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Schwartz JK, Unni E. Inclusion of People with Disabilities in Research to Improve Medication Adherence: A Systematic Review. Patient Prefer Adherence 2021; 15:1671-1677. [PMID: 34345167 PMCID: PMC8324980 DOI: 10.2147/ppa.s314135] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 07/10/2021] [Indexed: 01/10/2023] Open
Abstract
People with disabilities have high rates of chronic health conditions and often require complex medication regimens to manage their health. Approximately 20-50% of people with disabilities fail to take their medication as prescribed. It is unclear, however, to what extent the literature describes the effectiveness of medication adherence interventions for people with disabilities. In this review, the inclusion and exclusion criteria of the 182 studies included in the Cochrane Review on Interventions for Enhancing Medication Adherence were evaluated for their inclusion of people with disabilities. Of the studies, 1% excluded persons for hearing impairment, 3% for motor impairment, 7% for visual impairment, and 32% for cognitive impairment. Most studies (65%) did not exclude persons based on specific impairment. Medication event monitoring systems were used in 21% of studies, and investigators excluded people unable to use this device in 5% of studies. Caregiver assistance was an exclusion criteria in 4% of studies. Additional barriers like the ability of investigators to exclude persons based on their judgement were found. These barriers exist in addition to the known barriers affecting persons with disabilities, such as accessibility of research facilities and access to transportation. These data suggest that people with disabilities are systemically excluded from the medication adherence intervention literature. Subsequently, it cannot be assumed that current adherence interventions are effective for people with disabilities. More research is needed to understand how to address medication adherence for people with disabilities.
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Affiliation(s)
- Jaclyn K Schwartz
- Florida International University, Nicole Wertheim College of Nursing and Health Sciences, Occupational Therapy Department, Miami, FL, USA
- Correspondence: Jaclyn K Schwartz Florida International University, Nicole Wertheim College of Nursing and Health Sciences, Occupational Therapy Department, Miami, FL, USA Tel: +1-305-348-3106 Email
| | - Elizabeth Unni
- Touro College of Pharmacy, Social Behavioral and Administrative Science, New York, NY, USA
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Li WW, Lew D, Quach L. Efficacy of a Culturally and Linguistically Competent Community Health Coach Intervention for Chinese with Hypertension. Asian Pac Isl Nurs J 2020; 5:111-119. [PMID: 33324728 PMCID: PMC7733636 DOI: 10.31372/20200503.1087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Purpose: To develop and pilot test the efficacy of a culturally and linguistically sensitive, community health coach (CHC)-based intervention in Chinese immigrants in improving blood pressure control and medication adherence. Design: This study was conducted in 2017 with a cross-sectional design (n = 23). A CHC intervention was implemented using one 25-minute group educational presentation plus one 10-minute question and answer session at baseline, followed by four, 10-minute bi-weekly group question-and-answer sessions. Findings: There was a significant reduction in both systolic and diastolic blood pressure from baseline to week 8: Systolic BP −17.33 (±11.32) (p < 0.005) and diastolic BP −9.58 (±6.57) (p < 0.005). The mean score for medication adherence was 10.56 (±3.24) (possible range 3–15) at baseline and there was no significant change at week 8 (mean 10.89 ± 3.95) (p = 0.86). Conclusion: The CHC-based hypertension management program showed significant reductions in both systolic and diastolic blood pressures in Chinese immigrants. Since the proposed CHC-based hypertension management program is low cost and easy to establish, further investigation is recommended to generate more results for comparison. Practice Implications: There is potential for the CHC intervention to be implemented in clinical settings to help Chinese immigrants at large achieve optimal blood pressure control.
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Affiliation(s)
- Wen-Wen Li
- San Francisco State University, United States
| | - Donna Lew
- American Heart Association, United States
| | - Linda Quach
- San Francisco State University, United States
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Azizan NA, Majid HA, Nahar Mohamed A, Su TT. Improvement of nutritional intake for the low-income urban dwellers with hypertension in Malaysia. SAGE Open Med 2020; 8:2050312120960563. [PMID: 33014371 PMCID: PMC7509715 DOI: 10.1177/2050312120960563] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 08/31/2020] [Indexed: 01/08/2023] Open
Abstract
Objective: To ascertain the effect of dietary practice modification and a peer-support home blood pressure monitoring program on the nutritional intake (macronutrients and micronutrients), blood pressure and biochemical profiles of hypertension patients in a low-income community setting. Methods: This is a pre- and post-measurement intervention study conducted in low-income community housing projects in Kuala Lumpur, Malaysia. A total of 90 participants aged 18 years and above with hypertension received intervention. The participants were divided into small groups and received instructions on the use of home blood pressure measurement. They also attended a series of talks on dietary intake modification and exercise demonstration for the first six months (active phase). In another 6 months (maintenance phase), they received only pamphlet and SMS reminders. Their anthropometry, blood pressure, dietary, and biochemical parameter changes were measured at baseline, 6 months, and 12 months of intervention. Results: Macronutrients and micronutrients showed a significant improvement at the end of 12-month dietary intervention. The energy, carbohydrate, protein, total fat, sodium, and potassium are showing significant reduction from baseline to end of the 12-month intervention. There is no significant reduction in blood pressure. Fasting blood glucose, renal sodium, triglyceride, low-density lipoprotein cholesterol and high-density lipoprotein cholesterol showed a significant improvement, after controlling for age and reported physical activity. Conclusion: The intervention improved the nutritional intake and biochemical profiles of the low-income urban population with hypertension. This promising result should be replicated in a larger scale study.
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Affiliation(s)
- Nurul Ain Azizan
- Center of Population Health (CePH), Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.,Advanced Medical and Dental Institute, Universiti Sains Malaysia, Bertam, Pulau Pinang, Malaysia
| | - Hazreen Abdul Majid
- Center of Population Health (CePH), Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.,Department of Nutrition, Faculty of Public Health, Universitas Airlangga, Surabaya, Indonesia.,Harvard Chan School of Public Health, Boston, MA, USA
| | - Azmi Nahar Mohamed
- Sports Medicine Unit, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Tin Tin Su
- South East Asia Community Observatory (SEACO), Jeffery Cheah School of Medicine and Health Sciences, Monash University Malaysia, Subang Jaya, Malaysia
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Hariawan H, Soedirham O, Bakar A. The Individual Coaching Improves Spiritually Muslim Patients Hospitalized. JURNAL NERS 2019. [DOI: 10.20473/jn.v14i1.8568] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background: Inpatients who are attached in intravenous devices tend to experience physical discomfort. This condition can lead to the decrease in performing Salat as a Muslim prayer. The purpose of this study was to determine the effect of individual coaching on knowledge, attitude, and practice of Salat among Muslim inpatient. This study used quasi-experimental design.Mehods: The samples were 36 Muslim inpatients. The data were collected by self-constructed questionnaire and analyzed by using Independent t-test and Mann Whitney test with α ≤ 0.05.Results: Before giving intervention, the means of pretest score in both groups were 14.33+2.17 and 14.39+2.28 for knowledge, 26.17+2.31 and 26.50+3.17 for attitude, and 10.00+2.91 and 10.50+3.45 for practice. There was no significant difference scores of knowledge (p=0.941), attitude (p=0.924), and practice (p=0.635) between two groups before giving intervention. However, after giving intervention, these scores have changed to 19.00+1.72 and 14.89+2.29 for knowledge, 26.97+2.25 and 26.61+2.81 for attitude, 15.33+3.80 and 10.50+3.45 for practice and there was higher significance scores of knowledge (p=0.000), attitude (p=0.003), and practice (p=0.000) after giving intervention.Conclusions: Coaching is the suitable method to increase Muslim inpatients knowledge, attitude, and ability to practice Salat. This study recommends the nurse to do coaching as a nursing intervention in helping patient to perform Salat
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Fongwa MN, dela Cruz FA, Hays RD. African American women's perceptions of the meaning of support groups for improving adherence to hypertension treatment: a conceptual model. Nurs Open 2019; 6:860-870. [PMID: 31367409 PMCID: PMC6650675 DOI: 10.1002/nop2.266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 02/18/2019] [Indexed: 11/07/2022] Open
Abstract
AIM To investigate the meaning of support groups and the features of these groups that African American (AA) women view as improving adherence to high blood pressure (HBP) treatment. The study generated a conceptual model to illuminate features of these groups that influence adherence of AA women to HBP treatment. DESIGN Qualitative research. METHODS Used focus groups and open-ended questions to obtain the views of 26 eligible AA women, recruited from South Los Angeles. Line-by-line review and coding of interview transcripts were done. The feedback was used to specify a conceptual model depicting the meaning of support groups. The Consolidated Criteria for the Reporting of Qualitative Research guidelines were used. RESULTS The conceptual model depicts the meaning of support groups as information giving/knowledge sharing, emotional or psychological support, instrumental support and coaching, and facilitators and barriers to joining support groups and factors for consideration in forming these groups.
