A Community Health Worker-Led Intervention to Improve Blood Pressure Control in an Immigrant Community With Comorbid Diabetes: Data From Two Randomized, Controlled Trials Conducted in 2011-2019

Community health worker-led interventions for hypertension

OBJECTIVES

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the effects of community health worker-led interventions on controlling blood pressure for people with hypertension.

Understanding Perceptions of Care Coordination and Chronic Illness Management among Black Breast and Prostate Cancer Survivors and Providers: Findings from a Quality Improvement Study

Navigating cancer care is complex and is exacerbated by pre-existing comorbidities managed by multiple providers. In this quality improvement study, we evaluated changes in perceived care coordination, navigation, and chronic illness care with community health worker (CHW) and mHealth support among Black breast cancer and prostate cancer patients with hypertension and/or diabetes. We collected patient and provider surveys on chronic illness care coordination at baseline and six months and found improvements in multiple domains. These findings support engaging CHWs to improve care coordination among cancer patients with comorbidities and demonstrate a use case of importance with emerging navigation reimbursement policies.

An expanded chronic care management approach to multiple chronic conditions in Hispanics using community health workers as community extenders in the Rio Grande Valley of Texas

INTRODUCTION

The synergistic negative effects of type 2 diabetes (T2DM) and hypertension increases all-cause mortality and the medical complexity of management, which disproportionately impact Hispanics who face barriers to healthcare access. The Salud y Vida intervention was delivered to Hispanic adults living along the Texas-Mexico Border with comorbid poorly controlled T2DM and hypertension. The Salud y Vida multicomponent intervention incorporated community health workers (CHWs) into an expanded chronic care management model to deliver home-based follow-up visits and provided community-based diabetes self-management education.

METHODS

We conducted multivariable longitudinal analysis to examine the longitudinal intervention effect on reducing systolic and diastolic blood pressure among 3806 participants enrolled between 2013 and 2019. Participants were compared according to their program participation as either higher (≥ 10 combined educational classes and CHW visits) or lower engagement (<10 encounters). Data was collected between 2013 and 2020.

RESULTS

Baseline mean systolic and diastolic blood pressure were 138 and 81 mmHg respectively. There were overall improvements in systolic (-6.49; 95% CI = [-7.13, -5.85]; p < 0.001) and diastolic blood pressure (-3.97; 95% CI = [-4.37, -3.56]; p < 0.001). The higher engagement group had greater systolic blood pressure reduction at 3 months (adjusted mean difference = -1.8 mmHg; 95% CI = [-3.2, -0.3]; p = 0.016) and at 15 month follow-up (adjusted mean difference = -2.3 mmHg; 95% CI = [-4.2, -0.39]; p = 0.0225) compared to the lower engagement group.

CONCLUSION

This intervention, tested and delivered in a real-world setting, provides an example of how CHW integration into an expanded chronic care model can improve blood pressure outcomes for individuals with co-morbidities.

Lay advisor interventions for hypertension outcomes: A Systematic Review, Meta-analysis and a RE-AIM evaluation

Introduction

Lay advisor interventions improve hypertension outcomes; however, the added benefits and relevant factors for their widespread implementation into health systems are unknown. We performed a systematic review to: (1) summarize the benefits of adding lay advisors to interventions on hypertension outcomes, and (2) summarize factors associated with successful implementation in health systems using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework.

Methods

We systematically searched several databases, including Ovid MEDLINE, CINAHL, PsycINFO from January 1981 to May 2023. All study designs of interventions delivered solely by lay advisors for adults with hypertension were eligible. If both arms received the lay advisor intervention, the study arm with lower intensity was assigned as the low-intensity intervention.

Results

We included 41 articles, of which 22 were RCTs, from 7,267 screened citations. Studies predominantly included socially disadvantaged populations. Meta-analysis (9 RCTs; n = 4,220) of eligible lay advisor interventions reporting outcomes showed improved systolic blood pressure (BP) [-3.72 mm Hg (CI -6.1 to -1.3; I2 88%)], and diastolic BP [-1.7 mm Hg (CI -1 to -0.9; I2 7%)] compared to control group. Pooled effect from six RCTs (n = 3,277) comparing high-intensity with low-intensity lay advisor interventions showed improved systolic BP of -3.6 mm Hg (CI -6.7 to -0.5; I2 82.7%) and improved diastolic BP of -2.1 mm Hg (CI -3.7 to -0.4; I2 70.9%) with high-intensity interventions. No significant difference in pooled odds of hypertension control was noted between lay advisor intervention and control groups, or between high-intensity and low-intensity intervention groups. Most studies used multicomponent interventions with no stepped care elements or reporting of efficacious components. Indicators of external validity (adoption, implementation, maintenance) were infrequently reported.

