A clinic and community-based approach to hypertension control for an underserved minority population: design and methods

Reducing Disparities in Hypertension Control: A Community-Based Hypertension Control Project (CHIP) for an Ethnically Diverse Population

The Community Hypertension Intervention Project (CHIP) is investigating medical, environmental, and psychosocial factors related to adherence to treatment for hypertension and examining the efficacy of three interventions designed to improve treatment adherence in a high-risk, underserved, ethnically diverse population. There were 1,367 Black (76%) and Hispanic (21%) adults who participated in a 4-year longitudinal study. Participants were randomized to either usual care or one of three interventions: (a) individualized counseling sessions with community health workers (CHWs), (b) a computerized appointment tracking system, or (c) home visits/focus group discussions with CHWs. At baseline, a total of 33% of the participants had one or more comorbidities in addition to hypertension; only 35% had their blood pressure under control. Participants assigned to the patient tracking intervention exhibited the most significant improvement in appointment keeping and blood pressure control status at 6 months; however, the 12-month follow-up assessments indicated that individualized counseling and home visits resulted in significant, sustained improvements in appointment keeping and blood pressure control status. These findings are now being integrated into the patient care delivery system of the participating outpatient clinics.

Social support among African Americans with heart failure: is there a role for community health advisors?

OBJECTIVE

The study had 2 objectives: (1) to gather the observations of community health advisors (CHAs) on the role of social support in the lives of African Americans; and (2) to develop a lay support intervention framework, on the basis of the existing literature and observations of CHAs, depicting how social support may address the needs of African American patients with heart failure.

METHODS

Qualitative data were collected in semistructured interviews among 15 CHAs working in African American communities in Birmingham, Alabama.

RESULTS

Prominent themes included the challenge of meeting clients' overlapping health care and general life needs, the variation in social support received from family and friends, and the opportunities for CHAs to provide multiple types of social support to clients. CHAs also believed that their support activities could be implemented among populations with heart failure.

CONCLUSION

The experience of CHAs with social support can inform a potential framework of a lay support intervention among African Americans with heart failure.

Development and Implementation of an Academic-Community Partnership to Enhance Care among Homeless Persons

An academic-community partnership between a Health Care for the Homeless (HCH) clinic and a school of pharmacy was created in 2005 to provide medication education and identify medication related problems. The urban community based HCH clinic in the Richmond, VA area provides primary health care to the homeless, uninsured and underinsured. The center also offers eye care, dental care, mental health and psychiatric care, substance abuse services, case management, laundry and shower facilities, and mail services at no charge to those in need. Pharmacist services are provided in the mental health and medical clinics. A satisfaction survey showed that the providers and staff (n = 13) in the clinic were very satisfied with the integration of pharmacist services. The quality and safety of medication use has improved as a result of the academic-community collaborative. Education and research initiatives have also resulted from the collaborative. This manuscript describes the implementation, outcomes and benefits of the partnership for both the HCH clinic and the school of pharmacy.

Outcomes and costs of community health worker interventions: a systematic review

OBJECTIVES

We conducted a systematic review on outcomes and costs of community health worker (CHW) interventions. CHWs are increasingly expected to improve health outcomes cost-effectively for the underserved.

RESEARCH DESIGN

We searched Medline, Cochrane Collaboration resources, and the Cumulative Index to Nursing and Allied Health Literature for studies conducted in the United States and published in English from 1980 through November 2008. We dually reviewed abstracts, full-text articles, data abstractions, quality ratings, and strength of evidence grades and resolved disagreements by consensus.