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Affiliation(s)
| | | | - Ron D. Hays
- Department of MedicineUCLALos AngelesCalifornia
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Dymek J, Gołda A, Polak W, Lisowski B, Skowron A. Effect of Education for Hypertensive Patients with Correctly Performed Self-Blood Pressure Monitoring (SBPM). PHARMACY 2019; 7:E75. [PMID: 31252513 PMCID: PMC6789537 DOI: 10.3390/pharmacy7030075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 06/24/2019] [Accepted: 06/24/2019] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION The study objective was to assess the impact of pharmacist-led education on the patient's knowledge and skills on SBPM (self-blood pressure monitoring). METHODS Patient knowledge was assessed using tests and patients' skills were based on a checklist (20 parameters) completed by the researcher based on the SBPM video records. Patients taking pressure measurements were filmed for 20 days and after 6 months. After the first 10 days, patients were educated about the correct SBPM procedure. Knowledge tests were repeated three times (before/after/6 months after education). RESULTS All patients' knowledge and skills in the field of SBPM were improved after education. After the education, patients scored an average of 9 out of 10 points in the knowledge test (increasing an average of five points after education), six months later-an average increase of 7.36 points. Patient skills after training were rated at 17.4 out of 20 points on average (increase by an average of 5.14 points after education), six months later, there was an average of 16.23 points. CONCLUSIONS The study showed an increase in patients' knowledge and skills in the field of SBPM after training.
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Affiliation(s)
- Justyna Dymek
- Department of Social Pharmacy, Faculty of Pharmacy, Jagiellonian University Medical College Medyczna, 9 Street, 30-688 Kraków, Poland.
| | - Anna Gołda
- Department of Social Pharmacy, Faculty of Pharmacy, Jagiellonian University Medical College Medyczna, 9 Street, 30-688 Kraków, Poland
| | - Wioletta Polak
- Department of Social Pharmacy, Faculty of Pharmacy, Jagiellonian University Medical College Medyczna, 9 Street, 30-688 Kraków, Poland
| | - Bartosz Lisowski
- Department of Social Pharmacy, Faculty of Pharmacy, Jagiellonian University Medical College Medyczna, 9 Street, 30-688 Kraków, Poland
- Department of Biophysics, Jagiellonian University Medical College, św. Łazarza 16 Street, 31-530 Kraków, Poland
| | - Agnieszka Skowron
- Department of Social Pharmacy, Faculty of Pharmacy, Jagiellonian University Medical College Medyczna, 9 Street, 30-688 Kraków, Poland
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Effect of Home Medication Titration on Blood Pressure Control in Patients With Hypertension: A Meta-Analysis of Randomized Controlled Trials. Med Care 2019; 57:230-236. [PMID: 30762831 PMCID: PMC6410972 DOI: 10.1097/mlr.0000000000001064] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Supplemental Digital Content is available in the text. Background: Medication titration has been used in home blood pressure (BP) control, with the expectation of enabling patients with hypertension to better manage their BP. Objective: The study goal was to estimate the effects of medication titration intervention in lowering the systolic blood pressure and diastolic blood pressure of patients with hypertension. Methods: The meta-analysis included randomized controlled trials on adults diagnosed with hypertension and BP≧130/80 mm Hg, having a medication-titration intervention, and using a home BP measurement. We systematically searched PubMed, CINAHL, Ovid-Medline, and the Cochrane Library, for studies published from 1997 to 2017. The quality of the studies was evaluated by the Modified Jadad scale. Statistical heterogeneity among the trials was evaluated using Q statistics and I2. Publication bias was assessed with the funnel plot and Rosenthal’s fail-safe N. Results: The meta-analysis included 4 studies randomizing 1335 participants. Medication-titration intervention significantly assisted hypertensive patients to improve BP control; systolic blood pressure was reduced by 6.86 mm Hg [95% confidence interval (CI), 4.80-8.93, P<0.0001] and diastolic blood pressure by 3.03 mm Hg (95% CI, 2.07-3.99, P<0.0001), did not significantly affect EQ-5D scores (mean difference, 0.02; 95% CI, −0.01 to 0.04, P=0.13). Conclusions: Our findings suggest home medication titration of antihypertensive medication for hypertensive patients significantly improved home BP control. However, the strategy did not enhance quality of life in patients with hypertension.
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Domingo JLB, Macabeo AL, Kaiko-George M, Ropa DK, Sandi TK, Pascual OA, Takesue CL, Shaw DM, Humphry JW. Implementing a Health Coaching Curriculum in Hawaii's Community Health Centers. HAWAI'I JOURNAL OF MEDICINE & PUBLIC HEALTH : A JOURNAL OF ASIA PACIFIC MEDICINE & PUBLIC HEALTH 2019; 78:65-69. [PMID: 31285973 PMCID: PMC6603890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Chronic diseases impact 60% of Americans, with 42% reporting multiple chronic conditions, and account for $3.3 trillion in annual health care costs. In Hawai'i, about 80% of adults report having at least 1 chronic condition, and more than half of those report having multiple chronic conditions. Health coaching is a technique of engaging patients to help them obtain the knowledge, skills, and confidence to become an active and engaged participant in their health care. Health coaching aims to assist patients with understanding their care plans, exploring their perceptions of their care plans, and working collaboratively with their health care team to implement these plans to improve their overall health. In 2016, the Hawai'i Primary Care Association (HPCA) partnered with the University of California, San Francisco's Center for Excellence in Primary Care to train staff from HPCA and Hawaii's community health centers (CHCs) in health coaching. This 2-day training focused on using principles of adult learning theory to create interactive sessions aimed at building staff capacity to improve communication and empower patients to become active participants in their health care. The curriculum highlights 6 core elements of health coaching: ask-tell-ask, setting the agenda, closing the loop, know your numbers, behavior-change action plans, and medication adherence counseling. The aim of this case study is to present insights gained from the implementation of health coaching at 1 FQHC in Hawai'i. Health coaching is found to be an effective approach to engaging patients and improving communication with patients and across clinic departments. Health coaching is a promising practice to address the growing chronic disease burden in Hawai'i.
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Affiliation(s)
| | | | - Mairine Kaiko-George
- Lāna'i Community Health Center, Lāna'i City, HI (MK-G, DKR, TKS, OAP, CLT, DMVS, JWH)
| | - Denise K Ropa
- Lāna'i Community Health Center, Lāna'i City, HI (MK-G, DKR, TKS, OAP, CLT, DMVS, JWH)
| | - Thessalonica K Sandi
- Lāna'i Community Health Center, Lāna'i City, HI (MK-G, DKR, TKS, OAP, CLT, DMVS, JWH)
| | - Olivia A Pascual
- Lāna'i Community Health Center, Lāna'i City, HI (MK-G, DKR, TKS, OAP, CLT, DMVS, JWH)
| | - Cori L Takesue
- Lāna'i Community Health Center, Lāna'i City, HI (MK-G, DKR, TKS, OAP, CLT, DMVS, JWH)
| | - Diana Mv Shaw
- Lāna'i Community Health Center, Lāna'i City, HI (MK-G, DKR, TKS, OAP, CLT, DMVS, JWH)
| | - Joseph W Humphry
- Lāna'i Community Health Center, Lāna'i City, HI (MK-G, DKR, TKS, OAP, CLT, DMVS, JWH)
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9
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Kramer HJ, Townsend RR, Griffin K, Flynn JT, Weiner DE, Rocco MV, Choi MJ, Weir MR, Chang TI, Agarwal R, Beddhu S. KDOQI US Commentary on the 2017 ACC/AHA Hypertension Guideline. Am J Kidney Dis 2019; 73:437-458. [PMID: 30905361 PMCID: PMC6740329 DOI: 10.1053/j.ajkd.2019.01.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 01/08/2019] [Indexed: 02/07/2023]
Abstract
Hypertension is a modifiable risk factor for cardiovascular morbidity and mortality and reduction of elevated blood pressure (BP) remains an important intervention for slowing kidney disease progression. Over the past decade, the most appropriate BP target for initiation and titration of BP-lowering medications has been an area of intense research and debate within the clinical community. In 2017, the American College of Cardiology and the American Heart Association (ACC/AHA) in conjunction with several other professional societies released new hypertension guidelines based on data from a systematic review of clinical trials and observational data. While many of the recommendations in the ACC/AHA hypertension guideline are relevant to nephrology practice, BP targets and management strategies for patients receiving dialysis are not discussed. This Kidney Disease Outcomes Quality Initiative (KDOQI) commentary focuses largely on recommendations from the ACC/AHA hypertension guidelines that are pertinent to individuals at risk of chronic kidney disease or with non-dialysis-dependent chronic kidney disease. This KDOQI commentary also includes a brief discussion of the consensus statement regarding hypertension diagnosis and management for adults receiving maintenance dialysis published by the European Renal and Cardiovascular Medicine Working Group of the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) and the Hypertension and the Kidney working group of the European Society of Hypertension. Overall, we support the vast majority of the ACC/AHA recommendations and highlight select areas in which best diagnosis and treatment options remain controversial.
