Correlates of nonadherence to hypertension treatment in an inner-city minority population

Assessment of factors influencing blood pressure control in a managed care population

We attempted to determine the percentage of patients meeting Health Plan Employer Data Information Set (HEDIS) criteria for blood pressure control (< or = 140/90 mm Hg), to identify factors contributing to differences in blood pressure control among those who met HEDIS criteria and those who did not, and to assess compliance with blood pressure management recommendations established by the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-VI) for diabetes mellitus and myocardial infarction. In this retrospective analysis, we randomly selected 502 patient records from three primary care clinics in southeast Michigan. All patients were commercial members of one health maintenance organization, 74% of whom met HEDIS criteria for blood pressure control. These patients took fewer blood pressure drugs throughout the year (p=0.023) and had lower antihypertensive drug costs than those who did not achieve HEDIS blood pressure goals (p=0.016). According to JNC-VI criteria, 46% of diabetic patients were at their blood pressure goal of below 130/85 mm Hg and 71.6% were managed with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. Eighty-five percent of patients were taking beta-blockers after myocardial infarction. The percentage of patients achieving target blood pressure exceeded the national average and was associated with few antihypertensive drugs and low drug cost. Effective and appropriate management of blood pressure in people with diabetes remains a challenge.

Depression, substance use, adherence behaviors, and blood pressure in urban hypertensive black men

Relationships between depression, alcohol and illicit drug use, adherence behaviors, and blood pressure (BP) were examined in 190 urban hypertensive Black men enrolled in an ongoing hypertension control clinical trial. More than one fourth (27.4%) of the sample scored greater than 16 on the Center for Epidemiological Studies-Depression Scale (CES-D), indicating a high risk of clinical depression. Depression was significantly associated with an increased likelihood of meeting Diagnostic and Statistical Manual of Mental Disorders (4th ed.) criteria for alcohol abuse or dependence (odds ratio = 5.2; 95% confidence interval = 1.897-14.214). The level of depression was significantly correlated with poor medication (r =.301) and poor dietary compliance (r =.164). Both alcohol intake and illicit drug use were significantly correlated with poor dietary compliance (r =.195 and.185, respectively) and smoking (r =.190 and.269, respectively). Although no direct relationship between depression and the level of BP was substantiated by multivariate analysis, findings of descriptive analyses revealed statistically significant associations among depression, substance use, poor adherence, and poor BP outcomes. Given the harsh environment in which a large number of young urban Black men live, the high prevalence of substance abuse might be an attempt to fight off depression. Further in-depth investigation is needed to identify the role of depression and BP control in urban young Blacks in order to construct effective interventions that address their unique needs.

Predictors of medication-refill adherence in an indigent rural population

OBJECTIVE

We evaluated the association of medication refill adherence with demographic and prescription characteristics to determine whether such factors could guide intervention strategies in an indigent rural population.

METHODS

The study was conducted at a University-based internal medicine practice serving an indigent rural population. Refill data for diabetes, hypertension, and hypercholesterolemia drugs from a closed pharmacy system were used to calculate mean adherence (for all drugs taken by each patient) and minimum adherence (that of the least adhered to drug) for 1984 patients during a 9-month period.

RESULTS

Mean refill adherence was <80% for 33% of the population and minimum refill adherence was <80% for 55% of the patients. Increasing age, race (white), and prescription length were associated with higher mean and minimum adherence, independent of income, prescription copay, and insurance status. Number of drugs taken had a positive mean but negative minimum adherence association. Gender, number of primary care visits, and dosage schedule were not independently associated with adherence. The model explained 6.8% of the variance in mean adherence.

CONCLUSIONS

In a rural indigent population, medication refill adherence was associated with race, age, and prescription length, though these factors explained only a small amount of adherence variability. Although ingestion adherence is the goal, refill adherence is a necessary condition for ingestion adherence. To enhance adherence, physicians need better predictors to target their efforts to patients most in need of attention. Prescription claims data could serve this purpose.

Relationship between pain-specific beliefs and adherence to analgesic regimens in Taiwanese cancer patients: a preliminary study

This pilot cross-sectional study aimed to 1) explore pain beliefs and adherence to prescribed analgesics in Taiwanese cancer patients, and 2) examine how selected pain beliefs, pain sensory characteristics, and demographic factors predict analgesic adherence. Pain beliefs were measured by the Chinese version of Pain and Opioid Analgesic Beliefs Scale-Cancer (POABS-CA) and the Survey of Pain Attitudes (SOPA). Analgesic adherence was measured by patient self-report of all prescribed pain medicine taken during the previous 7 days. Only 66.5% of hospitalized cancer patients with pain (n = 194) adhered to their analgesic regimen. Overall, patients had relatively high mean scores in beliefs about disability, medications, negative effects, and pain endurance, and low scores in control and emotion beliefs. Medication and control beliefs significantly predicted analgesic adherence. Patients with higher medication beliefs and lower control beliefs were more likely to be adherent. Findings support the importance of selected pain beliefs in patients' adherence to analgesics, suggesting that pain beliefs be assessed and integrated into pain management and patient education to enhance adherence.

