Evaluation of self-measured blood pressure monitoring in a southern rural West Virginia health system.

INTRODUCTION: At the time of the 2021 Behavioral Risk Factor Surveillance System survey, an estimated 32.3% of adults in the US and nearly half (43.4%, 776 000) of adults in West Virginia (WV) had hypertension. Further, the Interactive Atlas of Heart Disease and Stroke estimates an increase in the percentage of adults with hypertension in the US from 32.3% to 47.0%, with hypertension rates in WV rising as high as 58.7%, indicating a significant public health concern in the community. Hypertension increases the risk of several negative health outcomes, including heart disease and stroke, and leads to increased economic and chronic disease burden. Although certain unmodifiable factors (sex, age, race, ethnicity, and family history) increase the risk of developing hypertension, a healthy lifestyle - including a nutritious diet, maintaining a healthy weight, avoiding nicotine products, and participating in regular moderate physical activity - can decrease the risk of developing hypertension. Self-measured blood pressure (SMBP) monitoring, or home BP monitoring, when integrated with a provider's clinical management approach, is linked to improvements in BP management and control. This study represents a mid-point assessment of a remote SMBP monitoring program implemented by Cabin Creek Health Systems (CCHS), a federally qualified health center, and its impact on BP control. METHODS: CCHS implemented SMBP programming in March 2020 as one element of a developing comprehensive program aimed at reducing uncontrolled hypertension, and therefore chronic disease burden, in its service area and patient population. The project, funded by the Health Resources and Services Administration, continued to February 2023. This report represents a mid-point analysis and was based on the retrospective analysis of de-identified data collected for 234 patients to June 2022, who were assessed for changes in BP between the date of enrollment and the most recently available BP measurement. Patients were enrolled in the SMBP program if they exhibited current or previous indicators of uncontrolled hypertension (systolic ≥140 mmHg and/or diastolic ≥90 mmHg), at the discretion of their provider, and were equipped with an iBloodPressure cellular connected home BP monitoring system, manufactured by Smart Meter. Their BP readings were documented in the integration software TimeDoc Health and electronic health record athenahealth. RESULTS: At the time of enrollment, 201 (86.0%) patients had uncontrolled hypertension, with 116 (49.6%) patients having both uncontrolled systolic (≥140 mmHg) and diastolic (≥90 mmHg) values. At follow-up, the number of patients with uncontrolled hypertension decreased from 201 to 98 (41.9%), with only 36 (15.4%) patients having both uncontrolled systolic and diastolic values. Additionally, 26 (11.1%) patients were in hypertensive crisis at the time of enrollment, and no patients remained in crisis at the time of follow-up. The number of patients with BP values in the controlled range (systolic <140 mmHg and diastolic <90 mmHg) increased from 33 (14.1%) at enrollment to 136 (58.1%) at follow-up. Overall, there was a 44.0% increase in the number of patients with BP values in the controlled range at follow-up, and a concomitant 44.1% decrease in the number of patients in the uncontrolled range. These observations were consistent across multiple demographic indicators, including clinic location, three-digit zip code, and patient sex. CONCLUSION: Systematic implementation of remote BP monitoring, when integrated into clinician workflows, was associated with a substantial reduction in the number of patients with uncontrolled hypertension in this rural federally qualified health center. Further, CCHS was successful in implementing a remote SMBP monitoring program in a community challenged with transportation insecurity, and poor cellular and broadband access, of which lessons learned are applicable to other health systems interested in pursuing comparable efforts.

Passive Sampling in Regulatory Chemical Monitoring of Nonpolar Organic Compounds in the Aquatic Environment.

