Faculty Bibliography

Despite strong evidence of effective interventions targeted at blood pressure (BP) control, there is little evidence on the translation of these approaches to routine clinical practice in care of hypertensive blacks. The goal of this study is to evaluate the effectiveness of a multilevel, multicomponent, evidence-based intervention compared with usual care in improving BP control among hypertensive blacks who receive care in community health centers. The primary outcomes are BP control rate at 12 months and maintenance of intervention 1 year after the trial. The secondary outcomes are within-patient change in BP from baseline to 12 months and cost-effectiveness of the intervention. Counseling African Americans to Control Hypertension (CAATCH) is a group randomized clinical trial with 2 conditions: intervention condition and usual care. Thirty community health centers were randomly assigned equally to the intervention condition group (n=15) or the usual care group (n=15). The intervention comprises 3 components targeted at patients (interactive computerized hypertension education, home BP monitoring, and monthly behavioral counseling on lifestyle modification) and 2 components targeted at physicians (monthly case rounds based on Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure guidelines, chart audit and provision of feedback on clinical performance and patients' home BP readings). All outcomes are assessed at quarterly study visits for 1 year. Chart review is conducted at 24 months to evaluate maintenance of intervention effects and sustainability of the intervention. Poor BP control is one of the major reasons for the mortality gap between blacks and whites. Findings from this study, if successful, will provide salient information needed for translation and dissemination of evidence-based interventions targeted at BP control into clinical practice for this high-risk population

African Americans with high blood pressure (BP) can benefit greatly from therapeutic lifestyle changes (TLC) such as diet modification, physical activity, and weight management. However, they and their health care providers face many barriers in modifying health behaviors. A multidisciplinary panel synthesized the scientific data on TLC in African Americans for efficacy in improving BP control, barriers to behavioral change, and strategies to overcome those barriers. Therapeutic lifestyle change interventions should emphasize patient self-management, supported by providers, family, and the community. Interventions should be tailored to an individual's cultural heritage, beliefs, and behavioral norms. Simultaneously targeting multiple factors that impede BP control will maximize the likelihood of success. The panel cited limited progress with integrating the Dietary Approaches to Stop Hypertension (DASH) eating plan into the African American diet as an example of the need for more strategically developed interventions. Culturally sensitive instruments to assess impact will help guide improved provision of TLC in special populations. The challenge of improving BP control in African Americans and delivery of hypertension care requires changes at the health system and public policy levels. At the patient level, culturally sensitive interventions that apply the strategies described and optimize community involvement will advance TLC in African Americans with high BP

BackgroundBetween the promise of evidence-based medicine and the reality of inadequate patient outcomes lies patient adherence. Studies of prescription adherence have been hampered by methodologic problems. Most rely on patient self-report of adherence or cross-sectional data of plan-wide prescription fills to estimate patient-level adherence.MethodsWe conducted a retrospective cohort study and linked individual patient data for incident prescriptions for antihypertensive medications from electronic health records (EHRs) to claims data obtained from the patient's insurance plan. Clinical data were obtained from the Geisinger Clinic, a 41 site group practice serving central and northeastern Pennsylvania with an EHR in use since 2001. Adherence was defined as a prescription claim generated for the first-fill prescription within 30 days of the prescribing date.ResultsOf the 3,240 patients written a new, first-time prescription for an antihypertensive medication, 2,685 (83%) generated a corresponding claim within 30 days. Sex, age, therapeutic class, number of other medications prescribed within 10 days of the antihypertensive prescription, number of refills, co-pay, comorbidity score, baseline blood pressure (BP), and change in BP were significantly associated with first-fill rates (P < 0.05).ConclusionsPatients who are older, female, have multiple comorbidities, and/or have relatively lower BPs may be less likely to fill a first prescription for antihypertensive medications and may be potential candidates for interventions to improve adherence to first-fill prescriptions.American Journal of Hypertension 2009; doi:10.1038/ajh.2008.367American Journal of Hypertension 2009; doi:10.1038/ajh.2008.367

Many studies have documented the negative effects of depression on adherence to recommended treatment; however, little is known about the mechanism underlying this relationship. Using the Kenny and Baron analytic framework of mediation, the authors assessed whether self-efficacy mediated the relationship between depression and medication adherence in 167 hypertensive African Americans followed in a primary care practice. Depressive symptoms are associated with poor medication adherence (beta = .013, p = .036) and low self-efficacy (beta = -.008, p = .023). Self-efficacy is negatively associated with medication adherence at follow-up (beta = -.612, p < .001). The relationship between depressive symptoms and medication adherence becomes nonsignificant when controlling for self-efficacy (beta = .010, p = .087). Implications for further examination into the mediating role of self-efficacy and the deleterious effect of depression on medication adherence are discussed

