Faculty Bibliography

Introduction: Fifteen million adults in the U.S. work shift schedules (characterized by work outside the conventional daytime), including on-call, night, and rotating shifts. Shift work is associated with health risks, including Type II Diabetes, hypertension, cardiovascular disease, and obstructive sleep apnea (OSA). Recent media coverage of drowsy driving incidents in transportation workers (bus and train operators) suggest current efforts to promote awareness and treatment for OSA are ineffective. In the current study, we examined sleep among transportation workers and identified avenues for programs to improve sleep health in this high-risk population. Methods: We analyzed data from surveys of employees who work in transportation (truck, snow plough, construction operators) on shift work schedules in the rural Northeast (N = 239). Participants filled out pen-and-paper surveys assessing sleep characteristics including total sleep time, sleep quality, sleep habits (using the Sleep Hygiene Index) daytime sleepiness using the Epworth Sleepiness Scale; sleep apnea risk (according to the Apnea Risk Evaluation System, ARES); and demographic/clinical factors. Results: Among the survey respondents, 42.7% (n=27) reported hypertension, 16.4% (n=18) reported sleep apnea, and 14.5% (n=16) reported diabetes. Overall, 40.5% (n=105) reported short sleep (<6hrs), while 52.1% reported sleep between 6 and 9hrs, and 0.8% reported long sleep (>9hrs). Among respondents, 24.7% (n=64) reported "very bad" or "fairly bad" sleep quality. Responses to sleep hygiene identified prevalent, but modifiable sleep habits; 55.6% (n=144) "think, plan, or worry in bed," and 48.6% (n=126) "use alcohol, tobacco, or caffeine within 4hrs of bedtime." In response to "frequency of snoring", 64.1% (n=166) of participants report "sometimes," "frequently," or "almost always" snoring. Finally, a majority of participants, 54.5% (n=60) were at "moderate" to "high" risk for OSA (>=4 on the ARES). Conclusion: Although sleep health is critical for vigilance and safe driving, individuals in transportation working on shift schedules have poor sleep quality, insufficient sleep, and are at risk for OSA. Future research should use tailored interventions to reduce modifiable barriers (e.g., caffeine close to bedtime) among transportation shift workers to improve sleep health and implement initiatives to improve OSA screening and treatment

Introduction: Sleep disorders are associated with hypertension and cardiovascular diseases (CVD), and treatment of sleep disorders may improve outcomes. To examine burden of sleep disorders, treatment rates, and racial/ethnic differences among patients with hypertension/ CVD, we examined the national burden of sleep disorders, compared with rates of sleep disorder treatments, and evaluated whether racial/ ethnic disparities exist among patients with hypertension/CVD. Methods: We analyzed data from a nationally representative US sample of 417,950 adult ambulatory visits from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey (NAMCS/NHAMCS), 2005-2012. We identified visits by adults with hypertension or CVD (coronary artery disease, congestive heart failure, or stroke) in which a diagnosis of sleep disorders or complaints were recorded. Primary measures were provision of a sleep study, medication, or behavioral therapy to improve diet, weight loss, or exercise). We conducted multivariate logistic regression analyses to examine sleep disorder treatment by demographic and clinical risk factors. Results: Sleep apnea was identified in 11.1-per-1,000 visits and insomnia in 10.5-per-1,000 visits, while any sleep disorder was identified in 22.5-per-1,000 visits. Overall, patients with hypertension and a sleep disorder were referred for a sleep study in 7.6% of visits, prescribed sleep medication in 29.7% of visits, and offered behavioral therapy in 31.0% of visits. In adjusted analyses, behavioral therapy was more likely to be provided to patients who were obese compared with those who were normal/overweight (OR=2.89; 95%CI[2.00- 4.17];p<0.001), but less likely to be provided to smokers than nonsmokers (OR=0.61; 95%CI[0.38-0.99];p<0.05). Non-hispanic blacks were less likely to receive medications than were non-Hispanic whites (OR=0.44; 95%CI[0.21-0.92];p<0.05). There were no differences in sleep study by race/ethnicity, but patients with insomnia were less likely to be referred for a sleep study compared with patients with sleep apnea (OR=0.07; 95%CI[0.03-0.18];p<.001). Conclusion: Although sleep disorders were observed in a small proportion of patients with hypertension/CVD, the prevalence rates were relatively lower than those reported for the general population. Behavioral therapy was provided in a small number of visits, and non-Hispanic Blacks were less likely to receive medications than non-Hispanic Whites