RESULTS

We included 53 studies on outcomes of CHW interventions and 6 on cost or cost-effectiveness. For outcomes, limited evidence (5 studies) suggests that CHW interventions can improve participant knowledge compared with alternative approaches or no intervention. We found mixed evidence for participant behavior change (22 studies) and health outcomes (27 studies). Some studies suggested that CHW interventions can result in greater improvements in participant behavior and health outcomes compared with various alternatives, but other studies suggested that CHW interventions provide no statistically different benefits than alternatives. We found low or moderate strength of evidence suggesting that CHWs can increase appropriate health care utilization for some interventions (30 studies). Six studies with economic information yielded insufficient data to evaluate the cost-effectiveness of CHW interventions relative to other interventions.

CONCLUSIONS

CHWs can improve outcomes for underserved populations for some health conditions. The effectiveness of CHWs in many health care areas requires further research that addresses the methodologic limitations of prior studies and that contributes to translating research into practice.

Predictive validity of a medication adherence measure in an outpatient setting

This study examines the psychometric properties and tests the concurrent and predictive validity of a structured, self-reported medication adherence measure in patients with hypertension. The authors also assessed various psychosocial determinants of adherence, such as knowledge, social support, satisfaction with care, and complexity of the medical regimen. A total of 1367 patients participated in the study; mean age was 52.5 years, 40.8% were male, 76.5% were black, 50.8% graduated from high school, 26% were married, and 54.1% had income <$5,000. The 8-item medication adherence scale was reliable (alpha=.83) and significantly associated with blood pressure control (P<.05). Using a cutpoint of <6, the sensitivity of the measure to identify patients with poor blood pressure control was estimated to be 93%, and the specificity was 53%. The medication adherence measure proved to be reliable, with good concurrent and predictive validity in primarily low-income, minority patients with hypertension and might function as a screening tool in outpatient settings with other patient groups.

Predictive validity of a medication adherence measure in an outpatient setting

This study examines the psychometric properties and tests the concurrent and predictive validity of a structured, self-reported medication adherence measure in patients with hypertension. The authors also assessed various psychosocial determinants of adherence, such as knowledge, social support, satisfaction with care, and complexity of the medical regimen. A total of 1367 patients participated in the study; mean age was 52.5 years, 40.8% were male, 76.5% were black, 50.8% graduated from high school, 26% were married, and 54.1% had income <$5,000. The 8-item medication adherence scale was reliable (alpha=.83) and significantly associated with blood pressure control (P<.05). Using a cutpoint of <6, the sensitivity of the measure to identify patients with poor blood pressure control was estimated to be 93%, and the specificity was 53%. The medication adherence measure proved to be reliable, with good concurrent and predictive validity in primarily low-income, minority patients with hypertension and might function as a screening tool in outpatient settings with other patient groups.

Antihypertensive adherence and drug class among Asian Pacific Americans

OBJECTIVE

Research on adherence has emphasized the need to consider patient ethnicity when developing adherence plans. The objective of this study is to identify predictors of adherence for specific groups, particularly Asian Americans and Pacific Islanders.

METHODS

We examined the factors, including drug class, associated with antihypertensive adherence for 28,395 adults in Hawaii (July 1999-June 2003) using health plan administrative data. The population included Japanese (n=13,836), Filipino (n=3,812), Chinese (n=2,280), Korean (n=450), part-Hawaiian (n=3,746) and white (n=3,920) patients. Members with antihypertensive medication in their possession >or=80% of the time were considered adherent. Multivariable logistic regression models were used to identify factors associated with adherence.

RESULTS

Overall adherence rates were less than 65% among all racial/ethnic groups. After adjustment for patient age, gender, morbidity level, health plan type, isle of residence, comorbidities and year of treatment, Japanese were more likely than whites to adhere to antihypertensive therapy [OR=1.21 (1.14-1.29)], whereas Filipino [OR=0.69 (0.64-0.74)], Korean [OR=0.79 (0.67-0.93)] and Hawaiian [OR=0.84 (0.78-0.91)] patients were less likely to adhere. These results were consistent across therapeutic class. Other patient factors associated with lower adherence included younger age, higher morbidity and history of heart disease. Patient factors were also significantly related to adherence, including gender and seeing a sub-specialist. Seeing a physician of the same ethnicity did not appear to improve adherence.