Antimicrobial postexposure prophylaxis for anthrax: adverse events and adherence

We collected data during postexposure antimicrobial prophylaxis campaigns and from a prophylaxis program evaluation 60 days after start of antimicrobial prophylaxis involving persons from six U.S. sites where Bacillus anthracis exposures occurred. Adverse events associated with antimicrobial prophylaxis to prevent anthrax were commonly reported, but hospitalizations and serious adverse events as defined by Food and Drug Administration criteria were rare. Overall adherence during 60 days of antimicrobial prophylaxis was poor (44%), ranging from 21% of persons exposed in the Morgan postal facility in New York City to 64% of persons exposed at the Brentwood postal facility in Washington, D.C. Adherence was highest among participants in an investigational new drug protocol to receive additional antibiotics with or without anthrax vaccine--a likely surrogate for anthrax risk perception. Adherence of <60 days was not consistently associated with adverse events.

American Society of Hypertension regional chapters: leveraging the impact of the clinical hypertension specialist in the local community

Hypertension control has remained at 24% to 27% for the past decade, despite revision of national treatment guidelines, expansion of therapeutic options, and evidence from clinical trials that higher control rates are attainable. Uncontrolled hypertension contributes to the enormous health and economic burden from cardiovascular and renal disease. The risk for hypertension-related complications is increasing in the United States as comorbidities such as diabetes mellitus and congestive heart failure rise in a population that is becoming progressively older, more obese, and more ethnically diverse. Given regional variations in demographic characteristics and disease burdens, implementing evidence-based guidelines will be more effective if tailored appropriately to the local community. The Clinical Hypertension Specialist program is a positive response to an impending health care crisis. The impact of the Hypertension Specialist on blood pressure control can be leveraged by extending the academic mission of education, patient care, and health services research to the local community. The American Society of Hypertension regional chapter can serve as a forum for Clinical Hypertension Specialists from academic medicine and the community to define mutual goals, develop an action plan which is responsive to community needs, and monitor progress. With support from the chapter, Clinical Hypertension Specialists in the community can have an impact on the practice of medicine locally by contributing to the education of primary care providers, receiving referrals of patients with complicated hypertension, monitoring progress in meeting evidence-based goals, providing feedback to peers, and participating in multicenter trials.

Adherence discourse among African-American women taking HAART

Low adherence is the single most important challenge to controlling HIV through the use of high acting anti-retrovirals (HAART). Non-adherence poses an immediate threat to individuals who develop resistant forms of the virus as well as a public health threat if those individuals pass on treatment-resistant forms of the virus. To understand the concerns and perceptions that promote or deter adherence to antiretroviral medication by HIV-positive African-American women, we conducted in-depth interviews with 15 African-American women taking HAART. We focused on the discourse and narratives women use in talking about their adherence practice. Discourse analysis was utilized to identify and explore the sources of influence used by these women in describing their adherence practice. Roughly a third of the sample fell into each of the three self-assessed adherence categories: always adherent, mostly adherent and somewhat adherent. Among the 'always adherent', 80% of the sources of influence cited supported adherence, while only 48% and 47% of the authoritative sources cited by women in the 'mostly' and 'somewhat' categories supported adherence. Each self-assessed adherence group was characterized by its own distinctive discourse style. Findings suggest that adherence to HAART among African-American HIV-positive women would be improved by identifying those influences undermining adherence. Focused study of the 'always adherent' types is recommended.

Community Health Centers and racial/ethnic disparities in healthy life

This study examined disparities in health status among individuals of different racial and ethnic groups cared for by the nation's community health centers (CHCs) and compared these results with the findings for individuals using non-CHC sites as their usual source of care. The sample consisted of CHC users from the 1994 CHC User Survey and non-CHC users from the 1994 National Health Interview Survey. Bivariate comparisons were made between individuals' race/ethnicity and their experience of healthy life, an integrated measure that incorporates both activity limitation and self-perceived health status. Multiple regressions were followed to examine the independent association of race/ethnicity with healthy life experience for both CHC and non-CHC users while controlling for sociodemographic correlates of health. Among CHC users, racial and ethnic minorities did not have worse health than whites, but among non-CHC users there were significant racial and ethnic disparities: whites experienced significantly healthier life than both blacks and non-white Hispanics. These findings persisted after controlling for sociodemographic correlates of health. The results indicate that while racial/ethnic disparities in health persist nationally, these disparities do not exist within CHCs, safety-net providers with an explicit mission to serve vulnerable populations.

