Patient and practice perspectives on strategies for controlling blood pressure, North Carolina, 2010-2012

Applicability of Precision Medicine Approaches to Managing Hypertension in Rural Populations

As part of the Heart Healthy Lenoir Project, we developed a practice level intervention to improve blood pressure control. The goal of this study was: (i) to determine if single nucleotide polymorphisms (SNPs) that associate with blood pressure variation, identified in large studies, are applicable to blood pressure control in subjects from a rural population; (ii) to measure the association of these SNPs with subjects' responsiveness to the hypertension intervention; and (iii) to identify other SNPs that may help understand patient-specific responses to an intervention. We used a combination of candidate SNPs and genome-wide analyses to test associations with either baseline systolic blood pressure (SBP) or change in systolic blood pressure one year after the intervention in two genetically defined ancestral groups: African Americans (AA) and Caucasian Americans (CAU). Of the 48 candidate SNPs, 13 SNPs associated with baseline SBP in our study; however, one candidate SNP, rs592582, also associated with a change in SBP after one year. Using our study data, we identified 4 and 15 additional loci that associated with a change in SBP in the AA and CAU groups, respectively. Our analysis of gene-age interactions identified genotypes associated with SBP improvement within different age groups of our populations. Moreover, our integrative analysis identified AQP4-AS1 and PADI2 as genes whose expression levels may contribute to the pleiotropy of complex traits involved in cardiovascular health and blood pressure regulation in response to an intervention targeting hypertension. In conclusion, the identification of SNPs associated with the success of a hypertension treatment intervention suggests that genetic factors in combination with age may contribute to an individual's success in lowering SBP. If these findings prove to be applicable to other populations, the use of this genetic variation in making patient-specific interventions may help providers with making decisions to improve patient outcomes. Further investigation is required to determine the role of this genetic variance with respect to the management of hypertension such that more precise treatment recommendations may be made in the future as part of personalized medicine.

Patient confidence regarding secondary lifestyle modification and knowledge of 'heart attack' symptoms following percutaneous revascularisation in Japan: a cross-sectional study

OBJECTIVE

To assess patient perspectives on secondary lifestyle modification and knowledge of 'heart attack' after percutaneous coronary intervention (PCI) for coronary artery disease (CAD).

DESIGN

Observational cross-sectional study.

SETTING

A single university-based hospital centre in Japan.

PARTICIPANTS

In total, 236 consecutive patients with CAD who underwent PCI completed a questionnaire (age, 67.4±10.1 years; women, 14.8%; elective PCI, 75.4%). The survey questionnaire included questions related to confidence levels about (1) lifestyle modification at the time of discharge and (2) appropriate recognition of heart attack symptoms and reactions to these symptoms on a four-point Likert scale (1=not confident to 4=completely confident).

PRIMARY OUTCOME MEASURE

The primary outcome assessed was the patients' confidence level regarding lifestyle modification and the recognition of heart attack symptoms.

RESULTS

Overall, patients had a high level of confidence (confident or completely confident,>75%) about smoking cessation, alcohol restriction and medication adherence. However, they had a relatively low level of confidence (<50%) about the maintenance of blood pressure control, healthy diet, body weight and routine exercise (≥3 times/week). After adjustment, male sex (OR 3.61, 95% CI 1.11 to 11.8) and lower educational level (OR 3.25; 95% CI 1.70 to 6.23) were identified as factors associated with lower confidence levels. In terms of confidence in the recognition of heart attack, almost all respondents answered 'yes' to the item 'I should go to the hospital as soon as possible when I have a heart attack'; however, only 28% of the responders were confident in their ability to distinguish between heart attack symptoms and other conditions.

CONCLUSIONS

There were substantial disparities in the confidence levels associated with lifestyle modification and recognition/response to heart attack. These gaps need to be studied further and disseminated to improve cardiovascular care.

[Community-based research in therapeutic patient education: practices and contributions. A literature review]

INTRODUCTION

Community-based research (CBR) in health involves both researchers and people concerned by the results of the research. It aims to empower populations, using their exposure to the phenomenon being studied as a starting point. The use of CBR in the field of therapeutic patient education (TPE) is of interest, as the two share such characteristics as the desire to foster self-reliance and participation and a culture of interdisciplinarity.