Discussion

Lay advisor interventions improve hypertension outcomes, with high intensity interventions having a greater impact. Further studies need to identify successful intervention and implementation factors of multicomponent interventions for stepped upscaling within healthcare system settings as well as factors used to help sustain interventions.

Paving a Path to Equity in Cardiorenal Care

Cardiorenal syndrome encompasses a dynamic interplay between cardiovascular and kidney disease, and its prevention requires careful examination of multiple predisposing underlying conditions. The unequal distribution of diabetes, heart failure, hypertension, and kidney disease requires special attention because of the influence of these conditions on cardiorenal disease. Despite growing evidence regarding the benefits of disease-modifying agents (e.g., sodium-glucose cotransporter 2 inhibitors) for cardiovascular, kidney, and metabolic (CKM) disease, significant disparities remain in access to and utilization of these essential therapeutics. Multilevel barriers impeding their use require multisector interventions that address patient, provider, and health system-tailored strategies. Burgeoning literature also describes the critical role of unequal social determinants of health, or the sociopolitical contexts in which people live and work, in cardiorenal risk factors, including heart failure, diabetes, and chronic kidney disease. This review outlines (i) inequality in the burden and treatment of hypertension, type 2 diabetes, and heart failure; (ii) disparities in the use of key disease-modifying therapies for CKM diseases; and (iii) multilevel barriers and solutions to achieve greater pharmacoequity in the use of disease-modifying therapies. In addition, this review provides summative evidence regarding the role of unequal social determinants of health in cardiorenal health disparities, further outlining potential considerations for future research and intervention. As proposed in the 2023 American Heart Association presidential advisory on CKM health, a paradigm shift will be needed to achieve cardiorenal health equity. Through a deeper understanding of CKM health and a commitment to equity in the prevention, detection, and treatment of CKM disease, we can achieve this critical goal.

Person-Centered Models for Cardiovascular Care: A Review of the Evidence: A Scientific Statement From the American Heart Association

Cardiovascular disease remains the leading cause of death and disability in the United States and globally. Disease burden continues to escalate despite technological advances associated with improved life expectancy and quality of life. As a result, longer life is associated with multiple chronic cardiovascular conditions. Clinical guidelines provide recommendations without considering prevalent scenarios of multimorbidity and health system complexities that affect practical adoption. The diversity of personal preferences, cultures, and lifestyles that make up one's social and environmental context is often overlooked in ongoing care planning for symptom management and health behavior support, hindering adoption and compromising patient outcomes, particularly in groups at high risk. The purpose of this scientific statement was to describe the characteristics and reported outcomes in existing person-centered care delivery models for selected cardiovascular conditions. We conducted a scoping review using Ovid MEDLINE, Embase.com, Web of Science, CINAHL Complete, Cochrane Central Register of Controlled Trials through Ovid, and ClinicalTrials.gov from 2010 to 2022. A range of study designs with a defined aim to systematically evaluate care delivery models for selected cardiovascular conditions were included. Models were selected on the basis of their stated use of evidence-based guidelines, clinical decision support tools, systematic evaluation processes, and inclusion of the patient's perspective in defining the plan of care. Findings reflected variation in methodological approach, outcome measures, and care processes used across models. Evidence to support optimal care delivery models remains limited by inconsistencies in approach, variation in reimbursement, and inability of health systems to meet the needs of patients with chronic, complex cardiovascular conditions.

