1
|
Khanal MK, Bhandari P, Dhungana RR, Bhandari P, Rawal LB, Gurung Y, Paudel KN, Singh A, Devkota S, de Courten B. Effectiveness of community-based health education and home support program to reduce blood pressure among patients with uncontrolled hypertension in Nepal: A cluster-randomized trial. PLoS One 2021; 16:e0258406. [PMID: 34637478 PMCID: PMC8509872 DOI: 10.1371/journal.pone.0258406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 09/03/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Hypertension is a major global public health problem. Elevated blood pressure can cause cardiovascular and kidney diseases. We assessed the effectiveness of health education sessions and home support programs in reducing blood pressure among patients with uncontrolled hypertension in a suburban community of Nepal. METHODS We conducted a community-based, open-level, parallel-group, cluster randomized controlled trial in Birendranagar municipality of Surkhet, Nepal. We randomly assigned four clusters (wards) into intervention and control arms. We provided four health education sessions, frequent home and usual care for intervention groups over six months. The participants of the control arm received only usual care from health facilities. The primary outcome of this study was the proportion of controlled systolic blood pressure (SBP). The analysis included all participants who completed follow-up at six months. RESULTS 125 participants were assigned to either the intervention (n = 63) or the control (n = 62) group. Of them, 60 participants in each group completed six months follow-up. The proportion of controlled SBP was significantly higher among the intervention participants compared to the control (58.3% vs. 40%). Odds ratio of this was 2.1 with 95% CI: 1.01-4.35 (p = 0.046) and that of controlled diastolic blood pressure (DBP) was 1.31 (0.63-2.72) (p = 0.600). The mean change (follow-up minus baseline) in SBP was significantly higher in the intervention than in the usual care (-18.7 mmHg vs. -11.2 mmHg, p = 0.041). Such mean change of DBP was also higher in the intervention (-10.95 mmHg vs. -5.53 mmHg, p = 0.065). The knowledge score on hypertension improved by 2.38 (SD 2.4) in the intervention arm, which was significantly different from that of the control group, 0.13 (1.8) (p<0.001). CONCLUSIONS Multiple health education sessions complemented by frequent household visits by health volunteers can effectively improve knowledge on hypertension and reduce blood pressure among uncontrolled hypertensive patients at the community level in Nepal. TRIAL REGISTRATION ClinicalTrial.gov: NCT02981251.
Collapse
Affiliation(s)
- Mahesh Kumar Khanal
- Provincial Ayurveda Hospital, Ministry of Health and Population, Lumbini Province, Nepal
| | | | - Raja Ram Dhungana
- Institute for Health and Sport, Victoria University, Melbourne, Australia
| | - Pratik Bhandari
- Faculty of SEBE, Deakin University, Warun Ponds, VIC, Australia
| | - Lal B. Rawal
- School of Health, Medical and Applied Sciences, College of Science and Sustainability, Central Queensland University, Sydney Campus, Australia
- Physical Activity Research Group, Appleton Institute, Central Queensland University, Rockhampton, Australia
- Translational Health Research Institute (THRI), Western Sydney University, Penrith, Australia
| | - Yadav Gurung
- Child and Youth Health Research Center, Auckland University of Technology, Auckland, New Zealand
| | - K. N. Paudel
- Province Hospital, Ministry of Social Development, Karnali Province, Surkhet, Nepal
| | - Amit Singh
- Province Hospital, Ministry of Social Development, Karnali Province, Surkhet, Nepal
| | - Surya Devkota
- Department of Cardiology, Manmohan Cardiothoracic Vascular and Transplant Centre, Institute of Medicine, Tribhuvan University, Kirtipur, Nepal
| | - Barbora de Courten
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| |
Collapse
|
2
|
Edmondson D, Falzon L, Sundquist KJ, Julian J, Meli L, Sumner JA, Kronish IM. A systematic review of the inclusion of mechanisms of action in NIH-funded intervention trials to improve medication adherence. Behav Res Ther 2018; 101:12-19. [PMID: 29033097 PMCID: PMC5800992 DOI: 10.1016/j.brat.2017.10.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 09/12/2017] [Accepted: 10/01/2017] [Indexed: 10/18/2022]
Abstract
Medication nonadherence contributes to morbidity/mortality, but adherence interventions yield small and inconsistent effects. Understanding the mechanisms underlying initiation and maintenance of adherence could improve interventions. The National Institutes of Health (NIH) support adherence research, but it is unclear whether existing NIH-funded research incorporates mechanisms. We conducted a systematic review to determine the proportion of NIH-funded adherence trials that have tested hypothesized mechanisms of intervention effects. We included randomized and quasi-randomized NIH-funded trials with medication adherence in adults as the primary outcome. Studies were identified by searching electronic databases from inception to 6/2016, references, and clinicaltrials.gov. Two of 18 (11%) NIH-funded trials tested a hypothesized mechanism of an intervention's effect on medication adherence. Another 44 studies with medication adherence as a secondary outcome were described in protocol form, and are either ongoing or never published results, but none mentioned mechanism tests. Overall, 3% of NIH-funded trials with adherence as an outcome conducted, or plan to conduct, tests of behavior change mechanisms. These results mirror previous findings that very few studies of behavior change interventions actually test the mechanism by which the intervention is hypothesized to improve health behaviors. We must understand mechanisms if we are to improve the effectiveness of interventions.