AIM

To characterize CBR in the therapeutic patient education field.

METHODS

A literature search on PUBMED using the keywords ?community-based (participatory) research?, ?patient education?, ?self-care? and ?self-management? retrieved 121 articles. The analysis looked at the type of research, the characteristics of both the populations involved and the co-researchers, the collaborative actions (analysed using a grid from the literature), and the difficulties in implementing these actions.

RESULTS

Thirty-one studies were included. Ten consisted of methodological studies, which tended to show the added value of collaborating with users in implementing TPE programmes compared to standard methods. The remaining 21 studies described the co-design and/or co-execution of new educational programmes. We identified 5 collaborative actions that involved a preparatory phase of the research, and 17 collaborative actions that involved the prioritization, conduct, and analysis of the research and dissemination of the results. Preventive measures are needed for potential methodological, organizational, ethical, and emotional difficulties.

DISCUSSION

The 22 identified actions need to be confirmed by other studies. The analysis grid could ultimately become a tool for guiding researchers for their researches within the CBR framework.

Changes in primary healthcare providers' attitudes and counseling behaviors related to dietary sodium reduction, DocStyles 2010 and 2015

High blood pressure is a major risk factor for cardiovascular disease. The 2013 ACC/AHA Lifestyle Management Guideline recommends counseling pre-hypertensive and hypertensive patients to reduce sodium intake. Population sodium reduction efforts have been introduced in recent years, and dietary guidelines continued to emphasize sodium reduction in 2010 and 2015. The objective of this analysis was to determine changes in primary health care providers' sodium-reduction attitudes and counseling between 2010 and 2015. Primary care internists, family/general practitioners, and nurse practitioners answered questions about sodium-related attitudes and counseling behaviors in DocStyles, a repeated cross-sectional web-based survey in the United States. Differences in responses between years were examined. In 2015, the majority (78%) of participants (n = 1,251) agreed that most of their patients should reduce sodium intake, and reported advising hypertensive (85%), and chronic kidney disease patients (71%), but not diabetic patients (48%) and African-American patients (43%) to consume less salt. Since 2010, the proportion of participants agreeing their patients should reduce sodium intake decreased while the proportion advising patients with these characteristics to consume less salt increased and the prevalence of specific types of advice declined. Changes in behaviors between surveys remained significant after adjusting for provider and practice characteristics. More providers are advising patients to consume less salt in 2015 compared to 2010; however, fewer agree their patients should reduce intake and counseling is not universally applied across patient groups at risk for hypertension. Further efforts and educational resources may be required to enable patient counseling about sodium reduction strategies.

A multicomponent quality improvement intervention to improve blood pressure and reduce racial disparities in rural primary care practices

The Southeastern United States has the highest prevalence of hypertension and African Americans have disproportionately worse blood pressure control. The authors sought to evaluate the effect of a multicomponent practice-based quality improvement intervention on lowering mean systolic blood pressure (SBP) at 12 and 24 months compared with baseline among 525 patients, and to assess for a differential effect of the intervention by race (African Americans vs white). At 12 months, both African Americans (-5.0 mm Hg) and whites (-7.8 mm Hg) had a significant decrease in mean SBP compared with baseline, with no significant between-group difference. Similarly, at 24 months, mean SBP decreased in both African Americans (-6.0 mm Hg) and whites (-7.2 mm Hg), with no significant difference between groups. Notably, no significant racial disparity in mean SBP at baseline was shown. The intervention was effective in lowering mean SBP in both African Americans and whites but there was no differential effect of the intervention by race.

The association of health literacy and blood pressure reduction in a cohort of patients with hypertension: The heart healthy lenoir trial

OBJECTIVE

Lower health literacy is associated with poorer health outcomes. Few interventions poised to mitigate the impact of health literacy in hypertensive patients have been published. We tested if a multi-level quality improvement intervention could differentially improve Systolic Blood Pressure (SBP) more so in patients with low vs. higher health literacy.

