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The Association of Racial and Ethnic Concordance in Primary Care with Patient Satisfaction and Experience of Care. J Gen Intern Med 2023; 38:727-732. [PMID: 35688996 PMCID: PMC9186269 DOI: 10.1007/s11606-022-07695-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 05/31/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND The lack of racial and ethnic concordance between patients and their physicians may contribute to American health disparities. OBJECTIVE To examine the level of racial and ethnic concordance for patients and primary care clinicians and its association with measures of patient experience. DESIGN Multivariate cross-sectional analysis of nationally representative data. PARTICIPANTS Adults 18 to 64 in the 2019 Medical Expenditure Panel Survey who had at least one medical visit in the past year. MAIN MEASURES Key independent variables include having a racially/ethnically concordant primary care clinician, lacking a usual source of care, and having a usual source that is a place rather than a person. Outcomes include overall satisfaction with health care, number of medical visits, having enough time in care, ease of understanding the clinician, and receiving respect. KEY RESULTS The comparison between the actual level of concordance with an expected distribution if all patients had the same probability of having a clinician of a given race or type indicates that Black, Latino, and Asian patients are three or more times as likely to have a concordant clinician than expected, suggesting a strong preference for clinicians of the same race or ethnicity. Racial or ethnic concordance has a modest positive association with overall health care satisfaction and respect but is not significantly associated with the number of medical visits or other outcomes. Poor health status, being uninsured, and lacking a usual source of care are more strongly associated with patient experience. DISCUSSION Efforts to increase the diversity of the primary care workforce could increase racial/ethnic concordance but may have only modest effects on patients' experience of care. Policies like lowering the number of uninsured or increasing those with a usual source of care may be more salient in improving experience of care.
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Ma A, Sanchez A, Ma M. Racial disparities in health care utilization, the affordable care act and racial concordance preference. INTERNATIONAL JOURNAL OF HEALTH ECONOMICS AND MANAGEMENT 2022; 22:91-110. [PMID: 34427837 DOI: 10.1007/s10754-021-09311-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 08/17/2021] [Indexed: 06/13/2023]
Abstract
The Affordable Care Act was implemented with the aim of increasing coverage and affordable access with hopes of improving health outcomes and reducing costs. Yet, disparities persist. Coverage and affordable access alone cannot explain the health care gap between racial/ethnic minorities and white patients. Instead, the focus has turned to other factors affecting utilization rates such as the patient-provider relationship. Data from nationally represented U.S. households in 2009-2017 were used to study the association between patient-provider social distance as measured by "racial/ethnic concordance" and health care utilization rates for periods covering pre- and post-ACA. Despite the reduction in financial barriers to health access with the implementation of the ACA, the correlation between racial/ethnic concordance and utilization remains positive and significant. The results suggest that while the ACA may have improved coverage and affordability, other dimensions of access, particularly acceptability, as measured by patient-provider clinical interaction experience, remains a factor in the decision to utilize care.
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Affiliation(s)
- Alyson Ma
- Department of Economics, University of San Diego School of Business, 5998 Alcala Park, San Diego, CA, 92110, USA
| | - Alison Sanchez
- Department of Economics, University of San Diego School of Business, 5998 Alcala Park, San Diego, CA, 92110, USA.
| | - Mindy Ma
- Department of Psychology and Neuroscience, Nova Southeastern University, 3301 College Avenue, Fort Lauderdale, FL, 33314, USA
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Ibe C, Bowie J, Roter D, Carson KA, Lee B, Monroe D, Cooper LA. Intensity of exposure to a patient activation intervention and patient engagement in medical visit communication. PATIENT EDUCATION AND COUNSELING 2017; 100:1258-1267. [PMID: 28162812 DOI: 10.1016/j.pec.2016.12.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 11/17/2016] [Accepted: 12/17/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE We examined associations between intensity of exposure to a community health worker (CHW) delivered communication activation intervention targeting low-income patients with hypertension. METHODS We analyzed question-asking behaviors of patients assigned to the intervention arms (n=140) in a randomized controlled trial. Intensity of exposure to the intervention was operationalized as the duration of face-to-face coaching and number of protocol-specified topics discussed. Mixed effects models characterized the relationship between intensity of exposure and patients' communication in a subsequent medical visit. RESULTS The number of topics discussed during the coaching session was positively associated with patients' asking psychosocial-related questions during their visit. The duration of the coaching session was positively associated with patients' use of communication engagement strategies to facilitate their participation in the visit dialogue. Exposure to a physician trained in patient-centered communication did not influence these relationships. CONCLUSIONS A dose-response relationship was observed between exposure to a CHW- delivered communication activation intervention and patient-provider communication. PRACTICE IMPLICATIONS This study supports the use of CHWs in activating patients toward greater communication in the therapeutic exchange.
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Affiliation(s)
- Chidinma Ibe
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.
| | - Janice Bowie
- Department of Health Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Debra Roter
- Department of Health Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Kathryn A Carson
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Bone Lee
- Department of Health Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Dwyan Monroe
- Institute for Public Health Innovation, Washington, D.C., USA
| | - Lisa A Cooper
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA; Department of Health Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA; Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, USA; Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
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4
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Koulayev S, Simeonova E, Skipper N. Can Physicians Affect Patient Adherence With Medication? HEALTH ECONOMICS 2017; 26:779-794. [PMID: 27311330 DOI: 10.1002/hec.3357] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Revised: 02/08/2016] [Accepted: 04/05/2016] [Indexed: 06/06/2023]
Abstract
Non-compliance with medication therapy remains an unsolved and expensive problem for healthcare systems around the world, yet we know little about the factors that affect a patient's decision to follow treatment recommendations. In particular, there is little evidence on the extent to which doctors can influence patient adherence behavior. This study uses a unique panel dataset comprising all prescription drug users, physicians, and all prescription drug sales in Denmark over 7 years to analyze the contributions of doctor-specific, patient-specific, and drug-specific factors to the adherence decision. We find that physicians exert substantial influence on patient compliance. Further, the quality of the match between a doctor and a patient accounts for a substantial portion of the variation in adherence outcomes. This suggests that the sorting of patients across doctors is an important mechanism that affects patient adherence beyond the effects of individual patient-specific and physician-specific factors. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
| | | | - Niels Skipper
- Department of Economics and Business Economics, Aarhus University, Aarhus V, Denmark
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Kressin NR, Chapman SE, Magnani JW. A Tale of Two Patients: Patient-Centered Approaches to Adherence as a Gateway to Reducing Disparities. Circulation 2017; 133:2583-92. [PMID: 27297350 DOI: 10.1161/circulationaha.116.015361] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The disparate effects of social determinants of health on cardiovascular health status and health care have been extensively documented by epidemiology. Yet, very little attention has been paid to how understanding and addressing social determinants of health might improve the quality of clinical interactions, especially by improving patients' adherence to recommended therapies. We present a case and suggested approach to illustrate how cardiovascular clinicians can use patient-centered approaches to identify and address social determinants of health barriers to adherence and reduce the impact of unconscious clinician biases. We propose that cardiovascular clinicians (1) recognize that patients may have different belief systems about illnesses' cause and treatment, which may influence their actions, and not assume they share one's experiences or explanatory model; (2) Endeavor to understand the individual patient before you; (3) based on that understanding, tailor your approach to that individual. We suggest a previously-developed mnemonic for an approach to RESPECT the patient: First, show Respect; then elicit patients' understandings of their illness by asking about their Explanatory model. Ask about the patient's Social context, share Power in the interaction, show Empathy, ask about Concerns or fears, and work to develop Trust by building the relationship over time. We provide additional clinical resources to support these efforts, including lay descriptions of cardiovascular conditions, challenges to adherence, and suggested strategies to address them.