Health care improvement and cost reduction opportunities in hypertensive Medicaid beneficiaries

Hypertension and its complications are more frequent and occur about a decade earlier in life among high-risk groups, especially in the Southeast. Moreover, socioeconomic status is inversely related to hypertension and cardiovascular complications. Low-income, young and middle-aged adults living in the Southeast may be at especially high risk. Data on inpatient admissions among hypertensive Medicaid beneficiaries living in this region may provide insights on the burden of hypertension-related disease and on opportunities for successful intervention. A study of hospitalization rates and costs among 44,440 hypertensive Medicaid beneficiaries in South Carolina from 1993-1996 showed that 16,883 (38%) were continuously enrolled in Medicaid. Of this group, 63% were African American and 74% were women. Among the continuously enrolled patients, 7637, or about 45%, were hospitalized during the 4-year period. These 7637 individuals accounted for 20,698 hospital admissions, i.e., 2.7 admissions per person, over the 4-year interval. Nearly two thirds of the hospitalizations included a cardiovascular or renal diagnosis. Hospital claims paid reached nearly $90 million for the 7637 hypertensive Medicaid recipients during the 4-year period. Among patients discharged from the hospital with congestive heart failure, 33% filled a prescription for an angiotensin-converting enzyme inhibitor within 90 days; 13% of patients discharged with an acute myocardial infarction filled a prescription for a beta blocker within 90 days. The data confirm that hypertensive Medicaid beneficiaries in the Southeast are hospitalized at high rates. Cardiovascular and renal morbidity account for the majority of the inpatient admissions. The findings suggest that the application of evidence-based guidelines would improve health, avoid cost, and reduce racial disparities in health outcomes.

Perceived health needs of urban African American church congregants

Theory-based assessment of congregant expectations and needs should be conducted prior to beginning a parish nurse program. However, no such assessments are found in the literature. Using Andersen's Health Access Model as a framework, investigators conducted interviews with 117 randomly selected congregants in five urban African American churches to describe their perceived needs and expectations. Causing most concern were the following: (a) symptoms of illness--high blood pressure (50.4%), dental problems (43.6%), and back pain (41%); and (b) health habits/risks--weight (75%), exercise (63%), and diet (63%). Younger adults were significantly more concerned about all aspects of their health than their older counterparts. Women were significantly more likely to express concern about health habits and health risks than males. No significant relationship was found between perceived need and access to care. Although terming health care services "adequate", congregants expressed many unmet health needs. This seemingly contradictory finding may illuminate a concrete role for the parish nurse, i.e., addressing personal health care concerns not alleviated by the current "adequate" health care delivery system. This study's significance lies not only in providing programming guidance, but also in theoretical insights into the role of the parish nurse.

Development and testing of the Hill-Bone Compliance to High Blood Pressure Therapy Scale

The Hill-Bone Compliance to High Blood Pressure Therapy Scale assesses patient behaviors for three important behavioral domains of high blood pressure treatment: 1) reduced sodium intake; 2) appointment keeping; and 3) medication taking. This scale is comprised of 14 items in three subscales. Each item is a four point Likert type scale. The content validity of the scale was assessed by a relevant literature review and an expert panel, which focused on cultural sensitivity and appropriateness of the instrument for low literacy. Internal consistency reliability and predictive validity of the scale were evaluated using two community based samples of hypertensive adults enrolled in clinical trials of high blood pressure care and control. The standardized alpha for the total scale were 0.74 and 0.84, and the average interitem correlations of the 14 items were 0.18 and 0.28, respectively. The construct and predictive validity of the scale was assessed by factor analysis and by testing of theoretically derived hypotheses regarding whether the scale demonstrated consistent and expected relationships with related variables. In this study, high compliance scale scores predicted significantly lower levels of blood pressure and blood pressure control. Moreover, high compliance scale scores at the baseline were significantly associated with blood pressure control at both baseline and at follow up in the two independent samples. This brief instrument provides a simple method for clinicians in various settings to use to assess patients' self reported compliance levels and to plan appropriate interventions.

Hypertension outcomes in an urban nurse-managed center

PURPOSE

To assess the quality of hypertension (HTN) care in an urban nurse-managed center (NMC) by chart audits of insured and uninsured (N = 52) African Americans who were managed by nurse practitioners.

DATA SOURCES

A chart audit form was developed by the authors that merged Health Plan Employer Data and Information Set (HEDIS) criteria with the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) criteria.

CONCLUSIONS

There was near comparable hypertension control among the two groups. No difference was found in systolic blood pressure (BP) control; however, the uninsured group had a slightly greater average diastolic BP compared with the insured group. There was no significant difference in the number of HTN medications or the number of risk factors. A significant difference was found in the number of NP visits per year between the two groups; the uninsured group averaged 3.2 more visits per year.

IMPLICATIONS FOR PRACTICE

Nurse practitioners in this NMC were able to manage HTN in a high-risk population despite a lack of insurance coverage for anti-hypertensive prescriptions. The finding that the uninsured group had more clinic visits per year than the insured group is significant in that it increases the cost of providing care for these patients and the health care system. The patient cost in time, transportation and burden needs further assessment.