Collapse
Affiliation(s)
- Donald Edmondson
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, 622 W. 168th Street, New York, NY, United States.
| | - Louise Falzon
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, 622 W. 168th Street, New York, NY, United States
| | - Kevin J Sundquist
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, 622 W. 168th Street, New York, NY, United States
| | - Jacob Julian
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, 622 W. 168th Street, New York, NY, United States
| | - Laura Meli
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, 622 W. 168th Street, New York, NY, United States; Teachers College, Department of Counseling and Clinical Psychology, Columbia University, 428 Horace Mann, New York, NY, United States
| | - Jennifer A Sumner
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, 622 W. 168th Street, New York, NY, United States
| | - Ian M Kronish
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, 622 W. 168th Street, New York, NY, United States
| |
Collapse
|
3
|
Edmondson D, Falzon L, Sundquist KJ, Julian J, Meli L, Sumner JA, Kronish IM. A systematic review of the inclusion of mechanisms of action in NIH-funded intervention trials to improve medication adherence. Behav Res Ther 2017. [PMID: 29033097 DOI: 10.1016/j.brat.2017.10.001.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2022]
Abstract
Medication nonadherence contributes to morbidity/mortality, but adherence interventions yield small and inconsistent effects. Understanding the mechanisms underlying initiation and maintenance of adherence could improve interventions. The National Institutes of Health (NIH) support adherence research, but it is unclear whether existing NIH-funded research incorporates mechanisms. We conducted a systematic review to determine the proportion of NIH-funded adherence trials that have tested hypothesized mechanisms of intervention effects. We included randomized and quasi-randomized NIH-funded trials with medication adherence in adults as the primary outcome. Studies were identified by searching electronic databases from inception to 6/2016, references, and clinicaltrials.gov. Two of 18 (11%) NIH-funded trials tested a hypothesized mechanism of an intervention's effect on medication adherence. Another 44 studies with medication adherence as a secondary outcome were described in protocol form, and are either ongoing or never published results, but none mentioned mechanism tests. Overall, 3% of NIH-funded trials with adherence as an outcome conducted, or plan to conduct, tests of behavior change mechanisms. These results mirror previous findings that very few studies of behavior change interventions actually test the mechanism by which the intervention is hypothesized to improve health behaviors. We must understand mechanisms if we are to improve the effectiveness of interventions.
Collapse
Affiliation(s)
- Donald Edmondson
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, 622 W. 168th Street, New York, NY, United States.