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Affiliation(s)
- Nancy R Kressin
- From VA Boston Healthcare System, Jamaica Plain, MA (N.R.K.); Department of Medicine, Boston University School of Medicine and Boston Medical Center, MA (N.R.K., S.E.C.); and Department of Medicine, Division of Cardiology, UPMC Heart & Vascular Institute, University of Pittsburgh, PA (J.W.M.).
| | - Sheila E Chapman
- From VA Boston Healthcare System, Jamaica Plain, MA (N.R.K.); Department of Medicine, Boston University School of Medicine and Boston Medical Center, MA (N.R.K., S.E.C.); and Department of Medicine, Division of Cardiology, UPMC Heart & Vascular Institute, University of Pittsburgh, PA (J.W.M.)
| | - Jared W Magnani
- From VA Boston Healthcare System, Jamaica Plain, MA (N.R.K.); Department of Medicine, Boston University School of Medicine and Boston Medical Center, MA (N.R.K., S.E.C.); and Department of Medicine, Division of Cardiology, UPMC Heart & Vascular Institute, University of Pittsburgh, PA (J.W.M.)
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Wu Y, Hu G, Pan F, Liu J, Mo X, Xie Y, Liang D, Lei Z, Liang B. Obstructive sleep apnea hypopnea syndrome was a risk factor for uncontrolled hypertension in adult snorers in South China. Clin Exp Hypertens 2016; 38:429-34. [PMID: 27359186 DOI: 10.3109/10641963.2016.1151525] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND The association of obstructive sleep apnea hypopnea syndrome (OSAHS) with uncontrolled hypertension has not been fully investigated to date. The present article will investigate the associated factors of uncontrolled hypertension in South China Method: A total of 668 patients (531 males, 137 females) in South China were enrolled in this study. All patients completed questionnaires and then underwent an in-hospital polysomnography. RESULT Univariate analysis showed that drinking, apnea-hypopnea index, Epworth Sleepiness Scale (ESS) index, the presence of OSAHS, MSaO2 and the lowest SaO2, circumference of neck and waist were predictors of uncontrolled hypertension. Multiple logistic regression analysis showed that ESS, presence of OSAHS, and the lowest SaO2 was independently associated with the risk for uncontrolled hypertension. CONCLUSION The lowest SaO2, ESS index, and OSAHS were risk factors for uncontrolled hypertension.
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Affiliation(s)
- Yankui Wu
- a Sleep-Disordered Breathing Center of Guangxi , People's Hospital of Guangxi Zhuang Autonomous Region , Guangxi Zhuang Autonomous Region, P R China
| | - Guoping Hu
- b Department of Respiratory Disease of the Third Hospital , Guangzhou Medical University , Guangzhou , Guangdong , China
| | - Fengjin Pan
- a Sleep-Disordered Breathing Center of Guangxi , People's Hospital of Guangxi Zhuang Autonomous Region , Guangxi Zhuang Autonomous Region, P R China
| | - Jianhong Liu
- a Sleep-Disordered Breathing Center of Guangxi , People's Hospital of Guangxi Zhuang Autonomous Region , Guangxi Zhuang Autonomous Region, P R China
| | - Xiaoyun Mo
- a Sleep-Disordered Breathing Center of Guangxi , People's Hospital of Guangxi Zhuang Autonomous Region , Guangxi Zhuang Autonomous Region, P R China
| | - Yuping Xie
- a Sleep-Disordered Breathing Center of Guangxi , People's Hospital of Guangxi Zhuang Autonomous Region , Guangxi Zhuang Autonomous Region, P R China
| | - Dahua Liang
- a Sleep-Disordered Breathing Center of Guangxi , People's Hospital of Guangxi Zhuang Autonomous Region , Guangxi Zhuang Autonomous Region, P R China
| | - Zhijian Lei
- a Sleep-Disordered Breathing Center of Guangxi , People's Hospital of Guangxi Zhuang Autonomous Region , Guangxi Zhuang Autonomous Region, P R China
| | - Bifang Liang
- a Sleep-Disordered Breathing Center of Guangxi , People's Hospital of Guangxi Zhuang Autonomous Region , Guangxi Zhuang Autonomous Region, P R China
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Undiagnosed and uncontrolled hypertension among the adults in rural Bangladesh: findings from a community-based study. J Hypertens 2016; 33:2399-406. [PMID: 26372322 DOI: 10.1097/hjh.0000000000000712] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVES This article reports the prevalence and prediction factors of undiagnosed and uncontrolled hypertension among the adults in rural Bangladesh. METHODS A cross-sectional study of the major noncommunicable disease risk factors was conducted in rural surveillance sites of Bangladesh in 2005. In addition to the self-report questions on risk factors, height, weight, and blood pressure were measured using standard protocols of the WHO STEPwise approach to Surveillance. Undiagnosed hypertension was defined when people reported no hypertension but were found hypertensive when measured, and uncontrolled hypertension was defined when people reported receiving antihypertensive treatment but their blood pressure was above the normal range when measured. RESULTS The prevalence of undiagnosed hypertension was 11.1%, increasing with age to 22.7% among those aged 60 years and above. Among the hypertensive patients receiving treatment, 54.9% were found to be uncontrolled (34.5% among 25-39 years and 67.9% among 60+ years). Increasing age and higher BMI were significantly positively associated with undiagnosed hypertension in multivariate analysis. Increasing age and more wealth have significant independent association with uncontrolled hypertension. CONCLUSION High prevalence of undiagnosed hypertension, and more than 50% of the treated hypertension being uncontrolled puts a great challenge ahead for Bangladesh, a resource-poor setting. Regular health check or health screening along with implementation of hypertensive guidelines should be reinforced.
