Faculty Bibliography

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.

BackgroundBlood pressure screening is an important component of cardiovascular disease prevention, but a hypertension diagnosis (i.e., label) can have unintended negative effects on patients' well-being. Despite persistent disparities in hypertension prevalence and outcomes, whether the impact of labeling differs by race is unknown. The purpose of this study was to evaluate possible race differences in the relationship between hypertension labeling and health-related quality of life and depression.MethodsThe sample included 308 normotensive and unmedicated hypertensive subjects from the Neighborhood Study of Blood Pressure and Sleep, a cross-sectional study conducted between 1999 and 2003. Labeled hypertension was defined (by self-report) as having been diagnosed with high blood pressure or prescribed antihypertensive medications. Effects of labeling and race on self-reported physical and mental health and depressive symptoms were tested using multivariate analysis of covariance, controlling for age, sex, body mass index (BMI), previous medication use, and "true" hypertension status, defined by average daytime ambulatory blood pressure (ABP).ResultsBoth black and white subjects who had been labeled as hypertensive reported similarly poorer physical health than unlabeled subjects (P = 0.001). However, labeling was associated with poorer mental health and greater depressive symptoms only among blacks (Ps < 0.05 for the interactions). These findings were not explained by differences in socioeconomic status.ConclusionsThese results are consistent with previous studies showing negative effects of hypertension labeling, and demonstrate important race differences in these effects. Clinical approaches to communicating diagnostic information that avoid negative effects on well-being are needed, and may require tailoring to patient characteristics such as race.American Journal of Hypertension 2012; doi:10.1038/ajh.2011.258.

OBJECTIVES: To test the hypothesis that family intervention to promote effective parenting in early childhood affects obesity in preadolescence. METHODS: Participants were 186 minority youth at risk for behavior problems who enrolled in long-term follow-up studies after random assignment to family intervention or control condition at age 4. Follow-up Study 1 included 40 girls at familial risk for behavior problems; Follow-up Study 2 included 146 boys and girls at risk for behavior problems based on teacher ratings. Family intervention aimed to promote effective parenting and prevent behavior problems during early childhood; it did not focus on physical health. BMI and health behaviors were measured an average of 5 years after intervention in Study 1 and 3 years after intervention in Study 2. RESULTS: Youth randomized to intervention had significantly lower BMI at follow-up relative to controls (Study 1 P = .05; Study 2 P = .006). Clinical impact is evidenced by lower rates of obesity (BMI >/=95th percentile) among intervention girls and boys relative to controls (Study 2: 24% vs 54%, P = .002). There were significant intervention-control group differences on physical and sedentary activity, blood pressure, and diet. CONCLUSIONS: Two long-term follow-up studies of randomized trials show that relative to controls, youth at risk for behavior problems who received family intervention at age 4 had lower BMI and improved health behaviors as they approached adolescence. Efforts to promote effective parenting and prevent behavior problems early in life may contribute to the reduction of obesity and health disparities.

BACKGROUND: Many insurance payors mandate that bariatric surgery candidates undergo a medically supervised weight management (MSWM) program as a prerequisite for surgery. However, there is little evidence to support this requirement. We evaluated in a randomized controlled trial the hypothesis that participation in a MSWM program does not predict outcomes after laparoscopic adjustable gastric banding (LAGB) in a publicly insured population. METHODS: This pilot randomized trial was conducted in a large academic urban public hospital. Patients who met NIH consensus criteria for bariatric surgery and whose insurance did not require a mandatory 6-month MSWM program were randomized to a MSWM program with monthly visits over 6 months (individual or group) or usual care for 6 months and then followed for bariatric surgery outcomes postoperatively. Demographics, weight, and patient behavior scores, including patient adherence, eating behavior, patient activation, and physical activity, were collected at baseline and at 6 months (immediately preoperatively and postoperatively). RESULTS: A total of 55 patients were enrolled in the study with complete follow-up on 23 patients. Participants randomized to a MSWM program attended an average of 2 sessions preoperatively. The majority of participants were female and non-Caucasian, mean age was 46 years, average income was less than $20,000/year, and most had Medicaid as their primary insurer, consistent with the demographics of the hospital's bariatric surgery program. Data analysis included both intention-to-treat and completers' analyses. No significant differences in weight loss and most patient behaviors were found between the two groups postoperatively, suggesting that participation in a MSWM program did not improve weight loss outcomes for LAGB. Participation in a MSWM program did appear to have a positive effect on physical activity postoperatively. CONCLUSION: MSWM does not appear to confer additional benefit as compared to the standard preoperative bariatric surgery protocol in terms of weight loss and most behavioral outcomes after LAGB in our patient population.

BACKGROUND: Despite evidence of a positive effect of collaborative patient-provider communication on patient outcomes, our understanding of this relationship is unclear. PURPOSE: The purpose of this paper is to determine whether racial composition of the relationship modified the association between ratings of provider communication and medication adherence. METHODS: Effect modification of the communication-adherence association, by racial composition of the relationship, was evaluated using general linear mixed models while adjusting for selected covariates. RESULTS: Three hundred ninety patients were in race-concordant (black patient, black provider) relationships, while 207 were in race-discordant (black patient, white provider) relationships. The communication-adherence association was significantly modified in race-discordant relationships (p = 0.04). Communication rated as more collaborative in race-discordant relationships was associated with better adherence, while communication rated as less collaborative was associated with poor adherence. There was no significant association between adherence and communication in race-concordant relationships (p = 0.24). CONCLUSIONS: Collaborative patient-provider communication may play an influential role in black patients' adherence behaviors when receiving care from white providers

Barriers to blood pressure control exist at the patient, physician, and system levels. We review the current evidence for interventions that target patient- and physician-related barriers, such as patient education, home blood pressure monitoring, and computerized decision-support systems for physicians, and we emphasize the need for more studies that address the effectiveness of these interventions in African American patients