We reviewed compliance monitoring requirements in the European Union, the United States, and the Oslo-Paris Convention for the protection of the marine environment of the North-East Atlantic, and evaluated if these are met by passive sampling methods for nonpolar compounds. The strengths and shortcomings of passive sampling are assessed for water, sediments, and biota. Passive water sampling is a suitable technique for measuring concentrations of freely dissolved compounds. This method yields results that are incompatible with the EU's quality standard definition in terms of total concentrations in water, but this definition has little scientific basis. Insufficient quality control is a present weakness of passive sampling in water. Laboratory performance studies and the development of standardized methods are needed to improve data quality and to encourage the use of passive sampling by commercial laboratories and monitoring agencies. Successful prediction of bioaccumulation based on passive sampling is well documented for organisms at the lower trophic levels, but requires more research for higher levels. Despite the existence of several knowledge gaps, passive sampling presently is the best available technology for chemical monitoring of nonpolar organic compounds. Key issues to be addressed by scientists and environmental managers are outlined.

Patient, Family, Caregiver, and Community Engagement in Research: A Sensibility Evaluation of a Novel Infographic and Planning Guide.

Background: Engaging patients, families, caregivers, and the community (PFCCs) throughout the research cycle ensures that research is meaningful for the target population. Although tools have been developed to promote PFCC engagement, many are lengthy, complex, and lack recommended behaviours. This study evaluated the sensibility of an infographic and accompanying planning guide for facilitating engagement of PFCCs in research. Methods: Thirteen rehabilitation researchers reviewed the PFCC engagement tool and planning guide, participated in a semi-structured interview, and completed a 10-item sensibility questionnaire. Interviews were transcribed, imported into NVivo, and analyzed using direct content analysis. Median scores and proportions of responses for each of the 10 items in the questionnaire were calculated. Results: Median scores for all questionnaire items were ≥ 4 on a 7-point Likert Scale. Participants reported the tool was easy to navigate, contained relevant items to promote PFCC engagement, and followed a logical sequence. Suggested modifications of the tool related to formatting, design, and changing the title. Conclusions: The tool was deemed sensible for overt format, purpose and framework, face and content validity, and ease of usage and provides guidance to engage PFCCs across the research cycle. Further studies are recommended to assess the effectiveness of the tool to engage PFCCs in research.

Historique: la mobilisation des patients, des familles, des proches et de la communauté (PFPC) tout au long du cycle de la recherche permet de garantir que celle-ci soit significative pour la population ciblée. Même si des outils ont été mis au point pour promouvoir la mobilité des PFPC, bon nombre sont longs, complexes et dénués d'indications sur les comportements recommandés. La présente étude visait à évaluer la sensibilité d'une infographie et du guide de planification qui l'accompagne pour favoriser la mobilisation des PFPC en recherche. Méthodologie: au total, 13 chercheurs en réadaptation ont examiné l'outil de mobilisation des PFPC et le guide de planification, ont participé à une entrevue semi-structurée et ont rempli un questionnaire de sensibilité en dix points. Les entrevues ont été transcrites, importées dans NVivo et évaluées au moyen d'une analyse directe de contenu. Les scores médians et les proportions des réponses ont été calculés pour chacun des dix points du questionnaire. Résultats: les scores médians à tous les points du questionnaire étaient d'au moins 4 sur une échelle de Likert en sept points. Les participants ont indiqué que l'outil était facile à parcourir, contenait des points appropriés pour favoriser la mobilisation des PFPC et respectait une séquence logique. Les modifications proposées portaient sur le formatage, le graphisme et le changement de titre. Conclusions: l'outil était considéré comme sensible pour son caractère explicite, son objectif et sa structure, sa validité apparente et de contenu et sa facilité d'utilisation. De plus, il contenait des conseils pour mobiliser les PFPC tout au long du cycle de recherche. II est recommandé de réaliser d'autres études pour évaluer l'efficacité de l'outil à mobiliser les PFPC en recherche.

The ebbs and flows of changing acute bed capacity delays.