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Hunter N, Barsky TV. Transactional Experiences of Existential Anxiety as a Barrier to Effective Humanistic Intervention. JOURNAL OF HUMANISTIC PSYCHOLOGY 2016. [DOI: 10.1177/0022167816646671] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
There are some who criticize mainstream mental health approaches and point out that individuals in distress appear to be getting worse, as opposed to better, while in treatment. Ex-patients often advocate for a person-centered, humanistic approach to working with emotional distress, while clinicians tend to offer a disease-based, deficit-focused model. This article is an exploration of the dynamics between patients and professionals that may be contributing to conflicting perspectives on what constitutes helpful intervention. Specifically, concepts of terror management theory are used to explore how the existential anxieties experienced both by individuals with serious emotional difficulties as well as their treating clinicians, which are consciously or unconsciously avoided in treatment, can reciprocally trigger distressing anxiety in the other. Suggestions are offered as to what could help mitigate this existential stalemate in the psychotherapeutic context.
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Affiliation(s)
- Noel Hunter
- Long Island University–Post, Brookville, NY, USA
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9
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Tkacz J, Ingham MP, Brady BL, Meyer R, Ruetsch C. Novel Adherence Measures for Infusible Therapeutic Agents Indicated for Rheumatoid Arthritis. AMERICAN HEALTH & DRUG BENEFITS 2015; 8:494-505. [PMID: 26834936 PMCID: PMC4719139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 06/25/2015] [Indexed: 06/05/2023]
Abstract
BACKGROUND Published studies on adherence to biologic medications show that many types of calculation methods are used. However, infused biologics are not well-suited to typical measures of adherence, such as proportion of days covered. OBJECTIVE To construct and assess 7 novel adherence measures potentially applicable to infusible biologic agents and compare outcomes for 2 infusible biologics used for the treatment of patients with rheumatoid arthritis (RA). METHODS Adults (aged ≥18 years) diagnosed with RA (ie, 2 or more 714.x claims) who received ≥24 months of continuous medical and pharmacy eligibility and who started taking abatacept or infliximab therapy were selected from a large commercial insurer database of medical and pharmacy claims. The 7 new adherence measures included cumulative amount of time with a refill gap ≥20% (CG20) beyond the expected infusion interval, cumulative time off treatment, days of uninterrupted use (DoUU), observed versus expected refill ratio (OvERR), repeated observations of underuse (RoUU), variance in time between infusions, and time to discontinuation (TTD). Mean observed infusion intervals were calculated and served as a reference measure of adherence. RESULTS The mean maintenance intervals approximated recommended guidelines. The mean observed infusion interval for abatacept recipients was 33 days (recommended, 28 days); it was 53 days (recommended, 56 days) for patients receiving infliximab. Three measures demonstrated a significant positive relationship to the mean observed infusion interval-CG20 (r = .258), DoUU (r = .212), and TTD (r = .081; P <.05). OvERR (r = -.072) and RoUU (r = -.189; P <.05) showed significant negative correlations. Real-world comparisons showed that adherence was significantly (P <.001) greater for the infliximab group according to most measures. CONCLUSION New measures of adherence correlate significantly with mean maintenance intervals. Future studies should examine relationships between these adherence measures and clinically relevant end points and/or cost outcomes to determine their predictive utility. Alternative methods of reporting adherence may have greater clinical significance than traditional measures.
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Affiliation(s)
- Joseph Tkacz
- Mr Tkacz is Director of Analytics, Health Analytics, Columbia, MD
| | - Michael P Ingham
- Mr Ingham is Director, HECOR, Janssen Scientific Affairs, Horsham, PA
| | - Brenna L Brady
- Dr Brady is Project Director, Health Analytics, Columbia, MD
| | - Roxanne Meyer
- Dr Meyer is Manager, HECOR, Janssen Scientific Affairs, Horsham, PA
| | - Charles Ruetsch
- Dr Ruetsch is President and Chief Executive Officer, Health Analytics, Columbia, MD
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10
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Martinez IL, Artze-Vega I, Wells AL, Mora JC, Gillis M. Twelve tips for teaching social determinants of health in medicine. MEDICAL TEACHER 2015; 37:647-652. [PMID: 25373885 DOI: 10.3109/0142159x.2014.975191] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND There has been a recent movement towards social accountability in medical schools, which includes integrating the social, economic, and cultural determinants of health into the curriculum. Medical schools and their guiding bodies have met this challenge of educating future physicians to provide effective care to diverse populations with varying response and successes. Because these topics have not been systematically taught in most medical school curricula, strategies are needed to teach them alongside clinical sciences. AIM AND METHOD We provide 12 tips on how to teach social determinants of health and cultural competency to undergraduate medical students. These recommendations are based on a review of the literature and our experience in developing and delivering a longitudinal course over the last five years. CONCLUSION Medical students must be taught to think critically about the social and cultural issues impacting health, and the intersection with the basic biology and clinical skills. Teaching social determinants of health in medicine requires keeping the material concrete and applicable. Educators must engage students in active learning strategies, reflection, and focus on how to make the material relevant to the clinical care of patients.
