Evaluation of Pharmacists' Work in a Physician-Pharmacist Collaborative Model for the Management of Hypertension. A Randomized Controlled Trial of Team-Based Care: Impact of Physician-Pharmacist Collaboration on Uncontrolled Hypertension Primary care-based, pharmacist-physician collaborative medication-therapy management of hypertension: a randomized, pragmatic trial. A randomized trial of the effect of community pharmacist and nurse care on improving blood pressure management in patients with diabetes mellitus: study of cardiovascular risk intervention by pharmacists-hypertension (SCRIP-HTN). Electronic communications and home blood pressure monitoring (e-BP) study: design, delivery, and evaluation framework. Conducting a randomized controlled trial of CQI and academic detailing to implement clinical guidelines. Comparing standard care with a physician and pharmacist team approach for uncontrolled hypertension The Team Education and Adherence Monitoring (TEAM) trial: pharmacy interventions to improve hypertension control in blacks. Effect of Adding Pharmacists to Primary Care Teams on Blood Pressure Control in Patients With Type 2 Diabetes Design of a trial to evaluate the impact of clinical pharmacists and community health promoters working with African-Americans and Latinos with Diabetes Enhancing diabetes care by adding a pharmacist to the primary care team. Changing model of nursing care from individual patient allocation to team nursing in the acute inpatient environment The Role of Clinical Uncertainty in Treatment Decisions for Diabetic Patients with Uncontrolled Blood Pressure Pharmacist-physician collaboration improves blood pressure control. Effectiveness of home blood pressure monitoring, Web communication, and pharmacist care on hypertension control: a randomized controlled trial. 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A quasi-experimental test of an intervention to increase the use of thiazide-based treatment regimens for people with hypertension Improving Blood Pressure Control through Provider Education, Provider Alerts, and Patient Education Critical Pathways as a Strategy for Improving Care: Problems and Potential Changes in Outcomes for Internal Medicine Inpatients after Work-Hour Regulations A Multimethod Quality Improvement Intervention To Improve Preventive Cardiovascular Care Randomized controlled trial of anticipatory and preventive multidisciplinary team care: for complex patients in a community-based primary care setting. 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Comparative effectiveness of home blood pressure telemonitoring (HBPTM) plus nurse case management versus HBPTM alone among Black and Hispanic stroke survivors: study protocol for a randomized controlled trial A randomized controlled trial of CQI teams and academic detailing: can they alter compliance with guidelines? Community-based care for chronic wound management: an evidence-based analysis. Implementation and evaluation of the 5As framework of obesity management in primary care: design of the 5As Team (5AsT) randomized control trial Cost-effectiveness of Wisconsin TEAM model for improving adherence and hypertension control in black patients. Patients' Perspectives of a Multifaceted Intervention With a Focus on Technology: A Qualitative Analysis Systematic review of the effectiveness of integrated care pathways: what works, for whom, in which circumstances? A quality improvement plan for hypertension control: the INCOTECA Project (INterventions for COntrol of hyperTEnsion in CAtalonia) Development of mWellcare: an mHealth intervention for integrated management of hypertension and diabetes in low-resource settings e-Care for heart wellness: a feasibility trial to decrease blood pressure and cardiovascular risk. EHR‐Based Medication Support and Nurse‐Led Medication Therapy Management: Rationale and Design for a Three‐Arm Clinic Randomized Trial Home-based blood pressure interventions for blacks. Pharmacist-Led Chronic Disease Management: A Systematic Review of Effectiveness and Harms Compared With Usual Care Improving hypertension care in a large group-model MCO. Center for stroke disparities solutions community- based care transition interventions: study protocol of a randomized controlled trial Fidelity to a behavioral intervention to improve goals of care decisions for nursing home residents with advanced dementia Discontinuing Inappropriate Medication Use in Nursing Home Residents Home blood pressure monitoring, secure electronic messaging and medication intensification for improving hypertension control: a mediation analysis. Training intervention for health care staff in the provision of existential support to patients with cancer: a randomized, controlled study. Sustained blood pressure control following discontinuation of a pharmacist intervention. Two self-management interventions to improve hypertension control: a randomized trial. Community pharmacy services to optimise the use of medications for mental illness: a systematic review Care homes’ use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people An integrated general practice and pharmacy-based intervention to promote the use of appropriate preventive medications among individuals at high cardiovascular disease risk: protocol for a cluster randomized controlled trial Palliative care in the community: setting practice guidelines for primary care teams. Is staff well-being and communication enhanced by multidisciplinary work shift evaluations? Design, rationale, and baseline characteristics of a cluster randomized controlled trial of pay for performance for hypertension treatment: study protocol
STUDY OBJECTIVE Physician-pharmacist collaborative models have been shown to improve the care of patients with numerous chronic medical conditions . Team-based health care using integrated clinical pharmacists provides one opportunity to improve quality in health care systems that use population -based financing . In November 2015 , the Centers for Medicare and Medicaid Services ( CMS ) requested that the relative value of pharmacists ' work in team-based care needs to be established . Thus the objective of this study was to describe the components of pharmacists ' work in the management of hypertension with a physician-pharmacist collaborative model . DESIGN Descriptive analysis of the components of pharmacists ' work in the Collaboration Among Pharmacists and Physicians to Improve Outcomes Now ( CAPTION ) study , a prospect i ve , cluster r and omized trial . MEASUREMENTS AND MAIN RESULTS This analysis was intended to provide policymakers with data and information , using the CAPTION study model , on the time and intensity of pharmacists ' work to underst and pharmacists ' relative value contributions in the context of CMS financing and population management aims . The CAPTION trial was conducted in 32 community-based medical offices in 15 U.S. states and included 390 patients with multiple cardiovascular risk factors .  Blood pressure was measured by trained study coordinators in each office , and patients were included in the study if they had uncontrolled blood pressure . Included patients were r and omized to a 9-month intervention , a 24-month intervention , or usual care .  The goal of the pharmacist intervention was to improve blood pressure control and resolve drug therapy problems impeding progress toward blood pressure goals . This intervention included medical record review , a structured assessment with the patient , collaboration to achieve goals of therapy , and patient follow-up . The two intervention arms ( 9 and 24 mo ) were identical the first 9 months , and that time frame is the focus of this workload evaluation . Pharmacists completed study encounter forms for every patient encounter and estimated time spent in pre-visit , face-to-face care , and post-visit activities . Among the 390 patients , there were 2811 encounters with pharmacists that involved 3.44 hours/patient for face-to-face care visits plus 1.55 hours/patient for pre-visit and post-visit work . Intensity of work was reflected in interventions to resolve drug therapy problems with patients ( 43 % of encounters ) and with physicians ( 1169 recommendations , of which physicians accepted 1153 [ 98.6 % ] ) , result ing in improvement of patients ' blood pressure goals achieved ( from 0 % at baseline to 43 % at 9 months based on the primary study end point ) . CONCLUSION Pharmacists provided extensive interventions to patients with hypertension . This analysis provides a framework for health systems , provider groups , and payers to measure pharmacists ' work in value-based financing and population management ABSTRACT OBJECTIVE Evaluate the effectiveness of collaborative management of hypertension by primary care-pharmacist teams in community-based clinics . STUDY DESIGN A 12-month prospect i ve , single-blind , r and omized , controlled trial in the Providence Primary Care Research Network of patients with hypertension and uncontrolled blood pressure . METHODS As compared to usual primary care , intervention consisted of pharmacy practitioners participating in the active management of hypertension  in the primary care office according to established collaborative treatment protocol s. At baseline , there was no significant difference in blood pressure between groups . Primary outcome measures were the differences in mean systolic and diastolic blood pressures between arms at study end . Secondary measures included blood pressure goal attainment ( < 140/90 mmHg ) , hypertension-related knowledge , medication adherence , home blood pressure monitoring , re source utilization , quality of life , and satisfaction . RESULTS A total of 463 subjects were enrolled ( n = 233 control , n = 230 intervention ) . Subjects receiving the intervention achieved significantly lower systolic ( p = 0.007 ) and diastolic ( p = 0.002 ) blood pressures compared to control ( 137/75 mmHg vs. 143/78 mmHg ) . In addition , 62 % of intervention subjects achieved target blood pressure compared to 44 % of control subjects ( p = 0.003 ) . The intervention group received more total office visits ( 7.2 vs. 4.9 , p < 0.0001 ) , however had fewer physician visits ( 3.2 vs. 4.7 , p < 0.0001 ) compared to control . Intervention subjects were prescribed more antihypertensive medications ( 2.7 vs. 2.4 , p = 0.02 ) , but did not take more antihypertensive pills per day ( 2.4 vs. 2.5 , p = 0.87 ) . There were minimal differences between groups in hypertension-related knowledge , medication adherence , quality of life , or satisfaction . CONCLUSIONS Patients r and omized to collaborative primary care-pharmacist hypertension management achieved significantly better blood pressure control compared to usual care with no difference in quality of life or satisfaction PURPOSE A collaborative pharmacist- primary care provider ( PharmD-PCP ) team approach to medication-therapy management ( MTM ) , with pharmacists initiating and changing medications at separate office visits , holds promise for the cost-effective management of hypertension , but has not been evaluated in many systematic trials . The primary objective of this study was to examine blood pressure ( BP ) control in hypertensive patients managed by a newly formed PharmD-PCP MTM team versus usual care in a university-based primary care clinic . METHODS This r and omized , pragmatic clinical trial was conducted in hypertensive patients r and omly selected for PharmD-PCP MTM or usual care .  In the PharmD-PCP MTM group , pharmacists managed drug-therapy initiation and monitoring , medication adjustments , biometric assessment s , laboratory tests , and patient education . In the usual-care group , patients continued to see their PCPs . Participants were aged ≥ 18 years , were diagnosed with hypertension , had a most recent BP measurement of ≥ 140/≥ 90 mm Hg ( ≥ 130/≥ 80 mm Hg if codiagnosed with diabetes mellitus ) , were on at least 1 antihypertensive medication , and were English speaking . The primary outcome was the difference in the mean change from baseline in systolic BP at 6 months . Secondary outcomes included the percentage achieving therapeutic BP goal and the mean changes from baseline in diastolic BP and low- and high-density lipoprotein cholesterol . FINDINGS A total of 166 patients were enrolled ( 69 men ; mean age , 67.7 years ; PharmD-PCP MTM group , n = 75 ; usual-care group , n = 91 ) . Mean reduction in SBP was significantly greater in the PharmD-PCP MTM group at 6 months ( -7.1 [ 19.4 ] vs + 1.6 [ 21.0 ] mm Hg ; P = 0.008 ) , but the difference was no longer statistically significant at 9 months ( -5.2 [ 16.9 ] vs -1.7 [ 17.7 ] mm Hg ; P = 0.22 ) , based on an intent-to-treat analysis . In the intervention group , greater percentages of patients who continued to see the MTM pharmacist versus those who returned to their PCP were at goal at 6 months ( 81 % vs 44 % ) and at 9 months ( 70 % vs 52 % ) . No significant between-group differences in changes in cholesterol were detected at 6 and 9 months ; however , the mean baseline values were near recommended levels . The PharmD-PCP MTM group had significantly fewer PCP visits compared with the usual-care group ( 1.8 [ 1.5 ] vs 4.2 [ 1.0 ] ; P < 0.001 ) . IMPLICATION S A PharmD-PCP collaborative MTM service was more effective in lowering BP than was usual care at 6 months in all patients and at 9 months in patients who continued to see the pharmacist . Incorporating pharmacists into the primary care team may be a successful strategy for managing medication therapy , improving patient outcomes and possibly extending the capacity of primary care . Clinical Trials.gov identifier : NCT01973556 BACKGROUND Blood pressure ( BP ) control in patients with diabetes mellitus is difficult to achieve and current patterns are suboptimal . Given increasing problems with access to primary care physicians , community pharmacists and nurses are well positioned to identify and observe these patients . This study aim ed to determine the efficacy of a community-based multidisciplinary intervention on BP control in patients with diabetes mellitus . METHODS We performed a r and omized controlled trial in 14 community pharmacies in Edmonton , Alberta , Canada , of patients with diabetes who had BPs higher than 130/80 mm Hg on 2 consecutive visits 2 weeks apart . Care from a pharmacist and nurse team included a wallet card with recorded BP measures , cardiovascular risk reduction education and counseling , a hypertension education pamphlet , referral to the patient 's primary care physician for further assessment or management , a 1-page local opinion leader-endorsed evidence summary sent to the physician reinforcing the guideline recommendations for the treatment of hypertension and diabetes , and 4 follow-up visits throughout 6 months .  Control-arm patients received a BP wallet card , a pamphlet on diabetes , general diabetes advice , and usual care by their physician . The primary outcome measure was the difference in change in systolic BP between the 2 groups at 6 months . RESULTS A total of 227 eligible patients were r and omized to intervention and control arms between May 5 , 2005 , and September 1 , 2006 . The mean ( SD ) patient age was 64.9 ( 12.1 ) years , 59.9 % were male , and the mean ( SD ) baseline systolic/diastolic BP was 141.2 (13.9)/77.3 ( 8.9 ) mm Hg at baseline . The intervention group had an adjusted mean ( SE ) greater reduction in systolic BP at 6 months of 5.6 ( 2.1 ) mm Hg compared with controls ( P = .008 ) . In the subgroup of patients with a systolic BP greater than 160 mm Hg at baseline , BP was reduced by an adjusted mean ( SE ) of 24.1 ( 1.9 ) mm Hg more in intervention patients than in controls ( P < .001 ) . CONCLUSION Even in patients who have diabetes and hypertension that are relatively well controlled , a pharmacist and nurse team-based intervention result ed in a clinical ly important improvement in BP . Trial Registration clinical trials.gov Identifier : NCT00374270 BACKGROUND R and omized controlled trials have provided unequivocal evidence that treatment of hypertension decreases mortality and major disability from cardiovascular disease ; however , blood pressure remains inadequately treated in most affected individuals . This large gap continues despite the facts that more than 90 % of adults with hypertension have health insurance , and hypertension is the leading cause of visits to the doctor . New approaches are needed to improve hypertension care . OBJECTIVES The Electronic Communications and Home Blood Pressure Monitoring ( e-BP ) study is a three-arm r and omized controlled trial design ed to determine whether care based on the Chronic Care Model and delivered over the Internet improves hypertension care . The primary study outcomes are systolic , diastolic , and blood pressure control ; secondary outcomes are medication adherence , patient self-efficacy , satisfaction and quality of life , and healthcare utilization and costs . METHODS Hypertensive patients receiving care at Group Health medical centers are eligible if they have uncontrolled blood pressure on two screening visits and access to the Web and an e-mail address . Study participants are r and omly assigned to three intervention groups : ( a ) usual care ; ( b ) home blood pressure monitoring receipt and proficiency training on its use and the Group Health secure patient website ( with secure e-mail access to their healthcare provider , access to a shared medical record , prescription refill and other services ) ; or ( c ) this plus pharmacist care management ( collaborative care management between the patient , the pharmacist , and the patient 's physician via a secure patient website and the electronic medical record ) . CONCLUSION We will determine whether a new model of patient-centered care that leverages Web communications , self-monitoring , and collaborative care management improves hypertension control . If this model proves successful and cost-effective , similar interventions could be used to improve the care of large numbers of patients with uncontrolled hypertension BACKGROUND A multisite , r and omized controlled trial was conducted from August 1994 through January 1996 to compare the impact of two strategies-academic detailing ( AD ) and continuous quality improvement ( CQI ) teams-on the implementation of national guidelines for the primary care of hypertension and depression . STUDY Twelve small groups of providers at four clinics-two at Group Health Cooperative of Puget Sound ( Seattle ) and two at academic medical centers-were r and omized in blocks along with their primary care patients to receive AD alone , AD plus CQI , or usual care .  A detailing session conducted by a physician and two follow-up sessions conducted by a pharmacist lasted an average of 8 - 9 minutes . Each CQI team , which met , on average , 14 times in nine months , devised at least one intervention ( for example , weight loss counseling for hypertensives by nurse practitioners ) . RESULTS The detailing endeavors differed greatly across organizations . Although all teams generally worked well together , organizational factors such as staff layoffs and reorganizations competed for the teams ' attention . Team leaders differed in their ability to inspire members to " run with " ideas and to motivate personnel outside the team to implement interventions . SUMMARY AND CONCLUSIONS Surveys and semi-structured interviews suggest that both the AD and CQI interventions involved complex social interactions that result ed in varied implementation across the different organizations . Final analyses will need to focus on identifying factors associated with the relative success or failure of both clinical change techniques OBJECTIVE : To assess the effect of a physician and pharmacist teamwork approach to uncontrolled hypertension in a medical resident teaching clinic , for patients who failed to meet the recommended goals of the fifth Joint National Commission on Detection , Evaluation and Treatment of High Blood Pressure . HYPOTHESIS : Physician and pharmacist teamwork can improve the rate of meeting national blood pressure goals in patients with previously uncontrolled hypertension . DESIGN : A single-blinded r and omized controlled trial lasting 6 months . SETTING : A primary care outpatient teaching clinic . PATIENTS : A sample of 95 adult hypertensive patients who failed to meet national blood pressure goals based on three consecutive visits over a 6-month period . INTERVENTION : Patients were r and omly assigned to a control arm of st and ard medical care or to an intervention arm in which a physician and pharmacist worked together as a team . MAIN RESULTS : At study completion , the percentage of patients achieving national goals due to intervention was more than double the percentage in the control arm ( 55 % vs 20 % , p < .001 ) . Systolic blood pressure declined 23 mm Hg in the intervention arm versus 11 mm Hg in the control arm ( p < .01 ) . Diastolic blood pressure declined 14 and 3 mm Hg in the intervention and control arms , respectively ( p < .001 ) . The intervention worked equally as well in men and women and demonstrated noticeable promise in a minority of mixed-ancestry Hawaiians in whom hypertension is of special concern . CONCLUSIONS : Patients who fail to achieve national blood pressure goals under st and ard outpatient medical care may benefit from a program that includes a physician and pharmacist teamwork approach Recent studies suggest that involving pharmacists is an effective strategy for improving patient adherence and blood pressure ( BP ) control . To date , few controlled studies have tested the cost-effectiveness of specific models for improving patient adherence and BP control in community pharmacies , where most Americans obtain prescriptions . We hypothesized that a team model of adherence monitoring and intervention in corporately owned community pharmacies can improve patient adherence , prescribing , and BP control among hypertensive black patients . The Team Education and Adherence Monitoring ( TEAM ) Trial is a r and omized controlled trial testing a multistep intervention for improving adherence monitoring and intervention in 28 corporately owned community pharmacies . Patients in the 14 control pharmacies received " usual care , " and patients in the 14 intervention pharmacies received TEAM Care by trained pharmacists and pharmacy technicians working with patients and physicians .  Data collectors screened 1250 patients and enrolled 597 hypertensive black patients . The primary end points were the proportion of patients achieving BP control and reductions in systolic and diastolic BP measured after 6 and 12 months . Secondary end points were changes in adherence monitoring and intervention , patient adherence and barriers to adherence , prescribing , and cost-effectiveness . Research ers also will examine potential covariates and barriers to change . Involving pharmacists is a potentially powerful means of improving BP control  in blacks . Pharmacists are in an excellent position to monitor patients between clinic visits and to provide useful information to patients and physicians OBJECTIVE To evaluate the effect of adding pharmacists to primary care teams on the management of hypertension and other cardiovascular risk factors  in patients with type 2 diabetes . RESEARCH DESIGN AND METHODS We conducted a r and omized controlled trial with blinded ascertainment of outcomes within primary care clinics in Edmonton , Canada .  Pharmacists performed medication assessment s and limited history and physical examinations and provided guideline -concordant recommendations to optimize medication management . Follow-up contact was completed as necessary . Control patients received usual care . The primary outcome was a ≥10 % decrease in systolic blood pressure at 1 year . RESULTS A total of 260 patients were enrolled , 57 % were women , the mean age was 59 years , diabetes duration was 6 years , and blood pressure was 129/74 mmHg . Forty-eight of 131 ( 37 % ) intervention patients and 30 of 129 ( 23 % ) control patients achieved the primary outcome ( odds ratio 1.9 [ 95 % CI 1.1–3.3 ] ; P = 0.02 ) . Among 153 patients with inadequately controlled hypertension at baseline , intervention patients ( n = 82 ) were significantly more likely than control patients ( n = 71 ) to achieve the primary outcome ( 41 [ 50 % ] vs. 20 [ 28 % ] ; 2.6 [ 1.3–5.0 ] ; P = 0.007 ) and recommended blood pressure targets ( 44 [ 54 % ] vs. 21 [ 30 % ] ; 2.8 [ 1.4–5.4 ] ; P = 0.003 ) . The 10-year risk of cardiovascular disease , based on changes to the UK Prospect i ve Diabetes Study Risk Engine , were predicted to decrease by 3 % for intervention patients and 1 % for control patients ( P = 0.005 ) . CONCLUSIONS Significantly more patients with type 2 diabetes achieved better blood pressure control  when pharmacists were added to primary care teams , which suggests that pharmacists can make important contributions to the primary care of these patients Background Given the increasing prevalence of diabetes and the lack of patients reaching recommended therapeutic goals , novel models of team-based care are emerging . These teams typically include a combination of physicians , nurses , case managers , pharmacists , and community-based peer health promoters ( HPs ) . Recent evidence supports the role of pharmacists in diabetes management to improve glycemic control , as they offer expertise in medication management with the ability to collaboratively intensify therapy . However , few studies of pharmacy-based models of care have focused on low income , minority population s that are most in need of intervention . Alternatively , HP interventions have focused largely upon low income minority groups , addressing their unique psychosocial and environmental challenges in diabetes self-care . This study will evaluate the impact of HPs as a complement to pharmacist management in a r and omized controlled trial . Methods / Design The primary aim of this r and omized trial is to evaluate the effectiveness of clinical pharmacists and HPs on diabetes behaviors ( including healthy eating , physical activity , and medication adherence ) , hemoglobin A1c , blood pressure , and LDL-cholesterol levels .  