OBJECTIVE: This case study provides a summary of changes in acute hospital bed delays that have occurred over a 4-year period as identified through a Capacity Audit process. BACKGROUND: Royal Adelaide Hospital (RAH) designed a Capacity Audit process and tool that provides a systematic method to evaluate factors limiting access to inpatient bed capacity. The aim of the audit is to improve understanding of bed capacity by identifying key causes of delay for hospital inpatients and quantify the most frequent causes of blocked bed capacity. This can then be used to underpin targeted improvement work. The Capacity Audit has been undertaken at the RAH over three cycles. METHOD: The Capacity Audit involves a survey of every open and staffed bed, identifying how the bed is being used: for acute care or treatment, if there was a delay to the patient for discharge, or if the bed was unavailable. The first and second cycle of the audit (2007-2008) involved a twice-daily survey over a 2-week period and the third audit cycle in 2010 occurred once daily for 1 week. RESULTS: On average, 620 beds were surveyed daily with an audit compliance rate ranging from 85-97%. This process has revealed almost 75% of beds are used positively for care. Of the remaining 25% of hidden capacity identified, non-clinical discharge delays account for 10% of total beds surveyed. Waiting for post-acute beds has consistently remained the main cause of acute bed delay. CONCLUSION: The Capacity Audit process and tool has been used to track progress, trends and change resulting from service improvement efforts, and to provide the evidence to commence strategies to reduce the hidden capacity issues. This case study has shown that whilst overall bed stock usage for positive care has not changed significantly there are various ebbs and flows over time in relation to the reasons for bed delays.

Metals concentrations in transitional and coastal waters by ICPMS and voltammetry analysis of spot samples and passive samplers (DGT).

This study investigates the relationships among Ni, Cd and Pb's different chemical forms determined by different methodologies in coastal and transitional waters across a broad geographical scale. Concentrations were measured in spot samples and through passive sampling (DGT). High variability of metal concentrations was found among sampling sites and methodologies due to natural water fluctuations rather than to a given metal or method. Total dissolved metal concentrations in spot samples were lower than the EQS-WFD values. The labile fractions of Cd and Pb, measured in spot samples by Anodic Stripping Voltammetry and by DGT-ICPMS, were highly correlated. Similar labilities were found for Cd, while for Pb, the ASV labile fraction was ≈50% lower. These results reflect the pool of mobile and labile species available towards each technique kinetic window, and they seem not to be affected by discrete sampling flaws.

Assessing variability in the ratio of metal concentrations measured by DGT-type passive samplers and spot sampling in European seawaters.

The current study evaluates the effect of seawater physico-chemical characteristics on the relationship between the concentration of metals measured by Diffusive Gradients in Thin films (DGT) passive samplers (i.e., DGT-labile concentration) and the concentrations measured in discrete water samples. Accordingly, Inductively Coupled Plasma Mass Spectrometry (ICP-MS) was used to measure the total dissolved metal concentrations in the discrete water samples and the labile metal concentrations obtained by DGT samplers; additionally, lead and cadmium conditional labile fractions were determined by Anodic Stripping Voltammetry (ASV) and total dissolved nickel was measured by Cathodic Stripping Voltammetry (CSV). It can be concluded that, in general, the median ratios of DGT/ICP and DGT/ASV(CSV) were lower than 1, except for Ni (median ratio close to 1) and Zn (higher than 1). This indicates the importance of speciation and time-integrated concentrations measured using passive sampling techniques, which is in line with the WFD suggestions for improving the chemical assessment of waterbodies. It is the variability in metal content in waters rather than environmental conditions to which the variability of the ratios can be attributed. The ratios were not significantly affected by the temperature, salinity, pH, oxygen, DOC or SPM, giving a great confidence for all the techniques used. Within a regulatory context such as the EU Water Framework Directive this is a great advantage, since the simplicity of not needing to use corrections to minimize the effects of environmental variables could help in implementing DGTs within monitoring networks.

Concurrent sampling of transitional and coastal waters by Diffusive Gradient in Thin-films (DGT) and spot sampling for trace metals analysis.

