Janusz Kaczorowski

Conventional versus automated measurement of blood pressure in primary care patients with systolic hypertension: randomised parallel design controlled trial

Objective To compare the quality and accuracy of manual office blood pressure and automated office blood pressure using the awake ambulatory blood pressure as a gold standard. Design Multi-site cluster randomised controlled trial. Setting Primary care practices in five cities in eastern Canada. Participants 555 patients with systolic hypertension and no serious comorbidities under the care of 88 primary care physicians in 67 practices in the community. Interventions Practices were randomly allocated to either ongoing use of manual office blood pressure (control group) or automated office blood pressure (intervention group) using the BpTRU device. The last routine manual office blood pressure (mm Hg) was obtained from each patient’s medical record before enrolment. Office blood pressure readings were compared before and after enrolment in the intervention and control groups; all readings were also compared with the awake ambulatory blood pressure. Main outcome measure Difference in systolic blood pressure between awake ambulatory blood pressure minus automated office blood pressure and awake ambulatory blood pressure minus manual office blood pressure. Results Cluster randomisation allocated 31 practices (252 patients) to manual office blood pressure and 36 practices (303 patients) to automated office blood pressure measurement. The most recent routine manual office blood pressure (149.5 (SD 10.8)/81.4 (8.3)) was higher than automated office blood pressure (135.6 (17.3)/77.7 (10.9)) (P<0.001). In the control group, routine manual office blood pressure before enrolment (149.9 (10.7)/81.8 (8.5)) was reduced to 141.4 (14.6)/80.2 (9.5) after enrolment (P<0.001/P=0.01), but the reduction in the intervention group from manual office to automated office blood pressure was significantly greater (P<0.001/P=0.02). On the first study visit after enrolment, the estimated mean difference for the intervention group between the awake ambulatory systolic/diastolic blood pressure and automated office blood pressure (−2.3 (95% confidence interval −0.31 to −4.3)/−3.3 (−2.7 to −4.4)) was less (P=0.006/P=0.26) than the difference in the control group between the awake ambulatory blood pressure and the manual office blood pressure (−6.5 (−4.3 to −8.6)/−4.3 (−2.9 to −5.8)). Systolic/diastolic automated office blood pressure showed a stronger (P<0.001) within group correlation (r=0.34/r=0.56) with awake ambulatory blood pressure after enrolment compared with manual office blood pressure versus awake ambulatory blood pressure before enrolment (r=0.10/r= 0.40); the mean difference in r was 0.24 (0.12 to 0.36)/0.16 (0.07 to 0.25)). The between group correlation comparing diastolic automated office blood pressure and awake ambulatory blood pressure (r=0.56) was stronger (P<0.001) than that for manual office blood pressure versus awake ambulatory blood pressure (r=0.30); the mean difference in r was 0.26 (0.09 to 0.41). Digit preference with readings ending in zero was substantially reduced by use of automated office blood pressure. Conclusion In compliant, otherwise healthy, primary care patients with systolic hypertension, introduction of automated office blood pressure into routine primary care significantly reduced the white coat response compared with the ongoing use of manual office blood pressure measurement. The quality and accuracy of automated office blood pressure in relation to the awake ambulatory blood pressure was also significantly better when compared with manual office blood pressure. Trial registration Clinical trials NCT 00214053.

Breastfeeding Rates and Hospital Breastfeeding Practices in Canada: A National Survey of Women