| | - Louise Falzon
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, 622 W. 168th Street, New York, NY, United States
| | - Kevin J Sundquist
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, 622 W. 168th Street, New York, NY, United States
| | - Jacob Julian
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, 622 W. 168th Street, New York, NY, United States
| | - Laura Meli
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, 622 W. 168th Street, New York, NY, United States; Teachers College, Department of Counseling and Clinical Psychology, Columbia University, 428 Horace Mann, New York, NY, United States
| | - Jennifer A Sumner
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, 622 W. 168th Street, New York, NY, United States
| | - Ian M Kronish
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, 622 W. 168th Street, New York, NY, United States
| |
Collapse
|
4
|
Burke LE, Ma J, Azar KMJ, Bennett GG, Peterson ED, Zheng Y, Riley W, Stephens J, Shah SH, Suffoletto B, Turan TN, Spring B, Steinberger J, Quinn CC. Current Science on Consumer Use of Mobile Health for Cardiovascular Disease Prevention: A Scientific Statement From the American Heart Association. Circulation 2015; 132:1157-213. [PMID: 26271892 DOI: 10.1161/cir.0000000000000232] [Citation(s) in RCA: 366] [Impact Index Per Article: 40.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
|
5
|
Whittle J, Schapira MM, Fletcher KE, Hayes A, Morzinski J, Laud P, Eastwood D, Ertl K, Patterson L, Mosack KE. A randomized trial of peer-delivered self-management support for hypertension. Am J Hypertens 2014; 27:1416-23. [PMID: 24755206 PMCID: PMC4263938 DOI: 10.1093/ajh/hpu058] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Accepted: 03/02/2014] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Peer-led interventions to improve chronic disease self-management can improve health outcomes but are not widely used. Therefore, we tested a peer-led hypertension self-management intervention delivered at regular meetings of community veterans' organizations. METHODS We randomized 58 organizational units ("posts") of veterans' organizations in southeast Wisconsin to peer-led vs. professionally delivered self-management education. Volunteer peer leaders at peer-led posts delivered monthly presentations regarding hypertension self-management during regular post meetings. Volunteer post representatives at seminar posts encouraged post members to attend 3 didactic seminars delivered by health professionals at a time separate from the post meeting. Volunteers in both groups encouraged members to self-monitor using blood pressure cuffs, weight scales, and pedometers. Our primary outcome was change in systolic blood pressure (SBP) at 12 months. RESULTS We measured SBP in 404 participants at baseline and in 379 participants at 12 months. SBP decreased significantly (4.4mm Hg; P < 0.0001) overall; the decrease was similar in peer-led and seminar posts (3.5mm Hg vs. 5.4mm Hg; P = 0.24). Among participants with uncontrolled BP at baseline, SBP decreased by 10.1mm Hg from baseline to 12 months but was again similar in the 2 groups. This pattern was also seen at 6 months and with diastolic blood pressure. CONCLUSIONS Our peer-led educational intervention was not more effective than didactic seminars for SBP control. Although peer-led educational programs have had important impacts in a number of studies, we did not find our intervention superior to a similar intervention delivered by healthcare professionals. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov NCT00571038.
Collapse
Affiliation(s)
| | - Marilyn M Schapira
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Center for Health Equity Research and Promotion, Philadelphia VA, Philadelphia, PA
| | | | - Avery Hayes
- Primary Care Division, Clement J. Zablocki VA Medical Center, Milwaukee, WI
| | - Jeffrey Morzinski
- Department of Family and Community Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Purushottam Laud
- Center for Patient Care Outcomes Research, Medical College of Wisconsin, Milwaukee, WI; Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, WI
| | - Dan Eastwood
- Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, WI
| | - Kristyn Ertl
- Center for Patient Care Outcomes Research, Medical College of Wisconsin, Milwaukee, WI
| | - Leslie Patterson
- Department of Family and Community Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Katie E Mosack
- Department of Psychology, University of Wisconsin-Milwaukee, Milwaukee, WI
| |
Collapse
|
6
|
Abstract
Hypertension is a major modifiable risk factor for cardiovascular, retinal, and kidney disease. In the past decade, attainment rates of treatment targets for blood pressure control in the UK and US have increased; however, <11% of adult men and women have achieved adequate blood pressure control. Technological advances in blood pressure measurement and data transmission may improve the capture of information but also alter the relationship between the patient and the provider of care. Telemonitoring systems can be used to manage patients with hypertension, and have the ability to enable best-practice decisions more consistently. The improvement in choice for patients as to where and who manages their hypertension, as well as better adherence to treatment, are potential benefits. An evidence base is growing that shows that telemonitoring can be more effective than usual care in improving attainment rates of goal blood pressure in the short-to-medium term. In addition, studies are in progress to assess whether this technology could be a part of the solution to address the health care needs of an aging population and improve access for those suffering health inequalities. The variation in methods and systems used in these studies make generalizability to the general hypertension population difficult. Concerns over the reliability of technology, impact on patient quality of life, longer-term utility and cost-benefit analyses all need to be investigated further if wider adoption is to occur.