This protocol was developed based on the knowledge acquired in the framework of the Interreg MONITOOL project (EAPA_565/2016) where extensive sampling campaigns were performed in transitional and coastal waters covering eight European countries. It provides detailed procedures and guidelines for the sampling of these waterbodies by concurrent collection of discrete water samples and the deployment of Diffusive Gradient in Thin-films (DGT) passive samplers for the measurement of trace metal concentrations. In order to facilitate the application of this protocol by end-users, it presents steps to follow in the laboratory prior to sampling campaigns, explains the procedures for field campaigns (including in situ measurement of supporting parameters) and subsequent sample processing in the laboratory in preparation for trace metal analyze by inductively coupled plasma-mass spectrometry (ICP-MS) and voltammetry. The protocol provides a systematic, coherent field sampling and sample preparation strategy that was developed in order to ensure comparability and reproducibility of the data obtained from each project Partner in different regions. • Standardization of the concurrent sampling of transitional and coastal waters by DGT passive samplers and spot sampling. • Robust procedures and tips based on existing international standards and comprehensive practical experience. • Links to demonstration videos produced within the MONITOOL project.

Spatial and temporal analysis of biliary 1-hydroxypyrene, hepatic ethoxyresorufin-O-deethylase and muscle acetylcholinesterase activity in UK flatfish.

Chemical pollution of the marine environment from anthropogenic sources is a global concern due to the potential for long term effects on the ecosystem. Chemical monitoring schemes can detect harmful substances in water, sediment or biota. However, the presence of specific determinants gives no information on how individual species or the ecosystem are impacted. Biological effects techniques are therefore used in environmental monitoring schemes to provide a clearer picture of whether the chemicals present are causing deleterious effects on the species sampled, or whether organisms have been exposed to certain classes of organic contaminants that they may be able to metabolise. Using these techniques, we can provide an assessment of the health of our marine environment (Thain et al., 2008).

Bioindicators and reproductive effects of prolonged 17beta-oestradiol exposure in a marine fish, the sand goby (Pomatoschistus minutus).

The effects of 17beta-oestradiol (E2) on mortality, growth rates, sexual maturation, hepatic vitellogenin (VTG) mRNA expression and reproductive success were investigated during an 8-month, water-borne exposure of a marine fish, the sand goby (Pomatoschistus minutus). Indicators of oestrogenic exposure were investigated as predictors of population-level reproductive success. E2 exposure concentrations were <5 (below limit of detection), 16+/-3, 97+/-20 and 669+/-151 ng l(-1) (bootstrap means and standard errors). The carrier solvent (<20 microl l(-1) propan-2-ol) significantly reduced the rate of egg production compared to untreated fish, but did not significantly affect male VTG mRNA expression, brood size, or the other studied parameters. Fish exposed to 16 ng l(-1) E2 showed few adverse effects compared with solvent only-exposed fish. Exposure to 97 ng l(-1) E2 significantly inhibited male sexual maturation, induced male VTG mRNA expression and delayed spawning. The 97 ng l(-1) E2 exposed population also produced fertile eggs at a significantly slower rate than solvent controls; however, brood size, fertility and overall reproductive success were not significantly affected. Exposure to 669 ng l(-1) E2 significantly increased mortality, adversely affected haematological parameters and caused an almost total lack of reproductive activity, with both sexes failing to mature. Reproductive failure following exposure to 669 ng l(-1) E2 was evident in both sexes when crossed with untreated animals. This work indicates that marine fish are similarly as sensitive to oestrogenic exposure as freshwater fish, that exposure biomarkers such as VTG are more sensitive to exposure than are reproductive effects, and that the use of carrier solvents in long-term reproductive studies should be avoided.

Evaluation and Management of Blunt Solid Organ Trauma.

Trauma is a leading cause of death in patients under the age of 45 and generally associated with a high kinetic energy event such as a motor vehicle accident or fall from extreme elevations. Blunt trauma can affect every organ system and major vascular structure with potentially devastating effect. When we consider abdominal solid organ injury from blunt trauma, we usually think of the liver, spleen, and kidneys. However, all of the abdominal organs, including the pancreas and adrenal glands, may be involved. Blunt hepatic trauma is more commonly associated with venous bleeding rather than arterial injury. Stable venous injury is often managed conservatively; when the patient is hemodynamically unstable from venous hepatic injury, operative management should be first-line therapy. When the injury is arterial, endovascular therapy should be initiated. Blunt trauma to the spleen is the most common cause of traumatic injury to the spleen. Management is controversial. In our institution unstable patients are taken to the operating room, and stable patients with Grades IV-V injuries and patients with active arterial injury are taken for endovascular treatment. Renal injuries are less common, and evidence of arterial injury such as active extravasation or pseudoaneurysm is warranted before endovascular therapy. Pancreatic trauma is uncommon and usually secondary to steering wheel/handlebar mechanism injuries. Adrenal injuries are rare in the absence of megatrauma or underlying adrenal abnormality.

