IMPPACT: Investigation of Medical Professionals and Patients Achieving Control Together.

OBJECTIVE: To determine whether home blood pressure monitoring (HBPM) led to physician-initiated medication titration and improved achievement of target BP levels compared with standard, office-based management. METHODS: Physicians were randomly assigned to a treatment group or a control group. Patients in the control group were monitored by their physician and were drug-adjusted according to the usual approach. In the treatment group, patients were given home BP monitors (UA-767P [A&D Medical/Lifesource, USA]), and drug dosing was adjusted according to HBPM readings and protocol. Long-acting diltiazem (240 mg/day) was added at baseline, which was adjusted as necessary (other medications were added if more than 360 mg/day of diltiazem was required). A final BP measurement was taken in the office after six weeks. RESULTS: Nineteen physicians were randomly assigned to the office BP monitoring group and 34 were assigned to the HBPM group. Of the 270 subjects recruited, 97 were in the office BP monitoring group and 173 were in the HBPM group. From baseline to the final visit, there was a statistically significant time by group interaction with lower BP in the HBPM group (P=0.034 for both systolic BP and diastolic BP). BP fell from 159/91+/-11/10 mmHg at baseline in the HBPM group to 138/80+/-13/8 mmHg on the final visit, and from 160/88+/-14/10 mmHg to 141/78+/-10/9 mmHg in the control group. CONCLUSIONS: BP was lowered significantly in both groups, and to a statistically greater degree in the HBPM group. The Hawthorne effect might have led to altered care by the physicians with improvement in BP control in both groups.

Knowledge translation in critical care: factors associated with prescription of commonly recommended best practices for critically ill patients.

OBJECTIVE: To describe prescription rates of commonly recommended best practices (clinical interventions with a strong base of evidence supporting their implementation) for critically ill patients and determine factors associated with increased rates of prescription. DESIGN: A retrospective observational study. SETTING: A university-affiliated medical-surgical-trauma intensive care unit over a 1-yr period. PATIENTS: One hundred randomly selected critically ill patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Among the best practices studied, there was great variability in the proportion of patients eligible (median 36.5%, range 10% to 100%) and the proportion without contraindication (32.5%, range 10% to 86%) for each practice. The median rate of prescription of best practices for eligible patients was 56.5%, with a range from 8% to 95%. There was greater prescription of best practices when standard admission orders included an option to prescribe them (p = .048). Among those practices with standard admission orders, there was greatest prescription for practices additionally having a specialty consultation service (p = .004). There was an inverse association between severity of illness and prescription of best practices (p = .001): Sicker patients were less likely to be prescribed best practices. CONCLUSIONS: There may be substantial variability in the acceptance and prescription of commonly recommended best practices for critically ill patients. Standard order sets and focused specialty consultation may improve knowledge translation and prescription of best practice.

The impact of job strain and marital cohesion on ambulatory blood pressure during 1 year: the double exposure study.

BACKGROUND: Psychosocial and lifestyle stressors, such as job strain and marital factors, have previously been associated with a sustained increase in blood pressure (BP). METHODS: In a 1-year longitudinal study, we evaluated whether job strain and marital cohesion continued to be associated with ambulatory blood pressure (ABP). The final study cohort included 229 male and female volunteers who were still employed and living with a significant other as at baseline and could complete all aspects of the follow-up testing. RESULTS: The interaction between job strain and marital cohesion was significantly associated with a change in ABP during 1 year for 24-h systolic BP but not diastolic BP (P = .018 and .13, respectively). This association also occurred for job strain (P = .011). Subjects with high job strain and a low cohesive marriage had an increase in systolic BP by 3 mm Hg during 1 year, and those with job strain who also had a highly cohesive marriage had a reduction of systolic BP by 3 mm Hg during 1 year. An exploratory analysis for gender effects found that the interaction between job strain and marital cohesion was found only in women (P = .025). CONCLUSIONS: Marital cohesion consistently interacted with the sustained elevation of BP associated with job strain over time in men and women. Low marital cohesion exacerbated the effect of job strain to elevate BP and high marital cohesion ameliorated it. This interaction may be gender specific in that it was demonstrated separately in women but not in men.