The contexts of adherence for African Americans with high blood pressure

The contexts of adherence for African Americans with high blood pressure African American men between the ages of 18 and 49 years have the lowest rates of awareness, treatment and control of high blood pressure (HBP) of all age/race/gender groups in the United States. A qualitative study was done to gain an understanding of urban black males' experiences of living with HBP. In-depth semi-structured interviews were conducted with 19 black males. The interviews explored perceptions of health, health problems and priorities, and concerns of daily living that influenced appointment keeping and medication taking. The sample was a subset of 309 men participating in a 3-year clinical trial to improve HBP control in an inner city African-American population. Content analysis of transcribed interviews identified the following themes and related concerns: (a) personal contexts: meaning of health, high blood pressure and treatments; (b) social context: living as a young black male in an urban environment; and (c) cultural context of relating: patient-provider relationship can make a difference. Influencing participants' responses were: interpreting symptoms; adjusting medication taking; protecting personal privacy; allocating limited resources; dealing with addiction; and feeling cared for by a health care provider. Adherence appeared to be multifaceted and changing depending upon: the men's social, economic and personal circumstances; empathetic and non-judgemental assistance from providers; financial concerns and employment; and drug addiction. Findings are useful in refining high blood pressure interventions.

Ethnic variation in attitudes toward hypertension in adults ages 75 and older

BACKGROUND

Although critical to the management of hypertension, the attitudes of geriatric patients and possible ethnic group differences in attitudes concerning the disease are poorly understood.

METHODS

Data from a 1995-1996 population-based survey of 507 Hispanic American, African American, and non-Hispanic white adults ages 75 and older were used to assess ethnic differences in perceptions regarding the cause, prevention, and treatment of hypertension, as well as associations between perceptions and use of preventive health services.

RESULTS

African Americans were more likely to attribute hypertension to health behaviors and stress. In contrast, Hispanic Americans were more likely consider the disease a normal part of aging, whereas non-Hispanic whites were more likely to attribute hypertension to heredity or mechanistic causes. Non-Hispanic whites were less likely to perceive hypertension as preventable, whereas Hispanic Americans were less likely to feel that hypertension was treatable. The odds of having a primary care physician, blood pressure checked, or glaucoma checked were lower among older African Americans and Hispanic Americans than older non-Hispanic whites. The odds of having had a recent physical and of emergency room use were higher among African Americans and lower among Hispanic Americans, in relation to non-Hispanic whites.

CONCLUSION

Ethnic differences regarding hypertension were clearly evident in this sample of older adults. In addition, attitudes regarding the cause and treatment of hypertension were found to be associated with both the use and the underuse of preventive health services in all three ethnic groups.

Home blood pressure teletransmission for better diagnosis and treatment

The rate of control of high blood pressure is disappointing, and noncompliance is one factor that contributes to this. The reasons for poor compliance are complex and include factors related to the patient, the healthcare provider, and the medical system. In general, the lack of regular communication between the patient and the physician, as occurs in the traditional model of clinic-based care, predicts a low rate of blood pressure control. In addition, clinic-based blood pressure rates are notoriously unreliable. A solution to this dilemma is teletransmission of self- measured blood pressure readings, which offers the dual advantages of more reliable measurements, and the establishment of regular telephone communication between the patient and the healthcare provider. Preliminary evidence with this type of system suggests that blood pressure control can be improved substantially.

Compliance of patients with hypertension and associated factors

The purpose of the study reported in this paper was to evaluate compliance, and factors associated with compliance, in patients who had hypertension. Compliance with lifestyle recommendations, medication and attendance of follow-up visits was evaluated. The data were collected using a questionnaire completed by 138 patients with hypertension aged under 63 years from one town and three municipalities in Finland. The patients responded when they visited a doctor or a nurse in a health centre or an occupational health station. The response percentage was 94%. The data were analysed using the SPSS for Windows software. The results are presented as frequency and percentage distributions. The connections between the variables were studied by cross-tabulations and the chi-square method. The series was 60% female and 40% male. According to the blood pressure readings, the control of hypertension was good in one-tenth of the patients, average in two-thirds and poor in one-fifth. Based on the weight index, the control of hypertension was good in 28% of the patients, average in 30% and poor in 42%. Compliance with the dietary restrictions was poorest, while compliance with medication was best. Symptoms were reported by 61% of the females and 29% of the males. Non-smoking, no symptoms, high level education and female sex were related to good compliance with dietary restrictions. Marital status and family size correlated significantly with smoking. Those who lived alone smoked more.

Persistence with treatment for hypertension in actual practice

BACKGROUND

Despite the existence of efficacious medications, many patients in actual practice remain with uncontrolled hypertension. Randomized clinical trials, cannot address this issue well given their highly restricted environment. This paper examines persistence with antihypertensive therapy among patients in actual practice.