Biomarkers of general stress in mussels as common indicators for marine biomonitoring programmes in Europe: The ICON experience.

This study investigated whether general stress biomarkers in mussels can be applied as common first-tier biomarkers in regional biomonitoring programmes in the North Sea (including Iceland) and western Mediterranean Sea. Stress on Stress (SoS) and lysosomal membrane stability (LMS) biomarkers were analysed in resident mussels (Mytilus sp.) from 8 coastal sites and in transplanted mussels (Mytilus galloprovincialis) from two Spanish Mediterranean coastal sites. The assessment of results, as input to pollution monitoring strategies, was performed jointly for LMS and SoS data from the two regions. Contaminant body burden of the mussels was compared with biomarker results. The results demonstrated that these two general and non-expensive stress biomarkers in mussel can be applied throughout European waters, providing a cost-effective and harmonised approach to screen contaminant-related biological effects within the framework of wide-scale pollution biomonitoring programmes, such as that proposed by the European Union, i.e. the Marine Strategy Framework Directive.

How can we quantify impacts of contaminants in marine ecosystems? The ICON project.

An international workshop on marine integrated contaminant monitoring (ICON) was organised to test a framework on integrated environmental assessment and simultaneously assess the status of selected European marine areas. Biota and sediment were sampled in selected estuarine, inshore and offshore locations encompassing marine habitats from Iceland to the Spanish Mediterranean. The outcome of the ICON project is reported in this special issue as method-oriented papers addressing chemical analyses, PAH metabolites, oxidative stress, biotransformation, lysosomal membrane stability, genotoxicity, disease in fish, and sediment assessment, as well as papers assessing specific areas. This paper provides a background and introduction to the ICON project, by reviewing how effects of contaminants on marine organisms can be monitored and by describing strategies that have been employed to monitor and assess such effects. Through the ICON project we have demonstrated the use of an integrating framework and gleaned more knowledge than ever before in any single field campaign about the impacts contaminants may have in European marine areas.

Assessment of contaminant concentrations in sediments, fish and mussels sampled from the North Atlantic and European regional seas within the ICON project.

Understanding the status of contaminants in the marine environment is a requirement of European Union Directives and the Regional Seas Conventions, so that measures to reduce pollution can be identified and their efficacy assessed. The international ICON workshop (Hylland et al., in this issue) was developed in order to test an integrated approach to assessing both contaminant concentrations and their effects. This paper describes and assesses the concentrations of trace metals, polycyclic aromatic hydrocarbons, and polychlorinated biphenyls in sediments, mussels, and fish collected from estuarine, coastal and offshore waters from Iceland to the Mediterranean Sea. For organic contaminants, concentrations progressively increased from Iceland, to the offshore North Sea, to the coastal seas, and were highest in estuaries. Metals had a more complex distribution, reflecting local anthropogenic inputs, natural sources and hydrological conditions. Use of internationally recognised assessment criteria indicated that at no site were concentrations of all contaminants at background and that concentrations of some contaminants were of significant concern in all areas, except the central North Sea.

Assessing environmental quality status by integrating chemical and biological effect data: The Cartagena coastal zone as a case.