A total of 300 minority patients with uncontrolled diabetes from the University of Illinois Medical Center ambulatory network in Chicago will be r and omized to either pharmacist management alone , or pharmacist management plus HP support . After one year , the pharmacist-only group will be intensified by the addition of HP support and maintenance will be assessed by phasing out HP support from the pharmacist plus HP group ( crossover design ) . Outcomes will be evaluated at baseline , 6 , 12 , and 24 months . In addition , program and healthcare utilization data will be incorporated into cost and cost-effectiveness evaluations of pharmacist management with and without HP support . Discussion The study will evaluate an innovative , integrated approach to chronic disease management in minorities with poorly controlled diabetes . The approach is comprised of clinic-based pharmacists and community-based health promoters collaborating together . They will target patient-level factors ( e.g. , lack of adherence to lifestyle modification and medications ) and provider-level factors ( e.g. , clinical inertia ) that contribute to poor clinical outcomes in diabetes . Importantly , the study design and analytic approach will help determine the differential and combined impact of adherence to lifestyle changes , medication , and intensification on clinical outcomes .Trial registration Clinical Trials.gov identifier : PURPOSE The impact of pharmacist interventions on short-term clinical markers and long-term cardiovascular risk in patients with type 2 diabetes is investigated . METHODS Selected health outcomes were retrospectively analyzed in 147 adults with type 2 diabetes whose care was managed by a team of providers including a pharmacist ( the enhanced care group ) and a matched sample of patients ( n = 147 ) managed by a primary care physician only ( the control group ) . All patients received services through the same health maintenance organization ( HMO ) . The primary study endpoints were ( 1 ) the changes from baseline to 12-month follow-up in glycosylated hemoglobin ( HbA(1c ) ) , low-density lipoprotein cholesterol ( LDL-C ) , and blood pressure ( BP ) values , ( 2 ) rates of attainment of HbA(1c ) , LDL-C and BP goals , and ( 3 ) changes from baseline in predicted 10-year risks of coronary heart disease ( CHD ) and stroke . RESULTS During the 12-month study period , the mean HbA(1c ) value was decreased from 9.5 % to 6.9 % in the enhanced care group and from 9.3 % to 8.4 % in the control group ( p < 0.001 ) ; patients in the enhanced care group were significantly more likely to attain goals for HbA(1c ) ( odds ratio [ OR ] , 3.9 ) , LDL-C ( OR , 2.0 ) , and BP reduction ( OR , 2.0 ) and three times more likely to attain all three goals ( OR , 3.2 ) . The estimated 10-year risk of CHD was decreased from 16.4 % to 9.3 % with enhanced care versus a reduction from 17.4 % to 14.8 % with usual care ( p < 0.001 ) . CONCLUSION The addition of a pharmacist to an HMO primary care team improved short-term surrogate markers as well as long-term cardiovascular risk in adult patients with type 2 diabetes Abstract Agreement was reached with 12 acute medical and surgical wards/units at Sydney ’s Prince of Wales Hospital to participate in a trial of team nursing ( TN ) . Six units employed action research principles to undertake a change to a team nursing model and six remained with the pre-existing individual patient allocation ( IPA ) model . Task-based teaming was widely discarded by the team nursing units in favour of allocating patients within the team and introducing more supportive and communicative processes aim ed at fostering responsibility sharing . Localised team-based models of care arose in the change wards and were outlined , implemented and refined using social action research principles . A 12-month prospect i ve experimental comparison of job satisfaction and staff retention between the TN and IPA groups indicated statistically significant job satisfaction benefits and practically important staff retention benefits associated with moving away from an IPA model of nursing care delivery towards a team-based model of care delivery . Perhaps not surprisingly , job satisfaction gains were most marked among new graduate nurses , who reported real benefits from a teaming inspired shift in model of care in the acute inpatient environment Context Why do clinicians fail to intensify antihypertensive therapy when a patient 's blood pressure is elevated ? Contribution This study involved 1169 diabetic patients seen by 92 primary care providers at 9 Veterans Affairs facilities . All had elevated triage blood pressures , but only half received antihypertensive treatment intensification by providers . Patient reports of home blood pressures or repeated blood pressures by providers within normal limits and discussion of medication issues decreased the likelihood of antihypertensive intensification at clinic visits . Implication Uncertainty about true blood pressure values may underlie many reasons why physicians do not intensify antihypertensive therapy . The Editors Despite some recent improvements in blood pressure control , the number of patients with inadequate control remains high and contributes to excess morbidity and mortality , especially among patients at high risk from complications of hypertension ( 18 ) . Several studies have suggested that clinical inertiathe failure by providers to initiate or intensify therapy ( medication intensification ) in the face of apparent need to do sois a main contributor to poor control of hypertension ( 912 ) . Although the failure to intensify treatment medications for patients with elevated blood pressures at visits has been well documented ( 5 , 6 , 1218 ) , factors underlying what seems to be clinical inertia have been studied less systematic ally . When providers are queried after clinic visits about the lack of medication intensification for elevated blood pressure , they variously report that the patient 's true blood pressure was lower than the clinic blood pressure reading , that other patient concerns precluded attention on blood pressure management , and that patient adherence should be improved before medication intensification ( 6 , 17 ) . Some studies have examined the role of various clinical and patient factors in intensification decisions ( 6 , 8 , 17 , 19 , 20 ) , but no study has used a detailed conceptual model to comprehensively examine the relative contribution of a broad array of potential patient , provider , organizational , and visit-specific contributors to a medication intensification decision . In addition , although a frequently cited reason for deferring medication changes is that the clinic blood pressure does not reflect the patient 's true blood pressure ( 21 , 22 ) , this clinical uncertainty and its effects have not been explored . To better underst and factors underlying apparent clinical inertia for hypertension , we design ed the ABATe ( Addressing Barriers to Treatment for Hypertension ) study to examine treatment change decisions for diabetic primary care patients with elevated triage blood pressures  before a primary care visit . We defined elevated blood pressure for this population to be 140/90 mm Hg , a value well above guideline targets for diabetic patients and one clearly requiring some type of action ( 4 ) . Our goals were to assess how often patients presenting with an elevated triage blood pressure  received medication intensification or were scheduled for close follow-up and the role that clinical uncertainty about blood pressure , competing dem and s and prioritization , medication-related factors , and care organization play in treatment change decisions . Methods Conceptual Model On the basis of theories of patient , provider , and organization behavior ( 2336 ) , we developed a conceptual modelthe hypertension clinical action modelto examine decisions that drive treatment change ( medication intensification or prompt blood pressure follow-up ) for elevated blood pressure ( Figure 1 ) . The model , developed by 2 internists and 3 PhD-level method ologists in conjunction with development of ABATe and before data collection , proposes such treatment change decisions at a visit are based on 4 main conceptual domains : clinical uncertainty ( Is the patient 's blood pressure truly elevated ? Does the clinic blood pressure reflect the true blood pressure ? ) , competing dem and s and prioritization ( What other problems need to be addressed at this visit ? Is blood pressure management a priority for this particular patient ? Does the provider place priority on blood pressure management in general ? ) , medication-related factors ( Should adherence be addressed first ? Is the medication regimen too complex ? Will the patient accept another medication ? ) , and care organization ( Is there sufficient time to address hypertension ? Are staff available for follow-up ? ) . In addition , as part of grant development , we hypothesized that the following factors would lead to a lower probability of treatment change : uncertainty about whether the patient 's visit blood pressure reflected their true blood pressure ( clinical uncertainty ) , comorbid conditions unrelated to hypertension and diabetes ( 37 ) , a lower priority placed by the provider on the importance of treating elevated blood pressure , a higher number of baseline medications , perceived medication adherence problems , shorter clinic visit times , and lack of staff to follow up for blood pressure medication adjustment . Figure 1 . Hypertension clinical action model . Design Setting We conducted a prospect i ve cohort study of patients with scheduled primary care visits at 9 Veterans Affairs facilities located in 3 midwestern states . These facilities varied in size and structure , with 3 large academic-affiliated medical centers , 1 large nonacademic medical center , and 1 large and 4 small community-based outpatient clinics . From 15 February 2005 to 14 February 2006 , approximately 33500 diabetic patients visited primary care providers ( including residents ) in these facilities ( range per facility , 1050 to 9200 diabetic patients ) . The institutional review boards of all participating facilities approved the study protocol . Both patients and providers gave written informed consent before participating . Providers received a $ 50 bookstore gift card , and patients received a $ 10 department store gift card for completing initial surveys . Providers were told that the study was about diabetes and hypertension , with the purpose being to study challenges in treating patients with diabetes and ways to overcome these challenges so that quality of care can be enhanced . Primary Care Providers We invited all nonresident primary care providers with patient care responsibility at least 2 half-days per week to participate in the study . Of the eligible 126 providers approached , 104 consented to participate , for an overall recruitment rate of 83 % ( median facility-level recruitment rate , 88 % ) . By the time recruitment started , 12 providers had stopped working at their facility or changed their patient care responsibilities , leaving 92 primary care providers still eligible to participate ( range per facility , 2 to 28 providers ; median , 8) . Patients As specified by our institutional review board protocol s , potentially eligible patients were referred to study staff by triage personnel . During the enrollment periods at each facility , study staff screened all referred patients who presented for a scheduled visit to participating primary care providers and whose lowest triage systolic blood pressure was 140 mm Hg or greater or whose lowest triage diastolic blood pressure was 90 mm Hg or greater ( Figure 2 ) . In each of the facilities , triage staff routinely used an electronic cuff to check the patient 's blood pressure  before the provider visit . Triage policies specified that a second blood pressure measurement should be obtained if the first blood pressure was elevated . In addition to the triage blood pressure , study staff screened patients for the following inclusion criteria : the participant confirmed a diagnosis of diabetes , the participating provider was the primary provider of diabetes care for the participant , and the participant spoke English . Patients with impaired decision-making ability ( for example , dementia and traumatic brain injury ) or terminal disease and residents of nursing homes were excluded . Of the 1556 patients approached by study staff , 213 were ineligible ( Figure 2 ) and 1169 provided written informed consent to participate in the study ( approached and eligible , 87 % ; median facility-level recruitment rate , 89 % ) . We enrolled a median of 14 patients per provider ( range , 1 to 16 patients ) from February 2005 to March 2006 . Recruitment time per facility varied from 4 to 12 months . Figure 2 . Study flow diagram . PCP = primary care provider . * Diabetic patients presenting for a primary care visit to 1 of 92 participating providers were referred for eligibility assessment if their lowest triage blood pressure was140/90 mm Hg . * Number of responses varied by individual item . Our prespecified sample size calculations stipulated that we needed at least 11 patients from 80 physicians across 8 sites ( that is , 880 patients ) to detect a moderate difference in treatment change ( about 12 % ) when competing dem and s were or were not present . Data Sources We included data from 5 sources in our analysis ( Table 1 ) . First , a baseline survey completed by all providers provided variables assessing provider prioritization to blood pressure management , general provider characteristics , and availability of ancillary support for blood pressure management . Second , providers completed a brief visit survey for each patient after the same clinic session in which they saw the patient ( completion rate , 99 % ) . This survey provided information on which issues were discussed during the visit , the provider 's blood pressure goal for the patient , and whether medications were changed during the visit . Third , a patient survey conducted at enrollment provided sociodemographic characteristics , self-reported adherence and difficulty with medications , and self-management practice s ( completion rate , 91 % ) . Fourth , review of electronic medical records documented free text blood pressure values and notes on actions taken at the enrollment visit . Finally , patient age , prescribed medications and OBJECTIVE To evaluate the effect of teamwork ( physician and pharmacist ) on the management of uncontrolled hypertensive patients . METHODS This is a r and omized controlled clinical trial conducted from March to November 2009 . Patients attending the Family Medicine Clinic at Jordan University Hospital , Amman , Jordan with uncontrolled hypertension were invited to participate in the study . A total of 253 patients were r and omly allocated to an intervention ( n=130 ) or control group . In the intervention group , patients were managed by a physician-pharmacist team . In the control group , patients were managed by physician(s ) only . RESULTS In the intervention group , 79.4 % of patients achieved blood pressure ( BP ) goals specified by the Joint National Committee on Prevention and Management , Detection , Evaluation , and Treatment of High Blood Pressure ( JNC VII ) compared to 65.6 % in the control group ( p=0.01 ) . Decline in systolic BP was 16.1 + /- 14.6 mm Hg in the intervention group , and 10.6 + /- 13.5 mm Hg in the control group ( p=0.002 ) . Reduction in diastolic BP was 10.5 + /- 12.9 mm Hg in the intervention group , and 7.17 + /- 13.11 mm Hg in the control group , ( p=0.04 ) . Data were presented as mean + /- st and ard deviation . CONCLUSION This study found that the physician-pharmacist collaborative approach to uncontrolled hypertension in Jordan improved the rate of BP control in hypertensive patients , and result ed in more profound decline in both systolic and diastolic BP , and this will probably reflect on better outcomes in cardiovascular diseases . Establishing pharmaceutical care managed clinic in the setting of outpatient-clinics is possible , and provides better management of patients 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 r and omized 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 r and omly 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 clinical trials.gov Identifier : NCT00158639 OBJECTIVE To compare the effectiveness of an evidence -based , systematic approach to hypertension care involving comanagement of patients by primary care physicians and clinical pharmacists versus usual care in reducing blood pressure in patients with uncontrolled hypertension . METHODS Patients in a staff model medical group with uncontrolled hypertension were r and omized to either a usual care ( UC ) or a physician-pharmacist comanagement ( PPCM ) group . All physicians in the study received both group and individual education and participated in the development of an evidence -based hypertension treatment algorithm . Physicians were then given the names of their patients whose medical records documented elevated blood pressures ( defined as systolic > or = 140 mm Hg and /or diastolic > or = 90 mm Hg for patients aged < 65 yrs , and systolic > or = 160 mm Hg and /or diastolic > or = 90 mm Hg for those aged > or = 65 yrs ) . Patients r and omized to the UC group were managed by primary care physicians alone . Those r and omized to the PPCM group were comanaged by their primary care physician and a clinical pharmacist , who provided patient education , made treatment recommendations , and provided follow-up .  Blood pressure measurements , antihypertensive drugs , and visit costs/patient were obtained from medical records . RESULTS One hundred ninety-seven patients with uncontrolled hypertension participated in the study . Both PPCM and UC groups experienced significant reductions in blood pressure ( systolic -22 and -11 mm Hg , respectively , p < 0.01 ; diastolic -7 and -8 mm Hg , respectively , p < 0.01 ) . The reduction in systolic blood pressure was greater in the PPCM group after adjusting for differences in baseline blood pressure between the groups ( p < 0.01 ) . More patients achieved blood pressure control in the PPCM than in the UC group ( 60 % vs 43 % , p = 0.02 ) . Average provider visit costs/patient were higher in the UC than the PPCM group ( $ 195 vs $ 160 , p = 0.02 ) . CONCLUSIONS An evidence -based , systematic approach using physician-pharmacist comanagement for patients with uncontrolled hypertension result ed in improved blood pressure control and reduced average visit costs/patient There is evidence for a team-based approach in the management of chronic disease in primary health care . However , the st and ard of care is variable , probably reflecting the limited organisational capacity of health services to provide the necessary structured and organised care for this group of patients . This study aim ed to evaluate the impact of a structured intervention involving non-GP staff in GP practice s  on the quality of care for patients with diabetes or cardiovascular disease . A cluster r and omised trial was undertaken across 60 GP practice s. The intervention was implemented in 30 practice s with staff and patients interviewed at baseline and at 12 - 15 months follow up . The change in team roles was evaluated using a  question naire completed by practice staff . The quality of care was evaluated using the Patient Assessment of Chronic Illness Care question naire . We found that although the team roles of staff improved in the intervention practice s and there were significant differences between practice s , there was no significant difference between those in the intervention and control groups in patient-assessed quality of care after adjusting for baseline-level score and covariates at the 12-month follow up . Practice team roles were not significantly associated with change in Patient Assessment of Chronic Illness Care scores .  Patients with multiple conditions were more likely to assess their quality of care to be better . Thus , although previous research has shown a cross-sectional association between team work and quality of care , we were unable to replicate these findings in the present study . These results may be indicative of insufficient time for organisational change to result in improved patient-assessed quality of care , or because non-GP staff roles were not sufficiently focussed on the aspects of care assessed . The findings provide important information for research ers when design ing similar studies Complex interventions , which have been shown to improve primary care depression outcomes , are difficult to disseminate to routine practice setting s. To address this problem , we developed a brief intervention to train primary care physicians and nurses employed by the practice to improve the detection and management of major depression . Before recruitment began , the research team conducted academic detailing conference calls with primary care physicians and nurses , and provided in-person training with nurses and administrative staff . Administrative staff screened over 11,000 patients before their visits to identify those with probable major depression . Primary care physicians delegated increased responsibility to office nurses , who educated over 90 % of patients about effective depression treatment and systematic ally monitored their progress over time . Early results demonstrate that community primary care practice s can rebundle traditional team roles over the short-term to provide more systematic mental health treatment without adding additional personnel . A rigorous evaluation of this effort will reduce time-consuming , expensive , and often unsuccessful efforts to " translate " research intervention findings into everyday practice BACKGROUND Improving the quality and efficiency of chronic disease care is an important goal . OBJECTIVE To test whether patients with chronic disease working with lay " care guides "  would achieve more evidence -based goals than those receiving usual care . DESIGN Parallel-group r and omized trial , stratified by clinic and conducted from July 2010 to April 2012 . Patients were assigned in a 2:1 ratio to a care guide or usual care . Patients , providers , and persons assessing outcomes were not blinded to treatment assignment . ( Clinical Trials.gov : NCT01156974 ) . SETTING 6 primary care clinics in Minnesota . PATIENTS Adults with hypertension , diabetes , or heart failure . INTERVENTION 2135 patients were given  disease-specific information about st and ard care goals and asked to work toward goals for 1 year , with or without the help of a care guide . Care guides were 12 laypersons who received brief training about these diseases and behavior change . MEASUREMENTS The primary end point for each patient was change in percentage of goals met 1 year after enrollment . RESULTS The percentage of goals met increased in both the care guide and usual care groups ( changes from baseline , 10.0 % and 3.9 % , respectively ) . Patients with care guides achieved more goals than usual care patients ( 82.6 % vs. 79.1 % ; odds ratio , 1.31 [ 95 % CI , 1.16 to 1.47 ] ; P < 0.001 ) ; reduced unmet goals by 30.1 % compared with 12.6 % for usual care patients ; and improved more than usual care patients in meeting several individual goals , including not using tobacco . Estimated cost was $ 286 per patient per year . LIMITATIONS Providers ' usual care may have been influenced by contact with care guides . Last available data in the electronic health record were used to assess end points . CONCLUSION Adding care guides to the primary care team can improve care for some patients with chronic disease at low cost It is important to underst and the effects of a new care model on health professionals ' satisfaction , which may help inform organizations ' decisions regarding the adoption of the model . This study evaluates the effect of the Guided Care model of primary care on physicians ' , Guided Care Nurses ' and practice staff satisfaction with processes of care for chronically ill older patients . In Guided Care , a specially educated registered nurse works with 2 - 5 primary care physicians , performing 8 clinical activities for 50 - 60 chronically ill older patients . This model was tested in a 3-year matched-pair cluster-r and omized controlled trial with 14 pods ( teams of physicians and staff ) r and omly assigned , within pairs , to provide Guided Care or usual care . Physicians and Guided Care Nurses were surveyed at baseline and annually for 3 years . Staff were surveyed at baseline and 2 years later . Physicians ' satisfaction with chronic care processes , knowledge of patients , and care coordination were measured , as well as Guided Care Nurses ' satisfaction with chronic care processes and staff perceptions of quality of care . Findings suggest that Guided Care improved physician satisfaction with patient/family communication and management of chronic care , and it may bolster staff beliefs that care is patient oriented . Differences in other aspects of care were not statistically significant PURPOSE To determine whether the type of health care provider ( i.e. , physician versus physician-nurse team ) affected the quality of hypertension care given to two groups of r and omly selected adult women . DATA SOURCES Three indicators measured the quality of hypertension care : blood pressure control level , knowledge of hypertension , and discussion about blood pressure medications with the health care provider(s ) .  Blood pressure readings were taken with a 24-hr ambulatory blood pressure monitor , and demographic data from survey results taken at orientation and research er-collected data on posttreatment knowledge of hypertension and cognitive representations of hypertension were gathered . Chi-square and t tests were used to analyze the data . CONCLUSIONS The group whose care was managed by a physician-nurse team demonstrated lower means for 24-hr systolic blood pressure and diastolic blood pressure ( systolic : M = 132 , SD = 14.9 ; diastolic : M = 75 , SD = 11.3 ) than the group whose care was managed only by one or more physicians ( systolic : M = 136 , SD = 13.4 ; diastolic : M = 79 , SD = 11.24 ) . Also , the group whose care was managed by a physician-nurse team revealed significantly higher scores for discussion of blood pressure medication than the group whose care was managed only by one or more physicians . There were no group differences for knowledge of hypertension . IMPLICATION S FOR PRACTICE Nurses qualified to assist with meeting the needs of hypertension clients in primary care setting s can positively affect clients ' knowledge about blood pressure medication and --perhaps as a result of this knowledge -- how well the clients control their blood pressure Background — Hypertension control rates remain suboptimal . Pharmacists ’ scope of practice is evolving , and their position in the community may be ideal for improving hypertension care . We aim ed to study the impact of pharmacist prescribing on blood pressure ( BP ) control in community-dwelling patients . Methods and Results — We design ed a patient-level , r and omized , controlled trial , enrolling adults with above-target BP ( as defined by Canadian guidelines ) through community pharmacies , hospitals , or primary care teams in 23 communities in Alberta . Intervention group patients received an assessment of BP and cardiovascular risk , education on hypertension , prescribing of antihypertensive medications , laboratory monitoring , and monthly follow-up visits for 6 months ( all by their pharmacist ) . Control group patients received a wallet card for BP recording , written hypertension information , and usual care from their pharmacist and physician . Primary outcome was the change in systolic BP at 6 months . A total of 248 patients ( mean age , 64 years ; 49 % male ) were enrolled .  