METHODS

Cohort study of patients who received a diagnosis of hypertension and were treated between 1989 and 1994 identified through the Saskatchewan Health databases. Patients with concurrent diagnoses likely to affect initial treatment choice were excluded. The resulting population of 79,591 subjects was grouped into those with established hypertension (52,227 [66%]) and those with newly diagnosed hypertension (27,364 [34%]). The initial antihypertensive prescription, subsequent changes in treatment and persistence with antihypertensive therapy were analysed.

RESULTS

Persistence with antihypertensive therapy decreased in the first 6 months after treatment was started and continued to decline over the next 4 years. Of the patients with newly diagnosed hypertension, only 78% persisted with therapy at the end of 1 year, as compared with 97% of the patients with established hypertension (p < 0.001). Among those with newly diagnosed hypertension, older patients were more likely than younger ones to persist, and women were more likely than men to persist (p < 0.001).

INTERPRETATION

This analysis of actual practice data indicates that barriers to persistence occur early in the therapeutic course and that achieving successful therapy when treatment is started is important to maintaining long-term persistence.

Effect of initial drug choice on persistence with antihypertensive therapy: the importance of actual practice data

BACKGROUND

Rational medical decisions should be based on the best possible evidence. Clinical trial results, however, may not reflect conditions in actual practice. In hypertension, for example, trials indicate equivalent antihypertensive efficacy and safety for many medications, yet blood pressure frequently remains uncontrolled, perhaps owing to poor compliance. This paper examines the effect of initial choice of treatment on persistence with therapy in actual practice.

METHODS

The authors examined all outpatient prescriptions for antihypertensive medications filled in Saskatchewan between 1989 and 1994 by over 22,000 patients with newly diagnosed hypertension whose initial treatment was with a diuretic, beta-blocker, calcium-channel blocker or angiotensin-converting-enzyme (ACE) inhibitor. Rates of persistence over the first year of treatment were compared.

RESULTS

After 6 months, persistence with therapy was poor and differed according to the class of initial therapeutic agent: 80% for diuretics, 85% for beta-blockers, 86% for calcium-channel blockers and 89% for ACE inhibitors (p < 0.001). These differences remained significant when age, sex and health status in the previous year were controlled for. Changes in the therapeutic regimen were also associated with lack of persistence.

INTERPRETATION

A relation not seen in clinical trials--between persistence with treatment and initial antihypertensive medication prescribed--was found in actual practice. This relation also indicates the importance of real-world studies for evidence-based medicine.

Hypertension control and access to medical care in the inner city

OBJECTIVES

This study assessed hypertension control among high-risk African Americans.

METHODS

We interviewed 583 African Americans aged 18 years and older residing in 438 randomly selected inner-city households.

RESULTS

Forty-two percent of the respondents were hypertensive. Blood pressure was uncontrolled in 74% of hypertensive persons, although 64% of hypertensive persons reported having seen a physician within the previous 3 months. Hypertension control was associated with female gender and higher socioeconomic strata but not with public versus private sources of medical care.

CONCLUSIONS

Hypertension control is inadequate in this population, although health care services are used frequently. Hypertension control efforts should focus on the effectiveness of health care delivery.

Ambulatory health care use by patients in a public hospital emergency department

OBJECTIVE

To describe primary care clinic use and emergency department (ED) use for a cohort of public hospital patients seen in the ED, identify predictors of frequent ED use, and ascertain the clinical diagnoses of those with high rates of ED use.

DESIGN

Cohort observational study.

SETTING

A public hospital in Atlanta, Georgia.

PATIENTS

Random sample of 351 adults initially surveyed in the ED in May 1992 and followed for 2 years.

MEASUREMENTS AND MAIN RESULTS

Of the 351 patients from the initial survey, 319 (91%) had at least one ambulatory visit in the public hospital system during the following 2 years and one third of the cohort was hospitalized. The median number of subsequent ED visits was 2 (mean 6.4), while the median number of visits to a primary care appointment clinic was O (mean 1.1) with only 90 (26%) of the patients having any primary care clinic visits. The 58 patients (16.6%) who had more than 10 subsequent ED visits accounted for 65.6% of all subsequent ED visits. Overall, patients received 55% of their subsequent ambulatory care in the ED, with only 7.5% in a primary care clinic. In multivariate regression, only access to a telephone (odds ratio [OR] 0.48; 95% confidence interval [CI] 0.39, 0.60), hospital admission (OR 5.90; 95% CI 4.01, 8.76), and primary care visits (OR 1.68; 95% CI 1.34, 2.12) were associated with higher ED visit rates. Regular source of care, insurance coverage, and health status were not associated with ED use. From clinical record review, 74.1% of those with high rates of use had multiple chronic medical conditions, or a chronic medical condition complicated by a psychiatric diagnosis, or substance abuse.