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11
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Onder G, Landi F, Fusco D, Corsonello A, Tosato M, Battaglia M, Mastropaolo S, Settanni S, Antocicco M, Lattanzio F. Recommendations to prescribe in complex older adults: results of the CRIteria to assess appropriate Medication use among Elderly complex patients (CRIME) project. Drugs Aging 2014; 31:33-45. [PMID: 24234805 DOI: 10.1007/s40266-013-0134-4] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The occurrence of several geriatric conditions may influence the efficacy and limit the use of drugs prescribed to treat chronic conditions. Functional and cognitive impairment, geriatric syndromes (i.e. falls or malnutrition) and limited life expectancy are common features of old age, which may limit the efficacy of pharmacological treatments and question the appropriateness of treatment. However, the assessment of these geriatric conditions is rarely incorporated into clinical trials and treatment guidelines. The CRIME (CRIteria to assess appropriate Medication use among Elderly complex patients) project is aimed at producing recommendations to guide pharmacologic prescription in older complex patients with a limited life expectancy, functional and cognitive impairment, and geriatric syndromes, and providing physicians with a tool to improve the quality of prescribing, independent of setting and nationality. To achieve these aims, we performed the following: (i) Existing disease-specific guidelines on pharmacological prescription for the treatment of diabetes, hypertension, congestive heart failure, atrial fibrillation and coronary heart disease were reviewed to assess whether they include specific indications for complex patients; (ii) a literature search was performed to identify relevant articles assessing the pharmacological treatment of complex patients; (iii) A total of 19 new recommendations were developed based on the results of the literature search and expert consensus. In conclusion, the new recommendations evaluate the appropriateness of pharmacological prescription in older complex patients, translating the recommendations of clinical guidelines to patients with a limited life expectancy, functional and cognitive impairment, and geriatric syndromes. These recommendations cannot represent substitutes for careful clinical consideration and deliberation by physicians; the recommendations are not meant to replace existing clinical guidelines, but they may be used to help physicians in the prescribing process.
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12
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Ephraim PL, Hill-Briggs F, Roter DL, Bone LR, Wolff JL, Lewis-Boyer L, Levine DM, Aboumatar HJ, Cooper LA, Fitzpatrick SJ, Gudzune KA, Albert MC, Monroe D, Simmons M, Hickman D, Purnell L, Fisher A, Matens R, Noronha GJ, Fagan PJ, Ramamurthi HC, Ameling JM, Charlston J, Sam TS, Carson KA, Wang NY, Crews DC, Greer RC, Sneed V, Flynn SJ, DePasquale N, Boulware LE. Improving urban African Americans' blood pressure control through multi-level interventions in the Achieving Blood Pressure Control Together (ACT) study: a randomized clinical trial. Contemp Clin Trials 2014; 38:370-82. [PMID: 24956323 PMCID: PMC4169070 DOI: 10.1016/j.cct.2014.06.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Revised: 06/10/2014] [Accepted: 06/13/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND Given their high rates of uncontrolled blood pressure, urban African Americans comprise a particularly vulnerable subgroup of persons with hypertension. Substantial evidence has demonstrated the important role of family and community support in improving patients' management of a variety of chronic illnesses. However, studies of multi-level interventions designed specifically to improve urban African American patients' blood pressure self-management by simultaneously leveraging patient, family, and community strengths are lacking. METHODS/DESIGN We report the protocol of the Achieving Blood Pressure Control Together (ACT) study, a randomized controlled trial designed to study the effectiveness of interventions that engage patient, family, and community-level resources to facilitate urban African American hypertensive patients' improved hypertension self-management and subsequent hypertension control. African American patients with uncontrolled hypertension receiving health care in an urban primary care clinic will be randomly assigned to receive 1) an educational intervention led by a community health worker alone, 2) the community health worker intervention plus a patient and family communication activation intervention, or 3) the community health worker intervention plus a problem-solving intervention. All participants enrolled in the study will receive and be trained to use a digital home blood pressure machine. The primary outcome of the randomized controlled trial will be patients' blood pressure control at 12months. DISCUSSION Results from the ACT study will provide needed evidence on the effectiveness of comprehensive multi-level interventions to improve urban African American patients' hypertension control.
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Affiliation(s)
- Patti L Ephraim
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Felicia Hill-Briggs
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Johns Hopkins University School of Nursing, Baltimore, MD, USA.
| | - Debra L Roter
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Lee R Bone
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Jennifer L Wolff
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - LaPricia Lewis-Boyer
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - David M Levine
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Hanan J Aboumatar
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Armstrong Institute for Safety and Quality, Johns Hopkins Medicine, Baltimore, MD, USA.
| | - Lisa A Cooper
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | | | - Kimberly A Gudzune
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Michael C Albert
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Johns Hopkins Community Physicians, Johns Hopkins University, Baltimore, MD, USA.
| | - Dwyan Monroe
- Community Advisory Board, Johns Hopkins Center to Eliminate Cardiovascular Health Disparities, Baltimore, MD, USA; Institute for Public Health Innovation, Washington, DC, USA.
| | - Michelle Simmons
- Community Advisory Board, Johns Hopkins Center to Eliminate Cardiovascular Health Disparities, Baltimore, MD, USA.
| | - Debra Hickman
- Community Advisory Board, Johns Hopkins Center to Eliminate Cardiovascular Health Disparities, Baltimore, MD, USA; Sisters Together and Reaching, Baltimore, MD, USA.
| | - Leon Purnell
- Community Advisory Board, Johns Hopkins Center to Eliminate Cardiovascular Health Disparities, Baltimore, MD, USA; The Men's Center, Baltimore, MD, USA.
| | - Annette Fisher
- Community Advisory Board, Johns Hopkins Center to Eliminate Cardiovascular Health Disparities, Baltimore, MD, USA; American Heart Association, Baltimore, MD, USA.
| | | | - Gary J Noronha
- Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Peter J Fagan
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Hema C Ramamurthi
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Jessica M Ameling
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Jeanne Charlston
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | | | - Kathryn A Carson
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Nae-Yuh Wang
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Deidra C Crews
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Division of Nephrology, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
| | - Raquel C Greer
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Valerie Sneed
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Sarah J Flynn
- University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Nicole DePasquale
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - L Ebony Boulware
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Johns Hopkins University School of Nursing, Baltimore, MD, USA; Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA.
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13
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Burla MJ, Brody AM, Ference BA, Flack JM, Mahn JJ, Marinica AL, Carroll JA, Nasser SA, Zhang S, Levy PD. Blood pressure control and perceived health status in African Americans with subclinical hypertensive heart disease. JOURNAL OF THE AMERICAN SOCIETY OF HYPERTENSION : JASH 2014; 8:321-9. [PMID: 24726098 DOI: 10.1016/j.jash.2014.02.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Revised: 02/22/2014] [Accepted: 02/23/2014] [Indexed: 11/22/2022]
Abstract
The role of antihypertensive therapy in reducing the risk of cardiovascular complications such as heart failure is well established, but the effects of different blood pressure goals on patient-perceived health status has not been well defined. We sought to determine if adverse effects on perceived health status will occur with lower blood pressure goals or more intensive antihypertensive therapy. Data were prospectively collected as a part of a single center, randomized controlled trial designed to evaluate standard (Seventh Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure-compliant) versus intense (<120/80 mm Hg) blood pressure goals for patients with uncontrolled hypertension and subclinical hypertensive heart disease. Blood pressure management was open label, and health status was measured at 3-month intervals over 1 year of follow-up using the short-form (SF)-36. Mixed linear models were constructed for each of the SF-36 summary scores. One hundred twenty-three (mean age 49.4 ± 8.2; 65% female; 95.1% African American) patients were randomized, 88 of whom completed the protocol. With the exception of a decrease in perceived health transition, health status did not change significantly on repeat measurement. Lower blood pressure goals and more intensive antihypertensive therapy appear to be well tolerated with limited effects on patients' perception of health status.