CONCLUSIONS

Our findings of substantial disparities among Asian Pacific American subgroups highlight the need to examine subgroups separately. Future qualitative research is needed to determine appropriate interventions, particularly for Filipino, Korean and Hawaiian patients.

Effectiveness of community health workers in the care of people with hypertension

BACKGROUND

The contributions of community health workers (CHWs) in the delivery of culturally relevant programs for hypertension control have been studied since the 1970s. This systematic review examines the effectiveness of CHWs in supporting the care of people with hypertension.

METHODS

Computerized searches were conducted of multiple bibliographic electronic databases from their inception until May 2006. No restrictions were applied for language or study design, and studies were restricted to those that reported at least one outcome among participants.

RESULTS

Fourteen studies were identified, including eight randomized controlled trials (RCTs). Many of the studies focused on poor, urban African Americans. Significant improvements in controlling blood pressure were reported in seven of the eight RCTs. Several studies reported significant improvements in participants' self-management behaviors, including appointment keeping and adherence to antihypertensive medications. Four studies reported positive changes in healthcare utilization and in systems outcomes. Two of the RCTs showed significant improvements in other patient outcomes, such as changes in heart mass and risk of CVD.

CONCLUSIONS

Community health workers may have an important impact on the self-management of hypertension. Programs involving CHWs as multidisciplinary team members hold promise, particularly for diverse racial/ethnic populations that are under-served.

Measurement of Adherence to Anti-Hypertensive Medication as Perceived by Doctors and Patients

Introduction: In the absence of objective evidence, doc-tors frequently overestimate the level of their patient's ad-herence to medication and there is no published work look-ing at what factors influence the doctor's perceptions of medication adherence by hypertensive patients. Therefore, the aim of this study to determine the doctor's perceptions of adherence to antihypertensive medication and to com-pare this with their perceptions of the clinical situation and with the patient's self -reported medication adherence.

Methods: An English self reporting measure (7-item questionnaire) was adapted and translated to Arabic and used to determine the adherence to hypertensive medica-tion. Also, a 10-item questionnaire was developed to elicit the doctor's perception of adherence (taking > 80% of doses) and the treatment and overall condition. This de-scriptive study was conducted in across 2 primary health centers in Abu-Dhabi, UAE.

Results: About 40 % of them were controlled regard-ing BP and 30% of hypertensive patients were diabetics. The doctors estimated adherence to be high (taking more than 80% of doses) in 143 (71%) of patients compared with 103(52%) patients who reported high adherence by using Morisky score where, there was a statistically significant relationship between them. Of the 143 subjects perceived by their doctors as having high adherence, only 64 (45%) succeeded to achieve the target blood pressure (p <  0.001) while 55 (52%) of the adherent patients from the self-reported point of view achieved their target BP (p <  0.001). The doctor evaluation was not as good as expected for treatment effectiveness and quality of communication (57% only were evaluated as good). Only the doctor's evaluation of the seriousness of the medical situation showed a sig-nificant correlation with the self-reported adherence and this was in the opposite direction (gamma = - 0.32, p < 0.05). 71% of the adherent patients perceived by doctors were estimated to have effective treatment (p <  0.0001) while 81% of patients achieved their target BP were estimated to have effective treatment by their doctors.

Conclusion: The practical assessment of adherence and drug management would have been greatly enhanced if the results of the Arabic/English self-reporting measure had been available to the doctors in the course of routine practice.

Education: nationally achievable solutions

Despite the efficacy of hypertension treatment, knowledge and compliance remain poor in Hispanic patients because of language barriers, low educational levels, and cultural differences. Yet effective physician-patient communication is crucial to patient compliance, satisfaction, and understanding of medical issues. Physicians and health care providers therefore need to develop "cultural competence" skills to achieve effective health education and good treatment outcomes in this patient population. Various strategies such as mnemonic devices can help practitioners communicate with Hispanic patients. National initiatives and research studies continue to address the provision of culturally and linguistically appropriate health care.