Collapse
Affiliation(s)
| | - Kenneth Anthony Earle
- Thomas Addison Unit, St George’s Hospital, London, UK
- Clinical Sciences, St George’s University of London, London, UK
| |
Collapse
|
7
|
Flynn SJ, Ameling JM, Hill-Briggs F, Wolff JL, Bone LR, Levine DM, Roter DL, Lewis-Boyer L, Fisher AR, Purnell L, Ephraim PL, Barbers J, Fitzpatrick SL, Albert MC, Cooper LA, Fagan PJ, Martin D, Ramamurthi HC, Boulware LE. Facilitators and barriers to hypertension self-management in urban African Americans: perspectives of patients and family members. Patient Prefer Adherence 2013; 7:741-9. [PMID: 23966772 PMCID: PMC3743518 DOI: 10.2147/ppa.s46517] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION We aimed to inform the design of behavioral interventions by identifying patients' and their family members' perceived facilitators and barriers to hypertension self-management. MATERIALS AND METHODS We conducted focus groups of African American patients with hypertension and their family members to elicit their views about factors influencing patients' hypertension self-management. We recruited African American patients with hypertension (n = 18) and their family members (n = 12) from an urban, community-based clinical practice in Baltimore, Maryland. We conducted four separate 90-minute focus groups among patients with controlled (one group) and uncontrolled (one group) hypertension, as well as their family members (two groups). Trained moderators used open-ended questions to assess participants' perceptions regarding patient, family, clinic, and community-level factors influencing patients' effective hypertension self-management. RESULTS Patient participants identified several facilitators (including family members' support and positive relationships with doctors) and barriers (including competing health priorities, lack of knowledge about hypertension, and poor access to community resources) that influence their hypertension self-management. Family members also identified several facilitators (including their participation in patients' doctor's visits and discussions with patients' doctors outside of visits) and barriers (including their own limited health knowledge and patients' lack of motivation to sustain hypertension self-management behaviors) that affect their efforts to support patients' hypertension self-management. CONCLUSION African American patients with hypertension and their family members reported numerous patient, family, clinic, and community-level facilitators and barriers to patients' hypertension self-management. Patients' and their family members' views may help guide efforts to tailor behavioral interventions designed to improve hypertension self-management behaviors and hypertension control in minority populations.
Collapse
Affiliation(s)
- Sarah J Flynn
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Jessica M Ameling
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Felicia Hill-Briggs
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jennifer L Wolff
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Division of Geriatric Medicine and gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lee R Bone
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - David M Levine
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Debra l Roter
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - LaPricia Lewis-Boyer
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Annette R Fisher
- Community and Provider Advisory Board, Johns Hopkins Center to Eliminate Cardiovascular Health Disparities, Baltimore, MD, USA
| | - Leon Purnell
- Community and Provider Advisory Board, Johns Hopkins Center to Eliminate Cardiovascular Health Disparities, Baltimore, MD, USA
| | - Patti L Ephraim
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jeffrey Barbers
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Stephanie L Fitzpatrick
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Michael C Albert
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins Community Physicians, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Lisa A Cooper
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Peter J Fagan
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins Healthcare LLC, Glen Burnie, MD, USA
| | - Destiny Martin
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hema C Ramamurthi
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - L Ebony Boulware
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| |
Collapse
|
8
|
Willard-Grace R, DeVore D, Chen EH, Hessler D, Bodenheimer T, Thom DH. The effectiveness of medical assistant health coaching for low-income patients with uncontrolled diabetes, hypertension, and hyperlipidemia: protocol for a randomized controlled trial and baseline characteristics of the study population. BMC FAMILY PRACTICE 2013; 14:27. [PMID: 23433349 PMCID: PMC3616979 DOI: 10.1186/1471-2296-14-27] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Accepted: 02/08/2013] [Indexed: 01/13/2023]
Abstract
BACKGROUND Many patients with chronic disease do not reach goals for management of their conditions. Self-management support provided by medical assistant health coaches within the clinical setting may help to improve clinical outcomes, but most studies to date lack statistical power or methodological rigor. Barriers to large scale implementation of the medical assistant coach model include lack of clinician buy-in and the absence of a business model that will make medical assistant health coaching sustainable. This study will add to the evidence base by determining the effectiveness of health coaching by medical assistants on clinical outcomes and patient self-management, by assessing the impact of health coaching on the clinician experience, and by examining the costs and potential savings of health coaching. METHODS/DESIGN This randomized controlled trial will evaluate the effectiveness of clinic-based medical assistant health coaches to improve clinical outcomes and self-management skills among low-income patients with uncontrolled type 2 diabetes, hypertension, or hyperlipidemia. A total of 441 patients from two San Francisco primary care clinics have been enrolled and randomized to receive a health coach (n = 224) or usual care (n = 217). Patients participating in the health coaching group will receive coaching for 12 months from medical assistants trained as health coaches. The primary outcome is a change in hemoglobin A1c, systolic blood pressure, or LDL cholesterol among patients with uncontrolled diabetes, hypertension and hyperlipidemia, respectively. Self-management behaviors, perceptions of the health care team and clinician, BMI, and chronic disease self-efficacy will be measured at baseline and after 12 months. Clinician experience is being assessed through surveys and qualitative interviews. Cost and utilization data will be analyzed through cost-predictive models. DISCUSSION Medical assistants are an untapped resource to provide self-management support for patients with uncontrolled chronic disease. Having successfully completed recruitment, this study is uniquely poised to assess the effectiveness of the medical assistant health coaching model, to describe barriers and facilitators to implementation, and to develop a business case for sustainability. TRIAL REGISTRATION ClinicalTrials.gov identifier NCT-01220336.
