Design of a pragmatic randomized implementation effectiveness trial testing a health system wide hypertension program for older adults.

Hypertension control remains poor. Multiple barriers at the level of patients, providers, and health systems interfere with implementation of hypertension guidelines and effective lowering of BP. Some strategies such as self-measured blood pressure (SMBP) and remote management by pharmacists are safe and effectively lower BP but have not been effectively implemented. In this study, we combine such evidence-based strategies to build a remote hypertension program and test its effectiveness and implementation in large health systems. This randomized, controlled, pragmatic type I hybrid implementation effectiveness trial will examine the virtual collaborative care clinic (vCCC), a hypertension program that integrates automated patient identification, SMBP, remote BP monitoring by trained health system pharmacists, and frequent patient-provider communication. We will randomize 1000 patients with uncontrolled hypertension from two large health systems in a 1:1 ratio to either vCCC or control (usual care with education) groups for a 2-year intervention. Outcome measures including BP measurements, cognitive function, and a symptom checklist will be completed during study visits. Other outcome measures of cardiovascular events, mortality, and health care utilization will be assessed using Medicare data. For the primary outcome of proportion achieving BP control (defined as systolic BP < 130 mmHg) in the two groups, we will use a generalized linear mixed model analysis. Implementation outcomes include acceptability and feasibility of the program. This study will guide implementation of a hypertension program within large health systems to effectively lower BP.

Assessing the Immunization Information System and electronic health record interface accuracy for COVID-19 vaccinations.

Objective: Our objective is to assess the accuracy of the COVID-19 vaccination status within the electronic health record (EHR) for a panel of patients in a primary care practice when manual queries of the state immunization databases are required to access outside immunization records. Materials and Methods: This study evaluated COVID-19 vaccination status of adult primary care patients within a university-based health system EHR by manually querying the Kansas and Missouri Immunization Information Systems. Results: A manual query of the local Immunization Information Systems for 4114 adult patients with "unknown" vaccination status showed 44% of the patients were previously vaccinated. Attempts to assess the comprehensiveness of the Immunization Information Systems were hampered by incomplete documentation in the chart and poor response to patient outreach. Conclusions: When the interface between the patient chart and the local Immunization Information System depends on a manual query for the transfer of data, the COVID-19 vaccination status for a panel of patients is often inaccurate.

Improving population health in resident clinics: increasing pneumonia vaccination rates in adults 65 years and older.

Streptococcus pneumoniae is a significant bacterial pathogen, especially in the elderly. There are two types of pneumococcal vaccines, one with polysaccharides from the capsule of 23 serotypes (PPSV23) and one with polysaccharides from 13 serotypes that have been conjugated to a protein (PCV13). Both vaccines decrease the incidence of invasive pneumococcal disease and are recommended for all people ≥65 years of age. We found the vaccination rate against S. pneumoniae in patients ≥65 years of age in our resident physician continuity clinics was 59.85%, which is considerably lower than the vaccination rate of 69.16% in our attending physician clinics. The aim of our study was to double the number of vaccinations given in the resident physician clinics over a 1-month period without compromising workflow or unduly burdening the rooming nurse or resident physicians. For our primary intervention, we assigned a designated nurse with expertise in vaccinations the task of reviewing charts ahead of clinic visits then pending the order for the appropriate pneumococcal vaccine. Our secondary intervention was the education of physicians through pocket cards, verbal encouragement and email reminders. χ² test was conducted to compare the proportion of patients 65 years or older who were vaccinated between the intervention and control groups. The results indicated that the intervention group patients were 2.61 times (95% CI 1.18 to 6.10) more likely to be vaccinated compared with the control group patients (20% vs 8.7%, χ2 (1)=5.16, p=0.02, Cramer's V=0.16). The intervention resulted in more than doubling the number of vaccinations in the intervention group compared with the control group. Moreover, poststudy interviews and surveys indicated our workflow is sustainable and amendable to wider use within the resident physician clinics.