Blood pressure control by home monitoring : meta-analysis of randomised trials

Objective To determine the effect of home blood pressure monitoring on blood pressure levels and proportion of people with essential hypertension achieving targets. Design Meta-analysis of 18 randomised controlled trials. Participants 1359 people with essential hypertension allocated to home blood pressure monitoring and 1355 allocated to the "control" group seen in the healthcare system for 2-36 months. Main outcome measures Differences in systolic (13 studies), diastolic (16 studies), or mean (3 studies) blood pressures, and proportion of patients achieving targets (6 studies), between intervention and control groups. Results Systolic blood pressure was lower in people with hypertension who had home blood pressure monitoring than in those who had standard blood pressure monitoring in the healthcare system (standardised mean difference 4.2 (95% confidence interval 1.5 to 6.9) mm Hg), diastolic blood pressure was lower by 2.4 (1.2 to 3.5) mm Hg, and mean blood pressure was lower by 4.4 (2.0 to 6.8) mm Hg. The relative risk of blood pressure above predetermined targets was lower in people with home blood pressure monitoring (risk ratio 0.90, 0.80 to 1.00). When publication bias was allowed for, the differences were attenuated: 2.2 ( − 0.9 to 5.3) mm Hg for systolic blood pressure and 1.9 (0.6 to 3.2) mm Hg for diastolic blood pressure. Conclusions Blood pressure control in people with hypertension (assessed in the clinic) and the proportion achieving targets are increased when home blood pressure monitoring is used rather than standard blood pressure monitoring in the healthcare system. The reasons for this are not clear. The difference in blood pressure control between the two methods is small but likely to contribute to an important reduction in vascular complications in the hypertensive population

Taking preventative health messages into the wider caring professions: the views of housing staff and tenants.

In order to harness the potential impact of the wider public health workforce, innovative services are providing opportunities for social housing staff to extend their public health role. This study explored the views of housing professionals and social housing residents on the delivery of preventative health messages by housing staff in the context of the evaluation of the roll-out of a new service. We conducted semi structured interviews with 21 neighbourhood housing officers, 4 managers and 30 social housing tenants to understand their views on the widening role and the potential impact on the preventative healthcare messages being delivered. Neighbourhood officers were willing to discuss existing health conditions with tenants; but they often did not feel comfortable discussing their lifestyle choices. Most tenants also reported that they would feel discussions around lifestyle behaviours to be intrusive and outside the remit of housing staff. Resistance to discussions of lifestyle topics during home visits was found among both housing staff and tenants. Appropriate staff training and the development of strong and trusting relationships between officers and tenants is needed, if similar programmes to extend the role of housing staff are to succeed in terms of health impact

Glycosaminoglycan profiles of repair tissue formed following autologous chondrocyte implantation differ from control cartilage

Currently, autologous chondrocyte implantation (ACI) is the most commonly used cell-based therapy for the treatment of isolated femoral condyle lesions of the knee. A small number of centres performing ACI have reported encouraging long-term clinical results, but there is currently a lack of quantitative and qualitative biochemical data regarding the nature of the repair tissue. Glycosaminoglycan (GAG) structure influences physiological function and is likely to be important in the long-term stability of the repair tissue. The objective of this study was to use fluorophore-assisted carbohydrate electrophoresis (FACE) to both quantitatively and qualitatively analyse the GAG composition of repair tissue biopsies and compare them with age-matched cadaveric controls. We used immunohistochemistry to provide a baseline reference for comparison. Biopsies were taken from eight patients (22 to 52 years old) 1 year after ACI treatment and from four cadavers (20 to 50 years old). FACE quantitatively profiled the GAGs in as little as 5 μg of cartilage. The pattern and intensity of immunostaining were generally comparable with the data obtained with FACE. In the ACI repair tissue, there was a twofold reduction in chondroitin sulphate and keratan sulphate compared with age-matched control cartilage. By contrast, there was an increase in hyaluronan with significantly shorter chondroitin sulphate chains and less chondroitin 6-sulphate in repair tissue than control cartilage. The composition of the repair tissue thus is not identical to mature articular cartilage

The Importance of Self-Management in the Context of Personalized Care in COPD

Despite current guidelines and decades of evidence on the benefits of a self-management approach, self-management of COPD remains relatively under-utilized in clinical care compared with other chronic diseases. However, self-management interventions can play a valuable role in supporting people with COPD to respond to changing symptoms, and thereby make appropriate decisions regarding the management of their own chronic condition. In this review, we discuss the history and evolution of the concept of self-management, assess current multidisciplinary support programs and clinical interactions designed to optimize self-management, and reflect on how effective these are in terms of clinical and humanistic outcomes. We also evaluate the mechanisms for encouraging change from protocol-based care towards a more personalized care approach, and discuss the role of digital self-management interventions and the importance of addressing health inequalities in COPD treatment, which have been accelerated by the COVID-19 pandemic. Reflecting on the importance of self-management in the context of symptom monitoring and provision of educational support, including information from patient organizations and charities, we discuss the ideal components of a self-management plan for COPD and provide six key recommendations for its implementation: 1) better education for healthcare professionals on disease management and consultation skills; 2) new targets and priorities for patient-focused outcomes; 3) skills gap audits to identify barriers to self-management; 4) best practice sharing within primary care networks and ongoing professional development; 5) enhanced initial consultations to establish optimal self-management from the outset; and 6) negotiation and sharing of self-management plans at the point of diagnosis

Important, misunderstood, and challenging: a qualitative study of nurses' and allied health professionals' perceptions of implementing self-management for patients with COPD.