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Affiliation(s)
- Holly J Kramer
- Department of Public Health Sciences, Loyola University Chicago Stritch School of Medicine, Maywood; Department of Medicine, Loyola University Chicago Stritch School of Medicine, Maywood; Hines VA Medical Center, Hines, IL.
| | - Raymond R Townsend
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Karen Griffin
- Department of Medicine, Loyola University Chicago Stritch School of Medicine, Maywood; Hines VA Medical Center, Hines, IL
| | - Joseph T Flynn
- Department of Pediatrics, University of Washington School of Medicine, Seattle WA
| | | | - Michael V Rocco
- Department of Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Michael J Choi
- Department of Medicine, Johns Hopkins School of Medicine
| | - Matthew R Weir
- Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Tara I Chang
- Department of Medicine, Stanford Medical School, Palo Alto, CA
| | - Rajiv Agarwal
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
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Milman T, Joundi RA, Alotaibi NM, Saposnik G. Clinical inertia in the pharmacological management of hypertension: A systematic review and meta-analysis. Medicine (Baltimore) 2018; 97:e11121. [PMID: 29924011 PMCID: PMC6025046 DOI: 10.1097/md.0000000000011121] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Clinical Inertia is defined as "failure of health care providers to initiate or intensify therapy according to current guidelines". This phenomenon is gaining increasing attention as a major cause of clinicians' failure to adequately manage hypertension, thus leading to an increased incidence of cardiovascular events. We performed a systematic review and meta-analysis of randomized controlled trials to determine whether interventions aimed at reducing clinical inertia in the pharmacological treatment of hypertension improve blood pressure (BP) control. METHODS MEDLINE, Embase, and Cochrane Database of Systematic Reviews were searched from the start of their database until October 3, 2017 for the MESH terms "Hypertension" or "Blood Pressure", their subheadings, and the keywords "Therapeutic Inertia" or "Clinical Inertia". Studies were included if they addressed pharmacologic hypertension management, clinical inertia, were randomized controlled trials, reported an outcome describing prescriber behavior, and were available in English. Data for the included studies was extracted by two independent observers. Quality of studies was analyzed using the Cochrane Risk of Bias Assessment. Data was pooled for statistical analysis using both fixed- and random-effects models. The primary study outcome was the percentage of patients achieving blood pressure control as defined by the Joint National Committee guidelines or study authors. RESULTS Of 474 citations identified, ten met inclusion criteria comprising a total of 26,871 patients, and eight were selected for meta-analysis. Interventions included Physician Education, Physician Reminders, Patient Education, Patient Reminders, Ambulatory BP Monitoring, Digital Medication Offerings, Physician Peer Visits, and Pharmacist-led Counselling. Pooled event rates revealed more patients with controlled BP in the intervention group versus control (55%, 95% CI 46-63% versus 45%, 95% CI 37-53%) and interventions significantly improved the odds of BP control (OR = 1.19, 95% CI = 1.12-1.27, P < .001). Heterogeneity in the quantitative analysis was moderate. CONCLUSIONS & RELEVANCE Addressing clinical inertia through physician reminders, ambulatory BP monitoring, and educational interventions for primary care providers was associated with an improvement in blood pressure control. Our findings encourage further research to investigate strategies at reducing clinical inertia in the management of hypertension.
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Affiliation(s)
- Tal Milman
- Faculty of Medicine Division of Neurology, Department of Medicine Division of Neurosurgery, Department of Surgery St. Michael's Hospital Department of Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto Institute for Clinical Evaluative Sciences (ICES), Toronto, ON, Canada
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Hartzler AL, Tuzzio L, Hsu C, Wagner EH. Roles and Functions of Community Health Workers in Primary Care. Ann Fam Med 2018; 16:240-245. [PMID: 29760028 PMCID: PMC5951253 DOI: 10.1370/afm.2208] [Citation(s) in RCA: 109] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 12/13/2017] [Accepted: 01/11/2017] [Indexed: 11/09/2022] Open
Abstract
Community health workers have potential to enhance primary care access and quality, but remain underutilized. To provide guidance on their integration, we characterized roles and functions of community health workers in primary care through a literature review and synthesis. Analysis of 30 studies identified 12 functions (ie, care coordination, health coaching, social support, health assessment, resource linking, case management, medication management, remote care, follow-up, administration, health education, and literacy support) and 3 prominent roles representing clusters of functions: clinical services, community resource connections, and health education and coaching. We discuss implications for community health worker training and clinical support in primary care.
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Affiliation(s)
- Andrea L Hartzler
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, Washington
| | - Leah Tuzzio
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Clarissa Hsu
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Edward H Wagner
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
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12
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Bus K, Peyer KL, Bai Y, Ellingson LD, Welk GJ. Comparison of In-Person and Online Motivational Interviewing–Based Health Coaching. Health Promot Pract 2017; 19:513-521. [DOI: 10.1177/1524839917746634] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Health coaching is a common approach for promoting lifestyle changes, but little is known about the effectiveness of different delivery methods. The purpose of this study was to evaluate the effectiveness of in-person versus online health coaching when used as part of a facilitated behavior change program. To increase translatability, the study used a naturalistic design that enabled participants to self-select the coaching delivery method (Group) as well as the target behavior (diet, physical activity, or weight management). Regardless of group, participants were provided with a behavior-based monitoring device and guided to use it by the health coach. A sample of 92 adults participated and 86 completed pre–post evaluations to assess behavior change strategies and posttest outcome measurements for their specific goal. Two-way (Group × Time) analyses of variance were used to evaluate changes in behavioral strategies. Intent-to-treat regression analyses were used to compare postintervention outcomes for groups. The in-person group had significantly higher Healthy Eating Index scores than the online group ( p < .05), but nonsignificant group differences were observed for those targeting physical activity or weight change ( p > .05). The results support the use of health coaching for promoting behavior change and suggest that online coaching may be equally effective as in-person methods.
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Affiliation(s)
| | | | - Yang Bai
- University of Vermont, Burlington, VT, USA
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Laviana AA, Pannell SC, Huen KHY, Bergman J. Engaging patients in complex clinical decision-making: Successes, pitfalls, and future directions. Urol Oncol 2017; 35:569-573. [PMID: 28789928 DOI: 10.1016/j.urolonc.2017.07.014] [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] [Received: 05/29/2017] [Revised: 07/05/2017] [Accepted: 07/12/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND By 2022, there will be 18 million predicted cancer survivors, which is an estimated 30% more than the number of survivors in 2012. In prostate cancer alone, the most common cancer in American men other than skin cancer, 1 in 7 men will be diagnosed during their lifetime. Nevertheless, only approximately 1 in 39 will actually die of the disease. Although life expectancy is often good, these men have multiple treatment management options to choose from, including active surveillance, surgery, or radiotherapy, each of which carries its own array of long-term adverse effects. The same applies to renal cancer where patient have to sift through information to decide among active surveillance, partial nephrectomy, racial nephrectomy, robotic vs. open surgery, and ablation. BASIC PROCEDURES Ultimately, patient, providers, and stakeholders lack high-quality evidence to effectively guide treatment decisions, and these decisions become even harder to discern when considering end-of-life care, palliative care, and the ethics regarding the new End of Life Option Act. As of November 1, 2016, the number of open urologic cancer clinical trials listed on ClinicalTrials.gov was 843. MAIN FINDINGS Although we continue to make tremendous strides in urologic cancer care, our options for choosing the best treatment from a patient and provider standpoint are seemingly growing murkier. We need to continue to understand how health-related quality of life varies from patient to patient, and ultimately, incorporate patient preferences and values into the treatment decision in order to make high-quality treatment decisions. CONCLUSIONS The remained of this articles will focus on the significant strides made in urologic oncology regarding these difficult decisions from localized disease to end-of-life care and also will detail what needs to be done as we continue to pivot forward.