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Affiliation(s)
- Michael J Burla
- Department of Emergency Medicine, Wayne State University, Detroit, MI, USA; College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA.
| | - Aaron M Brody
- Department of Emergency Medicine, Wayne State University, Detroit, MI, USA
| | - Brian A Ference
- Division of Translational Research and Clinical Epidemiology and Department of Medicine, Wayne State University, Detroit, MI, USA
| | - John M Flack
- Division of Translational Research and Clinical Epidemiology and Department of Medicine, Wayne State University, Detroit, MI, USA; Cardiovascular Research Institute, Wayne State University, Detroit, MI, USA
| | - James J Mahn
- Department of Emergency Medicine, Wayne State University, Detroit, MI, USA; School of Medicine, Wayne State University, Detroit, MI, USA
| | - Alexander L Marinica
- Department of Emergency Medicine, Wayne State University, Detroit, MI, USA; College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA
| | - Justin A Carroll
- Department of Emergency Medicine, Wayne State University, Detroit, MI, USA; School of Medicine, Wayne State University, Detroit, MI, USA
| | - Samar A Nasser
- College of Education, Health, and Human Services, University of Michigan-Dearborn, Dearborn, MI, USA
| | - Shiling Zhang
- Division of Translational Research and Clinical Epidemiology and Department of Medicine, Wayne State University, Detroit, MI, USA
| | - Phillip D Levy
- Department of Emergency Medicine, Wayne State University, Detroit, MI, USA; Cardiovascular Research Institute, Wayne State University, Detroit, MI, USA
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Cooper LA, Boulware LE, Miller ER, Golden SH, Carson KA, Noronha G, Huizinga MM, Roter DL, Yeh HC, Bone LR, Levine DM, Hill-Briggs F, Charleston J, Kim M, Wang NY, Aboumatar H, Halbert JP, Ephraim PL, Brancati FL. Creating a transdisciplinary research center to reduce cardiovascular health disparities in Baltimore, Maryland: lessons learned. Am J Public Health 2013; 103:e26-38. [PMID: 24028238 PMCID: PMC3828697 DOI: 10.2105/ajph.2013.301297] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2013] [Indexed: 01/08/2023]
Abstract
Cardiovascular disease (CVD) disparities continue to have a negative impact on African Americans in the United States, largely because of uncontrolled hypertension. Despite the availability of evidence-based interventions, their use has not been translated into clinical and public health practice. The Johns Hopkins Center to Eliminate Cardiovascular Health Disparities is a new transdisciplinary research program with a stated goal to lower the impact of CVD disparities on vulnerable populations in Baltimore, Maryland. By targeting multiple levels of influence on the core problem of disparities in Baltimore, the center leverages academic, community, and national partnerships and a novel structure to support 3 research studies and to train the next generation of CVD researchers. We also share the early lessons learned in the center's design.
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Affiliation(s)
- Lisa A Cooper
- Lisa A. Cooper, L. Ebony Boulware, Edgar R. Miller III, Sherita Hill Golden, Gary Noronha, Hsin-Chieh Yeh, David M. Levine, Felicia Hill-Briggs, Jeanne Charleston, Nae-Yuh Wang, Hanan Aboumatar, Jennifer P. Halbert, and Frederick L. Brancati are with the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. Kathryn A. Carson and Patti L. Ephraim are with the Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore. Mary Margaret Huizinga is with Vanderbilt University School of Medicine in Nashville, TN. Debra L. Roter and Lee R. Bone are with the Department of Health Behavior and Society at the Johns Hopkins Bloomberg School of Public Health. Miyong Kim is with the Johns Hopkins University School of Nursing, Baltimore
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15
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Flynn SJ, Ameling JM, Hill-Briggs F, Wolff JL, Bone LR, Levine DM, Roter DL, Lewis-Boyer L, Fisher AR, Purnell L, Ephraim PL, Barbers J, Fitzpatrick SL, Albert MC, Cooper LA, Fagan PJ, Martin D, Ramamurthi HC, Boulware LE. Facilitators and barriers to hypertension self-management in urban African Americans: perspectives of patients and family members. Patient Prefer Adherence 2013; 7:741-9. [PMID: 23966772 PMCID: PMC3743518 DOI: 10.2147/ppa.s46517] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION We aimed to inform the design of behavioral interventions by identifying patients' and their family members' perceived facilitators and barriers to hypertension self-management. MATERIALS AND METHODS We conducted focus groups of African American patients with hypertension and their family members to elicit their views about factors influencing patients' hypertension self-management. We recruited African American patients with hypertension (n = 18) and their family members (n = 12) from an urban, community-based clinical practice in Baltimore, Maryland. We conducted four separate 90-minute focus groups among patients with controlled (one group) and uncontrolled (one group) hypertension, as well as their family members (two groups). Trained moderators used open-ended questions to assess participants' perceptions regarding patient, family, clinic, and community-level factors influencing patients' effective hypertension self-management. RESULTS Patient participants identified several facilitators (including family members' support and positive relationships with doctors) and barriers (including competing health priorities, lack of knowledge about hypertension, and poor access to community resources) that influence their hypertension self-management. Family members also identified several facilitators (including their participation in patients' doctor's visits and discussions with patients' doctors outside of visits) and barriers (including their own limited health knowledge and patients' lack of motivation to sustain hypertension self-management behaviors) that affect their efforts to support patients' hypertension self-management. CONCLUSION African American patients with hypertension and their family members reported numerous patient, family, clinic, and community-level facilitators and barriers to patients' hypertension self-management. Patients' and their family members' views may help guide efforts to tailor behavioral interventions designed to improve hypertension self-management behaviors and hypertension control in minority populations.