BACKGROUND: Poor medication adherence is a significant public health problem in patients with hypertension. The patient-physician relationship offers an ideal opportunity to address patient non-adherence as physicians' communication skills contribute to as much as 50%of the quality of care patients' receive. Despite this evidence, there is no empirical data on how the informational and relational aspects of patient-physician communication affect patient's actual medication-taking behaviors. The aim of this study was to evaluate the impact of patient-physician communication on medication adherence among a sample of primary care physicians and their Black and White hypertensive patients. METHODS: Cohort study of 92 hypertensive patients (mean age: 60 years) and 27 primary care physicians (mean age: 36 years) in two safety-net primary care practices in New York City. Patient-physician encounters were audiotaped at baseline; medication adherence data were gathered continuously over the 3- month study with an electronic monitoring device. Audiotape analyses of patient physician communication were coded using the Medical Interaction Process System. Six categories of communication were computed: 1) patient centeredness; 2) patient assertiveness; 3) psychosocial focus; 4) information exchange; 5) physician disclosure-promoting; and 6) physician verbal dominance. Frequencies of content codes were also calculated for the proportion of the discussion specific to: hypertension; antihypertensive medications; patient-physician social conversation; and discussions about patient's social circumstances (i.e., patient's living situation, relationship with spouse/partner). Adaptive statistical modeling methods based on likelihood cross validation were used to analyze the adherence data. RESULTS: The majority of patients were Black, 58% women, and most were seeing the same physician for at least 1 year. Approximately half of physicians were White (56%), 67% women, and have been in practice for 6 years. Fifty eight percent of patients exhibited poor adherence to prescribed antihypertensive medications. Two categories of patient-physician communication predicted poor medication adherence in the multivariate adaptive logistic regression model: fewer discussions about patients' social circumstances (OR: 6.03, 95CI:2.15- 17) and about their antihypertensive medications (OR: 5.64, 95CI:1.49-21.3). CONCLUSIONS: The odds of poor medication adherence are nearly six times greater when patient-physician interactions do not address patients' social circumstances or their medication regimen. These findings support the importance of adherence counseling and attending to the social determinants of health in routine care of low-income patients in ambulatory practices

BACKGROUND: The use of task-shifting is an increasingly widespread delivery approach for health interventions targeting prevention, treatment, and control of hypertension in adults living in sub-Saharan Africa (SSA). Addressing a gap in the literature, this research examined the sustainability of an ongoing task-shifting strategy for hypertension (TASSH) from the perspectives of community health nurses (CHNs) implementing the program. METHODS: We used concept-mapping, a mixed-methods participatory approach to understand CHNs' perceptions of barriers and enablers to sustaining a task-shifting program. Participants responded to focal prompts, eliciting statements regarding perceived barriers and enablers to sustaining TASSH, and then rated these ideas based on importance to the research questions and feasibility to address. Twenty-eight community health nurses (21 women, 7 men) from the Ashanti region of Ghana completed the concept-mapping process. RESULTS: Factors influencing sustainability were grouped into five categories: Limited Drug Supply, Financial Support, Provision of Primary Health Care, Personnel Training, and Patient-Provider Communication. The limited supply of antihypertensive medication was considered by CHNs as the most important item to address, while providing training for intervention personnel was considered most feasible to address. LINKING EVIDENCE TO ACTION: This study's findings highlight the importance of examining nurses' perceptions of factors likely to influence the sustainability of evidence-based, task-shifting interventions. Nurses' perceptions can guide the widespread uptake and dissemination of these interventions in resource-limited settings.