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Affiliation(s)
- Aaron A Laviana
- Department of Urology, Institute of Urologic Oncology, David Geffen School of Medicine at University of California, Los Angeles, CA.
| | - Stephanie C Pannell
- Department of Urology, Institute of Urologic Oncology, David Geffen School of Medicine at University of California, Los Angeles, CA
| | - Kathy H Y Huen
- Department of Urology, Institute of Urologic Oncology, David Geffen School of Medicine at University of California, Los Angeles, CA
| | - Jonathan Bergman
- Department of Family Medicine, David Geffern School of Medicine at UCLA, Los Angeles, CA; Veterans Health Affairs-Greater Los Angeles, Los Angeles, CA; Department of Urology, Olive View-UCLA Medical Center, Sylmar, CA
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Twiner MJ, Marinica AL, Kuper K, Goodman A, Mahn JJ, Burla MJ, Brody AM, Carroll JA, Josiah Willock R, Flack JM, Nasser SA, Levy PD. Screening and Treatment for Subclinical Hypertensive Heart Disease in Emergency Department Patients With Uncontrolled Blood Pressure: A Cost-effectiveness Analysis. Acad Emerg Med 2017; 24:168-176. [PMID: 27797437 DOI: 10.1111/acem.13122] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 10/23/2016] [Accepted: 10/25/2016] [Indexed: 01/13/2023]
Abstract
OBJECTIVES Poorly controlled hypertension (HTN) is extremely prevalent and, if left unchecked, subclinical hypertensive heart disease (SHHD) may ensue leading to conditions such as heart failure. To address this, we designed a multidisciplinary program to detect and treat SHHD in a high-risk, predominantly African American community. The primary objective of this study was to determine the cost-effectiveness of our program. METHODS Study costs associated with identifying and treating patients with SHHD were calculated and a sensitivity analysis was performed comparing the effect of four parameters on cost estimates. These included prevalence of disease, effectiveness of treatment (regression of SHHD, reversal of left ventricular hypertrophy [LVH], or blood pressure [BP] control as separate measures), echocardiogram costs, and participant time/travel costs. The parent study for this analysis was a single-center, randomized controlled trial comparing cardiac effects of standard and intense (<120/80 mm Hg) BP goals at 1 year in patients with uncontrolled HTN and SHHD. A total of 149 patients (94% African American) were enrolled, 133 (89%) had SHHD, 123 (93%) of whom were randomized, with 88 (72%) completing the study. Patients were clinically evaluated and medically managed over the course of 1 year with repeated echocardiograms. Costs of these interventions were analyzed and, following standard practices, a cost per quality-adjusted life-year (QALY) less than $50,000 was defined as cost-effective. RESULTS Total costs estimates for the program ranged from $117,044 to $119,319. Cost per QALY was dependent on SHHD prevalence and the measure of effectiveness but not input costs. Cost-effectiveness (cost per QALY less than $50,000) was achieved when SHHD prevalence exceeded 11.1% for regression of SHHD, 4.7% for reversal of LVH, and 2.9% for achievement of BP control. CONCLUSIONS In this cohort of predominantly African American patients with uncontrolled HTN, SHHD prevalence was high and screening with treatment was cost-effective across a range of assumptions. These data suggest that multidisciplinary programs such as this can be a cost-effective mechanism to mitigate the cardiovascular consequences of HTN in emergency department patients with uncontrolled BP.
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Affiliation(s)
| | | | - Kenneth Kuper
- Department of Emergency Medicine St. John Hospital Detroit MI
| | - Allen Goodman
- Department of Economics Wayne State University Detroit MI
| | - James J. Mahn
- School of Medicine Wayne State University Detroit MI
| | - Michael J. Burla
- Department of Emergency Medicine Wayne State University Detroit MI
| | - Aaron M. Brody
- Department of Emergency Medicine Wayne State University Detroit MI
| | | | | | - John M. Flack
- Division of Transitional Research and Clinical Epidemiology and Department of Medicine Wayne State University Detroit MI
- Cardiovascular Research Institute Wayne State University Detroit MI
| | - Samar A. Nasser
- College of Education, Health, and Human Services University of Michigan‐Dearborn Dearborn MI
| | - Phillip D. Levy
- Cardiovascular Research Institute Wayne State University Detroit MI
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Schmittdiel JA, Adams SR, Goler N, Sanna RS, Boccio M, Bellamy DJ, Brown SD, Neugebauer RS, Ferrara A. The impact of telephonic wellness coaching on weight loss: A "Natural Experiments for Translation in Diabetes (NEXT-D)" study. Obesity (Silver Spring) 2017; 25:352-356. [PMID: 28124501 PMCID: PMC5300741 DOI: 10.1002/oby.21723] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 11/04/2016] [Accepted: 11/07/2016] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To evaluate the impact of a population-based telephonic wellness coaching program on weight loss. METHODS Individual-level segmented regression analysis of interrupted time series data comparing the BMI trajectories in the 12 months before versus the 12 months after initiating coaching among a cohort of Kaiser Permanente Northern California members (n = 954) participating in The Permanente Medical Group Wellness Coaching program in 2011. The control group was a 20:1 propensity-score matched control group (n = 19,080) matched with coaching participants based on baseline demographic and clinical characteristics. RESULTS Wellness coaching participants had a significant upward trend in BMI in the 12 months before their first wellness coaching session and a significant downward trend in BMI in the 12 months after their first session equivalent to a clinically significant reduction of greater than one unit of baseline BMI (P < 0.01 for both). The control group did not have statistically significant decreases in BMI during the post-period. CONCLUSIONS Wellness coaching has a positive impact on BMI reduction that is both statistically and clinically significant. Future research and quality improvement efforts should focus on disseminating wellness coaching for weight loss in patients with diabetes and those at risk for developing the disease.
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Affiliation(s)
- Julie A Schmittdiel
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Sara R Adams
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Nancy Goler
- Wellness Coaching Center, The Permanente Medical Group, Vallejo, California, USA
| | - Rashel S Sanna
- Regional Health Education, The Permanente Medical Group, Oakland, California, USA
| | - Mindy Boccio
- Regional Health Education, The Permanente Medical Group, Oakland, California, USA
| | - David J Bellamy
- Wellness Coaching Center, The Permanente Medical Group, Vallejo, California, USA
| | - Susan D Brown
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Romain S Neugebauer
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Assiamira Ferrara
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
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Total antihypertensive therapeutic intensity score and its relationship to blood pressure reduction. ACTA ACUST UNITED AC 2016; 10:906-916. [PMID: 27856202 DOI: 10.1016/j.jash.2016.10.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 09/01/2016] [Accepted: 10/20/2016] [Indexed: 01/13/2023]
Abstract
Predicting blood pressure (BP) response to antihypertensive therapy is challenging. The therapeutic intensity score (TIS) is a summary measure that accounts for the number of medications and the relative doses a patient received, but its relationship to BP change and its utility as a method to project dosing equivalence has not been reported. We conducted a prospective, single center, randomized controlled trial to compare the effects of Joint National Committee (JNC) 7 compliant treatment with more intensive (<120/80 mm Hg) BP goals on left ventricular structure and function in hypertensive patients with echocardiographically determined subclinical heart disease who were treated over a 12-month period. For this preplanned subanalysis, we sought to compare changes in BP over time with changes in TIS. Antihypertensive therapy was open label. TIS and BP were determined at 3-month intervals with titration of medication doses as needed to achieve targeted BP. Mixed linear models defined antihypertensive medication TIS as an independent variable and change in systolic BP as an outcome measure, while controlling for gender, age, baseline BP, and treatment group. A total of 123 patients (mean age 49.4 ± 8.2 years; 66% female; 95.1% African-American) were enrolled and 88 completed the protocol. For each single point increase in total antihypertensive TIS, a 14.5 (95% confidence interval: 11.5, 17.4) mm Hg decrease in systolic BP was noted (15.5 [95% confidence interval: 13.0, 18.0] mm Hg for those who completed the trial). Total TIS is a viable indicator of the anticipated BP-lowering effect associated with antihypertensive therapy.