Cartagena coastal zone (W Mediterranean) was chosen for a practical case study to investigate the suitability of an integrated indicator framework for marine monitoring and assessment of chemicals and their effects, which was developed by ICES and OSPAR. Red mullet (Mullus barbatus) and the Mediterranean mussel (Mytilus galloprovincialis) were selected as target species. Concentrations of contaminants in sediment and biota, and contaminant-related biomarkers were analysed. To assess environmental quality in the Cartagena coastal zone with respect to chemical pollution, data were assessed using available assessment criteria, and then integrated for different environmental matrices. A qualitative scoring method was used to rank the overall assessments into selected categories and to evaluate the confidence level of the final integrated assessment. The ICES/OSPAR integrated assessment framework, originally designed for the North Atlantic, was found to be applicable for Mediterranean species and environmental matrices. Further development of assessment criteria of chemical and biological parameters in sediments and target species from the Mediterranean will, however, be required before this framework can be fully applied for determining Good Environmental Status (GES) of the Marine Strategy Framework Directive in these regions.

Integrated chemical and biological assessment of contaminant impacts in selected European coastal and offshore marine areas.

This paper reports a full assessment of results from ICON, an international workshop on marine integrated contaminant monitoring, encompassing different matrices (sediment, fish, mussels, gastropods), areas (Iceland, North Sea, Baltic, Wadden Sea, Seine estuary and the western Mediterranean) and endpoints (chemical analyses, biological effects). ICON has demonstrated the use of a framework for integrated contaminant assessment on European coastal and offshore areas. The assessment showed that chemical contamination did not always correspond with biological effects, indicating that both are required. The framework can be used to develop assessments for EU directives. If a 95% target were to be used as a regional indicator of MSFD GES, Iceland and offshore North Sea would achieve the target using the ICON dataset, but inshore North Sea, Baltic and Spanish Mediterranean regions would fail.

Integrated monitoring of chemicals and their effects on four sentinel species, Limanda limanda, Platichthys flesus, Nucella lapillus and Mytilus sp., in Seine Bay: A key step towards applying biological effects to monitoring.

The International workshop on Integrated Assessment of CONtaminants impacts on the North sea (ICON) provided a framework to validate the application of chemical and biological assessment thresholds (BACs and EACs) in the Seine Bay in France. Bioassays (oyster larval anomalies, Corophium arenarium toxicity assay and DR Calux) for sediment and biomarkers: ethoxyresorufin-O-deethylase (EROD) activity, acetylcholinesterase (AChE) activity, lysosomal membrane stability (LMS), DNA strand breaks using the Comet assay, DNA adducts, micronucleus (MN), PAH metabolites, imposex, intersex and fish external pathologies were analysed in four marine sentinel species (Platichthys flesus, Limanda limanda, Mytilus sp. and Nucella lapilus). Polycyclic aromatic hydrocarbons (PAHs), polychlorinated biphenyls (PCBs) and heavy metals were analysed in biota and sediment. Results for sediment and four species in 2008-2009 made it possible to quantify the impact of contaminants using thresholds (Environmental Assessment Criteria/EAC2008: 70% and EAC2009: 60%) and effects (EAC2008: 50% and EAC2009: 40%) in the Seine estuary. The Seine estuary is ranked among Europe's most highly polluted sites.

Integrated indicator framework and methodology for monitoring and assessment of hazardous substances and their effects in the marine environment.

Many maritime countries in Europe have implemented marine environmental monitoring programmes which include the measurement of chemical contaminants and related biological effects. How best to integrate data obtained in these two types of monitoring into meaningful assessments has been the subject of recent efforts by the International Council for Exploration of the Sea (ICES) Expert Groups. Work within these groups has concentrated on defining a core set of chemical and biological endpoints that can be used across maritime areas, defining confounding factors, supporting parameters and protocols for measurement. The framework comprised markers for concentrations of, exposure to and effects from, contaminants. Most importantly, assessment criteria for biological effect measurements have been set and the framework suggests how these measurements can be used in an integrated manner alongside contaminant measurements in biota, sediments and potentially water. Output from this process resulted in OSPAR Commission (www.ospar.org) guidelines that were adopted in 2012 on a trial basis for a period of 3 years. The developed assessment framework can furthermore provide a suitable approach for the assessment of Good Environmental Status (GES) for Descriptor 8 of the European Union (EU) Marine Strategy Framework Directive (MSFD).