Baseline mean±SD systolic/diastolic BP was 150±14/84±11 mm Hg . The intervention group had a mean±SE reduction in systolic BP at 6 months of 18.3±1.2 compared with 11.8±1.9 mm Hg in the control group , an adjusted difference of 6.6±1.9 mm Hg ( P=0.0006 ) . The adjusted odds of patients achieving BP targets was 2.32 ( 95 % confidence interval , 1.17–4.15 in favor of the intervention ) . Conclusions — Pharmacist prescribing for patients with hypertension result ed in a clinical ly important and statistically significant reduction in BP . Policy makers should consider an exp and ed role for pharmacists , including prescribing , to address the burden of hypertension . Clinical Trial Registration — URL : http://www . clinical trials.gov . Unique identifier : NCT00878566 Background —Despite well-publicized guidelines on the appropriate management of cardiovascular disease and type 2 diabetes , the implementation of risk-reducing practice s remains poor . This report describes the results of a r and omized , controlled clinical trial evaluating the effectiveness of a comprehensive program of cardiovascular disease risk reduction delivered by nurse practitioner /community health worker ( NP/CHW ) teams versus enhanced usual care ( EUC ) to improve lipids , blood pressure , glycated hemoglobin ( HbA1c ) , and patient perceptions of the quality of their chronic illness care in patients in urban community health centers . Methods and Results —A total of 525 patients with documented cardiovascular disease , type 2 diabetes , hypercholesterolemia , or hypertension and levels of LDL cholesterol , blood pressure , or HbA1c that exceeded goals established by national guidelines were r and omly assigned to NP/CHW ( n=261 ) or EUC ( n=264 ) groups . The NP/CHW intervention included aggressive pharmacological management and tailored educational and behavioral counseling for lifestyle modification and problem solving to address barriers to adherence and control . Compared with EUC , patients in the NP/CHW group had significantly greater 12-month improvement in total cholesterol ( difference , 19.7 mg/dL ) , LDL cholesterol ( difference,15.9 mg/dL ) , triglycerides ( difference , 16.3 mg/dL ) , systolic blood pressure ( difference , 6.2 mm Hg ) , diastolic blood pressure ( difference , 3.1 mm Hg ) , HbA1c ( difference , 0.5 % ) , and perceptions of the quality of their chronic illness care ( difference , 1.2 points ) . Conclusions —An intervention delivered by an NP/CHW team using individualized treatment regimens based on treat-to-target algorithms can be an effective approach to improve risk factor status and perceptions of chronic illness care in high-risk patients . Clinical Trial Registration —URL : http://www . clinical trials.gov . Unique identifier : NCT00241904 Background Diabetes and hypertension are devastating , deadly , and costly conditions that are very common in seniors . Controlling hypertension in seniors with diabetes dramatically reduces hypertension-related complications . However , blood pressure ( BP ) must be lowered carefully because seniors are also susceptible to low BP and attendant harms . Achieving “ optimal BP control ” ( ie , avoiding both undertreatment and overtreatment ) is the ultimate therapeutic goal in such patients . Regular BP monitoring is required to achieve this goal . BP monitoring at home is cheap , convenient , widely used , and guideline endorsed . However , major barriers prevent proper use . These may be overcome through use of BP telemonitoring — the secure teletransmission of BP readings to a health portal , where BP data are summarized for provider and patient use , with or without protocol ized case management . Objective To examine the incremental effectiveness , safety , cost-effectiveness , usability , and acceptability of home BP telemonitoring , used with or without protocol ized case management , compared with “ enhanced usual care ” in community-dwelling seniors with diabetes and hypertension . Methods A 300-patient , 3-arm , pragmatic r and omized controlled trial with blinded outcome ascertainment will be performed in seniors with diabetes and hypertension living independently in seniors ’ residences in greater Edmonton . Consenting patients will be r and omized to usual care , home BP telemonitoring alone , or home BP telemonitoring plus protocol ized pharmacist case management . Usual care subjects will receive a home BP monitor but neither they nor their providers will have access to teletransmitted data . In both telemonitored arms , providers will receive telemonitored BP data summaries . In the case management arm , pharmacist case managers will be responsible for review ing teletransmitted data and initiating guideline -concordant and protocol ized changes in BP management . Results Outcomes will be ascertained at 6 and 12 months . Within- study -arm change scores will be calculated and compared between study arms . These include : ( 1 ) clinical outcomes : proportion of subjects with a mean 24-hour ambulatory systolic BP in the optimal range ( 110 - 129 mmHg in patients 65 - 79 years and 110 - 139 mmHg in those ≥80 years : primary outcome ) ; additional ambulatory and home BP outcomes ; A1c and lipid profile ; medications , cognition , health care use , cardiovascular events , and mortality . ( 2 ) Safety outcomes : number of serious episodes of hypotension , syncope , falls , and electrolyte disturbances ( requiring third party assistance or medical attention ) . ( 3 ) Humanistic outcomes : quality of life , satisfaction , and medication adherence . ( 4 ) Economic outcomes : incremental costs , incremental cost-utility , and cost per mmHg change in BP of telemonitoring ± case management compared with usual care ( health payor and societal perspectives ) . ( 5 ) Intervention usability and acceptability to patients and providers . Conclusion The potential benefits of telemonitoring remain largely unstudied and unproven in seniors . This trial will comprehensively assess the impact of home BP telemonitoring across a range of outcomes . Results will inform the value of implementing home-based telemonitoring within supportive living residences in Canada . Trial Registration Clinical trials.gov NCT02721667 ; https:// clinical trials.gov/ct2/show/NCT02721667 ( Archived by Webcite at http://www.webcitation.org/6i8tB20Mc The aim of this study was to investigate staff experiences in implementing guidelines for Kangaroo Mother Care in neonatal care . The study was part of a r and omized controlled trial , the overall goal of which was to assess the impact of external facilitation . A total of eight focus group interviews were held at two intervention and two control units . The establishment of a change team to implement the guideline result ed in activities that impacted staff behaviour , which in turn was perceived to influence patients ' well-being . The guideline and context ual factors , such as leadership and staff colleagues ' attitudes , were of significant importance in that process . The study intervention -- facilitation -- promoted implementation activities and was highly appreciated by the change teams . However , review ing the development of events at one of the control units , the provided facilitation appeared to be no more effective than an improvement-focused organizational culture in which the nurse manager was actively involved in the change process . Overall , learning and behaviour change seemed to be a social phenomenon , something that greatly benefited from people 's interaction with one another Background and objectives Many clinical management guidelines for chronic diseases have been published , but they have not been put into practice by busy clinicians at primary care levels . This study evaluates the implementation of national guidelines incorporated within a structured diabetes and hypertension clinical record ( SR ) in Cape Town in a r and omised controlled trial ( RCT ) . Methods Eighteen public sector community health centres ( CHC ) were r and omly selected and allocated as intervention or control CHC . At each clinic , 25 patients with diabetes and 35 patients with hypertension were enrolled at baseline . Question naires were completed , blood sample s were collected , blood pressure ( BP ) and anthropometric measures were taken and patient records were audited . SR with clinical guideline prompts were introduced at the intervention clinics after training doctors in their use and suggestions to incorporate them in regular patient records . Contact was maintained during the year of intervention with the clinic staff . A follow-up survey was conducted 1 year later to assess BP and HbA1c , and the patient records were examined to ascertain the extent of use of the SR in the intervention clinics . In-depth interviews were conducted with doctors and nurses to record their response to the intervention . Results The intervention evaluated in this RCT had no impact on either diabetes or hypertension control . In the intervention clinics , less than 60 % of the patient folders contained the SR and when present was seldom used . Although the staff were well disposed to the research team , their workload prohibited them from undertaking a true evaluation of the SR , and overall they did not perceive the SR as supporting their current process of patient care . Conclusions No benefit to diabetes of hypertension care by introducing and availability of the staff in the use of the SR was shown in this RCT . The process measures suggest that the SR was not widely used by the healthcare provided in the primary care clinics Background and objectives Many clinical management guidelines for chronic diseases have been published , but they have not been put into practice by busy clinicians at primary care levels . This study evaluates the implementation of national guidelines incorporated within a structured diabetes and hypertension clinical record ( SR ) in Cape Town in a r and omised controlled trial ( RCT ) . Methods Eighteen public sector community health centres ( CHC ) were r and omly selected and allocated as intervention or control CHC . At each clinic , 25 patients with diabetes and 35 patients with hypertension were enrolled at baseline . Question naires were completed , blood sample s were collected , blood pressure ( BP ) and anthropometric measures were taken and patient records were audited . SR with clinical guideline prompts were introduced at the intervention clinics after training doctors in their use and suggestions to incorporate them in regular patient records . Contact was maintained during the year of intervention with the clinic staff . A follow-up survey was conducted 1 year later to assess BP and HbA1c , and the patient records were examined to ascertain the extent of use of the SR in the intervention clinics . In-depth interviews were conducted with doctors and nurses to record their response to the intervention . Results The intervention evaluated in this RCT had no impact on either diabetes or hypertension control . In the intervention clinics , less than 60 % of the patient folders contained the SR and when present was seldom used . Although the staff were well disposed to the research team , their workload prohibited them from undertaking a true evaluation of the SR , and overall they did not perceive the SR as supporting their current process of patient care . Conclusions No benefit to diabetes of hypertension care by introducing and availability of the staff in the use of the SR was shown in this RCT . The process measures suggest that the SR was not widely used by the healthcare provided in the primary care clinics UNLABELLED In June 2008 , the Medical Advisory Secretariat began work on the Diabetes Strategy Evidence Project , an evidence -based review of the literature surrounding strategies for successful management and treatment of diabetes . This project came about when the Health System Strategy Division at the Ministry of Health and Long-Term Care subsequently asked the secretariat to provide an evidentiary platform for the Ministry 's newly released Diabetes Strategy .After an initial review of the strategy and consultation with experts , the secretariat identified five key areas in which evidence was needed . Evidence -based analyses have been prepared for each of these five areas : insulin pumps , behavioural interventions , bariatric surgery , home telemonitoring , and community based care . For each area , an economic analysis was completed where appropriate and is described in a separate report . To review these titles within the Diabetes Strategy Evidence series , please visit the Medical Advisory Secretariat Web site , http://www.health.gov.on.ca/english/providers/program/mas/mas_about.html,DIABETES STRATEGY EVIDENCE PLATFORM : Summary of Evidence -Based AnalysesContinuous Subcutaneous Insulin Infusion Pumps for Type 1 and Type 2 Adult Diabetics : An Evidence -Based Analysis Behavioural Interventions for Type 2 Diabetes : An Evidence -Based Analysis BARIATRIC SURGERY FOR PEOPLE WITH DIABETES AND MORBID OBESITY : An Evidence -Based Summary Community-Based Care for the Management of Type 2 Diabetes : An Evidence -Based Analysis Home Telemonitoring for Type 2 Diabetes  : An Evidence -Based Analysis Application of the Ontario Diabetes Economic Model ( ODEM ) to Determine the Cost-effectiveness and Budget Impact of Selected Type 2 Diabetes Interventions in Ontario OBJECTIVE The objective of this report is to determine the efficacy of specialized multidisciplinary community care for the management of type 2 diabetes compared to usual care . CLINICAL NEED TARGET POPULATION AND CONDITION Diabetes ( i.e. diabetes mellitus ) is a highly prevalent chronic metabolic disorder that interferes with the body 's ability to produce or effectively use insulin . The majority ( 90 % ) of diabetes patients have type 2 diabetes . ( 1 ) Based on the United Kingdom Prospect i ve Diabetes Study ( UKPDS ) , intensive blood glucose and blood pressure control significantly reduce the risk of microvascular and macrovascular complications in type 2 diabetics . While many studies have documented that patients often do not meet the glycemic control targets specified by national and international guidelines , factors associated with glycemic control are less well studied , one of which is the provider(s ) of care . Multidisciplinary approaches to care may be particularly important for diabetes management . According guidelines from the Canadian Diabetes Association ( CDA ) , the diabetes health care team should be multi- and interdisciplinary . Presently in Ontario , the core diabetes health care team consists of at least a family physician and /or diabetes specialist , and diabetes educators ( registered nurse and registered dietician ) . Increasing the role played by allied health care professionals in diabetes care and their collaboration with physicians may represent a more cost-effective option for diabetes management . Several systematic review s and meta-analyses have examined multidisciplinary care programs , but these have either been limited to a specific component of multidisciplinary care ( e.g. intensified education programs ) , or were conducted as part of a broader disease management program , of which not all were multidisciplinary in nature . Most review s also do not clearly define the intervention(s ) of interest , making the evaluation of such multidisciplinary community programs challenging . EVIDENCE -BASED ANALYSIS METHODS RESEARCH QUESTIONS What is the evidence of efficacy of specialized multidisciplinary community care provided by at least a registered nurse , registered dietician and physician ( primary care and /or specialist ) for the management of type 2 diabetes compared to usual care ? [ Henceforth referred to as Model 1]What is the evidence of efficacy of specialized multidisciplinary community care provided by at least a pharmacist and a primary care physician for the management of type 2 diabetes compared to usual care ? [ Henceforth referred to as Model 2 ] INCLUSION CRITERIA English language full-reportsPublished between January 1 , 2000 and September 28 , 2008R and omized controlled trials ( RCTs ) , systematic review s and meta-analysesType 2 diabetic adult population ( ≥18 years of age)Total sample size ≥30Describe specialized multidisciplinary community care defined as ambulatory-based care provided by at least two health care disciplines ( of which at least one must be a specialist in diabetes ) with integrated communication between the care providers . Compared to usual care ( defined as health care provision by non-specialist(s ) in diabetes , such as primary care providers ; may include referral to other health care professionals/services as necessary)≥6 months follow-up EXCLUSION CRITERIA Studies where discrete results on diabetes can not be abstract edPredominantly home-based interventions Inpatient-based interventions OUTCOMES OF INTEREST The primary outcomes for this review were glycosylated hemoglobin ( rHbA1c ) levels and systolic blood pressure ( SBP ) . SEARCH STRATEGY A literature search was performed on September 28 , 2008 using OVID MEDLINE , MEDLINE In-Process and Other Non-Indexed Citations , EMBASE , the Cumulative Index to Nursing & Allied Health Literature ( CINAHL ) , the Cochrane Library , and the International Agency for Health Technology Assessment ( INAHTA ) for studies published between January 1 , 2000 and September 28 , 2008 . Abstract s were review ed by a single review er and , for those studies meeting the eligibility criteria , full-text articles were obtained . Reference lists were also examined for any additional relevant studies not identified through the search . Articles with unknown eligibility were review ed with a second clinical epidemiologist , then a group of epidemiologists until consensus was established . The quality of evidence was assessed as high , moderate , low or very low according to GRADE methodology . Given the high clinical heterogeneity of the articles that met the inclusion criteria , specific models of specialized multidisciplinary community care were examined based on models of care that are currently being supported in Ontario , models of care that were commonly reported in the literature , as well as suggestions from an Expert Advisory Panel Meeting held on January 21 , 2009 . SUMMARY OF FINDINGS The initial search yielded 2,116 unique citations , from which 22 RCTs trials and nine systematic review s published were identified as meeting the eligibility criteria . Of these , five studies focused on care provided by at least a nurse , dietician , and physician ( primary care and /or specialist ) model of care ( Model 1 ; see Table ES 1 ) , while three studies focused on care provided by at least a pharmacist and primary care physician ( Model 2 ; see Table ES 2 ) . Based on moderate quality evidence , specialized multidisciplinary community care Model 2 has demonstrated a statistically and clinical ly significant reduction in HbA1c of 1.0 % compared with usual care . The effects of this model on SBP , however , are uncertain compared with usual care , based on very-low quality evidence . Specialized multidisciplinary community care Model 2 has demonstrated a statistically and clinical ly significant reduction in both HbA1c of 1.05 % ( based on high quality evidence ) and SBP of 7.13 mm Hg ( based on moderate quality evidence ) compared to usual care . For both models , the evidence does not suggest a preferred setting of care delivery ( i.e. , primary care vs. hospital outpatient clinic vs. community clinic ) . Table ES1 : Summary of Results of Meta-Analyses of the Effects of Multidisciplinary Care Model 1 Outcome Estimate of effect(95 % CI)Heterogeneity I(2)(p-value ) GRADE Glycosylated Hemoglobin ( HbA1c [%])-1.00 [ -1.27 , -0.73]4 % (p=0.37)Moderate- quality Subgroup : Moderate-to-High Quality -0.91 [ -1.19 , -0.62]0 % (p=0.74)Systolic Blood Pressure ( mm Hg)-2.04 [ -13.80 , 9.72]89 % (p=0.002)Very-low quality * Mean change from baseline to follow-up between intervention and control groupsTable ES2 : Summary of Results of Meta-Analyses of the Effects of Multidisciplinary Care Model 2 Outcome Estimate of effect(95 % CI)Heterogeneity I(2)(p-value ) GRADE Glycosylated Hemoglobin ( HbA1c [%])-1.05 [ -1.57 , -0.52]0 % (p=0.75)High- quality Systolic Blood Pressure ( mm Hg)-7.13 [ -11.78 , -2.48]46 % (p=0.17)Moderate quality * Mean change from baseline to follow-up between intervention and control groups BACKGROUND Only 31 % of Americans with hypertension have their blood pressure ( BP ) under effective control . We describe a study that tests 3 different interventions in a r and omized controlled trial using home BP telemedicine monitoring . METHODS A sample of hypertensive patients with poor BP control at baseline ( N = 600 ) are r and omized to 1 of 4 arms : ( 1 ) control group -- a group of hypertensive patients who receive usual care ; ( 2 ) nurse-administered tailored behavioral intervention ; ( 3 ) nurse-administered medication management according to a hypertension decision support system ; ( 4 ) combination of the 2 interventions . The interventions are triggered based on home BP values transmitted via telemonitoring devices over st and ard telephone lines . The tailored behavioral intervention involves promoting adherence with medication and health behaviors . Patients r and omized to the medication management or the combined arm have their hypertension regimen changed by the study team using a vali date d hypertension decision support system based on evidence -based hypertension treatment guidelines and individualized to patients ' comorbid illnesses . The primary outcome is BP control : < or = 140/90 mm Hg ( nondiabetic ) and < or = 130/80 mm Hg ( diabetics ) measured at 6-month intervals over 18 months ( 4 total measurements ) . CONCLUSIONS Given the increasing prevalence of hypertension and our inability to achieve adequate BP control using traditional models of care , testing novel interventions in patients ' homes may improve access , quality , and outcomes The majority of older adults receive health care in primary care setting s , yet many fail to receive the recommended st and ard of care for preventive services , chronic disease management , and geriatric syndromes . The Geriatric Re sources for Assessment and Care of Elders ( GRACE ) model of primary care for low-income seniors and their primary care physicians ( PCPs ) was developed to improve the quality of geriatric care so as to optimize health and functional status , decrease excess healthcare use , and prevent long-term nursing home placement . The catalyst for the GRACE intervention is the GRACE support team , consisting of a nurse practitioner and a social worker . Upon enrollment , the  GRACE  support team meets with the patient in the home to conduct an initial comprehensive geriatric assessment . The support team then meets with the larger GRACE interdisciplinary team ( including a geriatrician , pharmacist , physical therapist , mental health social worker , and community-based services liaison ) to develop an individualized care plan including activation of GRACE protocol s for evaluating and managing common geriatric conditions . The GRACE support team then meets with the patient 's PCP to discuss and modify the plan . Collaborating with the PCP , and consistent with the patient 's goals , the support team then implements the plan . With the support of an electronic medical record and longitudinal tracking system , the GRACE support team provides ongoing care management and coordination of care across multiple geriatric syndromes , providers , and sites of care . The effectiveness of the GRACE intervention is being evaluated in a r and omized , controlled trial OBJECTIVES Qualitatively describe the use of team and group processes  in intervention facilities participating in a study targeted to improve quality of care in nursing homes " in need of improvement . " DESIGN / SETTING / PARTICIPANTS A r and omized , two-group , repeated- measures design was used to test a 2-year intervention for improving quality of care and resident outcomes . Intervention group ( n = 29 ) received an experimental multilevel intervention design ed to help them : ( 1 ) use quality improvement methods , ( 2 ) use team and group process for direct-care decision-making , ( 3 ) focus on accomplishing the basics of care , and ( 4 ) maintain more consistent nursing and administrative leadership committed to communication and active participation of staff in decision-making . RESULTS The qualitative analysis revealed a subgroup of homes ( " Full Adopters " ) likely to continue quality improvement activities that were able to effectively use teams . " Full Adopters " had either the nursing home administrator or director of nursing who supported and were actively involved in the quality improvement work of the team . " Full Adopters " also selected care topics for the focus of their quality improvement team , instead of " communication " topics of the " Partial Adopters " or " Non-Adopters " in the study who were identified as unlikely to continue to continue quality improvement activities after the intervention . " Full Adopters " had evidence of the key elements of complexity science : information flow , cognitive diversity , and positive relationships among staff ; this evidence was lacking in other subgroups . All subgroups were able to recruit interdisciplinary teams , but only those that involved leaders were likely to be effective and sustain team efforts at quality improvement of care delivery systems . CONCLUSIONS Results of this qualitative analysis can help leaders and medical directors use the key elements and promote information flow among staff , residents , and families ; be inclusive as discussion s about care delivery , making sure diverse points of view are included ; and help build positive relationships among all those living and working in the nursing home . Wide-spread adoption of the intervention in the r and omized study is feasible and could be enabled by nursing home Medical Directors in collaborative practice with Advanced Practice Nurses OBJECTIVE Practice -based collaborative care is a complex evidence -based practice that is difficult to implement in smaller primary care practice s that lack on-site mental health staff . Telemedicine-based collaborative care virtually co-locates and integrates mental health providers into primary care setting s. The objective of this multisite r and omized pragmatic comparative effectiveness trial was to compare the outcomes of patients assigned to practice -based and telemedicine-based collaborative care . METHOD From 2007 to 2009 , patients at federally qualified health centers serving medically underserved population s were screened for depression , and 364 patients who screened positive were enrolled and followed for 18 months . Those assigned to practice -based collaborative care received evidence -based care from an on-site primary care provider and a nurse care manager . Those assigned to telemedicine-based collaborative care received evidence -based care from an on-site primary care provider and an off-site team : a nurse care manager and a pharmacist by telephone , and a psychologist and a psychiatrist via videoconferencing . The primary clinical outcome measures were treatment response , remission , and change in depression severity . RESULTS Significant group main effects were observed for both response ( odds ratio=7.74 , 95 % CI=3.94 - 15.20 ) and remission ( odds ratio=12.69 , 95 % CI=4.81 - 33.46 ) , and a significant overall group-by-time interaction effect was observed for depression severity on the Hopkins Symptom Checklist , with greater reductions in severity over time for patients in the telemedicine-based group . Improvements in outcomes appeared to be attributable to higher fidelity to the collaborative care evidence base in the telemedicine-based group . CONCLUSIONS Contracting with an off-site telemedicine-based collaborative care team can yield better outcomes than implementing practice -based collaborative care with locally available staff We evaluated blood pressure control , quality of life , quality of care , and satisfaction of patients who were monitored by specially trained community pharmacists in a group medical practice . After participating in an intensive skill development program , pharmacists performed in an interdisciplinary team in a rural clinic . The primary objective was assessed by evaluating outcome variables at 6 months compared with baseline in 25 patients r and omly assigned to a study group . A control group of 26 patients was also evaluated to determine if outcome variables remained constant from baseline to 6 months . Systolic blood pressure was reduced in the study group ( 151 mm Hg baseline , 140 mm Hg at 6 mo , p<0.001 ) and diastolic blood pressure was significantly lower at 2 , 4 , and 5 months compared with baseline . Ratings from a blinded peer review panel indicated significant improvement in the appropriateness of the blood pressure regimen , going from 8.7 + /- 4.7 to 10.9 + /- 4.5 in the study group ( p<0.01 ) , but they did not change in the control group . Several quality of life scores improved significantly in the study group after 6 months ( p<0.05 ) . These included physical functioning ( 61.6 vs 70.7 ) , physical role limitations ( 56.8 vs 72.8 ) , and bodily pain ( 60.0 vs 71.7 ) at baseline and 6 months , respectively . There were no significant changes in the control group . Patient satisfaction scores were consistently higher in the study group at the end of the study . Our results indicate that when community pharmacists in a clinic setting are trained and included as members of the primary care team , significant improvements in blood pressure control , quality of life , and patient satisfaction can be achieved Background Despite recent high- quality evidence for their cost-effectiveness , thiazides are underused for controlling hypertension . The goal of this study was to design and test a practice -based intervention aim ed at increasing the use of thiazide-based antihypertensive regimens . Methods This quasi-experimental study was carried out in general medicine ambulatory practice s of a large , academically-affiliated Veterans Affairs hospital . The intervention group consisted of the practitioners ( 13 staff and 215 trainees ) , nurses , and patients ( 3,502 ) of the teaching practice ; non-r and omized concurrent controls were the practitioners ( 31 providers ) and patients ( 18,292 ) of the non-teaching practice s. Design of the implementation intervention was based on Rogers ' Diffusion of Innovations model . Over 10.5 months , intervention teams met weekly or biweekly and developed and disseminated informational material s among themselves and to trainees , patients , and administrators . These teams also review ed summary electronic-medical-record data on thiazide use and blood pressure ( BP ) goal attainment . Outcome measures were the proportion of hypertensive patients prescribed a thiazide-based regimen  , and the proportion of hypertensive patients attaining BP goals regardless of regimen . Thirty-three months of time-series data were available ; statistical process control charts , change point analyses , and before-after analyses were used to estimate the intervention 's effects . Results Baseline use of thiazides and rates of BP control were higher in the intervention group than controls . During the intervention , thiazide use and BP control increased in both groups , but changes occurred earlier in the intervention group , and primary change points were observed only in the intervention group . Overall , the pre-post intervention difference in proportion of patients prescribed thiazides was greater in intervention patients ( 0.091 vs. 0.058 ; p = 0.0092 ) , as was the proportion achieving BP goals ( 0.092 vs. 0.044 ; p = 0.0005 ) . At the end of the implementation period , 41.4 % of intervention patients were prescribed thiazides vs. 30.6 % of controls ( p < 0.001 ) ; 51.6 % of intervention patients had achieved BP goals vs. 44.3 % of controls ( p < 0.001 ) . Conclusion This multi-faceted intervention appears to have result ed in modest improvements in thiazide prescribing and BP control . The study also demonstrates the value of electronic medical records for implementation research , how Rogers ' model can be used to design and launch an implementation strategy , and how all members of a clinical microsystem can be involved in an implementation effort Context Despite evidence showing that even mild elevation of blood pressure above 140/90 mm Hg puts patients at risk for cardiovascular complications , many patients who are treated for hypertension still have high blood pressure . Contribution The authors sought to improve the blood pressure of patients using a health systems approach .  