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Xiao H, Adams SR, Goler N, Sanna RS, Boccio M, Bellamy DJ, Brown SD, Neugebauer RS, Ferrara A, Schmittdiel JA. Wellness Coaching for People With Prediabetes: A Randomized Encouragement Trial to Evaluate Outreach Methods at Kaiser Permanente, Northern California, 2013. Prev Chronic Dis 2015; 12:E207. [PMID: 26605707 PMCID: PMC4674445 DOI: 10.5888/pcd12.150251] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Introduction Health coaching can improve lifestyle behaviors known to prevent or manage chronic conditions. Little is known about effective ways to encourage health and wellness coaching among people who might benefit. The purpose of this randomized encouragement trial was to assess the relative success of 3 outreach methods (secured email message, telephone message, and mailed letter) on the use of wellness coaching by people with prediabetes. Methods A total of 14,584 Kaiser Permanente Northern California (KPNC) patients with diagnosed prediabetes (fasting plasma glucose, 110–125mg/dL) were randomly assigned to be contacted via 1 of 4 intervention arms from January through May 2013. The uptake rate (making an appointment at the Wellness Coaching Center [WCC]) was assessed, and the association between uptake rate and patient characteristics was examined via multivariable logistic regression. Results The overall uptake rate across intervention arms was 1.9%. Secured email message had the highest uptake rate (3.0%), followed by letters and telephone messages (P < .05 for all pairwise comparisons). No participants in the usual-care arm (ie, no outreach) made an appointment with the WCC. For each year of increased age, the estimated odds of the uptake increased by 1.02 (odds ratio [OR] = 1.02; 95% CI, 1.01–1.04). Women were nearly twice as likely to make an appointment at the WCC as men (OR = 1.87; 95% CI, 1.40–2.51). Conclusion Our results suggest that the WCC can recruit and encourage KPNC members with prediabetes to participate in the WCC. Future research should focus on increasing participation rates in health coaching among patients who may benefit.
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Affiliation(s)
- Hong Xiao
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Sara R Adams
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Nancy Goler
- Wellness Coaching Center, Kaiser Permanente Northern California, Vallejo
| | - Rashel S Sanna
- Regional Health Education, Kaiser Permanente Northern California, Oakland, California
| | - Mindy Boccio
- Regional Health Education, Kaiser Permanente Northern California, Oakland, California
| | - David J Bellamy
- Wellness Coaching Center, Kaiser Permanente Northern California, Vallejo
| | - Susan D Brown
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Romain S Neugebauer
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Assiamira Ferrara
- Division of Research, Kaiser Permanente Northern California, Oakland, California
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Frontline experiences of a practice redesign to improve self-management of obesity in safety net clinics. J Ambul Care Manage 2015; 38:153-63. [PMID: 25748264 DOI: 10.1097/jac.0000000000000063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Teamlets of physicians and medical assistants may help improve obesity management in primary care settings. We aimed to understand the barriers and facilitators of implementing a teamlet approach to managing obesity in 3 safety net clinics. Key stakeholder interviews (n = 21) were conducted both during early implementation of practice change and 6 months later. Patient surveys (n = 393) examined obese patient activation and health status. Insufficient program resources and limited patient engagement due to external factors were implementation barriers despite fairly high patient activation. Staff members need time and resources to execute new responsibilities to support obesity management in safety net settings. Because of high turnover, multiple supporters may improve sustainability.
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Feldman PH, McDonald MV, Trachtenberg MA, Schoenthaler A, Coyne N, Teresi J. Center for stroke disparities solutions community- based care transition interventions: study protocol of a randomized controlled trial. Trials 2015; 16:32. [PMID: 25622823 PMCID: PMC4322449 DOI: 10.1186/s13063-015-0550-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Accepted: 01/05/2015] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Racial and ethnic disparities persist in stroke occurrence, recurrence, morbidity and mortality. Uncontrolled hypertension (HTN) is the most important modifiable risk factor for stroke risk. Home health care organizations care for many patients with uncontrolled HTN and history of stroke; however, recurrent stroke prevention has not been a home care priority. We are conducting a randomized controlled trial (RCT) to compare the effectiveness, relative to usual home care (UHC), of two Community Transitions Interventions (CTIs). The CTIs aim to reduce recurrent stroke risk among post-stroke patients via home-based transitional care focused on better HTN management. METHODS/DESIGN This 3-arm trial will randomly assign 495 black and Hispanic post-stroke home care patients with uncontrolled systolic blood pressure (SBP) to one of three arms: UHC, UHC complemented by nurse practitioner-delivered transitional care (UHC + NP) or UHC complemented by an NP plus health coach (UHC + NP + HC). Both intervention arms emphasize: 1) linking patients to continuous, responsive preventive and primary care, 2) increasing patients'/caregivers' ability to manage a culturally and individually tailored BP reduction plan, and 3) facilitating the patient's reintegration into the community after home health care discharge. The primary hypothesis is that both NP-only and NP + HC transitional care will be more effective than UHC alone in achieving a SBP reduction. The primary outcome is change in SPB at 3 and 12 months. The study also will examine cost-effectiveness, quality of life and moderators (for example, race/ethnicity) and mediators (for example, changes in health behaviors) that may affect treatment outcomes. All outcome data are collected by staff blinded to group assignment. DISCUSSION This study targets care gaps affecting a particularly vulnerable black/Hispanic population characterized by persistent stroke disparities. It focuses on care transitions, a juncture when patients are particularly susceptible to adverse events. The CTI is innovative in adapting for stroke patients an established transitional care model shown to be effective for HF patients, pairing the professional NP with a HC, implementing a culturally tailored intervention, and placing primary emphasis on longer-term risk factor reduction and community reintegration rather than shorter-term transitional care outcomes. TRIAL REGISTRATION ClinicalTrials.gov NCT01918891 ; Registered 5 August 2013.
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Affiliation(s)
- Penny H Feldman
- Center for Home Care Policy and Research, Visiting Nurse Service of New York, 107 East 70th Street, 10021, New York, NY, USA.
| | - Margaret V McDonald
- Center for Home Care Policy and Research, Visiting Nurse Service of New York, 5 Penn Plaza, 12th floor, 10001, New York, NY, USA.
| | - Melissa A Trachtenberg
- Center for Home Care Policy and Research, Visiting Nurse Service of New York, 5 Penn Plaza, 12th floor, 10001, New York, NY, USA.
| | - Antoinette Schoenthaler
- Center for Healthful Behavior Change, Department of Population Health, NYU School of Medicine, 227 East 30th Street, 634, 10016, New York, NY, USA.
| | - Noreen Coyne
- Center for Home Care Policy and Research, Visiting Nurse Service of New York, 5 Penn Plaza, 12th floor, 10001, New York, NY, USA.
| | - Jeanne Teresi
- Columbia University Stroud Center and New York State Psychiatric Institute, Research Division, Hebrew Home at Riverdale, 5901 Palisade Avenue, 10471, Bronx, NY, USA.