BACKGROUND The Baby-Friendly Hospital Initiative was launched by the World Health Organization and UNICEF in 1989 to promote, protect, and support breastfeeding worldwide. The objective of this study was to report breastfeeding rates and adherence to the Baby Friendly Hospital Initiative of the World Health Organization and UNICEF in Canada, as reported by participants in the Maternity Experiences Survey of the Canadian Perinatal Surveillance System. METHODS Eligible women (n = 8,244) were identified from a randomly selected sample of infants born 3 months before the May 2006 Canadian Census, and stratified by province or territory. Birth mothers living with their infants at the time of interview were invited to participate in a computer-assisted telephone interview conducted by Statistics Canada on behalf of the Public Health Agency of Canada. Interviews took approximately 45 minutes and were completed when infants were between 5 and 10 months old (between 9 and 14 months in the territories). Completed responses were obtained from 6,421 women (78% response rate). Nineteen of 309 questions concerned early mother-infant contact and breastfeeding practices. RESULTS Breastfeeding intention (90.0%) and initiation (90.3%) rates were high, although exclusive breastfeeding rates at 6 months after birth (14.4%) were lower than desirable. The findings suggested a low adherence to several best practices advocated by the Baby-Friendly Hospital Initiative. CONCLUSION Although breastfeeding initiation rates were relatively high in Canada, exclusive breastfeeding duration fell short of globally recommended standards.

Integrating Family Medicine and Pharmacy to Advance Primary Care Therapeutics

The prevalence of suboptimal prescribing of medications is well documented. 1 , 2 Patients are often undertreated or not offered therapeutic treatments that are likely to confer benefit. 3 , 4 As a result, drug‐related hospital admissions are common and often preventable. 5 Improvements to the health‐care system are clearly needed in order to maximize the benefits that can be derived from medications. Many countries are changing their primary health‐care systems to improve the quality of health‐care delivery. 6 , 7 One main transformation is the use of multidisciplinary care teams to provide care in a coordinated manner often from the same location or by using the common medical record of the patients. It has been demonstrated that pharmacists can improve prescribing, reduce health‐care utilization and medication costs, and contribute to clinical improvements in many chronic medical conditions, such as cardiovascular disease, diabetes, and psychiatric illness. 8 , 9 , 10 , 11 However, the effect of integrating a pharmacist providing general services into a primary care group has not been extensively studied. The Integrating Family Medicine and Pharmacy to Advance Primary Care Therapeutics (IMPACT) project was designed to provide a real‐world demonstration of the feasibility of integrating the pharmacist into primary care office practice. This article provides a description of the IMPACT project participants; the IMPACT practice model and the concepts incorporated in its development; some initial results from the program evaluation; sustainability of the model; and some reflections on the implementation of the practice model.

The Canadian Maternity Experiences Survey: Design and Methods

OBJECTIVE The Maternity Experiences Survey (MES) is an initiative of the Canadian Perinatal Surveillance System. Its primary objective is to provide representative, pan-Canadian data on womens experiences during pregnancy, birth, and the early postpartum period. METHODS The development of the survey involved input from a multidisciplinary study group, an extensive consultation process and two pilot studies. TheMES population consisted of birth mothers 15 years of age and over who had a singleton live birth in Canada during a three-month period preceding the 2006 Canadian Census of Population and who lived with their infants at the time of data collection. Experiences of teenage, immigrant, First Nations, Inuit, and Métis mothers were of particular interest. The sample was drawn from the 2006 Canadian Census. A 45-minute interview was conducted at five to 14 months postpartum, primarily by telephone by female professional Statistics Canada interviewers. RESULTS A response rate of 78% was achieved, corresponding to 6421 women who were weighted to represent an estimated 76508 women. The cooperation rate was 92% and the refusal rate was 1.0%. Item non-response was low, and few data errors were identified. The final MES sample was judged to be representative of the corresponding Census population for all characteristics investigated. CONCLUSION The MES marks an important milestone in the availability of information on maternity experiences in Canada. For the first time, it is possible to provide high quality data at national, provincial, and territorial levels on a wide spectrum of maternity experiences as reported by women.

