37% of subjective norms, 33.46% of intention and 50.95% of enabling factors. After intervention, there were significant increases in self-monitoring behavior (173.31%), attitude (62.60%), subjective norms (54.70%), intention (129.93%) and enabling factors (46.62%) in the intervention group. There was no significant difference between the constructs of BASNEF model in the control group after intervention compared to the baseline values (p > 0.05).

CONCLUSIONS

The results of this study showed that the level of self-monitoring behavior in the patients was low. Educational programs are helpful and necessary to improve self-monitoring behavior in patients with hypertension.

Mobile diabetes intervention study: testing a personalized treatment/behavioral communication intervention for blood glucose control

BACKGROUND

National data find glycemic control is within target (A1c<7.0%) for 37% of patients with diabetes, and only 7% meet recommended glycemic, lipid, and blood pressure goals.

OBJECTIVES

To compare active interventions and usual care for glucose control in a randomized clinical trial (RCT) among persons with diabetes cared for by primary care physicians (PCPs) over the course of 1 year.

METHODS

Physician practices (n=36) in 4 geographic areas are randomly assigned to 1 of 4 study groups. The intervention is a diabetes communication system, using mobile phones and patient/physician portals to allow patient-specific treatment and communication. All physicians receive American Diabetes Association (ADA) Guidelines for diabetes care. Patients with poor diabetes control (A1c> or =7.5%) at baseline (n=260) are enrolled in study groups based on PCP randomization. All study patients receive blood glucose (BG) meters and a year's supply of testing materials. Patients in three treatment groups select one of two mobile phone models, receive one-year unlimited mobile phone data and service plan, register on the web-based individual patient portal and receive study treatment phone software based on study assignment. Control group patients receive usual care from their PCP. The primary outcome is mean change in A1c over a 12-month intervention period.

CONCLUSION

Traditional methods of disease management have not achieved adequate control for BG and other conditions important to persons with diabetes. Tools to improve communication between patients and PCPs may improve patient outcomes and be satisfactory to patients and physicians. This RCT is ongoing.

Effectiveness of home blood pressure monitoring, Web communication, and pharmacist care on hypertension control: a randomized controlled trial

CONTEXT

Treating hypertension decreases mortality and disability from cardiovascular disease, but most hypertension remains inadequately controlled.

OBJECTIVE

To determine if a new model of care that uses patient Web services, home blood pressure (BP) monitoring, and pharmacist-assisted care improves BP control.

DESIGN, SETTING, AND PARTICIPANTS

A 3-group randomized controlled trial, the Electronic Communications and Home Blood Pressure Monitoring study was based on the Chronic Care Model. The trial was conducted at an integrated group practice in Washington state, enrolling 778 participants aged 25 to 75 years with uncontrolled essential hypertension and Internet access. Care was delivered over a secure patient Web site from June 2005 to December 2007.

INTERVENTIONS

Participants were randomly assigned to usual care, home BP monitoring and secure patient Web site training only, or home BP monitoring and secure patient Web site training plus pharmacist care management delivered through Web communications.

MAIN OUTCOME MEASURES

Percentage of patients with controlled BP (<140/90 mm Hg) and changes in systolic and diastolic BP at 12 months.

RESULTS

Of 778 patients, 730 (94%) completed the 1-year follow-up visit. Patients assigned to the home BP monitoring and Web training only group had a nonsignificant increase in the percentage of patients with controlled BP (<140/90 mm Hg) compared with usual care (36% [95% confidence interval {CI}, 30%-42%] vs 31% [95% CI, 25%-37%]; P = .21). Adding Web-based pharmacist care to home BP monitoring and Web training significantly increased the percentage of patients with controlled BP (56%; 95% CI, 49%-62%) compared with usual care (P < .001) and home BP monitoring and Web training only (P < .001). Systolic BP was decreased stepwise from usual care to home BP monitoring and Web training only to home BP monitoring and Web training plus pharmacist care. Diastolic BP was decreased only in the pharmacist care group compared with both the usual care and home BP monitoring and Web training only groups. Compared with usual care, the patients who had baseline systolic BP of 160 mm Hg or higher and received home BP monitoring and Web training plus pharmacist care had a greater net reduction in systolic BP (-13.2 mm Hg [95% CI, -19.2 to -7.1]; P < .001) and diastolic BP (-4.6 mm Hg [95% CI, -8.0 to -1.2]; P < .001), and improved BP control (relative risk, 3.32 [95% CI, 1.86 to 5.94]; P<.001).

CONCLUSION

Pharmacist care management delivered through secure patient Web communications improved BP control in patients with hypertension. Trial Registration clinicaltrials.gov Identifier: NCT00158639.