Background: Practical studies in real-world settings may be particularly vulnerable to unintended effects on intervention outcomes, including what is commonly known as the Hawthorne Effect. This phenomenon suggests that study subjects' behavior or study results are altered by the subjects' awareness that they are being studied or that they received additional attention. This is especially a concern when subjects are not blinded to randomization or when they participate in studies with observational components. As part of a larger practical intervention designed to improve the clinical management of skin and soft tissue infections (SSTIs), we specifically examined the potential for a Hawthorne Effect from the extra attention some clinicians received when completing follow-up case reviews.Methods: De-identified, electronic data from a larger practical intervention allowed for the comparison of the clinical management of SSTIs among 14 randomly selected clinicians who participated in follow-up case reviews versus 77 clinicians who did not.Results: There were no differences in the management of SSTIs between the 2 groups of clinicians. No evidence of a Hawthorne Effect was observed in this quality-improvement intervention.Conclusion :

Background Antibiotic overuse in the primary care setting is common. Our objective was to evaluate the effect of a clinical pathway-based intervention on antibiotic use. Methods Eight primary care clinics were randomized to receive clinical pathways for upper respiratory infection, acute bronchitis, acute rhinosinusitis, pharyngitis, acute otitis media, urinary tract infection, skin infections, and pneumonia and patient education materials (study group) versus no intervention (control group). Generalized linear mixed effects models were used to assess trends in antibiotic prescriptions for non-pneumonia acute respiratory infections and broad-spectrum antibiotic use for all eight conditions during a 2-year baseline and 1-year intervention period. Results In the study group, antibiotic prescriptions for non-pneumonia acute respiratory infections decreased from 42.7% of cases at baseline to 37.9% during the intervention period (11.2% relative reduction) (p <.0001) and from 39.8% to 38.7%, respectively, in the control group (2.8% relative reduction) (p=0.25). Overall use of broad-spectrum antibiotics in the study group decreased from 26.4% to 22.6% of cases, respectively, (14.4% relative reduction) (p <.0001) and from 20.0% to 19.4%, respectively, in the control group (3.0% relative reduction) (p=0.35). There were significant differences in the trends of prescriptions for acute respiratory infections (p<.0001) and broad-spectrum antibiotic use (p=0.001) between the study and control groups during the intervention period, with greater declines in the study group. Conclusions This intervention was associated with declining antibiotic prescriptions for non-pneumonia acute respiratory infections and use of broad-spectrum antibiotics over the first year. Evaluation of the impact over a longer study period is warranted.

Background: Blood pressure (BP) control among primary care patients with hypertension is suboptimal. Home BP monitoring (HBPM) has been shown to be effective but is underused.Methods: This study was a quasi-experimental evaluation of the impact of the A CARE HBPM program on hypertension control. Nonpregnant adults with hypertension or cardiovascular disease risk factors were given validated home BP monitors and reported monthly average home BP readings by Internet or phone. Patients and providers received feedback. Change in average home and office BP and the percentage of patients achieving target BP were assessed based on patient HBPM reports and a chart audit of office BPs.Results: A total of 3578 patients were enrolled at 26 urban and rural primary care practices. Of these, 36% of participants submitted >2 HBPM reports. These active participants submitted a mean of 13.5 average HBPM reports, with a mean of 19.3 BP readings per report. The mean difference in home BP between initial and final HBPM reports for active participants was ؊6.5/؊4.4 mmHg (P < .001) and ؊6.7/؊4.7 mmHg (P < .001) for those with diabetes. The percentage of active participants at or below target BP increased from 34.5% to 53.3% (P < .001) and increased 24.6% to 40.0% (P < .001) for those with diabetes. The mean difference in office BP over 1 year between participants and nonparticipants was ؊5.4/؊2.7 mmHg (P < .001 for systolic BP, P ‫؍‬ .01 for diastolic BP) for all participants and ؊8.5/؊1.5 mmHg (P ‫؍‬ .014 for systolic BP, P ‫؍‬ .405 for diastolic BP) for those with diabetes.Conclusions: An HBPM program with patient and provider feedback can be successfully implemented in a range of primary care practices and can play a significant role in BP control and decreased cardiovascular disease risk in patients with hypertension. (J Am Board Fam Med 2015;28:548 -555.)

Background: Home blood pressure monitoring (HBPM) predicts cardiovascular risk and increases hypertension control. Non-participation in HBPM is prevalent and decreases the potential benefit.Methods: Telephone surveys were conducted with a random quota sample of non-participants in a HBPM program, which supplied a complimentary automated blood pressure cuff and utilized a centralized reporting system. Questioning assessed use of monitors, perceived benefit, communication with providers, and barriers.Results: There were 320 completed surveys (response rate 53%). Of non-participants, 70.2% still used HBPM cuffs and 58% communicated values to providers. Spanish-speakers were 4.4 times more likely to not use cuffs (95% CI, 2.22-8.885). Barriers to participation were largely personal (forgetting, not having time, or self-described laziness). Reasons for not communicating readings with providers were largely clinic factors (no doctor visit, doctor didn't ask, thinking doctor wouldn't care). Lack of knowledge of HBPM and program design also contributed. After being surveyed, patients were over three times more likely to use the central reporting system. Discussion: Most non-participants still used HBPM and communicated values to providers, suggesting many "drop-outs" may still receive clinical benefit. However, much valuable information is not utilized. Future programs should focus on reminder systems, patient motivation, education, and minimizing time involvement.

Purpose The aim of this project was to develop and test information technology implementations that could assist patients with influenza self-management in primary care settings. Although testing was conducted in the context of seasonal influenza, the project aimed to develop a blueprint that primary care practices could use in an influenza pandemic. Methods Four primary care practice-based research networks (PBRNs) systematically designed, implemented, tailored and tested a tiered patient selfmanagement technology model in 12 primary care practices during the peak of the 2007 to 2008 influenza season. Participating clinicians received a customised practice website that included a bilingual influenza self-triage module, a downloadable influenza toolkit and electronic messaging capability. As an alternative option, a bilingual, interactive seasonal influenza telephone hotline that patients could call for assistance was provided. Results Influenza self-management web pages presented via nine customised practice websites received 1060 hits between February and April of 2008. The Self-management Influenza Toolkit was downloaded 76 times and 185 Influenza Self-Triage Module sessions

The Colorado Healthy Heart Solutions program uses community health workers to provide health promotion and navigation services for participants in medically underserved, predominantly rural areas who are at risk for developing cardiovascular disease. A text messaging program designed to increase participant engagement and adherence to lifestyle changes was pilot tested with English- and Spanish-speaking participants. Preimplementation focus groups with participants informed the development of text messages that were used in a 6-week pilot program. Postimplementation focus groups and interviews then evaluated the pilot program. Participants reported a preference for concise messages received once daily and for positive messages suggesting specific actions that could be feasibly accomplished within the course of the day. Participants also consistently reported the desire for clarity in message delivery and content, indicating that the source of the messages should be easy to recognize, messages should state clearly when participants were expected to respond to the messages, and any responses should be acknowledged. Links to other websites or resources were generally viewed as trustworthy and acceptable, but were preferred for supplementary material only. These results may inform the development of future chronic disease management programs in underserved areas or augment existing programs using text messaging reinforcement.

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