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The effectiveness of a life style modification and peer support home blood pressure monitoring in control of hypertension: protocol for a cluster randomized controlled trial. BMC Public Health 2014; 14 Suppl 3:S4. [PMID: 25436830 PMCID: PMC4251131 DOI: 10.1186/1471-2458-14-s3-s4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Background Death rates due to hypertension in low and middle income countries are higher compared to high income countries. The present study is designed to combine life style modification and home blood pressure monitoring for control of hypertension in the context of low and middle income countries. Methods The study is a two armed, parallel group, un-blinded, cluster randomized controlled trial undertaken within lower income areas in Kuala Lumpur. Two housing complexes will be assigned to the intervention group and the other two housing complexes will be allocated in the control group. Based on power analysis, 320 participants will be recruited. The participants in the intervention group (n = 160) will undergo three main components in the intervention which are the peer support for home blood pressure monitoring, face to face health coaching on healthy diet and demonstration and training for indoor home based exercise activities while the control group will receive a pamphlet containing information on hypertension. The primary outcomes are systolic and diastolic blood pressure. Secondary outcome measures include practice of self-blood pressure monitoring, dietary intake, level of physical activity and physical fitness. Discussion The present study will evaluate the effect of lifestyle modification and peer support home blood pressure monitoring on blood pressure control, during a 6 month intervention period. Moreover, the study aims to assess whether these effects can be sustainable more than six months after the intervention has ended.
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Nieuwlaat R, Wilczynski N, Navarro T, Hobson N, Jeffery R, Keepanasseril A, Agoritsas T, Mistry N, Iorio A, Jack S, Sivaramalingam B, Iserman E, Mustafa RA, Jedraszewski D, Cotoi C, Haynes RB. Interventions for enhancing medication adherence. Cochrane Database Syst Rev 2014; 2014:CD000011. [PMID: 25412402 PMCID: PMC7263418 DOI: 10.1002/14651858.cd000011.pub4] [Citation(s) in RCA: 671] [Impact Index Per Article: 67.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND People who are prescribed self administered medications typically take only about half their prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications. OBJECTIVES The primary objective of this review is to assess the effects of interventions intended to enhance patient adherence to prescribed medications for medical conditions, on both medication adherence and clinical outcomes. SEARCH METHODS We updated searches of The Cochrane Library, including CENTRAL (via http://onlinelibrary.wiley.com/cochranelibrary/search/), MEDLINE, EMBASE, PsycINFO (all via Ovid), CINAHL (via EBSCO), and Sociological Abstracts (via ProQuest) on 11 January 2013 with no language restriction. We also reviewed bibliographies in articles on patient adherence, and contacted authors of relevant original and review articles. SELECTION CRITERIA We included unconfounded RCTs of interventions to improve adherence with prescribed medications, measuring both medication adherence and clinical outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive findings at earlier time points. DATA COLLECTION AND ANALYSIS Two review authors independently extracted all data and a third author resolved disagreements. The studies differed widely according to medical condition, patient population, intervention, measures of adherence, and clinical outcomes. Pooling results according to one of these characteristics still leaves highly heterogeneous groups, and we could not justify meta-analysis. Instead, we conducted a qualitative analysis with a focus on the RCTs with the lowest risk of bias for study design and the primary clinical outcome. MAIN RESULTS The present update included 109 new RCTs published since the previous update in January 2007, bringing the total number of RCTs to 182; we found five RCTs from the previous update to be ineligible and excluded them. Studies were heterogeneous for patients, medical problems, treatment regimens, adherence interventions, and adherence and clinical outcome measurements, and most had high risk of bias. The main changes in comparison with the previous update include that we now: 1) report a lack of convincing evidence also specifically among the studies with the lowest risk of bias; 2) do not try to classify studies according to intervention type any more, due to the large heterogeneity; 3) make our database available for collaboration on sub-analyses, in acknowledgement of the need to make collective advancement in this difficult field of research. Of all 182 RCTs, 17 had the lowest risk of bias for study design features and their primary clinical outcome, 11 from the present update and six from the previous update. The RCTs at lowest risk of bias generally involved complex interventions with multiple components, trying to overcome barriers to adherence by means of tailored ongoing support from allied health professionals such as pharmacists, who often delivered intense education, counseling (including motivational interviewing or cognitive behavioral therapy by professionals) or daily treatment support (or both), and sometimes additional support from family or peers. Only five of these RCTs reported improvements in both adherence and clinical outcomes, and no common intervention characteristics were apparent. Even the most effective interventions did not lead to large improvements in adherence or clinical outcomes. AUTHORS' CONCLUSIONS Across the body of evidence, effects were inconsistent from study to study, and only a minority of lowest risk of bias RCTs improved both adherence and clinical outcomes. Current methods of improving medication adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. The research in this field needs advances, including improved design of feasible long-term interventions, objective adherence measures, and sufficient study power to detect improvements in patient-important clinical outcomes. By making our comprehensive database available for sharing we hope to contribute to achieving these advances.
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Affiliation(s)
- Robby Nieuwlaat
- McMaster UniversityDepartment of Clinical Epidemiology and BiostatisticsHamilton General Hospital campus, Room C3‐107237 Barton Street EastHamiltonONCanadaL8L 2X2
| | - Nancy Wilczynski
- McMaster UniversityDepartment of Clinical Epidemiology and BiostatisticsHamilton General Hospital campus, Room C3‐107237 Barton Street EastHamiltonONCanadaL8L 2X2
| | - Tamara Navarro
- McMaster UniversityDepartment of Clinical Epidemiology and BiostatisticsHamilton General Hospital campus, Room C3‐107237 Barton Street EastHamiltonONCanadaL8L 2X2
| | - Nicholas Hobson
- McMaster UniversityDepartment of Clinical Epidemiology and BiostatisticsHamilton General Hospital campus, Room C3‐107237 Barton Street EastHamiltonONCanadaL8L 2X2
| | - Rebecca Jeffery
- McMaster UniversityDepartment of Clinical Epidemiology and BiostatisticsHamilton General Hospital campus, Room C3‐107237 Barton Street EastHamiltonONCanadaL8L 2X2
| | - Arun Keepanasseril
- McMaster UniversityDepartments of Clinical Epidemiology & Biostatistics, and Medicine, Faculty of Health Sciences1280 Main Street WestHamiltonONCanadaL8S 4L8
| | - Thomas Agoritsas
- McMaster UniversityDepartment of Clinical Epidemiology and BiostatisticsHamilton General Hospital campus, Room C3‐107237 Barton Street EastHamiltonONCanadaL8L 2X2
| | - Niraj Mistry
- St. Michael's HospitalDepartment of Pediatrics30 Bond StreetTorontoONCanadaM5B 1W8
| | - Alfonso Iorio
- McMaster UniversityDepartment of Clinical Epidemiology and BiostatisticsHamilton General Hospital campus, Room C3‐107237 Barton Street EastHamiltonONCanadaL8L 2X2
| | - Susan Jack
- McMaster UniversitySchool of Nursing, Faculty of Health SciencesHealth Sciences CentreRoom 2J32, 1280 Main Street WestHamiltonONCanadaL8S 4K1
| | | | - Emma Iserman
- McMaster UniversityDepartment of Clinical Epidemiology and BiostatisticsHamilton General Hospital campus, Room C3‐107237 Barton Street EastHamiltonONCanadaL8L 2X2
| | - Reem A Mustafa
- McMaster UniversityDepartment of Clinical Epidemiology and BiostatisticsHamilton General Hospital campus, Room C3‐107237 Barton Street EastHamiltonONCanadaL8L 2X2
| | - Dawn Jedraszewski
- McMaster UniversityDepartment of Clinical Epidemiology and BiostatisticsHamilton General Hospital campus, Room C3‐107237 Barton Street EastHamiltonONCanadaL8L 2X2
| | - Chris Cotoi
- McMaster UniversityDepartment of Clinical Epidemiology and BiostatisticsHamilton General Hospital campus, Room C3‐107237 Barton Street EastHamiltonONCanadaL8L 2X2
| | - R. Brian Haynes
- McMaster UniversityDepartments of Clinical Epidemiology & Biostatistics, and Medicine, Faculty of Health Sciences1280 Main Street WestHamiltonONCanadaL8S 4L8
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Park YH, Chang H. Effect of a health coaching self-management program for older adults with multimorbidity in nursing homes. Patient Prefer Adherence 2014; 8:959-70. [PMID: 25045253 PMCID: PMC4094628 DOI: 10.2147/ppa.s62411] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND AND AIMS Although a growing number of older people are suffering from multimorbidity, most of the health problems related to multimorbidity can be improved by self-management. The aim of this study was to examine the effectiveness of a health coaching self-management program for older adults with multimorbidity in nursing homes. METHODS Older adults with multimorbidity from one nursing home in Korea were randomly allocated to either an intervention group (n=22) or conventional group (n=21). Participants in the intervention group met face to face with the researchers twice a week for 8 weeks, during which time the researchers engaged them in goal setting and goal performance using the strategies in the health coaching self-management program. Regular care was provided to the other participants in the conventional group. RESULTS Participants in the intervention group had significantly better outcomes in exercise behaviors (P=0.015), cognitive symptom management (P=0.004), mental stress management/relaxation (P=0.023), self-rated health (P=0.002), reduced illness intrusiveness (P<0.001), depression (P<0.001), and social/role activities limitations (P<0.001). In addition, there was a significant time-by-group interaction in self-efficacy (P=0.036). According to the goal attainment scales, their individual goals of oral health and stress reduction were achieved. CONCLUSION The health coaching self-management program was successfully implemented in older adults with multimorbidity in a nursing home. Further research is needed to develop and evaluate the long-term effects of an intervention to enhance adherence to self-management and quality of life for older adults with multimorbidity.