Can industrial pollution cause intersexuality in the amphipod, Echinogammarus marinus?

Following recent studies, in which intersex and/or reproductive abnormalities have been observed in a number of crustaceans in association with pollution, the prevalence of intersexuality in the amphipod, Echinogammarus marinus was monitored at sites receiving industrial discharges for one year in 2002/2003. Based upon reports of intersexuality occurring in amphipods due to feminising microsporidian parasites, the occurrence, and role of microsporidian parasites in causing intersex was investigated through histological examination. Results demonstrate a significantly higher prevalence of intersex organisms was found at sites receiving industrial discharges throughout the year when compared to a reference site, with the phenotype of intersex (intersex male and intersex female) varying in its dominance between impacted sites. Intersex specimens were significantly more likely to be infected with microsporidian parasites at sites receiving discharges than reference sites, however relatively few specimens (normal or intersex) were infected at reference sites suggesting parasitism is not the only cause of intersex. The direct/indirect role of pollution in the observed intersexuality is discussed.

Improving the Care of Dual Eligible Patients in Rural Federally Qualified Health Centers: The Impact of Care Coordinators and Clinical Pharmacists.

BACKGROUND: Dual eligible persons are those covered by both Medicare and Medicaid. There were 9.6 million dual eligible persons in the United States and 82 000 in West Virginia in 2010. Dual eligibles are poorer, sicker, and more burdened with serious mental health conditions than Medicare or Medicaid patients as a whole. Their health care costs are significantly higher and they are more likely to receive fragmented ineffective care. PURPOSE: To improve the care experience and health care outcomes of dual eligible patients by the expanded use of care coordinators and clinical pharmacists. METHODS: During 2012, 3 rural federally qualified community health centers in West Virginia identified 200 dual eligible patients each. Those with hospitalizations received more frequent care coordinator contacts. Those on more than 15 chronic medications had drug utilization reviews with recommendations to primary care providers. Baseline measures included demographics, chronic diseases, total medications and Beers list medications, hospitalization, and emergency room (ER) use in the previous year. Postintervention measures included hospitalization, ER use, total medications, and Beers list medications. RESULTS: Out of 556 identified patients, 502 were contacted and enrolled. Sixty-five percent were female. The median age was 69 years, with a range of 29 to 93 years. Nineteen percent (19%) of patients were on 15 or more medications, 56% on psychotropic medication, and 33% on chronic opiates. One site showed reductions of 34% in hospitalizations and 25% in ER visits during the intervention year. For all sites combined, there was a 5.5% reduction in total medications and a 14.8% reduction in Beers list medications. CONCLUSIONS: A modest investment in care coordination and clinical pharmacy review can produce significant reductions in hospitalization and harmful polypharmacy for community dwelling dual eligible patients.

Understanding the patient journey to the Emergency Department - A South Australian study.

BACKGROUND: To determine patients' points of contact prior to or decision making processes before presenting to an Emergency Department for treatment. To obtain data that may inform future exploration of targeted Emergency Department avoidance strategies. METHOD: All patients presenting to two metropolitan Emergency Departments over a 24h period were surveyed. Where information was unattainable, it was sought from computerised Patient Administration Systems used by each Emergency Department. A descriptive analysis of the results was undertaken. RESULTS: Three hundred and thirty two patients presented over the 48 h survey period. Results showed that 200 (60.2%) were self-referred, 65 patients (19.6%) contacted their general practitioner, 22 (6.6%) were transferred from other hospitals and 3 patients (0.9%) contacted the National Healthdirect Australia triage hotline prior to presenting to the Emergency Department. CONCLUSION: The study showed 39.8% had sought advice from other health care professionals prior to presenting to the Emergency Department and that 60.2% of patients were self-referred. This study has not revealed any new pathways that warrant targeting for Emergency Department avoidance strategies. The focus still needs to target primary care referrals, ambulance service transports and smaller hospital transfers.