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.

Crossing to safety: transforming healthcare organizations for patient safety.

The current healthcare system is not designed to ensure better patient safety. In addition, healthcare is simultaneously becoming increasingly complex and increasingly fragmented. Medical knowledge and technology are expanding at an incredible rate, making it difficult for the healthcare providers to keep pace with advancing knowledge. Patients' needs are changing too: shifting from the diagnosis and treatment of a single, acute problem to the long-term management of multiple, interrelated chronic conditions. Our systems of care are not keeping up with these changes and, consequently, patients are experiencing unnecessary risk. Improving patient safety requires a transformation in how we currently care for patients. Healthcare organizations must adopt a new paradigm of care that holds patient safety as a core value and practice. To achieve this aim, healthcare organizations should build and maintain a culture of patient safety, provide leadership for patient safety that establishes a blame-free environment, proactively survey and monitor for adverse events, continually engineer patient safety into healthcare processes, and provide information and communication technologies to support patient safety.

Incidence of severe unintentional carbon monoxide poisoning differs across racial/ethnic categories.

OBJECTIVE: This study was conducted to test the hypothesis that the incidence of severe, acute, unintentional carbon monoxide (CO) poisoning differs across racial/ethnic categories. METHODS: The authors retrospectively reviewed medical records of all Washington State residents treated with hyperbaric oxygen for severe, acute, unintentional CO poisoning from December 1, 1987, through February 28, 1997. RESULTS: Among 586 Washington State residents treated with hyperbaric oxygen for severe, acute, unintentional CO poisoning, racial/ethnic designations could be determined from record review for 530 (90%). The black and Hispanic white populations of Washington State had higher relative risks for severe, acute, unintentional CO poisoning than the non-Hispanic white population. The most common sources of CO poisoning differed by racial/ethnic category. CONCLUSIONS: Members of certain groups in Washington State are at higher risk for severe, unintentional CO poisoning. Public education programs regarding CO exposure should be targeted to populations at risk.