METHODS

We conducted a non-randomized prospective cohort trial of 525 patients referred with uncontrolled hypertension. Stakeholder informed and health literacy sensitive strategies were implemented at the practice and patient level. Outcomes were assessed at 0, 6, 12, 18 and 24 months.

RESULTS

At 12 months, the low and higher health literacy groups had statistically significant decreases in mean SBP (6.6 and 5.3mmHg, respectively), but the between group difference was not significant (Δ 1.3mmHg, P=0.067). At 24 months, the low and higher health literacy groups reductions were 8.1 and 4.6mmHg, respectively, again the between group difference was not significant (Δ 3.5mmHg, p=0.25).

CONCLUSIONS/PRACTICE IMPLICATIONS

A health literacy sensitive multi-level intervention may equally lower SBP in patients with low and higher health literacy. Practical health literacy appropriate tools and methods can be implemented in primary care settings using a quality improvement approach.

The effects of home blood pressure monitoring on blood pressure control and treatment planning

OBJECTIVES

Blood pressure monitoring is essential in hypertension, which is an important public health issue. Our objective was to compare the rates of blood pressure control and to investigate factors that affect blood pressure control in patients with hypertension.

METHODS

The records of 1006 patients with hypertension were examined retrospectively. The blood pressure control rates of the 394 patients who measured their blood pressure at home (group 1) and those who did not (group 2) were compared.

RESULTS

In group 1, the mean systolic and diastolic blood pressure was 123.91±12.63/78.64±8.92 mmHg measured at home, whereas it was 140.31±20.56/85.76±11.55 mmHg in the office setting (p<0.0001). In the total group (N=1006), the blood pressure control achievement rate was 56.1%. The number of cardiovascular events, hypertension duration, and the rate of being employed was higher in group 1 (p<0.0001, p<0.0001 and p=0.0001, respectively), while heart rate and grade 3-4 retinopathy was lower in group 1 (p<0.0001 for both) . Occupational status, geographical origin, BMI and the use of angiotensin converting enzyme (ACE) inhibitors were found to be the determinants of office BP control (p<0.05, p<0.05, p=0.001 and p<0.05, respectively), and BMI and grade 3-4 retinopathy findings were found to be the determinants of home BP control (p <0.05 for both).

CONCLUSION

Home blood pressure monitoring is useful in preventing complications and achieving therapy compliance and is essential in diagnosis and treatment planning of hypertension.

Using Photovoice to Understand Barriers to and Facilitators of Cardiovascular Health Among African American Adults and Adolescents, North Carolina, 2011-2012

INTRODUCTION

Cardiovascular disease is the leading cause of death in the United States, and mortality rates are higher among African Americans than among people of other races/ethnicities. We aimed to understand how African American adults and adolescents conceptualize cardiovascular health and perceive related barriers and facilitators.

METHODS

This qualitative study was conducted as formative research for a larger study, Heart Healthy Lenoir, which aimed to reduce cardiovascular disease disparities among African Americans in eastern North Carolina, part of the widely-known "stroke belt" that runs through the southeastern United States. Using photovoice, a community-based participatory research method, we conducted eight 90-minute photovoice sessions with 6 adults and 9 adolescents in Lenoir County, North Carolina. Topics for each discussion were selected by participants and reflected themes related to cardiovascular health promotion. All sessions were transcribed and coded using a data-driven, inductive approach.

RESULTS

Participants conceptualized cardiovascular health to have mental, spiritual, and social health dimensions. Given these broad domains, participants acknowledged many ecological barriers to cardiovascular health; however, they also emphasized the importance of personal responsibility. Facilitators for cardiovascular health included using social health (eg, family/community relationships) and spiritual health dimensions (eg, understanding one's body and purpose) to improve health behaviors.

CONCLUSION

The perspectives of African American adults and adolescents elicited through this formative research provided a strong foundation for Heart Healthy Lenoir's ongoing engagement of community members in Lenoir County and development and implementation of its intervention to prevent cardiovascular disease.