CONCLUSIONS

All subgroups of patients in this study relied heavily on the ED for ambulatory care, and high ED use was positively correlated with appointment clinic visits and inpatient hospitalization rates, suggesting that high resource utilization was related to a higher burden of illness among those patients. The prevalence of chronic medical conditions and substance abuse among these most frequent emergency department users points to a need for comprehensive primary care. Multidisciplinary case management strategies to identify frequent ED users and facilitate their use of alternative care sites will be particularly important as managed care strategies are applied to indigent populations who have traditionally received care in public hospital EDs.

Mortality in Hartford, Connecticut: a comparison with the South Bronx, New York

Very high mortality rates have been reported in large inner-city areas such as the South Bronx and Harlem in New York City, but also may occur in smaller US urban areas. Using published death rates for the South Bronx as the standard, the standardized mortality ratio was slightly lower than 1.00 for Hartford, Connecticut (population 139,739 in 1990), but more than 1.00 for three impoverished Hartford census tracts that contained public housing projects. Compared with the South Bronx, death rates in Hartford were lower for human immunodeficiency virus (HIV), injury-homicide, and alcohol-drugs, but higher for hypertension-stroke (in all three tracts) and cancer (in two of the three tracts). Variations in patterns of causes of death among impoverished US urban areas have implications for planning epidemiologic studies and targeting interventions.

Controlling tuberculosis in an urban emergency department: a rapid decision instrument for patient isolation

OBJECTIVES

This study examined whether data routinely available in emergency departments could be used to improve isolation decisions for tuberculosis patients.

METHODS

In a large emergency department in New York City, we compared the exposure histories of tuberculosis culture-positive and culture-negative patients and used these data to develop a rapid decision instrument to predict culture-positive tuberculosis. The screen used only data that are routinely available to emergency physicians.

RESULTS

The method had high sensitivity (.96) and moderate specificity (.54).

CONCLUSIONS

The method is easily adaptable for a broad range of settings and illustrates the potential benefits of applying basic epidemiologic methods in a clinical setting.

Cigarette smoking and severe uncontrolled hypertension in inner-city African Americans

PURPOSE

Although over the past 2 decades great strides have been made in increasing the awareness, detection, and treatment of hypertension (HTN), actual control of blood pressure is far from optimal. We hypothesized that current cigarette smoking, by acting as a marker for poor health related behavioral patterns, would be significantly associated with uncontrolled blood pressure (BP).

PATIENTS AND METHODS

Over a 3-month period in 1994, all patients who presented to a public hospital medical walk-in clinic were screened, and had their BP measured if they had been prescribed BP medication within 1 year and were aware of their diagnosis of HTN. Patients were defined as controlled hypertensives if both systolic BP and diastolic BP were < or = 140/90 mm Hg. Severe uncontrolled hypertensives were those with either systolic BP > or = 180 mm Hg or diastolic BP was > or = 110 mm Hg.

RESULTS

Of the 221 patients meeting all inclusion criteria (1 refusal), 86 had uncontrolled HTN (mean BP = 192/106 mm Hg), 130 were controlled (mean BP = 130/80 mm Hg), and 5 were not African American. Severe uncontrolled hypertensives, when compared with controlled hypertensives, were significantly more likely to be current (versus former) smokers (odds ratio [OR] = 4.17; 95% confidence interval [CI]: 1.8 to 9.5), and be less compliant with medications (OR = 2.33; 95% CI: 1.3 to 4.1). Age, gender, alcohol use, marital status, education, and comorbidity were not associated with HTN control. In an adjusted logistic regression model, both current and never-smokers when compared with former smokers were significantly more likely to have uncontrolled HTN in compliant patients (OR = 14.4; 95% CI: 3.3 to 63.3 and OR = 5.7; 95% CI: 1.5 to 21.7, respectively). In noncompliant patients, smoking status was not associated with uncontrolled HTN.

CONCLUSION

In disadvantaged African-American patients who report good medication compliance, former smoking status is strongly associated with HTN control. Physicians may need to be especially vigilant of BP control in patients who smoke.

Hypertension and obesity in African-American patients undergoing surgery

This study was designed to determine the prevalence of hypertension and obesity in a population of African-American patients scheduled to undergo surgery. Weight and blood pressure were measured in 431 randomly selected patients. This included 282 women (65%) and 149 men (35%). Hypertension was present in 27% of the women and 32% of the men. Obesity was present in 58% of the women and 23% of the men. Fifteen percent of all patients met the criteria for having both hypertension and obesity. This study confirms the high incidence of hypertension and obesity in the African-American population. The high morbidity and mortality associated with these conditions suggest that a renewed community-wide effort and public education program on the part of health-care providers is needed to inform this patient population of these dangers.