Collapse
Affiliation(s)
- Rachel Willard-Grace
- Department of Family and Community Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Denise DeVore
- Department of Family and Community Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Ellen H Chen
- Department of Family and Community Medicine, University of California San Francisco, San Francisco, CA, USA
- San Francisco Department of Public Health, Silver Avenue Family Health Center, San Francisco, CA, USA
| | - Danielle Hessler
- Department of Family and Community Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Thomas Bodenheimer
- Department of Family and Community Medicine, University of California San Francisco, San Francisco, CA, USA
| | - David H Thom
- Department of Family and Community Medicine, University of California San Francisco, San Francisco, CA, USA
| |
Collapse
|
9
|
Hebert PL, Sisk JE, Tuzzio L, Casabianca JM, Pogue VA, Wang JJ, Chen Y, Cowles C, McLaughlin MA. Nurse-led disease management for hypertension control in a diverse urban community: a randomized trial. J Gen Intern Med 2012; 27:630-9. [PMID: 22143452 PMCID: PMC3358388 DOI: 10.1007/s11606-011-1924-1] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2010] [Revised: 04/25/2011] [Accepted: 09/29/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND Treated but uncontrolled hypertension is highly prevalent in African American and Hispanic communities. OBJECTIVE To test the effectiveness on blood pressure of home blood pressure monitors alone or in combination with follow-up by a nurse manager. DESIGN Randomized controlled effectiveness trial. PATIENTS Four hundred and sixteen African American or Hispanic patients with a history of uncontrolled hypertension. Patients with blood pressure ≥150/95, or ≥140/85 for patients with diabetes or renal disease, at enrollment were recruited from one community clinic and four hospital outpatient clinics in East and Central Harlem, New York City. INTERVENTION Patients were randomized to receive usual care or a home blood pressure monitor plus one in-person counseling session and 9 months of telephone follow-up with a registered nurse. During the trial, the home monitor alone arm was added. MAIN MEASURES Change in systolic and diastolic blood pressure at 9 and 18 months. KEY RESULTS Changes from baseline to 9 months in systolic blood pressure relative to usual care was -7.0 mm Hg (Confidence Interval [CI], -13.4 to -0.6) in the nurse management plus home blood pressure monitor arm, and +1.1 mm Hg (95% CI, -5.5 to 7.8) in the home blood pressure monitor only arm. No statistically significant differences in systolic blood pressure were observed among treatment arms at 18 months. No statistically significant improvements in diastolic blood pressure were found across treatment arms at 9 or 18 months. Changes in prescribing practices did not explain the decrease in blood pressure in the nurse management arm. CONCLUSIONS A nurse management intervention combining an in-person visit, periodic phone calls, and home blood pressure monitoring over 9 months was associated with a statistically significant reduction in systolic, but not diastolic, blood pressure compared to usual care in a high risk population. Home blood pressure monitoring alone was no more effective than usual care.