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Affiliation(s)
- Yeon-Hwan Park
- College of Nursing, Seoul National University, Seoul, South Korea
- The Research Institute of Nursing Science, Seoul National University, Seoul, South Korea
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Kaplan AL, Crespi CM, Saucedo JD, Connor SE, Litwin MS, Saigal CS. Decisional conflict in economically disadvantaged men with newly diagnosed prostate cancer: baseline results from a shared decision-making trial. Cancer 2014; 120:2721-7. [PMID: 24816472 DOI: 10.1002/cncr.28755] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Revised: 03/15/2014] [Accepted: 03/21/2014] [Indexed: 11/07/2022]
Abstract
BACKGROUND Decisional conflict is a source of anxiety and stress for men diagnosed with prostate cancer given uncertainty surrounding myriad treatment options. Few data exist to help clinicians identify which patients are at risk for decisional conflict. The purpose of this study was to examine factors associated with decisional conflict in economically disadvantaged men diagnosed with prostate cancer before any treatment choices were made. METHODS A total of 70 men were surveyed at a Veterans Administration clinic with newly diagnosed localized prostate cancer enrolled in a randomized trial testing a novel shared decision-making tool. Baseline demographic, clinical, and functional data were collected. Independent variables included age, race, education, comorbidity, relationship status, urinary/sexual dysfunction, and prostate cancer knowledge. Tested outcomes were Decisional Conflict Scale, Uncertainty Subscale, and Perceived Effectiveness Subscale. Multiple linear regression modeling was used to identify factors associated with decisional conflict. RESULTS Mean age was 63 years, 49% were African American, and 70% reported an income less than $30,000. Poor prostate cancer knowledge was associated with increased decisional conflict and higher uncertainty (P < .001 and P = 0.001, respectively). Poor knowledge was also associated with lower perceived effectiveness (P = 0.003) whereas being in a relationship was associated with higher decisional conflict (P = 0.03). CONCLUSIONS Decreased patient knowledge about prostate cancer is associated with increased decisional conflict and lower perceived effective decision-making. Interventions to increase comprehension of prostate cancer and its treatments may reduce decisional conflict. Further work is needed to better characterize this relationship and identify effective targeted interventions.
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Affiliation(s)
- Alan L Kaplan
- Department of Urology, David Geffen School of Medicine at University of California Los Angeles (UCLA), Los Angeles, California
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Adams SR, Goler NC, Sanna RS, Boccio M, Bellamy DJ, Brown SD, Neugebauer RS, Ferrara A, Wiley DM, Schmittdiel JA. Patient satisfaction and perceived success with a telephonic health coaching program: the Natural Experiments for Translation in Diabetes (NEXT-D) Study, Northern California, 2011. Prev Chronic Dis 2013; 10:E179. [PMID: 24176083 PMCID: PMC3816609 DOI: 10.5888/pcd10.130116] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Introduction Health coaching can improve lifestyle behaviors known to prevent or manage chronic conditions such as diabetes. However, little is known about the patient experience with telephonic coaching programs in real-world care settings. We examined patient satisfaction, patient’s perceived success in achieving program goals, and the patient-level correlates of these outcomes in a voluntary telephonic coaching program at a large integrated health care delivery system in northern California. Methods Kaiser Permanente Northern California patients who participated in a telephonic coaching program in 2011 were sent a cross-sectional survey about their satisfaction with health coaching and perceived success with program goals. We examined associations with patient characteristics. Results The survey response rate was 34%; analyses were based on the 32% who completed the survey. Of those who had completed 2 or more sessions (n = 232 [52%]), most reported being satisfied (70%) or neutral (20%) with the program, and 71% would recommend health coaching. Healthy weight, healthful eating, and physical activity were the most common topics discussed (88%). Adjusting for demographic characteristics, 73% of those who had 2 or more sessions reported that health coaching helped achieve their weight-related goal. Outcomes were positively correlated with patient activation but not consistently correlated with patient demographic characteristics. Conclusion Levels of satisfaction and perceived success with telephonic health coaching provided by a health plan were high and positively correlated with the number of sessions completed and patient activation. Voluntary telephonic health coaching programs should promote retention and assess patients’ activation levels.
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Affiliation(s)
- Sara R Adams
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612. E-mail:
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Schmittdiel JA, Brown SD, Neugebauer R, Adams SR, Adams AS, Wiley D, Ferrara A. Health-plan and employer-based wellness programs to reduce diabetes risk: The Kaiser Permanente Northern California NEXT-D Study. Prev Chronic Dis 2013; 10:E15. [PMID: 23369768 PMCID: PMC3562174 DOI: 10.5888/pcd10.120146] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Primary prevention of diabetes is increasingly recognized by both health plans and employers as an important strategy to improve the health of insured populations. As a part of the Natural Experiments in Translation for Diabetes (NEXT-D) network, the Kaiser Permanente Northern California (KPNC) Division of Research is assessing the effectiveness of 2 health plan-initiated programs to prevent the onset of diabetes in patients at high risk. The first study evaluates a telephonic health-coaching program that provides counseling on healthful eating, active living, and weight loss to KPNC members. The second evaluation examines a postpartum glucose screening and educational diabetes prevention program for women with gestational diabetes mellitus that KPNC implemented in 2006. Identifying effective approaches to preventing diabetes will be of value to health care systems, policy makers, and public health officials seeking to understand the roles systems and employers can play in preventing chronic illness.
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Affiliation(s)
- Julie A Schmittdiel
- Kaiser Permanente Northern California Division of Research, 2000 Broadway, Oakland, CA 94612, USA.
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Santos MVRD, Oliveira DCD, Novaes MDA. A telehealth strategy for increasing adherence in the treatment of hypertension in primary care. Telemed J E Health 2013; 19:241-7. [PMID: 23509920 DOI: 10.1089/tmj.2012.0036] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE This study describes and analyzes a telehealth strategy for Family Health Teams (FHTs) providing primary care services. This strategy aimed to increase the adherence to the treatment of hypertension. SUBJECTS AND METHODS We conducted a before-after study that enrolled 21 professionals and 502 hypertensive patients in two of the Family Health Units connected to our Telehealth Center Network. Seminars addressing the treatment adherence of hypertension were offered by Web conferences, for a period of 6 months, to the FHTs. The adherence to antihypertensive drugs, low salt diet, and physical activity was measured by specific questionnaires. The rates of adherence were assessed before and after a continuing education program (CEP). After the telehealth intervention, 17 professionals and 465 patients were re-evaluated. RESULTS The participation in the question and answer session, after the seminar, was significant. The qualitative evaluation of the sessions by FHTs showed 87.5% of great/good. There was a trend toward a greater critical understanding of the results and targets set for the team, although at insignificant levels. The rates of adherence to antihypertensive medication, physical activity, and sodium control, before and after the CEP, were 37.8% versus 46.7% (p<0.004), 90.3% versus 89.9% (p=0.90), and 92.2% versus 96.3% (p<0.001), respectively. CONCLUSIONS The adherence to antihypertensive drugs and low salt diet improved after the CEP. Preliminarily, this telehealth strategy suggests a positive impact on hypertensive patients.