Innovative Remote Management Solutions for the Control of Hypertension

We stand at a critical juncture in the delivery of health care for hypertension. Blood pressure control rates have stagnated, and traditional health care is failing. Fortunately, hypertension is exceptionally well-suited to remote management, and innovative digital solutions are proliferating. Early strategies arose with the spread of digital medicine, long before the COVID-19 pandemic forced lasting changes to the way medicine is practiced. Highlighting one contemporary example, this review explores salient features of remote management hypertensive programs, including: an automated algorithm to guide clinical decisions, home (as opposed to office) blood pressure measurements, an interdisciplinary care team, and robust information technology and analytics. Dozens of emerging hypertension management solutions are contributing to a highly fragmented and competitive landscape. Beyond viability, profit and scalability are critical. We explore the challenges impeding large-scale acceptance of these programs and conclude with a hopeful look to the future when remote hypertension care will have dramatic impact on global cardiovascular health.

Participant engagement in a community health worker-delivered intervention and type 2 diabetes clinical outcomes: a quasiexperimental study in MexicanAmericans

OBJECTIVES

This study helps to fill the existing research gap related to participant engagement in behavioural interventions and diabetes management. We examined type 2 diabetes control over time among Mexican Americans by level of engagement in a chronic care management (CCM) program that included community health worker (CHW)-delivered multilevel interventions. The programme complemented clinical care and promoted behaviour changes to improve diabetes self-management.

DESIGN

Quasiexperimental study.

SETTING

The study was implemented in the Rio Grande Valley region in the USA. Recruitment was conducted in clinics and community events. All other visits were provided in participant homes and community locations.

PARTICIPANTS

5649 adults (aged ≥18 years) with poorly controlled type 2 diabetes who enrolled in a community-delivered CCM programme between September 2013 and 2018.

INTERVENTIONS

The intervention comprised two components: CHW home visits conducted every 3 months and diabetes self-management education (DSME) classes provided in community locations.

PRIMARY OUTCOME MEASURES

The primary outcome was haemoglobin A1c (HbA1c) measured at baseline every 3 months for up to 24 months. We first examined changes in HbA1c levels over time. The number of completed CHW and DSME encounters was used to classify participants into engagement groups-high engagement defined as ≥10 encounters (n=2952); low engagement defined as 1-9 encounters (n=2697). We used univariable and multivariable longitudinal linear regression models with a generalised estimating equation method. We tested interactions between engagement groups and time.

RESULTS

Participants' mean HbA1c decreased from 10.20% at baseline to 8.93% (p<0.0001) at 3 months, remaining stable thereafter. Changes in HbA1c were statistically different between the engagement groups. High engagement participants had lower HbA1c levels over the first 15 months of the follow-up period compared with low engagement participants, as compared at 3 months (-0.44%, 95% CI -0.57% to -0.31%; p<0.0001), 6 months (-0.31%, 95% CI -0.43% to -0.14%; p<0.0001), 9 months (-0.27%, 95% CI -0.42% to -0.13%; p=0.0001), 12 months (-0.23%, 95% CI -0.37% to -0.08%; p=0.0025) and 15 months (-0.32%, 95% CI -0.54% to -0.10%; p=0.0040). At months 18, 21 and 24, the HbA1c differences were not statistically significant (18 months: -0.34%, 95% CI -0.77% to 0.08%; p=0.1086; 21 months: -0.22%, 95% CI -1.00% to 0.56%; p=0.5721; 24 months: -0.42%, 95% CI -1.38% to 0.55%; p=0.3966).

CONCLUSIONS

Higher engagement in the CCM programme delivered by CHWs and coordinated with clinical care was associated with beneficial improvements in type 2 diabetes control, but both engagement groups showed strong improvements.

Protocol and baseline characteristics for a community health worker-led hypertension and diabetes management program for South Asians in Atlanta: The DREAM Atlanta study

BACKGROUND

South Asians are disproportionately affected by type 2 diabetes (DMII) and comorbid hypertension (HTN). Community health worker (CHW) interventions have been shown to improve chronic disease outcomes, yet few have been tailored for South Asians. This paper describes the study protocol and baseline characteristics of an evidence-based CHW intervention to improve blood pressure (BP) control among South Asian adults with diabetes and comorbid HTN in Atlanta, GA.

METHODS

A total of 195 South Asian adults were randomized to treatment and control groups, and of these 190 completed baseline surveys (97 treatment group and 93 control group). The treatment group receives five group education sessions on DMII and HTN management and two one-on-one goal setting sessions.