Hannah ML Young,1 Lindsay D Apps,1 Samantha L Harrison,1 Vicki L Johnson-Warrington,1 Nicky Hudson,2 Sally J Singh1,3 1National Institute of Health Research CLAHRC-LNR Pulmonary Rehabilitation Research Group, University Hospitals of Leicester NHS Trust, 2School of Applied Social Sciences, De Montfort University, Leicester, 3Applied Research Centre in Health and Lifestyle Interventions, Coventry University, Coventry, UK Background: In light of the growing burden of COPD, there is increasing focus on the role of self-management for this population. Currently, self-management varies widely. Little is known either about nurses’ and allied health professionals’ (AHPs’) understanding and provision of self-management in clinical practice. This study explores nurses’ and AHPs’ understanding and implementation of supported COPD self-management within routine clinical practice. Materials and methods: Nurses and AHPs participated in face-to-face semistructured interviews to explore their understanding and provision of COPD self-management, as well as their perceptions of the challenges to providing such care. Purposive sampling was used to select participants from a range of professions working within primary, community, and secondary care settings. Three researchers independently analyzed each transcript using a thematic approach. Results: A total of 14 participants were interviewed. Nurses and AHPs viewed self-management as an important aspect of COPD care, but often misunderstood what it involved, leading to variation in practice. A number of challenges to supporting self-management were identified, which related to lack of time, lack of insight regarding training needs, and assumptions regarding patients’ perceived self-management abilities. Conclusion: Nurses and AHPs delivering self-management require clear guidance, training in the use of effective self-management skills, and education that challenges their preconceptions regarding patients. The design of health care services also needs to consider the practical barriers to COPD self-management support for the implementation of such interventions to be successful. Keywords: self-management, COPD, qualitative, interviews, nurses, allied health professional

Enabling Adults With Severe Asthma to Exercise: A Qualitative Examination of the Challenges for Patients and Health Care Professionals

open access articleBackground Adults living with severe asthma have lower physical activity levels, particularly high-intensity physical activity, compared with their healthy peers. Physical inactivity is associated with increased morbidity and mortality. Objective To understand patient and health care professional attitudes toward exercise and physical activity to inform future strategies for the improvement of healthy lifestyle behaviors, including exercise. Methods Participants recruited from a specialist difficult asthma service were interviewed individually, and health care professionals (HCPs) from primary care, secondary care, and a tertiary center were invited to attend focus groups. Interviews and focus groups were transcribed verbatim. We performed thematic analysis on interviews and focus groups separately, followed by an adapted framework analysis to analyze datasets together. Results Twenty-nine people with severe asthma participated in a semi-structured interview. A total of 51 HCPs took part in eight focus groups across the East Midlands, United Kingdom. Final analysis resulted in three major themes: barriers to exercise and exercise counseling - in which patients and HCPs identified disease and non-disease factors affecting those living with severe asthma; attitudes toward HCP support for exercise - highlighting education needs for HCPs and preference for supervised exercise programs; and areas for system improvement in supporting patients and HCPs - challenges exist across health sectors that limit patient support are described. Conclusions Patients identified the important role of HCPs in supporting and advising on lifestyle change. Despite a preference for supervised exercise programs, both patient and HCP barriers existed. To meet patients’ varied support needs, improved integration of services is required and HCP skills need extending

How do informal self-care strategies evolve among patients with chronic obstructive pulmonary disease managed in primary care? A qualitative study

Background: There is much description in the literature of how patients with chronic obstructive pulmonary disease (COPD) manage their breathlessness and engage in self-care activities; however, little of this is from the perspective of those with less severe disease, who are primarily managed in primary care. This study aimed to understand the self-care experiences of patients with COPD who are primarily managed in primary care, and to examine the challenges of engaging in such behaviors. Methods: Semistructured interviews were carried out with 15 patients with COPD as part of a larger project evaluating a self-management intervention. Thematic analysis was supported by NVivo software (version 8, QSR International, Melbourne, Australia). Results: Three main themes are described, ie, experiencing and understanding symptoms of COPD, current self-care activities, and the importance of family perceptions in managing COPD. Conclusion: Self-care activities evolved spontaneously as participants experienced symptoms of COPD. However, there was a lack of awareness about whether these strategies would impact upon symptoms. Perceptions of COPD by family members posed a challenge to self-care for some participants. Health care professionals should elicit patients' prior disease experiences and utilize spontaneous attempts at disease management in future self-management. These findings have implications for promoting self-management and enhancing quality of life

High Deductible Health Plans and Use of Free Preventive Services Under the Affordable Care Act

The Affordable Care Act aimed to increase use of preventive services by eliminating cost-sharing to consumers. However, patients may be unaware of this benefit or they may not seek preventive services if they anticipate that the cost of potential diagnostic or treatment services will be too high, both more likely among those in high deductible health plans. We used nationally representative private health insurance claims (100% sample of IBM® MarketScan®) for the United States from 2006 to 2018, restricting the data to enrollment and claims for non-elderly adults who were enrolled for the full plan year. The cross-sectional sample (185 million person-years) is used to describe trends in preventive service use and costs from 2008 through 2016. The cohort sample (9 million people) focuses on the elimination of cost-sharing for certain high-value preventive services in late 2010, requiring continuous enrollment across 2010 and 2011. We examine whether HDHP enrollment is associated with use of eligible preventive services using semi-parametric difference-in-differences to account for endogenous plan selection. Our preferred model implies that HDHP enrollment was associated with a reduction of the post-ACA change in any use of eligible preventive services by 0.2 percentage points or 12.5%. Cancer screenings were unaffected but HDHP enrollment was associated with smaller increases in wellness visits, immunizations, and screening for chronic conditions and sexually transmitted infections. We also find that the policy was ineffective at reducing out-of-pocket costs for the eligible preventive services, likely due to implementation issues