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Affiliation(s)
- Sarah J Flynn
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Jessica M Ameling
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Felicia Hill-Briggs
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jennifer L Wolff
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Division of Geriatric Medicine and gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lee R Bone
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - David M Levine
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Debra l Roter
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - LaPricia Lewis-Boyer
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Annette R Fisher
- Community and Provider Advisory Board, Johns Hopkins Center to Eliminate Cardiovascular Health Disparities, Baltimore, MD, USA
| | - Leon Purnell
- Community and Provider Advisory Board, Johns Hopkins Center to Eliminate Cardiovascular Health Disparities, Baltimore, MD, USA
| | - Patti L Ephraim
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jeffrey Barbers
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Stephanie L Fitzpatrick
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Michael C Albert
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins Community Physicians, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Lisa A Cooper
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Peter J Fagan
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins Healthcare LLC, Glen Burnie, MD, USA
| | - Destiny Martin
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hema C Ramamurthi
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - L Ebony Boulware
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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16
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Bokhour BG, Cohn ES, Cortés DE, Solomon JL, Fix GM, Elwy AR, Mueller N, Katz LA, Haidet P, Green AR, Borzecki AM, Kressin NR. The role of patients' explanatory models and daily-lived experience in hypertension self-management. J Gen Intern Med 2012; 27:1626-34. [PMID: 22821569 PMCID: PMC3509311 DOI: 10.1007/s11606-012-2141-2] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Revised: 04/11/2012] [Accepted: 06/05/2012] [Indexed: 11/26/2022]
Abstract
BACKGROUND Uncontrolled hypertension remains a significant problem for many patients. Few interventions to improve patients' hypertension self-management have had lasting effects. Previous work has focused largely on patients' beliefs as predictors of behavior, but little is understood about beliefs as they are embedded in patients' social contexts. OBJECTIVE This study aims to explore how patients' "explanatory models" of hypertension (understandings of the causes, mechanisms or pathophysiology, course of illness, symptoms and effects of treatment) and social context relate to their reported daily hypertension self-management behaviors. DESIGN Semi-structured qualitative interviews with a diverse group of patients at two large urban Veterans Administration Medical centers. PARTICIPANTS (OR PATIENTS OR SUBJECTS): African-American, white and Latino Veterans Affairs (VA) primary care patients with uncontrolled blood pressure. APPROACH We conducted thematic analysis using tools of grounded theory to identify key themes surrounding patients' explanatory models, social context and hypertension management behaviors. RESULTS Patients' perceptions of the cause and course of hypertension, experiences of hypertension symptoms, and beliefs about the effectiveness of treatment were related to different hypertension self-management behaviors. Moreover, patients' daily-lived experiences, such as an isolated lifestyle, serious competing health problems, a lack of habits and routines, barriers to exercise and prioritizing lifestyle choices, also interfered with optimal hypertension self-management. CONCLUSIONS Designing interventions to improve patients' hypertension self-management requires consideration of patients' explanatory models and their daily-lived experience. We propose a new conceptual model - the dynamic model of hypertension self-management behavior - which incorporates these key elements of patients' experiences.
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Affiliation(s)
- Barbara G Bokhour
- Center for Health Quality, Outcomes & Economic Research, ENRM Veteran Affairs Medical Center, Bedford, MA 01730, USA.
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17
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Cooper LA, Roter DL, Carson KA, Bone LR, Larson SM, Miller ER, Barr MS, Levine DM. A randomized trial to improve patient-centered care and hypertension control in underserved primary care patients. J Gen Intern Med 2011; 26:1297-304. [PMID: 21732195 PMCID: PMC3208476 DOI: 10.1007/s11606-011-1794-6] [Citation(s) in RCA: 135] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Revised: 06/13/2011] [Accepted: 06/22/2011] [Indexed: 01/13/2023]
Abstract
BACKGROUND African Americans and persons with low socioeconomic status (SES) are disproportionately affected by hypertension and receive less patient-centered care than less vulnerable patient populations. Moreover, continuing medical education (CME) and patient-activation interventions have infrequently been directed to improve the processes of care for these populations. OBJECTIVE To compare the effectiveness of patient-centered interventions targeting patients and physicians with the effectiveness of minimal interventions for underserved groups. DESIGN Randomized controlled trial conducted from January 2002 through August 2005, with patient follow-up at 3 and 12 months, in 14 urban, community-based practices in Baltimore, Maryland. PARTICIPANTS Forty-one primary care physicians and 279 hypertension patients. INTERVENTIONS Physician communication skills training and patient coaching by community health workers. MAIN MEASURES Physician communication behaviors; patient ratings of physicians' participatory decision-making (PDM), patient involvement in care (PIC), reported adherence to medications; systolic and diastolic blood pressure (BP) and BP control. KEY RESULTS Visits of trained versus control group physicians demonstrated more positive communication change scores from baseline (-0.52 vs. -0.82, p = 0.04). At 12 months, the patient+physician intensive group compared to the minimal intervention group showed significantly greater improvements in patient report of physicians' PDM (β = +6.20 vs. -5.24, p = 0.03) and PIC dimensions related to doctor facilitation (β = +0.22 vs. -0.17, p = 0.03) and information exchange (β = +0.32 vs. -0.22, p = 0.005). Improvements in patient adherence and BP control did not differ across groups for the overall patient sample. However, among patients with uncontrolled hypertension at baseline, non-significant reductions in systolic BP were observed among patients in all intervention groups-the patient+physician intensive (-13.2 mmHg), physician intensive/patient minimal (-10.6 mmHg), and the patient intensive/physician minimal (-16.8 mmHg), compared to the patient+physician minimal group (-2.0 mmHg). CONCLUSION Interventions that enhance physicians' communication skills and activate patients to participate in their care positively affect patient-centered communication, patient perceptions of engagement in care, and may improve systolic BP among urban African-American and low SES patients with uncontrolled hypertension.
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Affiliation(s)
- Lisa A Cooper
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD 21287, USA.