They r and omly assigned providers caring for hypertensive patients to receive a Web link to the Seventh Report of the Joint National Committee on Prevention , Detection , Evaluation , and Treatment of High Blood Pressure ; the Web link and a computer alert notifying them of the patient 's blood pressure ; or the Web link , computer alert , and a letter educating the patient about ways to control his or her blood pressure .  Patients of providers r and omly assigned to the third group had greater decreases in blood pressure and were more likely to have a systolic blood pressure less than 140 mm Hg . Caution s The study took place in a Veterans Affairs setting , follow-up blood pressure measures were missing for many patients , and the study was not design ed to detect a mechanism for any observed changes . Implication s A health systems approach that gave providers feedback about their patients ' blood pressure and that gave patients information about ways to control it improved blood pressure control compared with provider education alone . The Editors Currently , more than 50 million persons in the United States have hypertension ( 1 ) . The Seventh Report of the Joint National Committee on Prevention , Detection , Evaluation , and Treatment of High Blood Pressure ( JNC 7 ) promotes blood pressure goals of less than 140/90 mm Hg ( 25 ) . Providers , however , often delay changes in therapy or use higher blood pressure thresholds for the treatment of hypertension ( 2 , 4 , 6 , 7 ) , which leads to a variance in guideline adherence that contributes to a quality gap in care . Despite widespread guideline promotion , 65 % of persons in the United States have poorly controlled hypertension ( 1 , 6 , 8 , 9 ) . Factors contributing to the achievement of hypertension goals include provider decision making and patient adherence to antihypertensive treatment . These factors can be influenced by other factors , such as patient interactions with clinicians , commercial influences , and patient participation in treatment decisions ( 6 , 1017 ) . A review of hypertension goal attainment in primary care ( 18 ) found that interventions with the largest positive change were complex , multifactorial , and involved 4 areas : activities directed at changing clinician behavior , changes to the organization , information enhancement , and educational programs directed at patients . Although these findings suggest opportunities to achieve effective intervention by directing a change at each component ( 2 , 17 , 1923 ) , the impact of each component is less well known . Our aim was 1 ) to improve the quality of care of patients with hypertension at our facility while examining the relative contribution of each aspect of a multifactorial intervention design ed to improve care and 2 ) to show the effects of physician-level clustering on quality assessment . We conducted a cluster r and omized , controlled study to evaluate common components of a multifactorial intervention in veterans with essential hypertension . Methods Study Design and Setting This project was a cluster r and omized , controlled trial design ed to examine the relative contribution of 3 quality improvement interventions of increasing intensity in improving blood pressure control in veterans . This study was the evaluation component of a Veterans Integrated Service Network campaign to improve blood pressure control in patients who are treated in the Tennessee Valley Healthcare System . The health care system comprises 2 teaching hospitals , 2 large community-based outpatient clinics , and 6 small community-based outpatient clinics . There were 523659 outpatient visits made by 69928 veterans during fiscal year 2004 . The institutional review board of V and erbilt University and the VA Tennessee Valley Healthcare System research and development committee for human subjects protection approved this study . Inclusion Criteria We first identified eligible patients and then r and omly assigned providers caring for at least 1 of those patients to receive study interventions . Patients were eligible for inclusion in the study if they were 21 to 90 years of age , filled their medications at Veterans Administration ( VA ) pharmacies , had at least 2 uncontrolled blood pressure measurements in the 6-month baseline period ( systolic blood pressure > 140 mm Hg or diastolic blood pressure 90 mm Hg ) , and were only taking 1 antihypertensive medication . We restricted our study sample to patients with uncontrolled hypertension who were only taking 1 antihypertensive medication because the JNC 7 guidelines propose that most patients with hypertension will require 2 or more medications to achieve their blood pressure goals ( 5 , 12 ) . Therefore , this sample includes patients for whom the quality of hypertension care could be improved . Eligible patients were identified between July and December 2003 by search ing data from the Mid-South Quality Improvement Data warehouse , which are downloaded monthly from Veterans Health Information System and Technology Architecture . The search initially identified 4648 patients with a primary care visit who had a diagnosis of hypertension indicated by International Classification of Diseases , Ninth Revision , Clinical Modification ( ICD-9-CM ) codes 401.1 or 401.9 and who were prescribed only 1 antihypertensive medication ( Figure ) . We excluded 2821 ( 60 % ) patients because they had at least 1 recorded blood pressure reading between July and December 2003 that was at goal ( systolic blood pressure 140 mm Hg and diastolic blood pressure < 90 mm Hg ) . We mailed an assent letter to the remaining 1827 patients in January 2004 asking permission to review their electronic medical record and indicating that their primary provider would potentially receive suggestions to improve their hypertension care . Another 486 patients were excluded after r and omization because they declined chart review ( n= 222 ) or were taking more than 1 antihypertensive medication at the time of chart review ( n= 264 ) . Figure . Study flow diagram . * Excluded providers who cared for patients who declined chart review or those who were taking more than 1 medication at the time of chart review after r and omization . Providers were eligible for r and omization if they provided care for at least 1 patient who fulfilled the eligibility criteria . Providers were classified as attending physicians , resident physicians , or nonphysician clinicians ( nurse practitioner or physician assistant ) and were stratified into providers with at least 30 eligible patients and those with less than 30 eligible patients to help balance the number of patients in each study group . One hundred eighty-two providers were r and omly assigned to study interventions ; after r and omization , 23 providers were additionally excluded because the patients they cared for declined chart review or were taking more than 1 antihypertensive medication at the time of chart review ( Figure ) . Interventions Providers were r and omly assigned to 1 of 3 study groups : provider education only ; provider education and alert ; or provider education , alert , and patient education . All interventions were performed during the week of 14 June through 18 June 2004 , and follow-up continued through 31 December 2004 . Provider Education All providers in the 3 study groups received an e-mail message that explained the planned intervention . Providers who received only the e-mail message were controls for those who received the other 2 more intensive interventions . The e-mail informed providers that they might receive electronic alerts in the computerized patient record requesting reevaluation of a patient 's antihypertensive regimen . It also reported that a letter was being sent to selected patients advocating medication adherence and lifestyle modification to lower blood pressure . The e-mail message included a Web link to the JNC 7 guidelines for the treatment of hypertension ( www.nhlbi.nih.gov/ guidelines /hypertension/jnc7full.pdf ) . The message was sent by the supervisory pharmacist at the VA Tennessee Valley Healthcare System and was signed by the medical director of the network . Provider Education and Alert In the second study group , an alert was added to provider education . The alert was a 1-time patient-specific electronic notification that was sent by the pharmacy to the prescribing provider through each eligible patient 's electronic medical record over a 1-week period in June 2004 . Each time providers signed on to a computer , any medical record that contained an alert was brought to their attention . The alert gave a brief outline of the JNC 7 recommendations ( 5 ) and reminded providers that goal blood pressure should be 140/90 mm Hg or less . It included date s and values of the patient 's last 3 recorded blood pressure measurements and offered the following options : addition of a thiazide or thiazide combination diuretic , addition of another antihypertensive medication , or continuation of current medications and dosages . The alert reminded providers of the available thiazides on the VA formulary and stated that thiazides were contraindicated in patients with renal insufficiency or allergies to sulfa medications . Provider Education , Alert , and Patient Education The third study group combined the provider education and alert described previously with a patient education component . We sent a personalized letter that contained educational information concerning hypertension to each eligible patient in this study group . The letter was labeled Notice : To Veterans with High Blood Pressure and was design ed at an eighth- grade reading level . The letter recommended the use of behavioral strategies , such as medication adherence , low-sodium diet , and exercise , In recent years , intense pressures to reduce the costs of health care have led many health care organizations to seek strategies that reduce re source utilization while maintaining the quality of care [ 1 - 5 ] . Among the most popular of the methods intended to meet this challenge are critical pathways . Critical pathways are management plans that display goals for patients and provide the corresponding ideal sequence and timing of staff actions to achieve those goals with optimal efficiency [ 6 - 8 ] . Interest in critical pathways has increased tremendously during the past several years as early anecdotal reports of their cost-saving potential have been disseminated , usually outside the peer- review ed medical literature [ 7 , 9 , 10 ] . The rapid push for critical pathway implementation comes from intense competitive pressures and the persistent evidence of unexplained variation in medical practice [ 11 , 12 ] . Many managed care organizations have added their weight to this process by m and ating certain critical pathways or seeking partner hospitals that are willing to develop their own [ 7 ] . However , no controlled study has shown a critical pathway to reduce the duration of hospital stay or to decrease re source use , nor has any study shown critical pathways to improve patient satisfaction or outcomes [ 13 ] . Nevertheless , like other promising medical technologies , critical pathways are being disseminated before controlled trials have been done to evaluate their effectiveness . Despite the lack of data , an increasing number of physicians will be asked to participate in critical pathway development . Even more will find that their hospitalized patients are already on pathways that they may or may not have endorsed . To enhance the effectiveness of critical pathways and minimize the disruption to the patientphysician relationshipphysicians and other caregivers must underst and the origin , potential benefits , and potential pitfalls of this new method . Critical Pathways : A New Form of Clinical Guideline Critical pathways have varying formats and are known by many names , including critical paths , clinical pathways , and care paths . Interpreted formally , a critical pathway is the sequence of events in a process that takes the greatest length of time . Like the techniques of continuous quality improvement , critical pathway techniques were first developed for use in industry as a tool to identify and manage the rate-limiting steps in production processes [ 14 - 17 ] . First developed in the 1950s , the Critical Path Method was frequently linked with a similar approach , the Program Evaluation and Review Technique , to coordinate multiple contractors or persons in a project by identifying the key sequence of events , or critical path , the requirements of which would drive the timeline of the overall project [ 18 , 19 ] . Critical pathway techniques have subsequently been applied to projects as diverse as construction , civil engineering , town planning , marketing , ship building , product design , and equipment installation [ 6 ] . Critical pathways were first developed and applied to health care in the 1980s , when prospect i ve payment systems focused greater interest on potential methods to improve hospital efficiency [ 6 ] . Most of the first critical pathways in hospitals were developed by nurses for nursing care alone [ 20 , 21 ] , but multidisciplinary teams soon began developing pathways to encompass all aspects of care for hospitalized patients [ 22 - 24 ] . In general , efforts to develop critical pathways in health care have not incorporated the formal techniques used by industrial predecessors to identify the true critical pathway in any care process [ 18 , 25 ] . Instead , when critical pathways are used to plan medical care , the specific goals usually include the following : 1 . Selecting a best practice when practice styles vary unnecessarily . 2 . Defining st and ards for the expected duration of hospital stay and for the use of tests and treatments . 3 . Examining the interrelations among the different steps in the care process to find ways to coordinate or decrease the time spent in the rate-limiting steps . 4 . Giving all hospital staff a common game plan from which to view and underst and their various roles in the overall care process . 5 . Providing a framework for collecting data on the care process so that providers can learn how often and why patients do not follow an expected course during their hospitalization . 6 . Decreasing nursing and physician documentation burdens . 7 . Improving patient satisfaction with care by educating patients and their families about the plan of care and involving them more fully in its implementation . The general format of critical pathway guidelines is the Gantt chart , which outlines the suggested patient care process based on a time-task matrix , listing the components of care in one column and cross-aligning these entries with columns pertaining to time [ 8 ] . Figure 1 is an example of such a chart for a critical pathway for patients who have had coronary artery bypass graft surgery . Categories of multidisciplinary staff actions are listed in the first column of the pathway , with specific actions for each day of hospitalization . As indicated in Figure 1 , a patient 's diet is expected to progress successfully from ice chips to clear liquids on the first day after surgery . For all other categories of patient care , critical pathways likewise explicitly mark the transition points of patient progress and lay out a coordinated map of staff activities to achieve those transitions in the most efficient way possible . Figure 1 . The first 2 days of a simplified critical pathway for patients who have had cardiac surgery .  Critical pathways differ from most clinical guidelines , protocol s , and algorithms in several key respects . First , clinical guidelines often address the appropriateness of care by delineating the indications for tests or treatments . Critical pathways , on the other h and , have almost always focused on the quality and efficiency of care after decisions have already been made to admit the patient or perform the procedure . Another way in which critical pathways differ from most clinical guidelines is that they are multidisciplinary in their development and in the scope of their implementation . Critical pathways are also design ed along specific timelines , sometimes even in hour-by-hour detail , for indicated actions , and pathways not only spell out these specific actions but also enumerate expected intermediate patient outcomes that serve as checkpoints for the performance of both the patient and the pathway . Yet another distinguishing feature of critical pathways is that their comprehensive design allows them to be used as a part of the patient record , often replacing other documentation entirely [ 6 , 24 ] . All staff interventions and intermediate clinical outcomes that occur as expected can be simply initialed on the critical pathway document . If staff actions or intermediate patient outcomes do not occur as expected , however , a variance from the pathway is said to have occurred [ 26 ] . Variances , too , can be noted on the document , along with an explanation of their cause or causes , and , if needed , a plan can be described to return the patient to the expected course of treatment and outcomes . Critical Pathway Development Topic Selection Critical pathways are typically developed for the hospital care associated with high-volume , high-cost diagnoses and procedures , particularly those for which inefficient variation in the process of care is thought to exist [ 6 ] . Surgical procedures , such as coronary artery bypass graft surgery and total hip replacement , lend themselves particularly well to critical pathways because the care process differs relatively little from patient to patient . For this same reason , obstetric procedures such as normal vaginal delivery and cesarean section have also been subjects of pathways in many institutions [ 24 ] . For most medical diagnoses , however , patient care has proved more difficult to translate successfully into critical pathways because of the greater heterogeneity among patients and problems [ 6 , 27 ] . Some institutions have reported that pathways fail when used for medical patients who have either multiple problems and therefore multiple relevant pathways or a problem that does not fit neatly within any single st and ardized pathway [ 27 - 29 ] . Despite these concerns , however , pathways have been design ed and implemented at many institutions for medical diagnoses such as myocardial infa rct ion , stroke , and deep venous thrombosis [ 23 ] . Team Composition The group that is organized to develop a critical pathway should be multidisciplinary in order to bring to the table the knowledge and perspectives that are necessary to view the care process in its entirety . Although many institutions have appointed nurses as the leaders of critical pathway teams [ 6 ] , we have found that having a physician-expert lead each team lends credibility to the pathways and builds a foundation of support among all clinicians . Each pathway team should also have a group facilitator from the hospital administration , a housestaff physician , a member of the quality management department who has expertise in critical pathway methods , and a community-based primary care physician , whose perspective on inpatient care is likely to differ from that of hospital-based physicians . The lack of active involvement by physician-experts is cited as a key reason for the failure of pathway programs ; critical pathways that are developed without physician input have ended up sequestered in a part of the medical record where physicians do not often look [ 27 , 30 ] . Simply gathering physicians , nurses , and other staff around the same table , however , may not be enough to generate the level of teamwork and communication necessary for success . It is an important challenge , especially for physicians trained in an individualistic ethic , to learn how to participate in and lead these teams Context Studies of  resident work-hour restrictions and patient outcomes  have had design limitations and inconsistent findings . Contribution This study compared changes in the rates of 7 clinical measures over a 2-year period for patients discharged from a teaching service that followed the ACGME work-hour rules to changes for patients discharged from a nonteaching hospitalist service . Favorable changes in rates of intensive care unit utilization , discharge to home or a rehabilitation facility , and pharmacist interventions to prevent drug error were more marked in the teaching service than in the hospitalist service . Caution Without a direct comparison of teaching services with and without restricted hours , this study has similar design limitations as those of previous studies . The Editors Work-hour regulations , implemented in July 2003 by the Accreditation Council for Graduate Medical Education ( ACGME ) ( 1 ) , have reportedly reduced housestaff fatigue ( 2 ) , but often at the cost of increased transfers of patient care among residents ( 3 ) . Each transfer of care requires the communication of patient information from the departing clinician to the arriving clinician . If this sign-out is performed imperfectly , with misunderst and ing or loss of information , harm to patients may result ( 412 ) . These risks of increased h and offs may mitigate the expected benefits of reduced housestaff fatigue , result ing in an uncertain net result for patients . Literature on the impact of work-hour limits on patient outcomes is conflicting and has been hampered by small sample sizes , few clinical outcomes , and design limitations ( 13 ) . Only 3 studies have included a control group to account for temporal trends in quality improvement ( 1416 ) . No study of the new ACGME regulations has included patients in an internal medicine ward , a high-volume group of complex patients . Given the expense of this policy change ( 17 ) , its broad effects on residency programs and residents ( 2 ) , the statement by the ACGME that improving patient care was a major impetus for the regulations ( 18 ) , and the lack of conclusive study before its wholesale enactment ( 13 ) , the impact of the new work-hour regulations on patient outcomes is critical to evaluate . R and omized trials are not feasible because the change was m and ated simultaneously for all residency programs . A simple comparison of patient outcomes in different years is subject to bias , however , because of changes in practice and quality of care over time . Lack of control for these temporal trends in outcomes is perhaps the most important limitation of most previous studies . To avoid this problem , we compared changes over time in outcomes of 2 cohorts at the same hospital , one cared for by housestaff ( teaching service ) and the other by hospitalists ( nonteaching service ) . This approach allowed us to evaluate the association of work-hour regulations with changes in a broad range of outcomes for internal medicine in patients while controlling for temporal trends by using a concurrent control group of similar patients whose caregivers were not directly affected by work-hour regulations . Methods We conducted a retrospective cohort study at YaleNew Haven Hospital , comparing outcomes before and after work-hour regulations in medical patients receiving care by housestaff and those receiving care by hospitalists . Patients were assigned to the  teaching or nonteaching services  on the basis of time of day . Each day , admitted patients were first assigned to teaching teams until the team caps were reached , regardless of severity of illness . All subsequent admissions for the day were assigned to the nonteaching service . This policy was consistent throughout the study . Of note , patients transferred out of the intensive care unit ( ICU ) were usually assigned to teaching teams . Transfers between teaching and nonteaching services were unusual . Teaching System before Work-Hour Regulation A team comprised 1 resident ( postgraduate year 2 or 3 ) and 2 interns . Before 1 July 2003 , the resident and 1 intern remained in the hospital overnight on call every fourth day , during which they cared for their own patients and briefly for those of 1 other team . A resident on night-float service arrived at 8 p.m. to assume care of the patients not on the on-call intern 's team . On days when no one from the team was on call , interns signed their patients out to a different team 's on-call intern , who then relinquished them to the resident on night-float service at 8 p.m. Over 4 weekdays , a patient typically experienced 8 transfers of care .  