Collapse
Affiliation(s)
- Paul L Hebert
- Department of Health Services, University of Washington School of Public Health, Washington, DC, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Cooper LA, Roter DL, Carson KA, Bone LR, Larson SM, Miller ER, Barr MS, Levine DM. A randomized trial to improve patient-centered care and hypertension control in underserved primary care patients. J Gen Intern Med 2011; 26:1297-304. [PMID: 21732195 PMCID: PMC3208476 DOI: 10.1007/s11606-011-1794-6] [Citation(s) in RCA: 135] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Revised: 06/13/2011] [Accepted: 06/22/2011] [Indexed: 01/13/2023]
Abstract
BACKGROUND African Americans and persons with low socioeconomic status (SES) are disproportionately affected by hypertension and receive less patient-centered care than less vulnerable patient populations. Moreover, continuing medical education (CME) and patient-activation interventions have infrequently been directed to improve the processes of care for these populations. OBJECTIVE To compare the effectiveness of patient-centered interventions targeting patients and physicians with the effectiveness of minimal interventions for underserved groups. DESIGN Randomized controlled trial conducted from January 2002 through August 2005, with patient follow-up at 3 and 12 months, in 14 urban, community-based practices in Baltimore, Maryland. PARTICIPANTS Forty-one primary care physicians and 279 hypertension patients. INTERVENTIONS Physician communication skills training and patient coaching by community health workers. MAIN MEASURES Physician communication behaviors; patient ratings of physicians' participatory decision-making (PDM), patient involvement in care (PIC), reported adherence to medications; systolic and diastolic blood pressure (BP) and BP control. KEY RESULTS Visits of trained versus control group physicians demonstrated more positive communication change scores from baseline (-0.52 vs. -0.82, p = 0.04). At 12 months, the patient+physician intensive group compared to the minimal intervention group showed significantly greater improvements in patient report of physicians' PDM (β = +6.20 vs. -5.24, p = 0.03) and PIC dimensions related to doctor facilitation (β = +0.22 vs. -0.17, p = 0.03) and information exchange (β = +0.32 vs. -0.22, p = 0.005). Improvements in patient adherence and BP control did not differ across groups for the overall patient sample. However, among patients with uncontrolled hypertension at baseline, non-significant reductions in systolic BP were observed among patients in all intervention groups-the patient+physician intensive (-13.2 mmHg), physician intensive/patient minimal (-10.6 mmHg), and the patient intensive/physician minimal (-16.8 mmHg), compared to the patient+physician minimal group (-2.0 mmHg). CONCLUSION Interventions that enhance physicians' communication skills and activate patients to participate in their care positively affect patient-centered communication, patient perceptions of engagement in care, and may improve systolic BP among urban African-American and low SES patients with uncontrolled hypertension.
Collapse
Affiliation(s)
- Lisa A Cooper
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD 21287, USA.
| | | | | | | | | | | | | | | |
Collapse
|
11
|
Bosworth HB, Powers BJ, Oddone EZ. Patient self-management support: novel strategies in hypertension and heart disease. Cardiol Clin 2010; 28:655-63. [PMID: 20937448 PMCID: PMC3763915 DOI: 10.1016/j.ccl.2010.07.003] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Cardiovascular diseases (CVDs) have become the leading cause of death and disability in most countries in the world. This article addresses how patient self-management is a crucial component of effective high-quality health care for hypertension and CVD. The patient must be a collaborator in this process, and methods of improving patients' ability and confidence for self-management are needed. Successful self-management programs have often supplemented the traditional patient-physician encounter by using nonphysician providers, remote patient encounters (telephone or Internet), group settings, and peer support for promoting self-management. Several factors need to be considered in self-management. Given the health care system's inability to achieve several quality indicators using traditional office-based physician visits, further consideration is needed to determine the degree to which these interventions and programs can be integrated into primary care, their effectiveness in different groups, and their sustainability for improving chronic disease care.
Collapse
Affiliation(s)
- Hayden B. Bosworth
- Center for Health Services Research in Primary Care, Durham VAMC, Durham NC, Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, 2424 Erwin Road, Hock Plaza, Durham, NC 27703. (O): 919 286-6936. (F): 919 668-1300.
| | - Benjamin J. Powers
- Center for Health Services Research in Primary Care, Durham VAMC, Durham NC, Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, 2424 Erwin Road, Hock Plaza, Durham, NC 27703. (O): 919 286-6936. (F): 919 668-1300.
| | - Eugene Z. Oddone
- Center for Health Services Research in Primary Care, Durham VAMC, Durham NC, Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, 2424 Erwin Road, Hock Plaza, Durham, NC 27703. (O): 919 286-6936. (F): 919 668-1300.