Awareness, treatment and control of hyperlipidaemia, hypertension and diabetes mellitus in a selected population of southern Italy

The purpose of the present study was to assess the degree of awareness, treatment and control of hyperlipidaemia compared with hypertension and diabetes mellitus in a selected population of southern Italy. All participants to a cardiovascular disease prevention campaign examined between April 1994 and July 1995 were screened for hyperlipidaemia, hypertension and diabetes mellitus. Subjects received also ECG, echo-Doppler of carotid arteries and filled in a questionnaire concerning personal and familial cardiovascular diseases, smoking habit and drug consumption. Of the 742 participants, 327 were found to have hypertension, 73 to have diabetes mellitus, 287 to have mild hyperlipidaemia and 322 to have moderate-severe hyperlipidaemia. Among hypertensive subjects, 60.2% were aware of their condition, 53.5% were treated and 15.6% had their blood pressure controlled at the recommended level (< 140/90 mmHg). Among diabetic subjects, 76.7% were aware, 64.4% treated and 19.2% reached fasting blood glucose level of less than 7.77 mmol/l (140 mg/dl). Only 24.0% of subjects with mild hyperlipidaemia were aware of their condition. Of the subjects found to have moderate-severe hyperlipidaemia, 64.9% were aware, 32.3% were treated and 9.0% had plasma cholesterol and triglycerides concentration of less than 6.45 and 5.65 mmol/l (250 and 500 mg/dl), respectively (cutoffs chosen to separate mild from moderate-severe hyperlipidaemia). These results show that mild hyperlipidaemia is almost neglected whereas awareness of moderave-severe hyperlipidaemia is quite widespread and comparable to that of hypertension and diabetes mellitus. Prevalence of treatment and control of moderate-severe hyperlipidaemia is, however, much lower than that of hypertension and diabetes.

Hypertension-related morbidity and mortality in the southeastern United States

Stroke mortality is higher in the Southeast compared with other regions of the United States. The prevalence of hypertension is also higher (black men = 35%, black women = 37.7%, white men = 26.5%, white women = 21.5%), and the proportion of patients whose hypertension is being controlled is poor, especially in white and black men. The prevalence of hypertension-related complications other than stroke is also higher in the Southeast. The five states with the highest death rates for congestive heart failure are all in the southern region. Of the 15 states with the highest rates of end-stage renal disease, 10 are in the Southeast. Obesity is very prevalent (24% to 28%) in the Southeast. Although Michigan tops the ranking for all states, 6 of the top 15 states are in the Southeast, as are 7 of the 10 states with the highest reported prevalence regarding no leisure-time physical activity. Similar to other areas of the United States, dietary sodium and saturated fat intake are high in the Southeast; dietary potassium intake appears to be relatively low. Other factors that may be associated with the high prevalence, poor control, and excess morbidity and mortality of hypertension-related complications in the Southeast include misperceptions of the seriousness of the problem, the severity of the hypertension, lack of adequate follow-up, reduced access to health care, the cost of treatment, and possibly, low birth weights. The Consortium of Southeastern Hypertension Control (COSEHC) is a nonprofit organization created in 1992 in response to a compelling need to improve the disproportionate hypertension-related morbidity and mortality throughout this region. The purpose of this position paper is to summarize the data that document the problem, the consequences, and possible causative factors.

The ecology of urban violence: its relationship to health promotion behaviors in low-income black and Latino communities

PURPOSE

The purpose of this review is to identify and examine relationships between exposure to violence and health promotion behaviors in low-income black and Latino groups.

DESIGN

Based on computer surveys of the psychologic, public health, medical, and sociologic literature, approximately 90 previous studies of the impact of exposure to violence on psychologic functioning, perceptions of health and well-being, and health decisions and behavior were identified. This article reviews those studies that examine the relationships between experiences of violence and subsequent feelings of alienation, powerlessness, and hopelessness, and perceptions of health and well-being and studies that examine relationships between alienation, hopelessness, and powerlessness and health promotion behaviors. Studies of health promotion behavior that did not examine or address the impact of exposure to violence are not reviewed in this article.

RESULTS

Violence affects low-income communities directly by contributing to rates of mortality, and indirectly by affecting health promotion behaviors. Exposure to violence can result in feelings of powerlessness, hopelessness, and alienation that significantly limit motivation, the extent of involvement, and persistence in overcoming barriers to health promotion behavior.

CONCLUSIONS

Future researchers must consider the confounding effects of exposure to violence when investigating differences in health promotion behaviors for low-income black and Latino groups. Community empowerment programs that address the impact of violence and focus on developing control over life and health outcomes may be needed to successfully address the effect of violence on health promotion behavior in low-income, black and Latino communities.