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18
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Nuckols TK, Aledort JE, Adams J, Lai J, Go MH, Keesey J, McGlynn E. Cost implications of improving blood pressure management among U.S. adults. Health Serv Res 2011; 46:1124-57. [PMID: 21306365 PMCID: PMC3165181 DOI: 10.1111/j.1475-6773.2010.01239.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To examine the cost-effectiveness of improving blood pressure management from the payer perspective. DATA SOURCE/STUDY SETTING Medical record data for 4,500 U.S. adults with hypertension from the Community Quality Index (CQI) study (1996-2002), pharmaceutical claims from four Massachusetts health plans (2004-2006), Medicare fee schedule (2009), and published literature. STUDY DESIGN A probability tree depicted blood pressure management over 2 years. DATA COLLECTION/EXTRACTION METHODS We determined how frequently CQI study subjects received recommended care processes and attained accepted treatment goals, estimated utilization of visits and medications associated with recommended care, assigned costs based on utilization, and then modeled how hospitalization rates, costs, and goal attainment would change if all recommended care was provided. PRINCIPAL FINDINGS Relative to current care, improved care would cost payers U.S.$170 more per hypertensive person annually (2009 dollars). The incremental cost per person newly attaining treatment goals over 2 years would be U.S.$1,696 overall, U.S.$801 for moderate hypertension, and U.S.$850 for severe hypertension. Among people with severe hypertension, blood pressure would decline substantially but seldom reach goal; the incremental cost per person attaining a relaxed goal (≤ stage 1) would be U.S.$185. CONCLUSIONS Under the Health Care Effectiveness Data and Information Set program, which monitors the attainment of blood pressure treatment goals, payers will find it slightly more cost-effective to improve care for moderate than severe hypertension. Having a secondary, relaxed goal would substantially increase payers' incentive to improve care for severe hypertension.
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Affiliation(s)
- Teryl K Nuckols
- RAND Corporation, 1776 Main Street, Santa Monica, CA 90407, USA.
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19
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Hill MN, Miller NH, DeGeest S. Adherence and persistence with taking medication to control high blood pressure. ACTA ACUST UNITED AC 2011; 5:56-63. [DOI: 10.1016/j.jash.2011.01.001] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2010] [Accepted: 06/15/2010] [Indexed: 10/18/2022]
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20
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Hill MN, Miller NH, DeGeest S. ASH position paper: Adherence and persistence with taking medication to control high blood pressure. J Clin Hypertens (Greenwich) 2010; 12:757-64. [PMID: 21029338 PMCID: PMC8673243 DOI: 10.1111/j.1751-7176.2010.00356.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2010] [Accepted: 06/15/2010] [Indexed: 01/23/2023]
Abstract
Nonadherence and poor or no persistence in taking antihypertensive medications results in uncontrolled high blood pressure, poor clinical outcomes, and preventable health care costs. Factors associated with nonadherence are multilevel and relate not only to the patient, but also to the provider, health care system, health care organization, and community. National guideline committees have called for more aggressive approaches to implement strategies known to improve adherence and technologies known to enable changes at the systems level, including improved communication among providers and patients. Improvements in adherence and persistence are likely to be achieved by supporting patient self-management, a team approach to patient care, technology-supported office practice systems, better methods to measure adherence, and less clinical inertia. Integrating high blood pressure control into health care policies that emphasize and improve prevention and management of chronic illness remains a challenge. Four strategies are proposed: focusing on clinical outcomes; empowering informed, activated patients; developing prepared proactive practice teams; and advocating for health care policy reform. With hypertension remaining the most common reason for office visits, the time is now.
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Affiliation(s)
- Martha N Hill
- Johns Hopkins University School of Nursing, Baltimore, MD, USA.
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21
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Lucas GM. Substance abuse, adherence with antiretroviral therapy, and clinical outcomes among HIV-infected individuals. Life Sci 2010; 88:948-52. [PMID: 20888839 DOI: 10.1016/j.lfs.2010.09.025] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2010] [Revised: 08/31/2010] [Accepted: 09/18/2010] [Indexed: 11/30/2022]
Abstract
Substance abuse and addiction are highly prevalent in HIV-infected individuals. Substance abuse is an important comorbidity that affects the delivery and outcomes of HIV medical management. In this paper I will review data examining the associations between substance abuse and HIV treatment and potential strategies to improve outcomes in this population that warrant further investigation. Current - but not past - substance abuse adversely affects engagement in care, acceptance of antiretroviral therapy, adherence with therapy, and long-term persistence in care. Substance abuse treatment appears to facilitate engagement in HIV care, and access to evidence-based treatment for substance abuse is central to addressing the HIV epidemic. Strategies that show promise for HIV-infected substance abusers include integrated treatment models, directly observed therapy, and incentive-based interventions.
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Affiliation(s)
- Gregory M Lucas
- Johns Hopkins University School of Medicine, Baltimore, MD 21287, United States.
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22
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Huizinga MM, Bleich SN, Beach MC, Clark JM, Cooper LA. Disparity in physician perception of patients' adherence to medications by obesity status. Obesity (Silver Spring) 2010; 18:1932-7. [PMID: 20186132 PMCID: PMC3149807 DOI: 10.1038/oby.2010.35] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Physician perception of medication adherence may alter prescribing patterns. Perception of patients has been linked to readily observable factors, such as race and age. Obesity shares a similar stigma to these factors in society. We hypothesized that physicians would perceive patients with a higher BMI as nonadherent to medication. Data were collected from the baseline visit of a randomized clinical trial of patient-physician communication (240 patients and 40 physicians). Physician perception of patient medication adherence was measured on a Likert scale and dichotomized as fully adherent or not fully adherent. BMI was the predictor of interest. We performed Poisson regression analyses with robust variance estimates, adjusting for clustering of patients within physicians, to examine the association between BMI and physician perception of medication adherence. The mean (s.d.) BMI was 32.6 (7.7) kg/m(2). Forty-five percent of patients were perceived as nonadherent to medications by their physicians. Higher BMI was significantly and negatively associated with being perceived as adherent to medication (prevalence ratio (PrR) 0.76, 95% confidence interval (CI): 0.64-0.90; P = 0.002; per 10 kg/m(2) increase in BMI). BMI remained significantly and negatively associated with physician perception of medication adherence after adjustment for patient and physician characteristics (PrR 0.80, 95% CI: 0.66-0.96; P = 0.020). In this study, patients with higher BMI were less likely to be perceived as adherent to medications by their providers. Physician perception of medication adherence has been shown to affect prescribing patterns in other studies. More work is needed to understand how this perception may affect the care of patients with obesity.