A scoping literature review of collaboration between primary care and public health

AIM The purpose of this scoping literature review was to determine what is known about: 1) structures and processes required to build successful collaborations between primary care (PC) and public health (PH); 2) outcomes of such collaborations; and 3) markers of their success. BACKGROUND Collaboration between PC and PH is believed to enable more effective individual and population services than what might be achieved by either alone. METHODS The study followed established methods for a scoping literature review and was guided by a framework that identifies systemic, organizational and interactional determinants for collaboration. The review was restricted to articles published between 1988 and 2008. Published quantitative and qualitative primary studies, evaluation research, systematic and other types of reviews, as well as descriptive accounts without an explicit research design, were included if they addressed either the structures or processes to build collaboration or the outcomes or markers of such collaboration, and were published in English. FINDINGS The combined search strategy yielded 6125 articles of which 114 were included. Systemic-level factors influencing collaboration included: government involvement, policy and fit with local needs; funding and resource factors, power and control issues; and education and training. Lack of a common agenda; knowledge and resource limitations; leadership, management and accountability issues; geographic proximity of partners; and shared protocols, tools and information sharing were influential at the organizational level. Interpersonal factors included having a shared purpose; philosophy and beliefs; clear roles and positive relationships; and effective communication and decision-making strategies. Reported benefits of collaboration included: improved chronic disease management; communicable disease control; and maternal child health. More research is needed to explore the conditions and contexts in which collaboration between PC and PH makes most sense and potential gains outweigh the associated risks and costs.

Prevalence of, and barriers to, preventive lifestyle behaviors in hypertension (from a national survey of Canadians with hypertension).

Patients with hypertension are advised to lower their blood pressure to <140/90 mm Hg through sustained lifestyle modification and/or pharmacotherapy. To describe the use of lifestyle changes for blood pressure control and to identify the barriers to these behaviors, the data from 6,142 Canadians with hypertension who responded to the 2009 Survey on Living With Chronic Diseases in Canada were analyzed. Most Canadians with diagnosed hypertension reported limiting salt consumption (89%), having changed the types of food they eat (89%), engaging in physical activity (80%), trying to control or lose weight if overweight (77%), quitting smoking if currently smoking (78%), and reducing alcohol intake if currently drinking more than the recommended levels (57%) at least some of the time to control their blood pressure. Men, those aged 20 to 44 years, and those with lower educational attainment and lower income were, in general, less likely to report engaging in lifestyle behaviors for blood pressure control. A low desire, interest, or awareness were commonly reported barriers to salt restriction, changes in diet, weight loss, smoking cessation, and alcohol reduction. In contrast, the most common barrier to engaging in physical activity to regulate blood pressure was the self-reported challenge of managing a coexisting physical condition or time constraints. In conclusion, programs and interventions to improve the adherence to lifestyle changes to treat hypertension may need to consider the identified barriers to lifestyle behaviors in their design.

Home blood pressure monitoring among Canadian adults with hypertension: results from the 2009 Survey on Living with Chronic Diseases in Canada.

BACKGROUND Canadians with hypertension are recommended to use home blood pressure monitoring (HBPM) on a regular basis. OBJECTIVES To characterize the use of HBPM among Canadian adults with hypertension. METHODS Respondents to the 2009 Survey on Living with Chronic Diseases in Canada who reported diagnosis of hypertension by a health professional (n=6142) were asked about blood pressure monitoring practices, sociodemographic characteristics, management of hypertension and blood pressure control. RESULTS Among Canadian adults with hypertension, 45.9% (95% CI 43.5% to 48.3%) monitor their own blood pressure at home, 29.7% (95% CI 41.1% to 46.3%) receive health professional instruction and 35.9% (95% CI 33.5% to 38.4%) share the results with their health professional. However, fewer than one in six Canadian adults diagnosed with hypertension monitor their own blood pressure at home regularly, with health professional instruction, and communicate results to a health professional. Regular HBPM was more likely among older adults (45 years of age and older); individuals who believed they had a plan for how to control their blood pressure; and those who had been shown how to perform HBPM by a health professional - with the latter factor most strongly associated with regular HBPM (prevalence rate ratio 2.8; 95% CI 2.4 to 3.4). CONCLUSIONS Although many Canadians with hypertension measure their blood pressure between health care professional visits, a minority do so according to current recommendations. More effective knowledge translation strategies are required to support self-management of hypertension through home measurement of blood pressure.