MEASURES

Primary outcomes include feasibility, acceptability, and BP control (systolic blood pressure [SBP] <130 and diastolic blood pressure [DBP] <80). Secondary outcomes included changes in glycated hemoglobin (HbA1c), weight, diabetes self-efficacy, diet, and physical activity.

BASELINE RESULTS

Of the enrolled sample, 56% are female and mean age is 56.0 (±11.7). All participants are foreign-born. Mean SBP was 139.2 ± 4.3 and mean DBP was 84.7 ± 9.5. Intervention outcomes are measured at baseline and 6-month endpoint for both study groups.

CONCLUSIONS

To our knowledge, this study is the first to document the efficacy of a HTN and DMII management intervention among South Asian adults in Atlanta, GA. Future findings of the submitted protocol will fill an important gap on the translation and adaption of evidence-based interventions that have relevance to immigrant and minority populations.

CLINICAL TRIALS REGISTRATION

NCT04263311.

"The More We Know, the More We're Able to Help": Participatory Development of an Evaluation Framework for Community Health Worker Programs

CONTEXT

It is critical to evaluate community health worker (CHW) programs to maximize effectiveness. However, there is little consensus, and structure, for how to evaluate such programs.

OBJECTIVE

The purpose of this study was to develop a flexible framework for evaluating components of CHW programs in community and clinical settings.

DESIGN

Semistructured interviews were conducted with CHWs and their supervisors to determine evaluation categories for the framework. A survey was then administered to pilot the framework at federally qualified health centers and community-based organizations with existing CHW programs.

SETTING

Eighteen federally qualified health centers and community-based organizations in Louisiana, Mississippi, Alabama, and Florida.

PARTICIPANTS

Participants consisted of 23 CHWs and 19 CHW supervisors.

RESULTS

Interview participants directly informed the development of an evaluation framework for CHW programs. The framework consists of 7 evaluation categories: client relations, intraorganizational relations, interorganizational relations, capacity development, program effectiveness, cost-efficiency, and sustainability. Survey respondents specified best practices for program implementation for each evaluation category. Recommendations for CHW program evaluation include tailoring evaluation efforts and data collection methods to program context, using mixed-methods approaches for collecting evaluation data, and streamlining evaluation efforts with an organization's existing evaluation systems.

CONCLUSIONS

The evaluation framework is a flexible and practical model for collecting information needed for monitoring and evaluating CHW programs. By relying on practitioners' perspectives, this study contributes to an evidence base for implementing and evaluating CHW programs.

Diabetes and hypertension among South Asians in New York and Atlanta leveraging hospital electronic health records

BACKGROUND

Diabetes and hypertension disparities are pronounced among South Asians. There is regional variation in the prevalence of diabetes and hypertension in the US, but it is unknown whether there is variation among South Asians living in the US. The objective of this study was to compare the burden of diabetes and hypertension between South Asian patients receiving care in the health systems of two US cities.

METHODS

Cross-sectional analyses were performed using electronic health records (EHR) for 90,137 South Asians receiving care at New York University Langone in New York City (NYC) and 28,868 South Asians receiving care at Emory University (Atlanta). Diabetes was defined as having 2 + encounters with a diagnosis of diabetes, having a diabetes medication prescribed (excluding Acarbose/Metformin), or having 2 + abnormal A1C levels (≥ 6.5%) and 1 + encounter with a diagnosis of diabetes. Hypertension was defined as having 3 + BP readings of systolic BP ≥ 130 mmHg or diastolic BP ≥ 80 mmHg, 2 + encounters with a diagnosis of hypertension, or having an anti-hypertensive medication prescribed.

RESULTS

Among South Asian patients at these two large, private health systems, age-adjusted diabetes burden was 10.7% in NYC compared to 6.7% in Atlanta. Age-adjusted hypertension burden was 20.9% in NYC compared to 24.7% in Atlanta. In Atlanta, 75.6% of those with diabetes had comorbid hypertension compared to 46.2% in NYC.

CONCLUSIONS

These findings suggest differences by region and sex in diabetes and hypertension risk. Additionally, these results call for better characterization of race/ethnicity in EHRs to identify ethnic subgroup variation, as well as intervention studies to reduce lifestyle exposures that underlie the elevated risk for type 2 diabetes and hypertension development in South Asians.