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Affiliation(s)
- Mary Margaret Huizinga
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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23
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Epstein RM, Fiscella K, Lesser CS, Stange KC. Why The Nation Needs A Policy Push On Patient-Centered Health Care. Health Aff (Millwood) 2010; 29:1489-95. [DOI: 10.1377/hlthaff.2009.0888] [Citation(s) in RCA: 551] [Impact Index Per Article: 39.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Ronald M. Epstein
- Ronald M. Epstein ( ) is a professor of family medicine, psychiatry, and oncology, and is director of the Rochester Center to Improve Communication in Health Care, University of Rochester Medical Center, in New York
| | - Kevin Fiscella
- Kevin Fiscella is a professor of family medicine, community and preventive medicine, and oncology at the University of Rochester
| | - Cara S. Lesser
- Cara S. Lesser is the director of foundation programs at ABIM Foundation, in Philadelphia, Pennsylvania
| | - Kurt C. Stange
- Kurt C. Stange is the editor of the Annals of Family Medicine and an American Cancer Society Clinical Research Professor. He is a professor of family medicine, epidemiology and biostatistics, sociology, and oncology at Case Western Reserve University, in Cleveland, Ohio
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Racial disparities in hypertension control, but not treatment intensification. Am J Hypertens 2010; 23:54-61. [PMID: 19893494 DOI: 10.1038/ajh.2009.201] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Racial disparities in hypertension control are well documented, yet the contribution of providers to these disparities remains unclear. The objective of this study was to examine whether provider management of uncontrolled hypertension differed by patient race. METHODS In a retrospective cohort of 16,881 hypertensive adults in six academic primary care practices from 1/2004 to 12/2006, we evaluated hypertension control in black vs. white patients according to expert guidelines and, among those with uncontrolled hypertension, whether antihypertensive drugs were intensified by providers. Generalized estimating equations accounted for clustering and adjusted sequentially and additively for patient, provider, and practice characteristics, as well as health-care utilization and antihypertensive medication potency. RESULTS Black patients' visits (55.5% of 132,730 visits) had a higher unadjusted odds (1.63, 95% confidence interval (CI) 1.57-1.69) of uncontrolled hypertension than white patients' visits; the fully adjusted odds ratio remained significant (1.40, CI 1.33-1.48, P < 0.001). Among 66,327 visits with uncontrolled hypertension, no intensification of antihypertensive drugs was less likely for blacks' visits before adjustment (0.80, CI 0.76-0.83, P < 0.001) but moderated in the fully adjusted model (adjusted odds ratio 0.93, CI 0.87-0.99, P < 0.05) compared with whites' visits. Accounting for provider race, intensification was more likely at black patients' visits compared with white patients' visits. CONCLUSIONS In our study, black patients had poorer hypertension control, and providers were more likely to intensify antihypertensive drugs at visits of black compared with white patients as appropriate. These data suggest that more research is needed to understand racial disparities in hypertension control.
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Bennett H, Laird K, Margolius D, Ngo V, Thom DH, Bodenheimer T. The effectiveness of health coaching, home blood pressure monitoring, and home-titration in controlling hypertension among low-income patients: protocol for a randomized controlled trial. BMC Public Health 2009; 9:456. [PMID: 20003300 PMCID: PMC2797520 DOI: 10.1186/1471-2458-9-456] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2009] [Accepted: 12/10/2009] [Indexed: 01/13/2023] Open
Abstract
Background Despite the many antihypertensive medications available, two-thirds of patients with hypertension do not achieve blood pressure control. This is thought to be due to a combination of poor patient education, poor medication adherence, and "clinical inertia." The present trial evaluates an intervention consisting of health coaching, home blood pressure monitoring, and home medication titration as a method to address these three causes of poor hypertension control. Methods/Design The randomized controlled trial will include 300 patients with poorly controlled hypertension. Participants will be recruited from a primary care clinic in a teaching hospital that primarily serves low-income populations. An intervention group of 150 participants will receive health coaching, home blood pressure monitoring, and home-titration of antihypertensive medications during 6 months. The control group (n = 150) will receive health coaching plus home blood pressure monitoring for the same duration. A passive control group will receive usual care. Blood pressure measurements will take place at baseline, and after 6 and 12 months. The primary outcome will be change in systolic blood pressure after 6 and 12 months. Secondary outcomes measured will be change in diastolic blood pressure, adverse events, and patient and provider satisfaction. Discussion The present study is designed to assess whether the 3-pronged approach of health coaching, home blood pressure monitoring, and home medication titration can successfully improve blood pressure, and if so, whether this effect persists beyond the period of the intervention. Trial Registration ClinicalTrials.gov identifier: NCT01013857
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Affiliation(s)
- Heather Bennett
- Department of Family and Community Medicine, University of California, San Francisco (UCSF), 1001 Potrero Ave, Building 80/83, San Francisco, CA 94110, USA.
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The effect of patient race and blood pressure control on patient-physician communication. J Gen Intern Med 2009; 24:1057-64. [PMID: 19575270 PMCID: PMC2726885 DOI: 10.1007/s11606-009-1051-4] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2008] [Revised: 05/21/2009] [Accepted: 06/04/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Racial disparities in hypertension control contribute to higher rates of cardiovascular mortality among blacks. Patient-physician communication quality is associated with better health outcomes, including blood pressure (BP) control. Both race/ethnicity and BP control may adversely affect communication. OBJECTIVE To determine whether being black and having poor BP control interact to adversely affect patient-physician communication more than either condition alone, a situation referred to as "double jeopardy." DESIGN, SETTINGS, AND PATIENTS Cross-sectional study of enrollment data from a randomized controlled trial of interventions to enhance patient adherence to therapy for hypertension. Participants included 226 hypertensive patients and 39 physicians from 15 primary care practices in Baltimore, MD. MEASUREMENTS Communication behaviors and visit length from coding of audiotapes. RESULTS After controlling for patient and physician characteristics, blacks with uncontrolled BP have shorter visits (B = -3.9 min, p < 0.01) with less biomedical (B = -24.0, p = 0.05), psychosocial (B = -19.4, p < 0.01), and rapport-building (B = -19.5, p = 0.01) statements than whites with controlled BP. Of all communication outcomes, blacks with uncontrolled BP are only in "double jeopardy" for a patient positive affect-coders give them lower ratings than all other patients. Blacks with controlled BP also experience shorter visits and less communication with physicians than whites with controlled BP. There are no significant communication differences between the visits of whites with uncontrolled versus controlled BP. CONCLUSIONS This study reveals that patient race is associated with the quality of patient-physician communication to a greater extent than BP control. Interventions that improve patient-physician communication should be tested as a strategy to reduce racial disparities in hypertension care and outcomes.
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