Teaching System after Work-Hour Regulation On 1 July 2003 , the teaching service schedule was reorganized to better comply with work-hour limitations . There was no transition period . Residents no longer stayed overnight ; they were replaced by nocturnalistsnonresident physicians who did the work of the night resident . This position was filled by 2 hospitalists and a large pool of moonlighting fellows . In addition , a resident on day-float service was instituted to assist with postcall care of patients so that the postcall team could leave by noon . This reorganization added 1 extra transfer of care every 4 days and increased discontinuity because of the large number of rotating nocturnalists , the new resident on day-float service , and the absence of an on-call primary resident at night . The average patient had approximately 2 physicians added to the care team ; patients with long lengths of stay saw a much greater increase . However , these changes also increased the average clinical experience of those supervising nighttime patient care because all nocturnalists had completed residency . Intermittent checks of time cards completed by housestaff showed that average weekly hours were within the 80-hour limits . No physician extenders were added to reduce housestaff workload , and housestaff on the wards was not extended beyond the addition of the resident on day-float service . Nonteaching System The nonteaching service did not change after work-hour regulation . The primary hospitalist team for each patient ( comprising a physician and 1 or more physician assistants ) was present during the day . Each night , including weekends , night staff was present in the hospital for coverage of the nonteaching service . Night physicians attempted to maintain continuity by covering the same patients each night , but this was not universally achieved . Day staff signed out directly to night staff every day of the week . Over 4 days , a patient typically experienced 8 transfers of care . In the year after work-hour regulations were enacted , the nonteaching service increased in both volume and number of providers , such that the number of patients per provider remained similar . ( The Appendix contains full details of work schedules before and after work-hour regulation on both services . ) Data Sources We obtained administrative cl aims data for all patients discharged from the medical wards between 1 July 2002 and 30 June 2004 , excluding patients discharged from HIV and oncology wards , which were restricted to teaching service teams . We derived medication error data from 2 data bases kept by the hospital pharmacy . One contained all automatically generated warnings of drugdrug combinations with potential for harm . The interaction list was dynamic : 53 % of the interactions ( 323 of 615 ) were added on or after 1 July 2003 . The other pharmacy data base recorded all direct interventions made by pharmacy staff . Pharmacists themselves generated each intervention and categorized the intent of the intervention . For this study , we restricted the data base to include only those interventions made to prevent an adverse event . Independent Variables Patients were stratified into the teaching or nonteaching cohorts on the basis of their team assignment at discharge . The unit of analysis was hospitalization ; patients admitted more than once could be included in more than 1 cohort . We collected data on age , sex , race or ethnicity , insurance status , and admission source for each patient . To account for variability in case mix over time , we grouped the principal diagnosis codes into 259 clinical ly similar diagnosis categories by using the Clinical Classifications Software categorization ( 19 ) and then constructed a case-mix variable that included the most common or severe 21 diagnoses plus 1 for all other diagnoses . We used the International Classification of Diseases , Ninth Revision , Clinical Modification ( ICD-9-CM ) , secondary diagnosis codes to assign a risk severity score to each patient by using the Deyo adaptation of the Charlson comorbidity index ( 20 , 21 ) . Analyses using the Elixhauser method of comorbidity adjustment yielded similar results ( 22 ) . Dependent Variables Outcome measures were ICU stay , length of hospital stay , discharge disposition , 30-day readmission rate to YaleNew Haven Hospital , pharmacist interventions to prevent adverse events , and  drugdrug interactions . We dichotomized discharge disposition as discharge to home or rehabilitation facility versus discharge elsewhere ( including death ) , and we included only patients admitted from home or through the emergency department for analysis of this outcome . We also evaluated in-hospital death , but this was an exploratory analysis because of the small number of events . Statistical Analysis Because this was a retrospective , single-center study , our sample size was determined by hospital volume . We compared patients ' characteristics and outcomes before and after work-hour regulation within each group and between groups by using chi-square tests for categorical variables and t tests for continuous variables . We used the generalized linear model for length of stay , which has a long right tail . After testing several link functions and distributional assumptions , we found that a distribution with a logarithmic link ( regression ) best fit the data . For pharmacy interventions and medication interactions , we constructed Context Interventions to promote guideline -recommended care have met with limited success . Quality improvement experts believe that multicomponent interventions are more effective than simpler strategies , but this belief rests on limited evidence . Contribution In this r and omized trial of 20 primary care practice s , intervention practice s received quarterly site visits and 2 network meetings about quality improvement in addition to copies of practice guidelines and quarterly performance reports . Intervention practice s had greater improvement in providing guideline -recommended care for cardiovascular disease prevention and treatment than practice s that received only the guidelines and performance reports . Caution s The study involved a small number of practice s. The Editors Widespread evidence reveals inadequate implementation of evidence -based clinical practice guidelines for prevention and management of cardiovascular disease and stroke in primary care setting s ( 1 - 3 ) . Primary prevention deficiencies exist in the screening and management of dyslipidemia ( 4 ) and hypertension ( 5 ) . Secondary prevention deficiencies include inadequate treatment of dyslipidemia in patients with coronary heart disease ( CHD ) ( 6 ) and inadequate use of antiplatelet therapy in patients with CHD or cerebrovascular disease ( 7 ) , inadequate use of -blockers after myocardial infa rct ion ( 8) , inadequate use of angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers in patients with heart failure ( 9 ) , and inadequate use of oral anticoagulant therapy in patients with atrial fibrillation ( 10 ) . Finally , patients with diabetes mellitus who are at high risk for cardiovascular disease as well as microvascular disease infrequently receive recommended screening and adequate treatment for elevated glycosylated hemoglobin levels , hypertension , and dyslipidemia ( 11 ) . Published systematic review s point to the importance of multifaceted interventions in increasing adherence to practice guidelines and improving disease control ( 12 , 13 ) . Little is known , however , about the relative effectiveness of different implementation strategies . More research is needed to develop and vali date effective , theoretically sound , and practical strategies for improving the provision of evidence -based medicine in primary care . Particularly important are studies that address multiple common , chronic conditions , which together reflect a large proportion of the work of primary care providers ( 14 ) . This study was design ed as a pragmatic clinical trial ( 15 ) , intended to assess whether a  multi method quality improvement intervention  was more effective than a less intensive intervention  for improving adherence to 21 quality indicators relevant to the primary and secondary prevention of cardiovascular disease and stroke . The multi method quality improvement intervention added practice site visits ( for academic detailing and quality improvement facilitation ) and network meetings ( for sharing best practice s ) to the approach of guideline dissemination and audit and feedback used in the less intensive intervention . The study was conducted in a practice -based research network ( PPRNet ) among users of a common electronic medical record ( Practice Partner Patient Records , Seattle , Washington ) , which historically provided audit and feedback to its practice members . Audit and feedback have already been shown to improve the practice of health care professionals , particularly in prescribing and test ordering ( 16 ) . Additional research is needed to assess the effect of audit and feedback in combination with other interventions . Methods Design The design was a cluster r and omized , controlled clinical trial , with the practice as the unit of r and omization . Twenty-three office-based primary care practice s in 15 states agreed to participate . The institutional review board at the Medical University of South Carolina approved the study . Study Indicators We derived the study indicators ( Table 1 ) from published sources ( 17 - 22 ) . Fourteen were process measures , which reflected whether recommended tests were done , appropriate diagnoses made , or appropriate medication prescribed . Seven were outcome measures , which reflected whether patients achieved recommended treatment goals . Some of the measures represented primary prevention , for example , screening for hypertension or dyslipidemia . Others represented secondary prevention , for example , reaching treatment goals for glycosylated hemoglobin levels , low-density lipoprotein ( LDL ) cholesterol levels , and blood pressure in patients with diabetes . An additional indicator , hormone replacement therapy for postmenopausal women , was included at the beginning of the study but was withdrawn in July 2002 when the results from the Women 's Health Initiative trial were published ( 23 ) . Table 1 . Study Indicators We determined practice performance for each study indicator at baseline and quarterly throughout the study . To determine performance , participating practice s ran a computer program to extract patient activity during the previous quarter from their electronic medical record . To protect patient confidentiality , the extract program assigned a unique , anonymous numerical identifier to each patient . The extract program obtained demographic information , such as age , race , and sex ; diagnoses ; medications ; laboratory data ; and vital signs . Text of progress notes , consultation reports , and discharge summaries were not extracted . The data were copied to a diskette and mailed to PPRNet or sent electronically via a secure server . In the PPRNet offices , the data were bridged to st and ard data dictionaries and converted to SAS data sets ( SAS Institute , Inc. , Cary , North Carolina ) on st and ard microcomputers for analyses . Interventions The intervention began on 1 January 2001 and was completed on 1 January 2003 . During the first quarter of 2001 , the medical director of each practice was sent printed copies of each practice guideline referenced in the study . Beginning in the first quarter of 2001 , the medical director was sent quarterly performance reports documenting the practice 's adherence to each of the 21 study indicators . Each report contained the practice 's current performance , calculated as the percentage of eligible patients who had received the recommended service , the number of patients who were receiving the recommended medication , or the number of patients who had achieved the treatment goal . The report also presented data on the practice s ' previous performance since the beginning of the study and the performance target , calculated as the 90th percentile at baseline among all practice s. In practice s with more than 1 clinician , individual provider data were not given because the study emphasized improvement at the practice level . The medical director was encouraged to share the reports with others in the practice in order to stimulate motivation for improvement . The 90th percentile was selected as the performance target because it reflected a bold but achievable goal ( at least 2 practice s were at this level of performance at baseline ) . Practice s in the control group received no other interventions during the study . An example of 1 page of a practice report is available in the Appendix Figure . Appendix Figure . Sample practice report for blood pressure in coronary heart disease .  Practice s in the intervention group also participated in practice site visits and network meetings . Six or seven 1- or 2-day site visits were held at each practice approximately every 3 months during 2001 and 2002 . The practice site visit was led by 1 of the physician co authors , assisted during the first few visits in 2001 by a clinical pharmacist with expertise in academic detailing ( 24 ) , and at later visits by other co authors with expertise in quality improvement . Initial site visits focused on engaging clinicians and staff members in the project , through a formal presentation by the site visitors and group discussion with all members of the practice team , including providers , nurses , medical assistants , and reception and administrative personnel . Because of vacation or hospital coverage responsibilities , 1 or 2 providers were occasionally absent in the multiprovider practice s , and 1 practice involved only a few members of their staff . We placed detailed attention on the scientific justification for the chosen study indicators and on published frameworks for clinician behavior change ( 25 , 26 ) . Baseline practice performance on each study indicator was discussed , and previous evidence of the ability of PPRNet practice s to improve care was presented ( 27 ) . Practice s were encouraged to increase the use of quality improvement tools available in the electronic medical record , such as note templates with embedded practice guidelines , query functions , prompts , reminders , and messaging . At each visit , a participatory planning session was held in which practice members identified specific clinical indicators they wished to work on and improvement activities to conduct before the next site visit . Lessons from complexity theory were used in this exercisethe influence of each practice member on the system , the importance of replicating successful approaches and focusing on motivators for patients and staff , and the notion that simple changes are easiest to adopt and can have profound effects . In subsequent site visits , we focused on discussing the practice 's success in adopting its planned improvement activities , presenting up date d performance data , and planning additional practice -level interventions . The site visitors presented results from recently published studies relevant to the study indicators . Successful and unsuccessful approaches to improvement by other intervention sites were also presented . Two-day network meetings were held in Charleston , South Carolina , in May 2001 and May 2002 . The lead clinician from each intervention practice and the research team attended the first meeting . At this OBJECTIVE T o examine whether quality of care ( QOC ) improves when nurse practitioners and pharmacists work with family physicians in community practice and focus their work on patients who are 50 years of age and older and considered to be at risk of experiencing adverse health outcomes . DESIGN R and omized controlled trial . SETTING A family health network with 8 family physicians , 5 nurses , and 11 administrative personnel serving 10 000 patients in a rural area near Ottawa , Ont . PARTICIPANTS Patients 50 years of age and older at risk of experiencing adverse health outcomes ( N = 241 ) . INTERVENTIONS At-risk patients were r and omly assigned to receive usual care from their family physicians or Anticipatory and Preventive Team Care ( APTCare ) from a collaborative team composed of their physicians , 1 of 3 nurse practitioners , and a pharmacist . MAIN OUTCOME MEASURES Quality of care for chronic disease management ( CDM ) for diabetes , coronary artery disease , congestive heart failure , and chronic obstructive pulmonary disease . RESULTS Controlling for baseline demographic characteristics , the APTCare approach improved CDM QOC by 9.2 % ( P < .001 ) compared with traditional care . The APTCare intervention also improved preventive care by 16.5 % ( P < .001 ) . We did not observe significant differences in other secondary outcome measures ( intermediate clinical outcomes , quality of life [ Short-Form 36 and health-related quality of life scales ] , functional status [ instrumental activities of daily living scale ] and service usage ) . CONCLUSION Additional re sources in the form of collaborative multidisciplinary care teams with intensive interventions in primary care can improve QOC for CDM in a population of older at-risk patients . The appropriateness of this intervention will depend on its cost-effectiveness . TRIAL REGISTRATION NUMBER NCT00238836 ( CONSORT ) Background Primary care providers do not routinely follow guidelines for the care of patients with chronic kidney disease ( CKD ) . Multidisciplinary efforts may improve care for patients with chronic disease .  Pharmacist based interventions have effectively improved management of hypertension . We performed a pragmatic , r and omized , controlled trial to evaluate the effect of a pharmacist based quality improvement program on 1 ) outcomes for patients with CKD and 2 ) adherence to CKD guidelines in the primary care setting . Methods Patients with moderate to severe CKD receiving primary care services at one of thirteen community-based Veterans Affairs outpatient clinics were r and omized to a multifactorial intervention that included a phone-based pharmacist intervention , pharmacist-physician collaboration , patient education , and a CKD registry ( n = 1070 ) or usual care ( n = 1129 ) . The primary process outcome was measurement of parathyroid hormone ( PTH ) during the one year study period . The primary clinical outcome was blood pressure ( BP ) control in subjects with poorly controlled hypertension at baseline . Results Among those with poorly controlled baseline BP , there was no difference in the last recorded BP or the percent at goal BP during the study period ( 42.0 % vs. 41.2 % in the control arm ) . Subjects in the intervention arm were more likely to have a PTH measured during the study period ( 46.9 % vs. 16.1 % in the control arm , P < 0.001 ) and were on more classes of antihypertensive medications at the end of the study ( P = 0.02 ) . Conclusions A one-time pharmacist based intervention proved feasible in patients with CKD . While the intervention did not improve BP control , it did improve guideline adherence and increased the number of antihypertensive medications prescribed to subjects with poorly controlled BP . These findings can inform the design of quality improvement programs and future studies which are needed to improve care of patients with CKD.Trial registration Clinical Trials.gov : NCT01290614 Increasing dem and to deliver and document therapeutic and preventive care sharpens the need for disease management strategies that accomplish these goals efficiently while preserving quality of care . The purpose of this study was to compare selected outcomes for a new chronic disease management program involving a nurse practitioner - physician team with those of an existing model of care . One hundred fifty-seven patients with hypertension and diabetes mellitus were r and omly assigned to their primary care physician and a nurse practitioner or their primary care physician alone  . Costs for personnel directly involved in patient management , calculated from hourly rates and encounter time with patients , and pre- and post- study glycosylated hemoglobin ( HbA1c ) , high-density lipoprotein cholesterol ( HDL-c ) , satisfaction with care and health-related quality of life ( HRQoL ) were assessed . Although 1-year costs for personnel were higher in the team-treated group , participants experienced significant improvements in mean HbA1c ( − 0.7 % , p = 0.02 ) and HDL-c ( + 2.6 mg dL − 1 , p = 0.02 ) . Additionally , satisfaction with care improved significantly for team-treated subjects in several sub-scales whereas the mean change over time in HRQoL did not differ significantly between groups . This study demonstrates the value of a complementary team approach to chronic disease management in improving patient-derived and clinical outcomes at modest incremental costs Background Unexpected obstetric emergencies threaten the safety of pregnant women . As emergencies are rare , they are difficult to learn . Therefore , simulation-based medical education ( SBME ) seems relevant . In non- systematic review s on SBME , medical simulation has been suggested to be associated with improved learner outcomes . However , many questions on how SBME can be optimized remain unanswered . One unresolved issue is how ' in situ simulation ' ( ISS ) versus ' off site simulation ' ( OSS ) impact learning . ISS means simulation-based training in the actual patient care unit ( in other words , the labor room and operating room ) . OSS means training in facilities away from the actual patient care unit , either at a simulation centre or in hospital rooms that have been set up for this purpose . Methods and design The objective of this r and omized trial is to study the effect of ISS versus OSS on individual learning outcome , safety attitude , motivation , stress , and team performance amongst multi-professional obstetric-anesthesia teams . The trial is a single-centre r and omized superiority trial including 100 participants . The inclusion criteria were health-care professionals employed at the department of obstetrics or anesthesia at Rigshospitalet , Copenhagen , who were working on shifts and gave written informed consent . Exclusion criteria were managers with staff responsibilities , and staff who were actively taking part in preparation of the trial . The same obstetric multi-professional training was conducted in the two simulation setting s. The experimental group was exposed to training in the ISS setting , and the control group in the OSS setting . The primary outcome is the individual score on a knowledge test . Exploratory outcomes are individual scores on a safety attitudes question naire , a stress inventory , salivary cortisol levels , an intrinsic motivation inventory , results from a question naire evaluating perceptions of the simulation and suggested changes needed in the organization , a team-based score on video-assessed team performance and on selected clinical performance . Discussion The perspective is to provide new knowledge on context ual effects of different simulation setting s . Trial registration ClincialTrials.gov NCT01792674 PROBLEM Teaching hospital multidisciplinary work rounds are often inefficient , delaying the completion of patient care tasks and detracting from teaching . Participants often act as working groups rather than interdependent teams . Athletic principles were used to train multidisciplinary rounding teams to adopt the systems used by manufacturing to improve the efficiency and quality of patient care , as well as teamwork and didactic teaching . APPROACH Experimental groups of general medical rounding teams-faculty member , house staff , medical students , bedside nurses , pharmacists , and a case manager-were introduced to individual job descriptions ( playbooks ) , key customer-supplier relation ships , and efficient communication protocol s , accompanied by weekly feed back ( game films ) . A two-phase pilot 11-month prospect i ve trial ( February to July 2009 and September 2011 to January 2012 ) compared the experimental and control rounding teams on the basis of length of stay , 30-day readmission rates , and physician , student , and patient satisfaction . OUTCOMES These interventions result ed in a 30 % reduction in 30-day readmissions and , in the 2011 - 2012 phase , an 18 % shorter length of stay . Anonymous surveys documented greater satisfaction of faculty , residents , and medical students , and student ratings of teaching were markedly improved . Patient satisfaction did not change . NEXT STEPS The new rounding system has the potential to reduce waste and improve the quality of patient care while improving caregiver satisfaction and medical student teaching . Adaptive leadership skills will be required to overcome resistance to change . The use of athletic analogies can improve teamwork and facilitate the adoption of a systems approach to the delivery of patient care Objective : To determine if high fidelity simulation based team training can improve clinical team performance when added to an existing didactic teamwork curriculum . Setting : Level 1 trauma center and academic emergency medicine training program . Participants : Emergency department ( ED ) staff including nurses , technicians , emergency medicine residents , and attending physicians . Intervention : : ED staff who had recently received didactic training in the Emergency Team Coordination Course ( ETCC ® )  also received an 8 hour intensive experience in an ED simulator in which three scenarios of graduated difficulty were encountered . A comparison group , also ETCC trained  , was assigned to work together in the ED for one 8 hour shift . Experimental and comparison teams were observed in the ED before and after the intervention . Design : Single , crossover , prospect i ve , blinded and controlled observational study . Teamwork ratings using previously vali date d behaviorally anchored rating scales ( BARS ) were completed by outside trained observers in the ED . Observers were blinded to the identification of the teams . Results : There were no significant differences between experimental and comparison groups at baseline . The experimental team showed a trend towards improvement in the quality of team behavior ( p = 0.07 ) ; the comparison group showed no change in team behavior during the two observation periods ( p = 0.55 ) . Members of the experimental team rated simulation based training as a useful educational method . Conclusion : High fidelity medical simulation appears to be a promising method for enhancing didactic teamwork training . This approach , using a number of patients , is more representative of clinical care and is therefore the proper paradigm in which to perform teamwork training . It is , however , unclear how much simulator based training must augment didactic teamwork training for clinical ly meaningful differences to become apparent Background Black and Hispanic stroke survivors experience higher rates of recurrent stroke than whites . This disparity is partly explained by disproportionately higher rates of uncontrolled hypertension in these population s. Home blood pressure telemonitoring ( HBPTM ) and nurse case management ( NCM ) have proven efficacy in addressing the multilevel barriers to blood pressure ( BP ) control and reducing BP . However , the effectiveness of these interventions has not been evaluated in stroke patients . This study is design ed to evaluate the comparative effectiveness , cost-effectiveness and sustainability of these two telehealth interventions in reducing BP and recurrent stroke among high-risk Black and Hispanic stroke survivors with uncontrolled hypertension . Methods / Design A total of 450 Black and Hispanic patients with recent nondisabling stroke and uncontrolled hypertension are r and omly assigned to one of two 12-month interventions : 1 ) HBPTM with wireless feedback to primary care providers or 2 ) HBPTM plus individualized , culturally-tailored , telephone-based NCM .  