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Watson AJ, Singh K, Myint-U K, Grant RW, Jethwani K, Murachver E, Harris K, Lee TH, Kvedar JC. Evaluating a web-based self-management program for employees with hypertension and prehypertension: a randomized clinical trial. Am Heart J 2012; 164:625-31. [PMID: 23067923 DOI: 10.1016/j.ahj.2012.06.013] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2011] [Accepted: 06/22/2012] [Indexed: 12/31/2022]
Abstract
BACKGROUND Web-based self-management programs offer a novel approach for self-insured employers seeking to improve and maintain employee health. METHODS We conducted a 6-month prospective, cluster-randomized controlled trial designed to evaluate whether worksite access to an automated, web-based, self-management program resulted in better blood pressure control. The trial was conducted at 6 EMC Corporation worksites in Massachusetts, each of which had at least 600 employees; 404 EMC employees with pre-hypertension or hypertension participated. Participants at 3 worksites received a home blood pressure cuff that uploaded readings to a Web site where they could view trends and read automated rules-based messages. Participants at 3 worksites received access to an onsite blood pressure cuff. Primary outcome measure was change in systolic blood pressure. Secondary outcome measures were change in diastolic blood pressure, proportion of participants achieving significant changes in systolic and diastolic blood pressure, and subject satisfaction. RESULTS Although the mean change in systolic blood pressure was not significantly different between intervention and control groups (-1.69 vs. -0.86 mm HG, respectively, P = .49) the change in diastolic blood pressure between groups was significant. (-1.08 vs. = 1.47 mm HG, respectively, P < .001). Significantly more intervention participants experienced a >10-mm Hg decrease in systolic blood pressure or >5-mm Hg decrease in diastolic blood pressure compared to controls (22% vs 17%, P = .02 and 29% vs 16%, P = .03, respectively). Intervention participants were twice as likely to report starting a new medication (P = .02) and more likely to report improved communication with their doctor (P = .02). CONCLUSIONS Participation in an automated online self-management program resulted in improved blood pressure among employees with prehypertension or hypertension.
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Drawz PE, Abdalla M, Rahman M. Blood pressure measurement: clinic, home, ambulatory, and beyond. Am J Kidney Dis 2012; 60:449-62. [PMID: 22521624 PMCID: PMC4128481 DOI: 10.1053/j.ajkd.2012.01.026] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2011] [Accepted: 01/23/2012] [Indexed: 01/01/2023]
Abstract
Blood pressure traditionally has been measured in the clinic setting using the auscultatory method and a mercury sphygmomanometer. Technologic advances have led to improvements in measuring clinic blood pressure and allowed for measuring blood pressures outside the clinic. This review outlines various methods for evaluating blood pressure and the clinical utility of each type of measurement. Home blood pressures and 24-hour ambulatory blood pressures have improved our ability to evaluate the risk of target-organ damage and hypertension-related morbidity and mortality. Measuring home blood pressures may lead to more active participation in health care by patients and has the potential to improve blood pressure control. Ambulatory blood pressure monitoring enables measuring nighttime blood pressures and diurnal changes, which may be the most accurate predictors of risk associated with elevated blood pressure. Additionally, reducing nighttime blood pressure is feasible and may be an important component of effective antihypertensive therapy. Finally, estimating central aortic pressures and pulse wave velocity are 2 of the newer methods for assessing blood pressure and hypertension-related target-organ damage.
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Affiliation(s)
- Paul E. Drawz
- Division of Nephrology and Hypertension, Case Western Reserve University, Cleveland, OH
- MetroHealth Medical Center, Louis Stokes Cleveland VA Medical Center
| | - Mohamed Abdalla
- Department of Medicine, MetroHealth Medical Center, Cleveland, OH
| | - Mahboob Rahman
- Division of Nephrology and Hypertension, Case Western Reserve University, Cleveland, OH
- University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center
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Margolius D, Bodenheimer T, Bennett H, Wong J, Ngo V, Padilla G, Thom DH. Health coaching to improve hypertension treatment in a low-income, minority population. Ann Fam Med 2012; 10:199-205. [PMID: 22585883 PMCID: PMC3354968 DOI: 10.1370/afm.1369] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
PURPOSE Poor blood pressure control is common in the United States. We conducted a study to determine whether health coaching with home titration of antihypertensive medications can improve blood pressure control compared with health coaching alone in a low-income, predominantly minority population. METHODS We randomized 237 patients with poorly controlled hypertension at a primary care clinic to receive either home blood pressure monitoring, weekly health coaching, and home titration of blood pressure medications if blood pressures were elevated (n = 129) vs home blood pressure monitoring and health coaching but no home titration (n = 108). The primary outcome was change in systolic blood pressure from baseline to 6 months. RESULTS Both the home-titration arm and the no-home-titration arm had a reduction in systolic blood pressure, with no significant difference between them. When both arms were combined and analyzed as a before-after study, there was a mean decrease in systolic blood pressure of 21.8 mm Hg (P <.001) as well as a decrease in the number of primary care visits from 3.5 in the 6 months before the study to 2.6 during the 6-month study period (P <.001) and 2.4 in the 6 months after the study (P <.001). The more coaching encounters patients had, the greater their reduction in blood pressure. CONCLUSIONS Blood pressure control in a low-income, minority population can be improved by teaching patients to monitor their blood pressure at home and having nonprofessional health coaches assist patients, in particular, by counseling them on medication adherence. The improved blood pressure control can be achieved while reducing the time spent by physicians.
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Affiliation(s)
- David Margolius
- Department of Family and Community Medicine, University of California-San Francisco, CA 94110, USA
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Affiliation(s)
- Gbenga Ogedegbe
- Center for Healthful Behavior Change, Division of General Internal Medicine, Department of Medicine, New York University School of Medicine, New York, NY 10010, USA.
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McManus RJ, Mant J, Bray EP, Holder R, Jones MI, Greenfield S, Kaambwa B, Banting M, Bryan S, Little P, Williams B, Hobbs FDR. Telemonitoring and self-management in the control of hypertension (TASMINH2): a randomised controlled trial. Lancet 2010; 376:163-72. [PMID: 20619448 DOI: 10.1016/s0140-6736(10)60964-6] [Citation(s) in RCA: 369] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Control of blood pressure is a key component of cardiovascular disease prevention, but is difficult to achieve and until recently has been the sole preserve of health professionals. This study assessed whether self-management by people with poorly controlled hypertension resulted in better blood pressure control compared with usual care. METHODS This randomised controlled trial was undertaken in 24 general practices in the UK. Patients aged 35-85 years were eligible for enrolment if they had blood pressure more than 140/90 mm Hg despite antihypertensive treatment and were willing to self-manage their hypertension. Participants were randomly assigned in a 1:1 ratio to self-management, consisting of self-monitoring of blood pressure and self-titration of antihypertensive drugs, combined with telemonitoring of home blood pressure measurements or to usual care. Randomisation was done by use of a central web-based system and was stratified by general practice with minimisation for sex, baseline systolic blood pressure, and presence or absence of diabetes or chronic kidney disease. Neither participants nor investigators were masked to group assignment. The primary endpoint was change in mean systolic blood pressure between baseline and each follow-up point (6 months and 12 months). All randomised patients who attended follow-up visits at 6 months and 12 months and had complete data for the primary outcome were included in the analysis, without imputation for missing data. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN17585681. FINDINGS 527 participants were randomly assigned to self-management (n=263) or control (n=264), of whom 480 (91%; self-management, n=234; control, n=246) were included in the primary analysis. Mean systolic blood pressure decreased by 12.9 mm Hg (95% CI 10.4-15.5) from baseline to 6 months in the self-management group and by 9.2 mm Hg (6.7-11.8) in the control group (difference between groups 3.7 mm Hg, 0.8-6.6; p=0.013). From baseline to 12 months, systolic blood pressure decreased by 17.6 mm Hg (14.9-20.3) in the self-management group and by 12.2 mm Hg (9.5-14.9) in the control group (difference between groups 5.4 mm Hg, 2.4-8.5; p=0.0004). Frequency of most side-effects did not differ between groups, apart from leg swelling (self-management, 74 patients [32%]; control, 55 patients [22%]; p=0.022). INTERPRETATION Self-management of hypertension in combination with telemonitoring of blood pressure measurements represents an important new addition to control of hypertension in primary care. FUNDING Department of Health Policy Research Programme, National Coordinating Centre for Research Capacity Development, and Midlands Research Practices Consortium.
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Affiliation(s)
- Richard J McManus
- Primary Care Clinical Sciences, University of Birmingham and National Institute for Health Research (NIHR) National School for Primary Care Research, Birmingham, UK.
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