Correlates of health care satisfaction in inner-city patients with hypertension and chronic renal insufficiency

Barriers to effective health care are potential contributors to the increased prevalence of hypertension and hypertension-related renal disease observed in black patients. We have enrolled 333 primarily elderly (mean age 69 years) black (87%) patients with hypertension and chronic renal insufficiency into a prospective randomized trial testing the effect of intense multidisciplinary management on progression of chronic renal insufficiency. These patients have an average 6 years of education and $400-$800 monthly household income: 57% have diabetes. Our baseline data include the Patient Satisfaction Questionnaire administered by home interviewers who also recorded sociodemographic data, medications and questionnaires regarding medication compliance and symptoms related to anti-hypertensive drugs. Inpatient and outpatient vital signs, test results and diagnoses came from patients' computerized medical records. We used multiple linear regression to identify correlates of overall satisfaction. We also analyzed three subscales: access to care, financial aspects and interpersonal manner of physicians. We included only variables with univariate correlations (P < 0.05) in the models. Decreased overall satisfaction correlated with more symptoms related to anti-hypertensive drugs (P < 0.001), lower medication compliance (P = 0.01), and higher diastolic blood pressure (P = 0.08). Decreased satisfaction with access to care correlated with more symptoms related to anti-hypertensive drugs (P < 0.001) and decreased medication compliance (P = 0.08). Decreased satisfaction with financial aspects of care correlated with more symptoms related to anti-hypertensive drugs (P < 0.001), lower medication compliance (P = 0.01) and more proteinuria (P = 0.02). Finally, decreased satisfaction with interpersonal manner of physicians correlated with lower medication compliance (P < 0.001), lower albumin (P = 0.01) and sodium (P = 0.04), and higher diastolic blood pressure (P = 0.04). These cross-sectional baseline data describe a group of mostly black inner-city patients with hypertension and chronic renal insufficiency in whom decreased satisfaction with care correlates with decreased medication compliance, increased symptoms related to anti-hypertensive drug therapy, higher diastolic blood pressure and more proteinuria. Our prospective study may help determine whether improving satisfaction improves compliance and blood pressure control, and forestalls complications in this high-risk population.

Predictors of patient adherence to long-term home nebulizer therapy for COPD. The IPPB Study Group. Intermittent Positive Pressure Breathing

STUDY OBJECTIVE

Patients with moderate to severe COPD are frequently prescribed expensive and complicated therapies that require adjustments in usual activities of daily living. However, little is known about factors that are associated with adherence to such treatment. The objective of this study was to identify characteristics of patients who were adherent to long-term home nebulizer therapy.

DESIGN

Patients were stratified into two adherence groups based on average minutes of nebulizer use each day. A logistic regression model was developed to predict adherence based on baseline variables. A questionnaire was administered to patients to assess reasons for adherence to therapy.

SETTING

Five clinical centers in the United States and Canada.

PARTICIPANTS

Nine hundred eighty-five patients with moderate to severe COPD enrolled in the Intermittent Positive Pressure Breathing (IPPB) Trial.

INTERVENTIONS

Long-term home IPPB and nebulizer therapy.

MEASUREMENTS AND RESULTS

Altogether 50.6% of patients were adherent, and 49.4% were nonadherent. Among baseline variables, good adherence was predicted by white race, married status, abstinence from cigarettes and alcohol, serum theophylline level > or = 9 micrograms/mL, more severe dyspnea, and reduced FEV1 (p < 0.05). Subjects who were adherent to nebulizer therapy were older, better educated, had a stable lifestyle, were more likely to report that the therapy made them feel better, and were more likely to keep clinic appointments.

CONCLUSIONS

Sociodemographic, physiologic, and quality of life variables were associated with adherence to long-term nebulizer therapy.

The efficacy of primary care for vulnerable population groups

This article reviews the existing literature on the efficacy of primary care with an emphasis on the evaluation of primary care for vulnerable populations: groups whose demographic, geographic, or economic characteristics impede or prevent their access to health care services. A significant portion of the literature derives from studies of poor and underserved populations. However, to construct a more complete evaluation of primary care services, the authors cite literature that has examined both advantaged and disadvantaged populations. Even then the literature is incomplete, at best. The article describes a definition of primary care suitable for policy analysis and formulation, reviews evidence on the efficacy of care that meets that definition, and concludes that widespread use of primary care services is likely to result in improved patient satisfaction and health status.

Violence as a barrier to compliance for the hypertensive urban African American

Violence is now recognized as a health epidemic. Violence is especially prevalent in inner-city African-American communities. Most of the attention has focused on youths. However, the effects of violence extend to the communities' hypertensive patients. Patients are subjected to the emotional impact of violence on and individual level. Studies linking stress, with hypertension have not directly addressed the role of violence. As a group, they suffer from violence's diverting of funds in the health-care system. For this particular subgroup, violence is ingrained in their daily lives. Their coping mechanisms often place compliance with antihypertensive measures in jeopardy. Community intervention is needed to address the violence. However, primary care physicians in these communities must inquire about the impact violence has on their hypertensive patients to eliminate possible compliance barriers.

Nonurgent use of the emergency department: appropriate or not?

People often assume that the use of hospital emergency departments for nonurgent problems is inappropriate. To test this assumption, several questions must be answered. These include, "How do we determine what is appropriate use of an ED?"; "How can we measure urgency in the ED?"; "Is care for nonurgent problems less effective in an ED than in a primary care facility?"; and "Is nonurgent care more costly in an ED than in a primary care facility?" These four questions are addressed, and suggestions for future research that would help answer these questions are made.