| |
Collapse
|
12
|
Galzerano D, Capogrosso C, Di Michele S, Bobbio E, Paparello P, Gaudio C. Do we need more than just powerful blood pressure reductions? New paradigms in end-organ protection. Vasc Health Risk Manag 2010; 6:479-94. [PMID: 20730064 PMCID: PMC2922309 DOI: 10.2147/vhrm.s7969] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2010] [Indexed: 01/13/2023] Open
Abstract
Antihypertensive therapy can lower the risk of cardiovascular morbidity and mortality. Yet, partly because of inadequate dosing, wrong pharmacological choices, and poor patient adherence, hypertension control remains suboptimal in the majority of hypertensive patients. Achieving greater blood pressure control requires a multifaceted approach that raises awareness of hypertension, uses effective therapies, and improves adherence. Particular classes of antihypertensive therapy have beneficial actions beyond blood pressure and studies have evaluated differences in cardiovascular protection among classes. The LIFE and HOPE studies showed between-class differences that may be due to effects other than blood pressure-lowering. In the ONTARGET study, telmisartan and ramipril provided similar cardiovascular protection but adherence was higher with telmisartan, which was better tolerated. This difference in compliance is likely to be important for long-term therapy. The selection of an agent for cardiovascular protection should depend on an appreciation of its composite properties, including any beneficial effects on tolerability and increased patient adherence, as these are likely to be advantageous for the long-term management of hypertension. This review examines the evidence that the effects beyond blood pressure provided by some antihypertensive agents can also lower the risk of cardiovascular, cerebrovascular, and renal events in patients with hypertension.
Collapse
|
13
|
McAlister FA, Majumdar SR, Padwal RS, Fradette M, Thompson A, Tsuyuki R, Grover SA, Dean N, Shuaib A. The preventing recurrent vascular events and neurological worsening through intensive organized case-management (PREVENTION) trial protocol [clinicaltrials.gov identifier: NCT00931788]. Implement Sci 2010; 5:27. [PMID: 20385021 PMCID: PMC2868046 DOI: 10.1186/1748-5908-5-27] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2009] [Accepted: 04/12/2010] [Indexed: 11/10/2022] Open
Abstract
Background Survivors of transient ischemic attack (TIA) or stroke are at high risk for recurrent vascular events and aggressive treatment of vascular risk factors can reduce this risk. However, vascular risk factors, especially hypertension and high cholesterol, are not managed optimally even in those patients seen in specialized clinics. This gap between the evidence for secondary prevention of stroke and the clinical reality leads to suboptimal patient outcomes. In this study, we will be testing a pharmacist case manager for delivery of stroke prevention services. We hypothesize this new structure will improve processes of care which in turn should lead to improved outcomes. Methods We will conduct a prospective, randomized, controlled open-label with blinded ascertainment of outcomes (PROBE) trial. Treatment allocation will be concealed from the study personnel, and all outcomes will be collected in an independent and blinded manner by observers who have not been involved in the patient's clinical care or trial participation and who are masked to baseline measurements. Patients will be randomized to control or a pharmacist case manager treating vascular risk factors to guideline-recommended target levels. Eligible patients will include all adult patients seen at stroke prevention clinics in Edmonton, Alberta after an ischemic stroke or TIA who have uncontrolled hypertension (defined as systolic blood pressure (BP) > 140 mm Hg) or dyslipidemia (fasting LDL-cholesterol > 2.00 mmol/L) and who are not cognitively impaired or institutionalized. The primary outcome will be the proportion of subjects who attain 'optimal BP and lipid control'(defined as systolic BP < 140 mm Hg and fasting LDL cholesterol < 2.0 mmol/L) at six months compared to baseline; 12-month data will also be collected for analyses of sustainability of any effects. A variety of secondary outcomes related to vascular risk and health-related quality of life will also be collected. Conclusions Nearly one-quarter of those who survive a TIA or minor stroke suffer another vascular event within a year. If our intervention improves the provision of secondary prevention therapies in these patients, the clinical (and financial) implications will be enormous.