Patients are recruited from stroke centers and primary care practice s within the Health and Hospital Corporations ( HHC ) Network in New York City . Study visits occur at baseline , 6 , 12 and 24 months . The primary outcomes are within-patient change in systolic BP at 12 months , and the rate of stroke recurrence at 24 months . The secondary outcome is the comparative cost-effectiveness of the interventions at 12 and 24 months ; and exploratory outcomes include changes in stroke risk factors , health behaviors and treatment intensification . Recruitment for the stroke telemonitoring hypertension trial is currently ongoing . Discussion The combination of two established and effective interventions along with the utilization of health information technology supports the sustainability of the HBPTM + NCM intervention and feasibility of its widespread implementation . Results of this trial will provide strong empirical evidence to inform clinical guidelines for management of stroke in minority stroke survivors with uncontrolled hypertension . If effective among Black and Hispanic stroke survivors , these interventions have the potential to substantially mitigate racial and ethnic disparities in stroke recurrence . Trial registration Clinical Trials.gov NCT02011685 . Registered 10 December 2013 BACKGROUND The availability of clinical guidelines in isolation has generally failed to promote voluntary change in practice patterns . Accordingly , a r and omized controlled trial was conducted to determine the effectiveness of academic detailing ( AD ) techniques and continuous quality improvement ( CQI ) teams in increasing compliance with national guidelines for the primary care of hypertension and depression . METHODS Fifteen small group practice s at four Seattle primary care clinics were assigned to one of three study arms -- AD alone , AD plus CQI teams , or usual care . The activity of 95 providers and 4,995 patients was monitored from August 1 , 1993 , through January 31 , 1996 . Twelve-month baseline and study periods were separated by a six-month " wash-in " period during which training sessions were held . Changes in hypertension prescribing , blood pressure control , depression recognition , use of older tricyclics , and scores on the Hopkins Symptom Checklist depression scale were examined . RESULTS Clinics varied considerably in their implementation of both the AD and the CQI team interventions . Across all sites , AD was associated with change in a single process measure , a decline in the percentage of depressives prescribed first-generation tricyclics ( -4.7 percentage points versus control , p = 0.04 ) . No intervention effects were demonstrated for CQI teams across all sites for either disease condition . Within the clinic independently judged most successful at implementing both change strategies , the use of CQI teams and AD in combination did increase the percentage of hypertensives adequately controlled ( 17.3 percentage points versus control , p = 0.03 ) . SUMMARY AND CONCLUSIONS The AD techniques and the CQI teams evaluated were generally ineffective in improving guideline compliance and clinical outcomes regarding the primary care of hypertension and depression UNLABELLED In August 2008 , the Medical Advisory Secretariat ( MAS ) presented a vignette to the Ontario Health Technology Advisory Committee ( OHTAC ) on a proposed targeted health care delivery model for chronic care . The proposed model was defined as multidisciplinary , ambulatory , community-based care that bridged the gap between primary and tertiary care , and was intended for individuals with a chronic disease who were at risk of a hospital admission or emergency department visit . The goals of this care model were thought to include : the prevention of emergency department visits , a reduction in hospital admissions and re-admissions , facilitation of earlier hospital discharge , a reduction or delay in long-term care admissions , and an improvement in mortality and other disease-specific patient outcomes .OHTAC approved the development of an evidence -based assessment to determine the effectiveness of specialized community based care for the management of  heart failure , Type 2 diabetes and chronic wounds .  PLEASE VISIT THE MEDICAL ADVISORY SECRETARIAT WEB SITE AT : www.health.gov.on.ca/ohtas to review the following reports associated with the Specialized Multidisciplinary Community-Based care series . Specialized multidisciplinary community-based care series : a summary of evidence -based analysesCommunity-based care for the specialized management of heart failure : an evidence -based analysis Community-based care for chronic wound management : an evidence -based analysis Please note that the evidence -based analysis of specialized community-based care for the management of diabetes titled : " Community-based care for the management of type 2 diabetes : an evidence -based analysis " has been published as part of the Diabetes Strategy Evidence Platform at this URL : http://www.health.gov.on.ca/english/providers/program/mas/tech/ohtas/tech_diabetes_20091020.htmlPLEASE VISIT THE TORONTO HEALTH ECONOMICS AND TECHNOLOGY ASSESSMENT COLLABORATIVE WEB SITE AT : http://theta.utoronto.ca/papers/MAS_CHF_Clinics_Report.pdf to review the following economic project associated with this series : Community-based Care for the specialized management of heart failure : a cost-effectiveness and budget impact analysis . OBJECTIVE The objective of this evidence -based review is to determine the effectiveness of a multidisciplinary wound care team for the management of chronic wounds . CLINICAL NEED CONDITION AND TARGET POPULATION Chronic wounds develop from various aetiologies including pressure , diabetes , venous pathology , and surgery . A pressure ulcer is defined as a localized injury to the skin/ and or underlying tissue occurring most often over a bony prominence and caused , alone or in combination , by pressure , shear , or friction . Up to three fifths of venous leg ulcers are due to venous aetiology . Approximately 1.5 million Ontarians will sustain a pressure ulcer , 111,000 will develop a diabetic foot ulcer , and between 80,000 and 130,000 will develop a venous leg ulcer . Up to 65 % of those afflicted by chronic leg ulcers report experiencing decreased quality of life , restricted mobility , anxiety , depression , and /or severe or continuous pain . MULTIDISCIPLINARY WOUND CARE TEAMS : The term ' multidisciplinary ' refers to multiple disciplines on a team and ' interdisciplinary ' to such a team functioning in a coordinated and collaborative manner . There is general consensus that a group of multidisciplinary professionals is necessary for optimum specialist management of chronic wounds stemming from all aetiologies . However , there is little evidence to guide the decision of which professionals might be needed form an optimal wound care team . EVIDENCE -BASED ANALYSIS METHODS LITERATURE SEARCH A literature search was performed on July 7 , 2009 using OVID MEDLINE , MEDLINE In-Process and Other Non-Indexed Citations , OVID EMBASE , Wiley Cochrane , Centre for Review s and Dissemination/International Agency for Health Technology Assessment , and on July 13 , 2009 using the Cumulative Index to Nursing & Allied Health Literature ( CINAHL ) , and the International Agency for Health Technology Assessment ( INAHTA ) for studies pertaining to leg and foot ulcers . A similar literature search was conducted on July 29 ' 2009 for studies pertaining to pressure ulcers . Abstract s were review ed by a single review er and , for those studies meeting the eligibility criteria , full-text articles were obtained . Reference lists were also examined for any additional relevant studies not identified through the search . Articles with an unknown eligibility were review ed with a second clinical epidemiologist and then a group of epidemiologists until consensus was established . INCLUSION CRITERIA R and omized controlled trials and Controlled clinical Trials ( CCT ) Systematic review with meta analysis Population includes persons with pressure ulcers ( anywhere ) and /or leg and foot ulcersThe intervention includes a multidisciplinary ( two or more disciplines ) wound care team . The control group does not receive care by a wound care team Studies published in the English language between 2004 and 2009 EXCLUSION CRITERIA : Single centre retrospective observational studies OUTCOMES OF INTEREST Proportion of persons and /or wounds completely healedTime to complete healing Quality of LifePain assessment SUMMARY OF FINDINGS Two studies met the inclusion and exclusion criteria , one a r and omized controlled trial ( RCT ) , the other a CCT using a before and after study design . There was variation in the setting , composition of the wound care team , outcome measures , and follow up periods between the studies . In both studies , however , the wound care team members received training in wound care management and followed a wound care management protocol . In the RCT , Vu et al. reported a non-significant difference between the proportion of wounds healed in 6 months using a univariate analysis ( 61.7 % for treatment vs. 52.5 % for control ; p=0.074 , RR=1.19 ) There was also a non-significant difference in the mean time to healing in days ( 82 for treatment vs. 101 for control ; p=0.095 ) . More persons in the intervention group had a Brief Pain Inventory ( BPI ) score equal to zero ( better pain control ) at 6 months when compared with the control group ( 38.6 % for intervention vs. 24.4 % for control ; p=0.017 , RR=1.58 ) . By multivariate analysis a statistically significant hazard ratio was reported in the intervention group ( 1.73 , 95 % CI 1.20 - 1.50 ; p=0.003 ) . In the CCT , Harrison et al. reported a statistically significant difference in healing rates between the pre ( control ) and post ( intervention ) phases of the study . Of patients in the pre phase , 23 % had healed ulcers 3 months after study enrolment , whereas 56 % were healed in the post phase ( P<0.001 , OR=4.17 ) ( Figure 3 ) . Furthermore , 27 % of patients were treated daily or more often in the pre phase whereas only 6 % were treated at this frequency in the post phase ( P<0.001 ) , equal to a 34 % relative risk reduction in frequency of daily treatments . The authors did not report the results of pain relief assessment . The body of evidence was assessed using the GRADE methodology for 4 outcomes : proportion of wounds healed , proportion of persons with healed wounds , wound associated pain relief , and proportion of persons needing daily wound treatments . In general , the evidence was found to be low to very low quality . CONCLUSION The evidence supports that managing chronic wounds with a multidisciplinary wound care team significantly increases wound healing and reduces the severity of wound-associated pain and the required daily wound treatments compared to persons not managed by a wound care team . The quality of evidence supporting these outcomes is low to very low meaning that further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate Background Obesity is a pressing public health concern , which frequently presents in primary care . With the explosive obesity epidemic , there is an urgent need to maximize effective management in primary care . The 5As of Obesity Management ™ ( 5As ) are a collection of knowledge tools developed by the Canadian Obesity Network . Low rates of obesity management visits in primary care suggest provider behaviour may be an important variable . The goal of the present study is to increase frequency and quality of obesity management in primary care using the 5As Team ( 5AsT ) intervention to change provider behaviour . Methods / design The 5AsT trial is a theoretically informed , pragmatic r and omized controlled trial with mixed methods evaluation . Clinic-based multidisciplinary teams ( RN/NP , mental health , dietitians ) will be r and omized to control or the 5AsT intervention group , to participate in biweekly learning collaborative sessions supported by internal and external practice facilitation . The learning collaborative content addresses provider-identified barriers to effective obesity management in primary care . Evidence -based shared decision making tools will be co-developed and iteratively tested by practitioners . Evaluation will be informed by the RE- AIM framework . The primary outcome measure , to which participants are blinded , is number of weight management visits/full-time equivalent ( FTE ) position . Patient-level outcomes will also be assessed , through a longitudinal cohort study of patients from r and omized practice s. Patient outcomes include clinical ( e.g. , body mass index [ BMI ] , blood pressure ) , health-related quality of life ( SF-12 , EQ5D ) , and satisfaction with care . Qualitative data collected from providers and patients will be evaluated using thematic analysis to underst and the context , implementation and effectiveness of the 5AsT program . Discussion The 5AsT trial will provide a wide range of insights into current practice s , knowledge gaps and barriers that limit obesity management in primary practice . The use of existing re sources , collaborative design , practice facilitation , and integrated feedback loops cultivate an applicable , adaptable and sustainable approach to increasing the quantity and quality of weight management visits in primary care . Trial registration NCT01967797 OBJECTIVES To assess the cost-effectiveness of the 6-month Team Education and Adherence Monitoring ( TEAM ) intervention for black patients with hypertension in community pharmacies using prospect ively collected cost data . DESIGN Cost-effectiveness analysis of a cluster-r and omized trial . SETTING Twenty-eight chain pharmacies in 5 Wisconsin cities from December 2006 to February 2009 . PARTICIPANTS Five hundred seventy-six black patients with uncontrolled hypertension . INTERVENTION Pharmacists and pharmacy technicians using novel tools for improving adherence and feedback to patients and physicians as compared to information-only control group . MAIN OUTCOME MEASURES Incremental cost analysis of variable costs from the pharmacy perspective captured prospect ively at the participant level . Outcomes ( effect measures ) were 6-month refill adherence , changes in systolic blood pressure ( SBP ) and diastolic blood pressure ( DBP ) , and proportion of patients achieving blood pressure ( BP ) control . RESULTS Mean cost of intervention personnel time and tools was $ 104.8 ± $ 45.2 . Incremental variable costs per millimeter of mercury decrease in SBP and DBP were $ 22.2 ± 16.3 and $ 66.0 ± 228.4 , respectively . The cost of helping 1 more person achieve the BP goal ( < 140/90 mm Hg ) was $ 665.2 ± 265.2 ; the cost of helping 1 more person achieve good refill adherence was $ 463.3 ± 110.7 . Prescription drug costs were higher for the TEAM group ( $ 392.8 [ SD = 396.3 ] versus $ 307.0 [ SD = 295.2 ] ; P = 0.02 ) . The startup cost for pharmacy furniture , equipment , and privacy screen was $ 168 per pharmacy . CONCLUSION Our r and omized , practice -based intervention demonstrates that community pharmacists can implement a cost-effective intervention to improve hypertension control in blacks . This approach imposes a nominal expense at the pharmacy level that can be integrated into the ongoing pharmacist-patient relationship , and can enhance clinical and behavioral outcomes Background —Few studies have investigated the effectiveness of multifaceted interventions from the study participants ' perspective . We conducted qualitative interviews to underst and patients ' experiences with a multifaceted blood pressure ( BP ) control intervention involving interactive voice response technology , home BP monitoring , and pharmacist-led BP management . In the r and omized study , the intervention result ed in clinical ly significant decreases in BP . Methods and Results —We used insights generated from in-depth interviews from all study participants r and omly assigned to the multifaceted intervention or usual care ( n=146 ) to create a model explaining the observed improvements in health behavior and clinical outcomes . The data were analyzed using qualitative content analysis methods and consultative and reflexive team analysis . Six explanatory factors emerged from the patients ' interviews : ( 1 ) improved relationships with medical personnel ; ( 2 ) increased knowledge of hypertension ; ( 3 ) increased participation in their health care and personal empowerment ; ( 4 ) greater underst and ing of the impact of health behavior on BP ; ( 5 ) high satisfaction with technology used in the intervention ; and , for some patients , ( 6 ) increased health care utilization .  Eighty-six percent of the intervention patients and 62 % of the usual care patients stated that study participation had a positive effect on them . Of those expressing a positive effect , 68 % ( intervention ) and 55 % ( usual care ) reached their systolic BP goal . Conclusions —Establishing bidirectional conversations between patients and providers is a key element of successful hypertension management . Home BP monitoring coupled with interactive voice response technology reporting facilitates such conversations UNLABELLED Aim Integrated care pathways ( ICP ) are management technologies which formalise multidisciplinary team-working and enable professionals to examine their roles and responsibilities . ICPs are now being implemented across international healthcare arena , but evidence to support their use is equivocal . The aim of this study was to identify the circumstances in which ICPs are effective , for whom and in what context s. Methods A systematic review of high- quality r and omised controlled trials published between 1980 and 2008 ( March ) evaluating  ICP use in child and adult population s in the full range of healthcare setting s. RESULTS 1 For relatively predictable trajectories of care ICPs can be effective in supporting proactive care management and ensuring that patients receive relevant clinical interventions and /or assessment s in a timely manner . This can lead to improvements in service quality and service efficiency without adverse consequences for patients . 2 ICPs are an effective mechanism for promoting adherence to guidelines or treatment protocol s thereby reducing variation in practice . 3 ICPs can be effective in improving documentation of treatment goals , documentation of communication with patients , carers and health professionals . 4 ICPs can be effective in improving physician agreement about treatment options . 5 ICPs can be effective in supporting decision-making when they incorporate a decision-aide . 6 The evidence considered in this review indicates that ICPs may be particularly effective in changing professional behaviours in the desired direction , where there is scope for improvement or where roles are new . 7 Even in context s in which health professionals are already experienced with a particular pathway , ICP use brings additional beneficial effects in directing professional practice in the desired direction . 8 ICPs may be less effective in bringing about service quality and efficiency gains in variable patient trajectories . 9 ICPs may be less effective in bringing about quality improvements in circumstances in which services are already based on best evidence and multidisciplinary working is well established . 10 Depending on their purpose , the benefits of ICPs may be greater for certain patient subgroups than others . 11 We do not know whether the costs of ICP development and implementation are justified by any of their reported benefits . 12 ICPs may need supporting mechanisms to underpin their implementation and ensure their adoption in practice , particularly in circumstances in which ICP use is a significant change in organisational culture . 13 ICP documentation can introduce scope for new kinds of error . Conclusions ICPs are most effective in context s where patient care trajectories are predictable . Their value in setting s in which recovery pathways are more variable is less clear . ICPs are most effective in bringing about behavioural changes where there are identified deficiencies in services ; their value in context s where inter-professional working is well established is less certain . None of the studies review ed included an economic evaluation and thus it is not known whether their benefits justify the costs of their implementation Abstract Background Different studies have shown insufficient blood pressure ( BP ) control in hypertensive patients . Multiple factors influence hypertension management , and the quality of primary care is one of them . We decided therefore to evaluate the effectiveness of a  quality improvement plan directed at professionals of Primary Health Care Teams ( PHCT ) with the aim to achieve a better control of hypertension . The hypothesis of the study is that the implementation of a quality improvement plan will improve the control of hypertension . The primary aim of this study will be to evaluate the effectiveness of this plan . Methods and design Design : multicentric study quasi-experimental before – after with control group . The non-r and omised allocation of the intervention will be done at PHCT level . Setting : 18 PHCT in the Barcelona province ( Spain ) . Sample : all patients with a diagnosis of hypertension ( population based study ) . Exclusion criteria : patients with a diagnosis of hypertension made later than 01/01/2006 and patients younger than 18 years . Intervention : a quality improvement plan , which targets primary health care professionals and includes educational sessions , feedback to health professionals , audit and implementation of recommended clinical practice guidelines for the management of hypertensive patients . Measurements : age , sex , associated co-morbidity ( diabetes mellitus type I and II , heart failure and renal failure ) . The following variables will be recorded : BP measurement , cardiovascular risk and antihypertensive drugs used . Results will be measured before the start of the intervention and twelve months after the start of the study . Dependent variable : prevalence of hypertensive patients with poor BP control . Analysis : Chi-square test and Student 's t-test will be used to measure the association between independent qualitative and quantitative variables , respectively . Non-parametric tests will be used for the analysis of non-normally distributed variables . Significance level ( α ) will be set at < 0.05 . Outcomes will be analysed on an intention-to-treat basis . Discussion The implementation of a quality improvement plan might benefit the coordination of different professionals of PHCTs and may also improve blood pressure control . Trial Registration This protocol has been registered at clinical trials.gov with the ID number MS : 1998275938244441 ABSTRACT Background : Cardiovascular diseases and diabetes are among the leading causes of premature adult deaths in India . Innovative approaches such as clinical decision support ( CDS ) software could play a major role in improving the quality of hypertension/diabetes care in primary care setting s. Objective : To describe the steps and processes in the development of mWellcare , a complex intervention based on mobile health ( mHealth ) technology . Methods : The Medical Research Council framework was used to develop mWellcare in four steps : ( 1 ) identify gaps in usual care through literature review and health facility assessment s ; ( 2 ) identify the components of the intervention through discussion s and consultations with experts ; ( 3 ) develop intervention ( clinical algorithms and mHealth system ) ; and ( 4 ) evaluate acceptability and feasibility through pilot testing in five community health centers . Results : Lack of evidence -based , integrated , and systematic management of chronic conditions were major gaps identified . Experts in information technology , clinical fields , and public health professionals identified intervention components to address these gaps . Thereafter , clinical algorithm context ualized to primary care setting s were prepared and the mWellcare intervention was developed . During the 2-month pilot , 631 patients diagnosed with hypertension and /or diabetes were registered , with a follow-up rate of 36.2 % . The major barrier was resistance to follow mWellcare recommended patient workflow , and to overcome it , we emphasized onsite training and orientation program to cover all health care team member in each CHC . Conclusion : A pilot-tested mWellcare intervention is an mHealth system with important components , i.e. integrated management of chronic conditions , evidence -based CDS , longitudinal health data and automated short-messaging service to reinforce compliance to drug intake and follow-up visit , which will be used by nurses at primary health care setting s in India . The effectiveness and cost-effectiveness of the intervention will be tested through a cluster r and omized trial ( trial registration number NCT02480062 ) BACKGROUND Pharmacist- or nurse-led team care decreases  patient blood pressure ( BP ) and cardiovascular disease ( CVD ) risk . PURPOSE To evaluate whether a Web-based dietitian-led ( WD ) team care intervention was feasible and result ed in decreased BP , CVD risk , and weight compared to usual care ( UC ) . METHODS Electronic health record ( EHR ) data identified patients aged 30 - 69 years with BMI > 26 , elevated BP , and 10%-25 % 10-year Framingham CVD risk who were registered patient website users . Patients with uncontrolled BP at screening were r and omized to UC or WD , which included a home BP monitor , scale , and dietitian team care . WD participants had a single in-person dietitian visit to obtain baseline information and create a plan to reduce CVD risk . Planned follow-up occurred via secure messaging to report BP , weight , and fruit and vegetable intake and receive ongoing feedback . If needed , dietitians encouraged patients and their physicians to intensify antihypertensive and lipid-lowering medications . Primary outcomes were change in systolic BP and weight loss ≥4 kg at 6 months . Feasibility outcomes included intervention utilization and satisfaction . RESULTS Between 2010 and 2011 , a total of 90 of 101 participants completed 6-month follow-ups . The WD group had higher rates of secure messaging utilization and patient satisfaction . The WD group lost significantly more weight than the UC group ( adjusted net difference=-3.2 kg , 95 % CI=-5.0 , -1.5 , p<0.001 ) and was more likely to lose ≥4 kg ( adjusted relative risk [RRadj]=2.96 , 95 % CI=1.16 , 7.53 ) . BP control and CVD risk reduction were greater in WD than UC , but differences were not statistically significant . CONCLUSIONS WD intervention was feasible and result ed in decreased weight , BP , and CVD risk . A larger trial is justified . TRIAL REGISTRATION NUMBER Trial Registration Number : NCT01077388 Background Patients with chronic conditions often use complex medical regimens . A nurse‐led strategy to support medication therapy management incorporated into primary care teams may lead to improved use of medications for disease control . Electronic health record ( EHR ) tools may offer a lower‐cost , less intensive approach to improving medication management . Methods and Results The Northwestern and Access Community Health Network Medication Education Study is a health center – level cluster‐r and omized trial being conducted within a network of federally qualified community health centers . Health centers have been enrolled in groups of 3 and r and omized to ( 1 ) usual care , ( 2 ) EHR‐based medication management tools alone  , or ( 3 ) EHR tools plus nurse‐led medication therapy management . Patients with uncontrolled hypertension who are prescribed ≥3 medications of any kind are recruited from the centers .  