Faculty Bibliography

Objectives: In spite of gains in hypertension awareness and treatment among African-Americans (AAs) over the past two decades, the proportion of AAs who achieve control still lags behind other groups. In 2004, NHLBI funded five projects to evaluate clinically feasible interventions in health care settings to increas the proportion of AA patients with controlled BP. Three of the groups collaborated to perform a pooled analysis of their trial results to: (1) determine whether small intervention effects seen in the individual trials were significant in the pooled sample; and (2) identify trends that could inform the design of future health-system level BP interventions. Methods: Each trial enrolled AAs with uncontrolled hypertension and targeted both patient and clinician behaviors to reduce BP. Randomization was by cluster. We used mixed effects longitudinal regression to assess the 12-month effect on SBP and

Introduction: Lifestyle changes of modernization, increased automation, dietary changes and related events have contributed to increased prevalence of heart disease worldwide. Rate of heart disease among

Patient adherence to antihypertensive medication is an important strategy for blood pressure control in hypertensive patients. However, rates of antihypertensive medication adherence among hypertensive African-Americans are unacceptably low. This article examines the current understanding of patient, clinical, provider and healthcare system factors associated with medication adherence in hypertensive African-Americans. Studies demonstrated that patient and clinical factors, such as self-efficacy and depression, are consistently associated with medication adherence in hypertensive African-Americans patients. Provider communication shows promise as a correlate of medication adherence, but more research on provider and healthcare system factors are still needed. The authors recommend that interventions targeted at increasing medication adherence among hypertensive African-Americans focus on self-efficacy. It is also imperative that clinicians screen hypertensive patients for depression and treat, if necessary.

BACKGROUND: Several reports have demonstrated a relationship between post-traumatic stress disorder (PTSD) and type 2 diabetes (T2DM) mainly in combat veterans. The relationship between PTSD and T2DM has not been evaluated among vulnerable migrant populations. The main objective of this study was therefore to assess the relationship between PTSD and T2DM among asylum seekers in the Netherlands. METHODS: Analysis of a national electronic database of the Dutch Community Health Services for Asylum seekers aged>/=18 years (N=105,180). RESULTS: Asylum seekers with PTSD had a higher prevalence of T2DM compared with those without PTSD. The age-adjusted prevalence ratios (APR) were 1.40 (95% CI, 1.12-1.76) in men and 1.22 (95% CI, 0.95-1.56) in women compared with individuals without PTSD, respectively. There was an interaction between PTSD and comorbid depression (P<0.05) in men and women, indicating that the effect of PTSD and comorbid depression on T2DM differed. When the analyses were stratified by depression status, among non-depressed group, individuals with PTSD had a higher prevalence of T2DM compared with those without PTSD [APR=1.47 (95% CI, 1.15-1.87) in men and APR=1.27 (95% CI, 0.97-1.66) in women]. Among the depressed individuals, however, there was no association between PTSD and T2DM [APR=0.87 (95% CI, 0.43-1.76) in men, and APR=1.00, (95% CI, 0.54-1.83) in women]. CONCLUSION: The findings suggest that history of PTSD is related to high levels of T2DM among asylum seekers independent of comorbid depression. Clinicians and policy makers need to take PTSD into account when assessing and treating diabetes among vulnerable migrant populations.

OBJECTIVE: To assess whether functional capacity is a better predictor of coronary heart disease (CHD) than depression or abnormal sleep duration. METHODS: Adult civilians in the USA (n=29,818, mean age 48+/-18years, range 18-85years) were recruited by a cross-sectional household interview survey using multistage area probability sampling. Data on chronic conditions, estimated habitual sleep duration, functional capacity, depressed moods, and sociodemographic characteristics were obtained. RESULTS: Thirty-five percent of participants reported reduced functional capacity. The CHD rates among White and Black Americans were 5.2% and 4%, respectively. Individuals with CHD were more likely to report extreme sleep durations (short sleep [5h] or long sleep [9h]; odds ratio [OR] 1.65, 95% confidence interval [CI] 1.38-1.97; P<0.0001), less likely to be functionally active (anchored by the ability to walk one-quarter of a mile without assistance [OR 6.27, 95% CI 5.64-6.98; P<0.0001]) and more likely to be depressed (OR 1.78, 95% CI 1.60-1.99; P<0.0001) than their counterparts. On multivariate regression analysis adjusting for sociodemographic factors and health characteristics, only functional capacity remained an independent predictor of CHD (OR 1.81, 95% CI 1.42-2.31; P<0.0001). CONCLUSION: Functional capacity was an independent predictor of CHD in the study population, whereas depression and sleep duration were not independent predictors.

BACKGROUND: Electronic monitoring devices (EMDs) are regarded as the "gold standard" for assessing medication adherence in research. Although EMD data provide rich longitudinal information, they are typically not used to their maximum potential. Instead, EMD data are usually combined into summary measures, which lack sufficient detail for describing complex medication-taking patterns. This paper uses recently developed methods for analyzing EMD data that capitalize more fully on their richness. METHODS: Recently developed adaptive statistical modeling methods were used to analyze EMD data collected with medication event monitoring system (MEMS) caps in a clinical trial testing the effects of motivational interviewing on adherence to antihypertensive medications in a cohort of hypertensive African-Americans followed for 12 months in primary care practices. This was a secondary analysis of EMD data for 141 of the 190 patients from this study for whom MEMS data were available. RESULTS: Nonlinear adherence patterns for 141 patients were generated, clustered into seven adherence types, categorized into acceptable (for example, high or improving) versus unacceptable (for example, low or deteriorating) adherence, and related to adherence self-efficacy and blood pressure. Mean adherence self-efficacy was higher across all time points for patients with acceptable adherence in the intervention group than for other patients. By 12 months, there was a greater drop in mean post-baseline blood pressure for patients in the intervention group, with higher baseline blood pressure values than those in the usual care group. CONCLUSION: Adaptive statistical modeling methods can provide novel insights into patients' medication-taking behavior, which can inform development of innovative approaches for tailored interventions to improve medication adherence.

J Clin Hypertens (Greenwich). 2012;14:250-255. (c)2012 Wiley Periodicals, Inc. The problem of medication adherence is pronounced in hypertensive black men. However, factors influencing their adherence are not well understood. This secondary analysis of the ongoing Counseling African Americans to Control Hypertension (CAATCH) randomized clinical trial investigated the patient, provider, and health care system factors associated with medication adherence among hypertensive black men. Participants (N=253) were aged 56.6+/-11.6 years, earned <$20,000 yearly (72.7%), and almost one half were on Medicaid (44%). Mean systolic blood pressure was 148.7+/-15.8 mm Hg and mean diastolic blood pressure was 92.7+/-9.8 mm Hg. Over one half of participants (54.9%) were nonadherent. In a hierarchical regression analysis, the patient factors that predicted medication adherence were age, self-efficacy, and depression. The final model accounted for 32.1% of the variance (F=7.80, df 10, 165, P<.001). In conclusion, age, self-efficacy, and depression were associated with antihypertensive medication adherence in black men followed in Community/Migrant Health Centers. Age is a characteristic that may allow clinicians to predict who may be at risk for poor medication adherence. Depression can be screened for and treated. Self-efficacy is modifiable and its implications for practice would be the development of interventions to increase self-efficacy in black men with hypertension.