Collapse
Affiliation(s)
- Finlay A McAlister
- Division of General Internal Medicine, University of Alberta Hospital, 8440 112 Street, Edmonton, Canada.
| | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Horowitz CR, Robinson M, Seifer S. Community-based participatory research from the margin to the mainstream: are researchers prepared? Circulation 2009; 119:2633-42. [PMID: 19451365 PMCID: PMC2796448 DOI: 10.1161/circulationaha.107.729863] [Citation(s) in RCA: 303] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Despite an increasing arsenal of effective treatments, there are mounting challenges in developing strategies that prevent and control cardiovascular diseases, and that can be sustained and scaled to meet the needs of those most vulnerable to their impact. Community-based participatory research (CBPR) is an approach to conducting research by equitably partnering researchers and those directly affected by and knowledgeable of the local circumstances that impact health. To inform research design, implementation and dissemination, this approach challenges academic and community partners to invest in team building, share resources, and mutually exchange ideas and expertise. CBPR has led to a deeper understanding of the myriad factors influencing health and illness, a stream of ideas and innovations, and there are expanding opportunities for funding and academic advancement. To maximize the chance that CBPR will lead to tangible, lasting health benefits for communities, researchers will need to balance rigorous research with routine adoption of its conduct in ways that respectfully, productively and equally involve local partners. If successful, lessons learned should inform policy and inspire structural changes in healthcare systems and in communities.
Collapse
Affiliation(s)
- Carol R Horowitz
- Department of Health Policy, Mount Sinai School of Medicine, 1425 Madison Ave, New York, NY 10029, USA.
| | | | | |
Collapse
|
15
|
Feldman PH, McDonald MV, Mongoven JM, Peng TR, Gerber LM, Pezzin LE. Home-based blood pressure interventions for blacks. Circ Cardiovasc Qual Outcomes 2009; 2:241-8. [PMID: 20031844 PMCID: PMC2846559 DOI: 10.1161/circoutcomes.109.849943] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Efforts to increase blood pressure (BP) control rates in blacks, a traditionally underserved high-risk population must address both provider practice and patient adherence issues. The home-based BP Intervention for blacks study is a 3-arm randomized controlled trial designed to test 2 strategies to improve hypertension management and outcomes in a decentralized service setting serving a vulnerable and complex home care population. The primary study outcomes are systolic BP, diastolic BP, and BP control; secondary outcomes are nurse adherence to hypertension management recommendations and patient adherence to medication, healthy diet, and other self-management strategies. Nurses (n=312) in a nonprofit Medicare-certified home health agency are randomized along with their eligible hypertensive patients (n=845). The 2 interventions being tested are (1) a "basic" intervention delivering key evidence-based reminders to home care nurses and patients while the patient is receiving traditional postacute home health care; and (2) an "augmented" intervention that includes that same as the basic intervention, plus transition to an ongoing Hypertension Home Support Program that extends support for 12 months. Outcomes are measured at 3 and 12 months after baseline interview. The interventions will be assessed relative to usual care and to each other. Systems change to improve BP management and outcomes in home health will not easily occur without new intervention models and rigorous evaluation of their impact. Results from this trial will provide important information on potential strategies to improve BP control in a low-income chronically ill patient population.
Collapse
Affiliation(s)
- Penny H Feldman
- Center for Home Care Policy and Research, Visiting Nurse Service of New York, New York, NY 10021, USA.
| | | | | | | | | | | |
Collapse
|
16
|
Cooper LA. A 41-year-old African American man with poorly controlled hypertension: review of patient and physician factors related to hypertension treatment adherence. JAMA 2009; 301:1260-72. [PMID: 19258571 PMCID: PMC2846298 DOI: 10.1001/jama.2009.358] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Mr R is an African American man with a long history of poorly controlled hypertension and difficulties with adherence to recommended treatments. Despite serious complications such as hypertensive emergency requiring hospitalization and awareness of the seriousness of his illness, Mr R says at times he has ignored his high blood pressure and his physicians' recommendations. African Americans are disproportionately affected by hypertension and its complications. Although most pharmacological and dietary therapies for hypertension are similarly efficacious for African Americans and whites, disparities in hypertension treatment persist. Like many patients, Mr R faces several barriers to effective blood pressure control: societal, health system, individual, and interactions with health professionals. Moreover, evidence indicates that patients' cognitive, affective, and attitudinal factors and the patient-physician relationship play critical roles in improving outcomes and reducing racial disparities in hypertension control.
Collapse
Affiliation(s)
- Lisa A Cooper
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
| |
Collapse
|