The HEDIS performance NAVIGATOR for controlling high blood pressure: a resource to assist health plans improve patient adherence

This article describes how the resources in the Health Plan Employer and Data Information Set (HEDIS; a registered trademark of the National Committee for Quality Assurance) Performance NAVIGATOR for Controlling High Blood Pressure (HEDIS NAVIGATOR) developed by Merck & Co., Inc. assist managed care organizations in understanding and encouraging the active involvement of their members in adhering to a treatment plan developed in partnership by physicians and patients. (HEDIS is a set of standardized performance measures that enable purchasers and consumers to make informed decisions regarding the quality of managed care organizations.) The discussion uses the Health Belief and Transtheoretical Models as a framework to better understand patient behavior change. Targeted strategies to facilitate adherence are also addressed. Examples of structured programs using nationally recommended guidelines and HEDIS NAVIGATOR resources are included to illustrate coordinated efforts to assist patients with high blood pressure adhere to their treatment plan and help managed care organizations improve patient outcomes and HEDIS scores.

Awareness, treatment and control of hypertension in patients attending hospital clinics in China

OBJECTIVES

To determine awareness, treatment and control of hypertension in patients attending hospital clinics in China.

DESIGN

A cross-sectional survey.

PATIENTS AND SETTING

Patients over the age of 35 years, who were attending outpatient clinics in 18 hospitals of eight major cities of Northern and Southern China, were interviewed face-to-face between June and July 1999.

METHODS

Trained fieldworkers completed questionnaires regarding demographics, hypertension knowledge and awareness, treatment history and quality of life issues. Qualified physicians performed blood pressure assessment.

RESULTS

A total of 9703 volunteers enrolled, of which 4510 (46.5%) were hypertensives. Among hypertensives, 23% were unaware of their high blood pressure. Although 89% of those aware reported receiving therapy, only 56% of them were taking medication regularly, and 33% were thus controlled. Although 69% of all hypertensives measuring at examination reported taking antihypertensive therapy, only 44% of them were actually taking medication regularly. Furthermore, 73% of hypertensives believed hypertension was not a serious problem, and required no regular medication.

CONCLUSIONS

The results showed that a substantial number of outpatients have a hypertensive range of blood pressure. Although most of these patients are already being treated with drug regimen, the patient's misconceptions and lack of knowledge about the disease appear to be the major cause of treatment failure. The low rate of high blood pressure control for both sexes calls for further improvements.

Hypertension and current issues in compliance and patient outcomes

Economic and human costs associated with untreated or inadequately controlled hypertension and its complications continue to be an issue in the United States despite the availability of numerous antihypertensive agents. Knowledge of hypertension, product profiles, tolerability concerns, convenience of dosing, health-related quality of life effects, and cost of therapy are some of the factors that may influence the compliance of patients to their medication regimens. Recent reports on patient noncompliance have focused on patient-provider relationships, psychosocial barriers, home blood pressure monitoring, and electronic monitoring systems to improve blood pressure control. The use of health-related quality of life assessment in antihypertensive studies and in routine clinical practice provides another opportunity to optimize a patient's regimen for short- and long-term hypertension control in a cost-effective manner.

Barriers to hypertension care and control

Despite clinical trial evidence and public health data documenting the benefits of controlling hypertension in individuals and populations, implementation in practice is less than optimal. Barriers to hypertension care and control are remarkably persistent and continue to impede improvement in rates of awareness, treatment, and control. Barriers have been identified at the patient, provider, health care organization, and community levels. At every level, knowledge, attitudes, values, and beliefs can impede the evidence-based recommended behaviors needed to lower blood pressure and sustain lowering over time. Numerous new studies provide data that reinforce the need for culturally sensitive interventions at each level.