EHR tools include a printed medication list to prompt review at each visit and automated plain‐ language medication information within the after‐visit summary to encourage proper medication use . In the nurse‐led intervention , patients receive one‐on‐one counseling about their medication regimens to clarify medication discrepancies and identify drug‐related concerns , safety issues , and nonadherence . Nurses also provide follow‐up telephone calls following new prescriptions and periodically to perform medication review . The primary study outcome is systolic blood pressure after 1 year . Secondary outcomes include measures of underst and ing of dosing instructions , discrepancies between patient‐reported medications and the medical record , adherence , and intervention costs . Conclusions The Northwestern and Access Community Health Network Medication Education Study will assess the effects of 2 approaches to support outpatient medication management among patients with uncontrolled hypertension in federally qualified health center setting s. Clinical Trial Registration URL : clinical trials.gov . Unique identifier : NCT01578577 Efforts to increase blood pressure ( BP ) control rates in blacks , a traditionally underserved high-risk population must address both provider practice and patient adherence issues . The home-based BP Intervention for blacks study is a 3-arm r and omized controlled trial design ed to test 2 strategies to improve hypertension management and outcomes in a de central ized service setting serving a vulnerable and complex home care population . The primary study outcomes are systolic BP , diastolic BP , and BP control ; secondary outcomes are nurse adherence to hypertension management recommendations and patient adherence to medication , healthy diet  , and other self-management strategies .  Nurses ( n=312 ) in a nonprofit Medicare-certified home health agency are r and omized along with their eligible hypertensive patients ( n=845 ) . The 2 interventions being tested are ( 1 ) a " basic " intervention delivering key evidence -based reminders to home care nurses and patients while the patient is receiving traditional postacute home health care ; and ( 2 ) an " augmented " intervention that includes that same as the basic intervention , plus transition to an ongoing Hypertension Home Support Program that extends support for 12 months . Outcomes are measured at 3 and 12 months after baseline interview . The interventions will be assessed relative to usual care and to each other . Systems change to improve BP management and outcomes in home health will not easily occur without new intervention models and rigorous evaluation of their impact . Results from this trial will provide important information on potential strategies to improve BP control in a low-income chronically ill patient population Integration of clinical pharmacists in patient care may offer increased access to health care and improved patient outcomes . Recently introduced legislation would establish pharmacists as health care providers and enable coverage of pharmacists ' services through Medicare Part B in medically underserved communities ( 1 , 2 ) . Pharmaceutical care involves pharmacist collaboration with health team members to optimize therapeutic outcomes ( 3 ) . Since 1995 , the Department of Veterans Affairs has allowed clinical pharmacy specialists an exp and ed scope of practice , with independent prescribing privileges ( 4 ) . The scope of practice for clinical pharmacy specialists includes pharmaceutical care or comprehensive medication management for patients with chronic diseases in addition to less complex services , such as counseling patients on medications or responding to questions about drug information . A 2014 systematic review evaluated outpatient medication therapy management interventions ( 5 ) . Study inclusion criteria required that interventions have , at minimum , 3 elements : comprehensive medication review ; patient-directed education and counseling ; and coordination of care , including prescriber-directed interventions . The research ers concluded that evidence was insufficient for health outcomes , although interventions may reduce the frequency of some medication-related problems and decrease some health care use and costs . We determined the effectiveness and harms of pharmacist-led chronic disease management compared with usual care for community-dwelling adults . Chronic disease management is typically a multicomponent intervention ( Figure 1 ) , and we required that the pharmacist take a lead role in at least 1 component . Studies where the pharmacist was a collaborator on a Patient Aligned Care Team or similar care strategy were not included . This report summarizes findings of a Department of Veterans Affairs Evidence -based Synthesis Program review ( available at www.hsrd . research .va.gov/publications/esp ) . Figure 1 . Components of pharmacist-led chronic disease management . * Follow-up after prescription for medication effectiveness and safety and drug-related problems . Includes medication reconciliation . The pharmacist provides immunization , which was not an outcome of interest . Facilitate access to other health care professionals and provide education about disease , lifestyle changes , aspirin therapy , and tobacco cessation . Supplement . Study Protocol Methods We developed a protocol for the review with input from content experts and method ologists . The protocol was not registered but was available for comment during review development . Data Sources and Search es We search ed MEDLINE ( Ovid ) , CINAHL , the Cochrane Library , and International Pharmaceutical Abstract s from 1995 through February 2016 for English- language literature ( Appendix Table 1 ) . We obtained additional articles by h and - search ing reference lists of systematic review s and other articles and from peer- review ers . Appendix Table 1 . Search Strategy for MEDLINE ( Ovid ) Study Selection We focused on chronic disease management for out patients in health care facilities , excluding retail pharmacies . We emphasized patient- or health system-centered outcomes but also addressed intermediate measures . MEDLINE abstract s were review ed for eligibility by 2 research ers ; abstract s from other data bases were review ed by a single research er . Full-text articles of studies identified as potentially eligible on the basis of abstract review were obtained for further review . Each article was independently review ed by 2 investigators or research associates . We included studies of any design that had a control group , evaluated outpatient adults with or at risk for a chronic disease , tested an intervention where the pharmacist was responsible for a distinct component of patient care , and were set in U.S. health care facilities . We excluded studies that did not involve interventions intended to manage or prevent 1 or more chronic diseases and studies of anticoagulation clinics because pharmacist management is considered st and ard care in those setting s. The Appendix Figure shows the reasons for study exclusion at full-text review . Appendix Figure . Summary of evidence search and selection . CCT = controlled clinical trial ; IPA = International Pharmaceutical Abstract s ; RCT = r and omized , controlled trial . Data Extraction and Quality Assessment Study data were extracted by one investigator and independently verified by a second . Our main outcomes of interest were clinical events , mortality , patient satisfaction , health care utilization ( including urgent care or emergency department visits and hospitalizations ) , medication adherence , and goal attainment ( Appendix Table 2 ) We also assessed access to care , quality of life , drug-related problems , and costs . We assessed risk of bias ( low , medium , or high ) for individual studies on the basis of sequence generation , allocation concealment , confounding ( for nonr and omized studies ) , blinding , and incomplete or selective outcome reportinga modification of the Cochrane approach ( 6 ) ( Appendix Table 2 ) . Appendix Table 2 . Evidence From Included Studies Appendix Table 2Continued Appendix Table 2Continued Appendix Table 2Continued Data Synthesis and Analysis We grouped studies by disease state and described and qualitatively compared the characteristics and findings of included studies . We rated the overall strength of the body of evidence across disease states for clinical events , patient satisfaction , target goal attainment , urgent care or emergency department visits and hospitalizations , and medication adherence by using the method of Owens and colleagues ( 7 ) . Two trained review ers grade d the strength of evidence regarding the outcomes as high , moderate , low , or insufficient on the basis of risk of bias , consistency , precision , and directness . We resolved discrepancies in risk of bias and strength of evidence ratings by discussion with final determination arrived through consensus that included the principal investigator . Most findings are summarized in narrative form , but we pooled results if studies were r and omized ( noncluster ) trials and enrolled participants and outcome measures were similar within each disease condition . DerSimonianLaird r and om-effects models were used to calculate pooled risk ratios ( RRs ) and 95 % CIs . We assessed statistical heterogeneity by using the I 2 statistic ( 75 % indicates substantial heterogeneity ) ( 8) . Role of the Funding Source The Department of Veterans Affairs , Veterans Health Administration , Office of Research and Development , Quality Enhancement Research Initiative assigned the topic and review ed the key questions but was not involved in data collection , analysis , or manuscript preparation or su bmi ssion . Results Search results are shown in the Appendix Figure . We included 72 articles representing 63 studies ( 40 r and omized , controlled trials [ RCTs ] ) with 65 unique study population s ( 940 - 4172 - 7381 ) . We grouped studies by disease state of the population and study characteristics ( Table 1 ) . Most studies were conducted in primary care setting s ( community-based or university-affiliated ) , but a few were in specialty clinics ( cardiology , nephrology , endocrinology ) . Interventions were typically delivered by pharmacists in person or with a mix of in-person and remote visits ( in 89 % of studies ) over multiple sessions ( 89 % ) . However , interventions varied in composition , delivery mode , and intensity , making it difficult to identify important intervention characteristics . Fifty-two studies were judged as low or medium risk of bias . Table 1 . Summary of Included Studies , by Disease State and Study Characteristics * Studies were generally short term ( 12 months ) and had small sample s. They mainly assessed intermediate outcomes , such as blood pressure , cholesterol , or glucose goal attainment , in patients with hypertension , cardiovascular disease , or diabetes ( 45 of 65 unique studies ) . Goal attainment was listed as the primary study outcome in 23 unique studies . Clinical events were described in 15 unique studies and were the primary outcome in 2 of those studies . Office visits , medication adherence or nonadherence , hospitalizations , patient satisfaction , and health-related quality of life were noted in 26 , 27 , 20 , 19 , and 19 studies , respectively , but they rarely were the primary outcome . Additional study details are presented in Appendix Table 2 . Findings Across All Disease Conditions In 15 trials ( 12 RCTs ) reporting clinical events ( for example , hypotension or hypoglycemia requiring additional intervention ) , pharmacist-led care and usual care ( typically continuing a pre study visit schedule ) were generally similar ( Appendix Table 3 ) ( 12 , 14 , 1922 , 3437 , 59 , 62 , 64 , 71 , 75 , 77 ) Eight studies reported all-cause mortality  , of which 6 found similar mortality in the pharmacist-led care and control groups and 2 did not report significance ( 12 , 13 , 16 , 18 , 28 , 30 , 37 , 71 ) . One of these studies in patients with diabetes also reported no disease-related deaths ( 28 ) . However , of studies reporting clinical events or mortality , only 2 were design ed to assess clinical events ( 13 , 14 ) , outcomes were sporadically and inconsistently reported , and there were few events ( low strength of evidence ) ( Table 2 ) . Evidence was insufficient to evaluate the effect of pharmacist-led care on patient satisfaction ( overall and for each disease condition ) and limited reporting of quality -of-life outcomes . Compared with usual care , pharmacist-led care improved study -selected goal attainment ( typically for blood pressure , lipid , and glycemic goals ) . Strength of evidence was moderate , with consistent findings across disease conditions . Table 2 . Strength of Evidence , by Outcome Evaluated * Appendix Table 3 . Summary of Direction of Evidence For re source use outcomes , pharmacist-led care was similar to usual care for incidences or rates of office visits ( 26 studies ) , urgent care or The effectiveness of a quality improvement program for hypertension management practice s and patient health outcomes in a group-model managed care organization was evaluated . Health-system pharmacists analyzed medical and pharmacy cl aims data to identify hypertensive patients . Chart review was conducted on a r and om sample of these patients to vali date a hypertension diagnosis and to obtain blood pressure ( BP ) control rates and prevalence of cardiovascular risk factors and comorbid conditions . The interventions consisted of educating health care providers and recommending appropriate pharmacotherapy for compelling indications . Patient outcomes were compared with baseline hypertension data . After interventions were implemented , medical and pharmacy cl aims identified 30,721 hypertensive patients and chart review s were performed on a r and om sample of 417 patients . Pharmacy cl aims revealed a total of 193,311 antihypertensive prescriptions . Approximately 47 % of all hypertensive patients were managed with monotherapy , while 24 % received dual therapy , and 11 % were taking three or more antihypertensive medications per day . Of the patients on monotherapy , 93 % received an angiotensin-converting-enzyme inhibitor ( 27.3 % ) , diuretic ( 26.6 % ) , beta-blocker ( 23.4 % ) , or calcium channel blocker ( 15.4 % ) . The overall level of BP control significantly improved from 37.2 % at baseline to 49.2 % at follow-up ( p = 0.0007 ) . BP control in the follow-up evaluation was 22.2 % in diabetic patients . For treatment of patients with comorbid disease states , provider practice patterns were evaluated at baseline and follow-up . Improving the quality of hypertension management increased BP control from 37.2 % to 49.2 % . Continued efforts to improve hypertension management , particularly in patients with concomitant diabetes and in elderly patients with isolated systolic hypertension , are needed Background Racial and ethnic disparities persist in stroke occurrence , recurrence , morbidity and mortality . Uncontrolled hypertension ( HTN ) is the most important modifiable risk factor for stroke risk . Home health care organizations care for many patients with uncontrolled HTN and history of stroke ; however , recurrent stroke prevention has not been a home care priority . We are conducting a r and omized controlled trial ( RCT ) to compare the effectiveness , relative to usual home care ( UHC ) , of two Community Transitions Interventions ( CTIs ) . The CTIs aim to reduce recurrent stroke risk among post-stroke patients via home-based transitional care focused on better HTN management . Methods / Design This 3-arm trial will r and omly assign 495 black and Hispanic post-stroke home care patients with uncontrolled systolic blood pressure ( SBP ) to one of three arms : UHC , UHC complemented by nurse practitioner-delivered transitional care ( UHC + NP ) or UHC complemented by an NP plus health coach ( UHC + NP + HC ) . Both intervention arms emphasize : 1 ) linking patients to continuous , responsive preventive and primary care , 2 ) increasing patients ’ /caregivers ’ ability to manage a culturally and individually tailored BP reduction plan , and 3 ) facilitating the patient ’s reintegration into the community after home health care discharge . The primary hypothesis is that both NP-only and NP + HC transitional care will be more effective than UHC alone in achieving a SBP reduction . The primary outcome is change in SPB at 3 and 12 months . The study also will examine cost-effectiveness , quality of life and moderators ( for example , race/ethnicity ) and mediators ( for example , changes in health behaviors ) that may affect treatment outcomes . All outcome data are collected by staff blinded to group assignment . Discussion This study targets care gaps affecting a particularly vulnerable black/Hispanic population characterized by persistent stroke disparities . It focuses on care transitions , a juncture when patients are particularly susceptible to adverse events . The CTI is innovative in adapting for stroke patients an established transitional care model shown to be effective for HF patients , pairing the professional NP with a HC , implementing a culturally tailored intervention , and placing primary emphasis on longer-term risk factor reduction and community reintegration rather than shorter-term transitional care outcomes .Trial registration Clinical Trials.gov NCT01918891 ; Registered 5 August 2013 Background / aims : Ensuring fidelity to a behavioral intervention implemented in nursing homes requires awareness of the unique considerations of this setting for research . The purpose of this article is to describe the goals of care cluster-r and omized trial and the methods used to monitor and promote fidelity to a goals of care decision aid intervention delivered in nursing homes . Methods : The cluster r and omized trial tested whether a decision aid for goals of care in advanced dementia could improve ( 1 ) the quality of communication and decision-making , ( 2 ) the quality of palliative care , and ( 3 ) the quality of dying for nursing home residents with advanced dementia . In 11 intervention nursing homes , family decision-makers for residents with advanced dementia received a two-component intervention : viewing a video decision aid about goals of care choices and then participating in a structured decision-making discussion with the nursing home care plan team , ideally within 3 months after the decision aid was viewed . Following guidelines from the National Institutes of Health Behavior Change Consortium , fidelity was assessed in study design , in nursing home staff training for intervention implementation , and in monitoring and receipt of the intervention . We also monitored the content and timing of goals of care discussion s. Results : Investigators enrolled 151 family decision-maker/resident dyads in intervention sites ; of those , 136 ( 90 % ) received both components of the intervention , and 92%–99 % of discussion s addressed each of four recommended content areas —health status , goals of care , choice of a goal , and treatment planning . A total of 94 ( 69 % ) of the discussion s between family decision-makers and the nursing home care team were completed within 3 months . Conclusion : The methods we used for intervention fidelity allowed nursing home staff to implement a goals of care decision aid intervention for advanced dementia . Key supports for implementation included design features that aligned with nursing home practice , efficient staff training , and a structured guide for goals of care discussion s between family decision-makers and staff . These approaches may be used to promote fidelity to behavioral interventions in future clinical trials Polypharmacy , often defined as coincident prescribing of at least 5 long-term medications , is associated with an increased risk for inappropriate prescribing . As many as 40 % of nursing home residents may receive 1 or more inappropriate drugs ( 1 ) , a rate similar to that among community-dwelling older persons ( 2 ) . In nursing home residents , inappropriate prescribing has been shown to be associated with adverse events ( 3 ) and hospitalizations ( 4 ) . Inappropriate prescribing of antihypertensives , benzodiazepines , and the atypical antipsychotic quetiapine has been associated with increased fall risk in community-dwelling older persons ( 5 ) , loss of physical function in community-dwelling older women ( 6 ) , and an increase in cognitive decline in nursing home residents ( 7 ) , respectively . In addition to overprescribing , inappropriate prescribing may also manifest as underprescribing ( the omission of appropriate medication ) . Underprescribing of oral anticoagulants among nursing home residents has been reported ( 8) . Deprescribing has been defined as the process of withdrawal of an inappropriate medication , supervised by a health care professional with the goal of managing polypharmacy and improving outcomes ( 9 ) . Studies targeting discontinuation of use of specific medications have shown mixed results . Bergh and colleagues ( 10 ) found a worsening of depressive symptoms after discontinuation of antidepressant use but concluded that this worsening was in the sub clinical range . A systematic review showed that many patients remained normotensive after withdrawal of antihypertensives , although proportions ranged from 20 % to 85 % across studies ( 11 ) . Furthermore , conflicting results were found for discontinuation of antipsychotic use and risk for relapse of neuropsychiatric symptoms ( 12 , 13 ) . Multidisciplinary systematic medication review s done by physicians and pharmacists working together are aim ed at improving prescribing in patients with polypharmacy , but findings about their effectiveness have been equivocal ( 1418 ) . Negative findings may have been due to inclusion of inappropriate outcomes ( 17 ) and heterogeneity of interventions . Medication review s were performed by a multidisciplinary team of physicians and pharmacists in some studies but were done by a single health professional in others ( 19 ) . More extensive intervention studies using well-defined pharmacologic outcome measures and proximal outcomes indicative of patients ' well-being are needed ( 18 ) . Moreover , evidence on the effectiveness of multidisciplinary systematic medication review s is limited for nursing home residents , a particularly vulnerable population . Accordingly , the aim of this study was to assess whether multidisciplinary systematic medication review s increase successful discontinuation of inappropriate medication use , improve prescribing in other respects , and improve clinical outcomes in nursing home residents . Methods Design Overview We conducted the DIM-NHR ( Discontinuing Inappropriate Medication in Nursing Home Residents ) study , a pragmatic cluster r and omized controlled trial . Clusters of elder care physicians and their wards with residents from the 3 northern provinces of the Netherl and s were r and omly allocated to the intervention or control group in a 1:1 ratio . Participants were recruited between June 2014 and December 2015 , and follow-up was completed in April 2016 . The Medical Ethical Committee of the University Medical Center Groningen approved the study ( protocol number NL48091.042.14 ) . Written informed consent was requested from residents in wards for disabling conditions if they were deemed capable by the nursing staff . Informed consent from a legal representative was requested for residents who were not capable of providing informed consent and for those from dementia special care units . The study 's methods have been published ( 20 ) . The original trial protocol and a summary of changes to it are provided in the Supplement . Supplement . Study Protocol Changes and Original Protocol Setting and Participants We screened nursing home wards , elder care physicians , and nursing home residents for eligibility . Nursing home wards were eligible if they were dementia special care units or if they provided care for residents with disabling conditions . We included long-term care wards to reduce loss of participants to follow-up . Nursing home wards were excluded if they primarily cared for atypical patients ( for example , those with lifelong psychiatric disorder or intellectual disability ) , if they participated in other research aim ed at improving drug prescribing within the previous 12 months , or if medication review s had been done within 6 months before the beginning of recruitment . Unlike in many other countries , where different nursing home residents have different primary care physicians , in the Netherl and s , specialized elder care physicians are based in the nursing home . We recruited pharmacists and elder care physicians who were committed to performing the medication review s. Elder care physicians were ineligible if they previously received or were about to receive recertification for systematic medication review s. Nursing home residents were included if they had a life expectancy greater than 4 weeks and were deemed ineligible if they declined treatment with medication or at the discretion of nursing staff ( for example , because of a difficult relationship between nursing home staff and family members ) . R and omization and Intervention Cluster r and omization was performed at the level of the elder care physicians and the wards they were responsible for in order to minimize contamination that might occur if individual nursing home residents who shared the same elder care physician were r and omly assigned to different groups . Elder care physicians and their wards were first matched on relevant characteristics , including supplying pharmacy , health care organization , and ward type ( for example , wards for residents with dementia vs. residents with disabling conditions and number of residents in the ward ) . For each matched pair of physicians , one was r and omly assigned to the intervention group and the other to the control group . The r and om assignment was generated using the r and om variable function in SPSS software and was done by a research er who was not involved in data collection . Because physicians and pharmacists implemented the intervention , they were not blinded to the allocation of wards to the intervention or control group . Other nursing home staff , nursing home residents , and assessors of outcomes were not informed about the treatment allocation . The intervention consisted of a single Multidisciplinary Multistep Medication Review ( 3MR ) ( Table 1 ) that was done by the treating elder care physicians in collaboration with hospital pharmacists or pharmacists appointed to conduct medication review s in nursing homes . Participating elder care physicians and pharmacists received brief training about the 3MR before performing it . Adherence to the 3MR was checked by confirming with the pharmacists whether steps 1 to 3 had been completed and confirming with the physicians whether step 4 had been completed . The control condition consisted of usual care , including medication safety monitoring and ad hoc medication review s for individual residents when clinical ly indicated . These review s differed in quality and frequency from the st and ardized 3MRs performed in the intervention group . Table 1 . Overview of 3MR Steps Outcomes and Follow-up Primary and secondary outcome measures were collected at baseline and after 4 months . This