Background -Ambulatory blood pressure (BP) monitoring (ABPM) is the reference standard for out-of-clinic BP measurement. Thresholds for identifying ambulatory hypertension (daytime systolic BP [SBP]/diastolic BP [DBP] >/= 135/85 mmHg, 24-hour SBP/DBP >/= 130/80 mmHg, and nighttime SBP/DBP >/= 120/70 mmHg) have been derived from European, Asian and South American populations. We determined BP thresholds for ambulatory hypertension in a US population-based sample of African Americans. Methods -We analyzed data from the Jackson Heart Study (JHS), a population-based cohort study comprised exclusively of African-American adults (n=5,306). Analyses were restricted to 1,016 participants who completed ABPM at baseline in 2000-2004. Mean systolic BP (SBP) and diastolic BP (DBP) levels were calculated for daytime (10:00am-8:00pm), 24-hour (all available readings) and nighttime (midnight-6:00am) periods, separately. Daytime, 24-hour, and nighttime BP thresholds for ambulatory hypertension were identified using regression- and outcome-derived approaches. The composite of a cardiovascular disease (CVD) or all-cause mortality event was used in the outcome-derived approach. For this latter approach, BP thresholds were identified only for SBP as clinic DBP was not associated with the outcome. Analyses were stratified by antihypertensive medication use. Results -Among participants not taking antihypertensive medication, the regression-derived thresholds for daytime, 24-hour, and nighttime SBP/DBP corresponding to clinic SBP/DBP of 140/90 mmHg were 134/85 mmHg, 130/81 mmHg, and 123/73 mmHg, respectively. The outcome-derived thresholds for daytime, 24-hour, and nighttime SBP corresponding to a clinic SBP >/= 140 mmHg were 138 mmHg, 134 mmHg, and 129 mmHg, respectively. Among participants taking antihypertensive medication, the regression-derived thresholds for daytime, 24-hour, and nighttime SBP/DBP corresponding to clinic SBP/DBP of 140/90 mmHg were 135/85 mmHg, 133/82 mmHg, and 128/76 mmHg, respectively. The corresponding outcome-derived thresholds for daytime, 24-hour, and nighttime SBP were 140 mmHg, 137 mmHg, and 133 mmHg, respectively, among those taking antihypertensive medication. Conclusions -Based on the outcome-derived approach for SBP and regression-derived approach for DBP, the following definitions for daytime hypertension, 24-hour hypertension, and nighttime hypertension corresponding to clinic SBP/DBP >/= 140/90 mmHg are proposed for African Americans: daytime SBP/DBP >/= 140/85 mmHg, 24-hour SBP/DBP >/= 135/80 mmHg, and nighttime SBP/DBP >/= 130/75 mmHg, respectively.

Study Objectives: To assess effectiveness of a culturally and linguistically tailored telephone-delivered intervention to increase adherence to physician-recommended evaluation and treatment of obstructive sleep apnea (OSA) among blacks. Methods: In a two-arm randomized controlled trial, we evaluated effectiveness of the tailored intervention among blacks with metabolic syndrome, relative to those in an attention control arm (n = 380; mean age = 58 +/- 13; female = 71%). The intervention was designed to enhance adherence using culturally and linguistically tailored OSA health messages delivered by a trained health educator based on patients' readiness to change and unique barriers preventing desired behavior changes. Results: Analysis showed 69.4% of the patients in the intervention arm attended initial consultation with a sleep specialist, compared to 36.7% in the control arm; 74.7% of those in the intervention arm and 66.7% in the control arm completed diagnostic evaluation; and 86.4% in the intervention arm and 88.9% in the control arm adhered to PAP treatment based on subjective report. Logistic regression analyses adjusting for sociodemographic factors indicated patients in the intervention arm were 3.17 times more likely to attend initial consultation, compared to those in the control arm. Adjusted models revealed no significant differences between the two arms regarding adherence to OSA evaluation or treatment. Conclusion: The intervention was successful in promoting importance of sleep consultation and evaluation of OSA among blacks, while there was no significant group difference in laboratory-based evaluation and treatment adherence rates. It seems that the fundamental barrier to OSA care in that population may be the importance of seeking OSA care.

Blood pressure (BP) can differ substantially when measured in the clinic versus outside of the clinic setting. Few population-based studies with ambulatory blood pressure monitoring (ABPM) include African Americans. We calculated the prevalence of clinic hypertension and ABPM phenotypes among 1016 participants in the population-based Jackson Heart Study, an exclusively African-American cohort. Mean daytime systolic BP was higher than mean clinic systolic BP among participants not taking antihypertensive medication (127.1[standard deviation 12.8] vs. 124.5[15.7] mm Hg, respectively) and taking antihypertensive medication (131.2[13.6] vs. 130.0[15.6] mm Hg, respectively). Mean daytime diastolic BP was higher than clinic diastolic BP among participants not taking antihypertensive medication (78.2[standard deviation 8.9] vs. 74.6[8.4] mm Hg, respectively) and taking antihypertensive medication (77.6[9.4] vs. 74.3[8.5] mm Hg, respectively). The prevalence of daytime hypertension was higher than clinic hypertension for participants not taking antihypertensive medication (31.8% vs. 14.3%) and taking antihypertensive medication (43.0% vs. 23.1%). A high percentage of participants not taking and taking antihypertensive medication had nocturnal hypertension (49.4% and 61.7%, respectively), white-coat hypertension (30.2% and 29.3%, respectively), masked hypertension (25.4% and 34.6%, respectively), and a nondipping BP pattern (62.4% and 69.6%, respectively). In conclusion, these data suggest hypertension may be misdiagnosed among African Americans without using ABPM.