Comparison of Maternity Experiences of Canadian-Born and Recent and Non-Recent Immigrant Women: Findings From the Canadian Maternity Experiences Survey

OBJECTIVE To compare the maternity experiences of immigrant women (recent, ≤ 5 years in Canada; non-recent > 5 years) with those of Canadian-born women. METHODS This study was based on data from the Canadian Maternity Experiences Survey of the Public Health Agency of Canada. A stratified random sample of 6421 women was drawn from a sampling frame based on the 2006 Canadian Census of Population. Weighted proportions were calculated using survey sample weights. Multivariable logistic regression was used to estimate odds ratios comparing recent immigrant women with Canadian-born women and non-recent immigrant women with Canadian-born women, adjusting for education, income, parity, and maternal age. RESULTS The sample comprised 7.5% recent immigrants, 16.3% non-recent immigrants, and 76.2% Canadian-born women. Immigrant women reported experiencing less physical abuse and stress, and they were less likely to smoke or consume alcohol during pregnancy, than Canadian women; however, they were more likely to report high levels of postpartum depression symptoms and were less likely to have access to social support, to take folic acid before and during pregnancy, to rate their own and their infants health as optimal, and to place their infants on their backs for sleeping. Recent and non-recent immigrant women also had different experiences, suggesting that duration of residence in Canada plays a role in immigrant womens maternity experiences. CONCLUSION These findings can assist clinicians and policy-makers to understand the disparities that exist between immigrant and non-immigrant women in order to address the needs of immigrant women more effectively.

2009 Canadian Hypertension Education Program recommendations: The scientific summary - an annual update

The present report highlights the key messages of the 2009 Canadian Hypertension Education Program (CHEP) recommendations for the management of hypertension and the supporting clinical evidence. In 2009, the CHEP emphasizes the need to improve the control of hypertension in people with diabetes. Intensive reduction in blood pressure (to less than 130/80 mmHg) in people with diabetes leads to significant reductions in mortality rates, disability rates and overall health care system costs, and may lead to improved quality of life. The CHEP recommendations continue to emphasize the important role of patient self-efficacy by promoting lifestyle changes to prevent and control hypertension, and encouraging home measurement of blood pressure. Unfortunately, most Canadians make only minor changes in lifestyle after a diagnosis of hypertension. Routine blood pressure measurement at all appropriate visits, and screening for and management of all cardiovascular risks are key to blood pressure management. Many young hypertensive Canadians with multiple cardiovascular risks are not treated with antihypertensive drugs. This is despite the evidence that individuals with multiple cardiovascular risks and hypertension should be strongly considered for antihypertensive drug therapy regardless of age. In 2009, the CHEP specifically recommends not to combine an angiotensin-converting enzyme inhibitor with an angiotensin receptor blocker in people with uncomplicated hypertension, diabetes (without micro- or macroalbuminuria), chronic kidney disease (without nephropathy [micro- or overt proteinuria]) or ischemic heart disease (without heart failure).

2010 Canadian Hypertension Education Program (CHEP) recommendations: The scientific summary – an update of the 2010 theme and the science behind new CHEP recommendations

The present article is a summary of the theme, the key recommendations for management of hypertension and the supporting clinical evidence of the 2010 Canadian Hypertension Education Program (CHEP). In 2010, CHEP emphasizes the need for health care professionals to stay informed about hypertension through automated updates at www.htnupdate.ca. A new interactive Internet-based lecture series will be available in 2010 and a program to train community hypertension leaders will be expanded. Patients can also sign up to receive regular updates in a pilot program at www.myBPsite.ca. In 2010, the new recommendations include consideration for using automated office blood pressure monitors, new targets for dietary sodium for the prevention and treatment of hypertension that are aligned with the national adequate intake values, and recommendations for considering treatment of selected hypertensive patients at high risk with calcium channel blocker/angiotensin-converting enzyme inhibitor combinations and the use of angiotensin receptor blockers.