follow-up was chosen because it allowed for consolidation of medication changes while also preventing excessive loss to follow-up owing to substantial mortality risk among these frail patients . The primary outcome was the proportion of residents who successfully discontinued use of at least 1 inappropriate medication ( that is , without relapse symptoms or severe withdrawal effects ) after 4 months of follow-up . Pharmacy and medical interns review ed all physician notes in each resident 's medical chart between baseline and follow-up to detect potential withdrawal or relapse symptoms . Medications that had to be tapered gradually ( such as narcotics or steroids ) because of the potential for severe withdrawal effects were not excluded from the intervention and were included in the count of successful discontinuations . A switch of an inappropriate medication to another medication in the same Anatomical Therapeutic Chemical ( ATC ) group was not considered a successful discontinuation . Medications were excluded if they were prescribed temporarily ( for example , antibiotics , dermatologic agents , or as-needed medications ) . Secondary pharmacologic outcomes were the number of residents for whom at least 1 underprescribed medication ( according to the START [ Screening Tool to Alert doctors to Right Treatment ] criteria [ 21 ] ) was initiated between baseline and follow-up , at least 1 dose was adjusted , and at least 1 potentially hazardous drug was replaced by a safer alternative . We also assessed cumulative exposure to anticholinergic and sedative drugs as measured with the Drug Burden Index ( DBI ) ( 23 ) at follow-up . Assessment of the primary and secondary pharmacologic outcomes was based on data from computerized pharmacy dispensing records . Data included the generic drug names , ATC codes , dosages , and start and stop date s for all prescribed medications between baseline and follow-up . All pharmacologic outcomes were review ed and adjudicated by a panel consisting of the interns , an elder care physician who was not involved in conducting the 3MRs , and a professor of clinical pharmacy . Secondary clinical outcome measures included the number of falls , visits to outpatient clinics , visits by elder care physicians , and consultations by other health care professionals ( for example , physiotherapists ) , as documented in residents ' medical charts . Cognitive function was 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 r and omized 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 CONTEXT When a patient receives a cancer diagnosis , existential issues become more compelling . Throughout the illness trajectory , patients with cancer are cared for in oncology wards , by home care teams or in hospices . Nurses working with these patients are sometimes aware of the patients ' existential needs but do not feel confident when discussing these issues . OBJECTIVES To determine the effects of a training intervention , where the focus is on existential issues and nurses ' perceived confidence in communication and their attitude toward caring for dying patients . METHODS This was a r and omized , controlled trial with a training intervention comprising theoretical training in existential issues combined with individual and group reflection . In total , 102 nurses in oncology and hospice wards and in palliative home care teams were r and omized to a training or non-training group . Primary outcomes , confidence in communication , and attitude toward the care of dying patients were measured at baseline , immediately after the training , and five to six months later . RESULTS Confidence in communication improved significantly in the training group from baseline ( before the training ) to both the first and second follow-up , that is , immediately after the training and five months later . The attitude toward caring for the dying did not improve in the training group . CONCLUSION This study shows that short-term training with reflection improves the confidence of health care staff when communicating , which is important for health care managers with limited re sources . Further studies are needed to explore how patients experience the communication skills of health care staff after such training Team-based care can improve  hypertension control . The purpose of the present study was to evaluate blood pressure ( BP ) control 18 months following the discontinuation of a physician-pharmacist collaborative intervention . This was a retrospective analysis of patients who had previously participated in a prospect i ve , cluster r and omized , controlled clinical trial . Six community-based family medicine offices were r and omized to control or intervention groups . Research nurses measured BPs using an automated device during the prospect i ve trial . The research nurses then abstract ed data from medical records , including BPs , medications , changes in therapy , and laboratory values for 18 months following the discontinuation of the 6-month prospect i ve trial . The study included 228 patients in the control ( n = 146 ) or intervention ( n = 82 ) groups . The control group contained more patients with diabetes or chronic kidney disease ( P < .013 ) , were older ( P = .047 ) , and had more coexisting conditions ( P < .001 ) than the intervention group . Systolic BP 9 months following discontinuation of the physician-pharmacist intervention was 137.2 ± 18.2 mm Hg and 129.8 ± 13.3 mm Hg in the control and intervention groups , respectively ( P = .0015 ) . BP control was maintained in 61 ( 41.8 % ) control patients and 55 ( 67.1 % ) intervention patients ( P = .0003 ) . At 18 months post-intervention , systolic BP was 138.1 ± 20.4 mm Hg and 130.0 ± 16.0 mm Hg in the control and intervention groups , respectively ( P = .023 ) . BP control was maintained in 53 ( 36.3 % ) control patients and 55 ( 67.1 % ) intervention patients at 18 months post-intervention ( P < .0001 ) . A sensitivity analysis was conducted to address the uneven distribution of patients with diabetes or chronic kidney disease , and the differences between groups were still significant . BP control rates remained significantly higher following a physician-pharmacist intervention compared with usual care for 18 months after discontinuation of the intervention . This model has the potential value as a useful long-term strategy to benefit patients with hypertension Context Can self-management interventions help improve blood pressure control in hypertensive patients ? Contribution In this trial , 636 patients with hypertension were r and omly assigned to receive usual care ; a telephone-delivered , nurse-administered behavioral self-management intervention ; home blood pressure self-monitoring ; or both of the latter 2 interventions . Compared with usual care , the adjusted improvement in the proportion of patients with blood pressure control at 24 months was 4.3 % for the behavioral intervention group , 7.6 % for the blood pressure monitoring group , and 11.0 % for the combined intervention group . Caution Patients were recruited from 2 university-affiliated clinics , and most ( 73 % ) already had reasonable blood pressure control at trial entry . The Editors Although multiple treatment options are available for hypertension , only one third of U.S. patients with hypertension have their blood pressure ( BP ) under effective control ( 1 ) . Home BP monitoring is a potentially important aspect of successful hypertension management ( 2 ) . Adopting a healthy lifestyle and adhering to provider recommendations are also important in managing hypertension . Few educational and BP monitoring studies have provided long-term follow-up ( > 12 months ) or implemented a multidimensional intervention that is tailored to patients ' needs and delivered by telephone ( 3 ) . A tailored telephone behavioral intervention and home BP monitoring may be a cost-effective method for improving BP outcomes ( 4 ) . We compared the effectiveness of BP self-monitoring , a tailored , nurse-administered behavior self-management intervention , and a combination of the 2 interventions with that of usual care . Methods The study was approved by the Duke University Institutional Review Board , and all patients provided written informed consent . Setting and Participants Recruitment occurred from May 2004 to December 2005 , with follow-up from November 2004 to January 2008 . Potentially eligible study patients were identified through weekly data extraction s from the billing and appointment data base for 2 Duke University Health System primary care clinics . Patients were cared for by 7 faculty general internists in 1 clinic and 85 residents under the supervision of faculty at the other clinic . Initial inclusion criteria were hypertension diagnosed at least 12 months before the data extraction date ( International Classification of Diseases , 9th revision , codes 401.0 , 401.1 , or 401.9 ) , enrollment with a primary care physician at the included clinic for at least 12 months before data extraction , self-report of current antihypertensive medication use , a scheduled appointment with a nonlaboratory primary care provider during the next 30 days , and residence in 1 of 32 specified ZIP codes in the areas around Duke University Health System . Exclusion criteria applied before r and omization were a diagnosis of dementia , Parkinson disease , atrial fibrillation , or end-stage renal disease ; patient of a study investigator or physician not expected to remain at the practice during the entire study period ; resident in nursing home or receiving home health care ; hospitalization for stroke or heart attack , surgery for blocked arteries , or diagnosis of metastatic cancer in the previous 3 months ; poor vision or difficulty hearing on the telephone ; difficulty underst and ing English on the telephone ; participant in another BP study ; spouse participating in current study ; arm circumference greater than 17 inches and wrist circumference greater than 8.5 inches ; pregnant or planning to become pregnant in the next 2 years ; or not receiving most medical care from Duke clinics . Patients also were excluded after r and omization because they were no longer receiving medical care at the Duke clinics , had initiated dialysis , had received an organ transplant in the previous 6 months , resided in a nursing home or receiving home health care , had no telephone , or received a diagnosis of pulmonary hypertension in the previous 6 months . The study team mailed qualifying patients a letter from the patient 's primary care provider that gave information about the study and stated that the study team may contact them to participate . Research assistants made weekly screening telephone calls to patients from a r and omly ordered list of eligible patients with upcoming clinic appointments . Figure 1 shows the flow of participants in the study . Overall , 2060 invitation letters were mailed to patients . Research assistants attempted to contact 1728 potential participants by telephone . Six hundred fifty-six patients were enrolled and consented to participate ; the remaining 1072 were not enrolled for various reasons . Twenty additional patients were excluded at the time of the baseline interview . Figure 1 . Study flow diagram . BP = blood pressure . * No longer receiving care at Duke clinics , receiving dialysis , received an organ transplant , residing in a nursing home or receiving home health care , had no telephone , or had pulmonary hypertension . R and omization and Intervention The 636 eligible patients were r and omly assigned to receive usual care , a tailored behavioral telephone intervention , home BP monitoring , or the behavioral intervention plus BP monitoring . In a 22 design , r and omization was stratified at baseline by enrollment site ( 2 primary care clinics ) and health literacy status , as determined by using the Rapid Estimate of Adult Literacy in Medicine ( 5 ) ( low literacy , score of 0 to 60 [ 9th- grade level or less ] [ 6 ] , vs. adequate literacy , score of 61 to 66 [ greater than 9th- grade level ] [ 7 ] ) . Consecutively numbered envelopes were used to r and omly assign patients in each stratum . R and omization blocks of 16 were computer generated by the study statistician and used to ensure ongoing balanced enrollment across the 4 groups . The research assistants were blinded to block size , and patient r and omization sequences were maintained by the study statistician in a separate office from the clinics . At completion of the baseline interview , a research assistant opened an envelope and disclosed the patient 's r and omization status . Participants were reimbursed $ 25 for the baseline visit and for each of the 4 subsequent 6-month BP measurement visits ( $ 125 total ) . Usual Care Patients assigned to usual care received hypertension care from their primary care provider . They were not provided home BP monitors and did not have access to the nurse-administered behavioral intervention . They underwent the same 6-month outcome assessment measurements as the other groups . Tailored Behavioral Self-management Intervention Patient factors targeted in the behavioral intervention included perceived risk for hypertension , memory , literacy , social support , patients ' relationships with their health care providers , and side effects of antihypertension medication . In addition , the intervention focused on improving  adherence to the Dietary Approaches to Stop Hypertension ( DASH ) dietary pattern  ( 811 ) ,  weight loss  ( 12 , 13 ) ,  reduced sodium intake  ( 13 , 14 ) ,  regular moderate-intensity physical activity  ( 15 , 16 ) ,  smoking cessation  , and moderation of alcohol intake  ( 17 ) . The intervention was delivered by 1 nurse during bimonthly telephone calls . All information was presented in an easily understood format with a FleschKincaid readability score of less than 9th grade ( 18 ) . Each encounter included a core group of modules potentially implemented during each call ( for example , medication and side effects ) plus additional modules activated at specific intervals ( for example , diet and social support ) ( 19 ) . Home BP Monitoring Intervention Patients assigned to home BP monitoring received an Omron HEM 773AC arm monitor ( OMRON Healthcare , Bannockburn , Illinois ) if arm circumference was 17 inches or less or an Omron HEM 637 wrist monitor if arm circumference was greater than 17 inches and wrist circumference was less than 8.5 inches . Two research assistants trained patients in proper use of the home BP devices . At each 6-month assessment , patients were retrained if their BP assessment procedure was incorrect . Patients were asked to measure their BP 3 times weekly on 3 separate days , at the same time of day , and record their values in a log . Patients were asked to mail their logs in every 2 months by using study -provided , preaddressed , stamped envelopes . Combined Intervention Patients assigned to the combined intervention received a home BP monitor , training on its use , and the behavioral self-management intervention . The nurse did not examine home BP values and did not use the home BP values to adjust the intervention . Outcomes and Measurements Baseline Measurement Patient demographic information and diagnosis of diabetes were obtained from patients during a face-to-face baseline interview . Inadequate income was assessed by asking patients to report whether they had enough money to pay bills only by cutting back on things or had difficulty paying bills ( 20 ) . Health literacy was evaluated as a dichotomous variable ( 7 ) . Body weight abstract ed from the medical record and self-reported height were used to calculate body mass index . Study Outcomes : BP Control and Systolic and Diastolic BP The primary outcome was the proportion of participants with adequate BP control at each study time point ( baseline and 6 , 12 , 18 , and 24 months ) . Blood pressure control was defined as systolic BP less than 140 mm Hg and diastolic BP less than 90 mm Hg for patients without diabetes , and systolic BP less than 130 mm Hg and diastolic BP less than 80 mm Hg for patients with diabetes ( 21 ) . Secondary outcomes were systolic and diastolic BP at each time point over 24 months . At each time point , a research assistant who was blinded to the patient 's group assignment obtained 2 BP measurements with a digital sphygmomanometer ( BPTRU Automated Non-invasive BP monitor , Model BPM-100 , BpTRU Medical Devices Headquarters , Coquitlam , British Columbia , Canada ) ; the first was obtained after patients were The objective of this systematic review was to evaluate the impact of pharmacist delivered community-based services to optimise the use of medications for mental illness . Twenty-two controlled ( r and omised and non-r and omised ) studies of  pharmacists ' interventions in community and residential aged care setting s identified in international scientific literature were included for review . Papers were assessed for study design , service recipient , country of origin , intervention type , number of participating pharmacists , method ological quality and outcome measurement . Three studies showed that pharmacists ' medication counselling and treatment monitoring can improve adherence to antidepressant medications among those commencing treatment when calculated using an intention-to-treat analysis . Four trials demonstrated that pharmacist conducted medication review s may reduce the number of potentially inappropriate medications prescribed to those at high risk of medication misadventure . The results of this review provide some evidence that pharmacists can contribute to optimising the use of medications for mental illness in the community setting . However , more well design ed studies are needed to assess the impact of pharmacists as members of community mental health teams and as providers of comprehensive medicines information to people with schizophrenia and bipolar Introduction : Care home residents are at particular risk from medication errors , and our objective was to determine the prevalence and potential harm of prescribing , monitoring , dispensing and administration errors in UK care homes , and to identify their causes . Methods : A prospect i ve study of a r and om sample of residents within a purposive sample of homes in three areas . Errors were identified by patient interview , note review , observation of practice and examination of dispensed items . Causes were understood by observation and from theoretically framed interviews with home staff , doctors and pharmacists . Potential harm from errors was assessed by expert judgement . Results : The 256 residents recruited in 55 homes were taking a mean of 8.0 medicines . One hundred and seventy-eight ( 69.5 % ) of residents had one or more errors . The mean number per resident was 1.9 errors . The mean potential harm from prescribing , monitoring , administration and dispensing errors was 2.6 , 3.7 , 2.1 and 2.0 ( 0 = no harm , 10 = death ) , respectively . Contributing factors from the 89 interviews included doctors who were not accessible , did not know the residents and lacked information in homes when prescribing ; home staff ’s high workload , lack of medicines training and drug round interruptions ; lack of team work among home , practice and pharmacy ; inefficient ordering systems ; inaccurate medicine records and prevalence of verbal communication ; and difficult to fill ( and check ) medication administration systems . Conclusions : That two thirds of residents were exposed to one or more medication errors is of concern . The will to improve exists , but there is a lack of overall responsibility . Action is required from all concerned Background Cardiovascular diseases ( CVD ) are responsible for significant morbidity , premature mortality , and economic burden . Despite established evidence that supports the use of preventive medications among patients at high CVD risk , treatment gaps remain . Building on prior evidence and a theoretical framework , a complex intervention has been design ed to address these gaps among high-risk , under-treated patients in the Australian primary care setting . This intervention comprises a general practice quality improvement tool incorporating clinical decision support and audit/feedback capabilities ; availability of a range of CVD polypills ( fixed-dose combinations of two blood pressure lowering agents , a statin ± aspirin ) for prescription when appropriate ; and access to a pharmacy-based program to support long-term medication adherence and lifestyle modification . Methods Following a systematic development process , the intervention will be evaluated in a pragmatic cluster r and omized controlled trial including 70 general practice s for a median period of 18 months . The 35 general practice s in the intervention group  will work with a nominated partner pharmacy , whereas those in the control group will provide usual care without access to the intervention tools . The primary outcome is the proportion of patients at high CVD risk who were inadequately treated at baseline who achieve target blood pressure ( BP ) and low-density lipoprotein cholesterol ( LDL-C ) levels at the study end . The outcomes will be analyzed using data from electronic medical records , utilizing a vali date d extraction tool . Detailed process and economic evaluations will also be performed . Discussion The study intends to establish evidence about an intervention that combines technological innovation with team collaboration between patients , pharmacists , and general practitioners ( GPs ) for CVD prevention . Trial registration Australian New Zeal and Clinical Trials Registry BACKGROUND Previous studies have demonstrated deficiencies in palliative care in the community . One method of translating the results of research into clinical practice , in order to produce more effective health care , is the development of clinical guidelines . Setting st and ards for such care has been performed by care teams in both hospital and hospice setting s but not in primary care . AIM This study set out to develop guidelines for primary care teams to follow in the provision of palliative care in the community using facilitated case discussion s with the members of such teams , as a form of internal audit . METHOD Five practice s were r and omly chosen from the family health services authority medical list . Meetings between the facilitators and primary care teams were held over a period of one year . The teams were asked to describe good aspects of care , areas of concern and suggestions to improve these , in recent cases of patient deaths . RESULTS In total 56 cases were discussed . All practice s felt that cohesive teamwork , coordinated management , early involvement of nursing staff and the identification of a key worker were essential for good terminal care . Concerns arose in clinical and administrative areas but the majority were linked to poor communication , either between patient and professionals within the primary care team or between primary and secondary care . All the positive aspects of care , concerns and suggestions were collated by the facilitators into guidelines for teams to refer to from the initial diagnosis of a terminal illness through to the patient 's death and care of the relatives afterwards . CONCLUSION Developing multidisciplinary as opposed to medical guidelines for palliative care allows primary health care teams to create st and ards that are acceptable to them and stimulates individuals within the teams to accept responsibility for initiating the change necessary for more effective care . The process of facilitating teams to discuss their work allows for recognition and respect of individuals ' roles and more importantly provides shared ownership , an important contributory factor in the implementation of guidelines Objective To study the implementation of multidisciplinary structured work shift evaluations at a pediatric intensive care unit ( PICU ) to enhance team communication . Design and setting Prospect i ve , repeated measurements design , comparison of pre/post measurements and process measures in a Dutch tertiary care , university-affiliated PICU . Participants All 61 PICU staff members . Interventions Implementing multidisciplinary structured work shift evaluations . Before the implementation phase the PICU team received feedback training and eight participants ( four physicians , four nurses ) were trained as “ work shift evaluation leader .  ” Measurements and results Outcome measures covered : ( a ) quality and process of the implementation through prestructured checklists during the 3 months of implementation , ( b ) a subjective evaluation of a feedback training on team communication as anticipated action and on the level of communication ( about patients and with colleagues ) , and ( c ) emotional exhaustion complaints and work-related fatigue . The interdisciplinary structured work shift evaluations were implemented successfully as planned during the work shift ; all staff were trained ahead , and the process was followed almost completely . Almost two-thirds ( 62 % ) of the staff felt a positive influence on team communication . Almost all staff members ( 92 % ) were satisfied regarding communication with their colleagues after the intervention , compared to 76 % before . Emotional exhaustion in the PICU team decreased significantly after the implementation , but no differences in work-related fatigue levels were found . Conclusions As organizational change the implementation of a multidisciplinary structured work shift evaluation at a PICU was successful and team communication improved . Emotional exhaustion decreased during the study period Background Despite compelling evidence of the benefits of treatment and well-accepted guidelines for treatment , hypertension is controlled in less than one-half of United States citizens . Methods / design This r and omized controlled trial tests whether explicit financial incentives promote the translation of guideline -recommended care for hypertension into clinical practice and improve blood pressure ( BP ) control in the primary care setting . Using constrained r and omization , we assigned 12 Veterans Affairs hospital outpatient clinics to four study arms : physician-level incentive ; group-level incentive ; combination of physician and group incentives ; and no incentives ( control ) . All participants at the hospital ( cluster ) were assigned to the same study arm . We enrolled 83 full-time primary care physicians and 42 non-physician personnel . The intervention consisted of an educational session about guideline -recommended care for hypertension , five audit and feedback reports , and five disbursements of incentive payments . Incentive payments rewarded participants for chart-documented use of guideline -recommended antihypertensive medications , BP control , and appropriate responses to uncontrolled BP during a prior four-month performance period over the 20-month intervention . To identify potential unintended consequences of the incentives , the study team interviewed study participants , as well as non-participant primary care personnel and leadership at study sites . Chart review s included data collection on quality measures not related to hypertension . To evaluate the persistence of the effect of the incentives , the study design includes a washout period . Discussion We briefly describe the rationale for the interventions being studied , as well as the major design choices . Rigorous research design s such as the one described here are necessary to determine whether performance-based payment arrangements such as financial incentives result in meaningful quality improvements . Trial Registration http://www . clinical
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 .
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 .