BACKGROUND: The white coat effect (defined as the difference between blood pressure [BP] measurements taken at the physician's office and those taken outside the office) is an important determinant of misdiagnosis of hypertension, but little is known about the mechanisms underlying this phenomenon. We tested the hypothesis that the white coat effect may be a conditioned response as opposed to a manifestation of general anxiety. METHODS: A total of 238 patients in a hypertension clinic wore ambulatory blood pressure monitors on 3 separate days 1 month apart. At each clinic visit, BP readings were manually triggered in the waiting area and the examination room (in the presence and absence of the physician) and were compared with the mercury sphygmomanometer readings taken by the physician in the examination room. Patients completed trait and state anxiety measures before and after each BP assessment. RESULTS: A total of 35% of the sample was normotensive, and 9%, 37%, and 19% had white coat, sustained, and masked hypertension, respectively. The diagnostic category was associated with the state anxiety measure (F(3,237) = 6.4, P < .001) but not with the trait anxiety measure. Patients with white coat hypertension had significantly higher state anxiety scores (t = 2.67, P < .01), with the greatest difference reported during the physician measurement. The same pattern was observed for BP changes, which generally paralleled the changes in state anxiety (t = 4.86, P < .002 for systolic BP; t = 3.51, P < .002 for diastolic BP). CONCLUSIONS: These findings support our hypothesis that the white coat effect is a conditioned response. The BP measurements taken by physicians appear to exacerbate the white coat effect more than other means. This problem could be addressed with uniform use of automated BP devices in office settings

Study purpose was to revise and examine the validity of the Medication Adherence Self-Efficacy Scale (MASES) in an independent sample of 168 hypertensive African Americans: mean age 54 years (SD = 12.36); 86% female; 76% high school education or greater. Participants provided demographic information; completed the MASES, self-report and electronic measures of medication adherence at baseline and three months. Confirmatory (CFA), exploratory (EFA) factor analyses, and classical test theory (CTT) analyses suggested that MASES is unidimensional and internally reliable. Item response theory (IRT) analyses led to a revised 13-item version of the scale: MASES-R. EFA, CTT, and IRT results provide a foundation of support for MASES-R reliability and validity for African Americans with hypertension. Research examining MASES-R psychometric properties in other ethnic groups will improve generalizability of findings and utility of the scale across groups. The MASES-R is brief, quick to administer, and can capture useful data on adherence self-efficacy

OBJECTIVES: To test the feasibility, acceptability, and effect of a senior center-based behavioral counseling lifestyle intervention on systolic blood pressure (BP). DESIGN: A pre-post design pilot trial of behavioral counseling for therapeutic lifestyle changes in minority elderly people with hypertension. Participants completed baseline visit, Visit 1 (approximately 6 weeks postbaseline), and a final study Visit 2 (approximately 14 weeks postbaseline) within 4 months. SETTING: The study took place in six community-based senior centers in New York City with 65 seniors (mean age 72.29+/-6.92; 53.8% female; 84.6% African American). PARTICIPANTS: Sixty-five minority elderly people. INTERVENTION: Six weekly and two monthly 'booster' group sessions on lifestyle changes to improve BP (e.g., diet, exercise, adherence to prescribed antihypertensive medications). MEASUREMENTS: Primary outcome was systolic BP (SBP) measured using an automated BP monitor. Secondary outcomes were diastolic BP (DBP), physical activity, diet, and adherence to prescribed antihypertensive medications. RESULTS: There was a significant reduction in average SBP of 13.0+/-21.1 mmHg for the intervention group (t(25)=3.14, P=.004) and a nonsignificant reduction in mean SBP of 10.6+/-30.0 mmHg for the waitlist control group (t(29)=1.95, P=.06). For the intervention group, adherence improved 26% (t(23)=2.31, P=.03), and vegetable intake improved 23% (t(25)=2.29, P=.03). CONCLUSION: This senior center-based lifestyle intervention was associated with a significant reduction in SBP and adherence to prescribed antihypertensive medications and diet in the intervention group. Participant retention and group attendance rates suggest that implementing a group-counseling intervention in senior centers is feasible

BackgroundPoor medication adherence is a significant problem in hypertensive African Americans. Although motivational interviewing (MINT) is effective for adoption and maintenance of health behaviors in patients with chronic diseases, its effect on medication adherence remains untested in this population.MethodsThis randomized controlled trial tested the effect of a practice-based MINT counseling vs. usual care (UC) on medication adherence and blood pressure (BP) in 190 hypertensive African Americans (88% women; mean age 54 years). Patients were recruited from two community-based primary care practices in New York City. The primary outcome was adherence measured by electronic pill monitors; the secondary outcome was within-patient change in office BP from baseline to 12 months.ResultsBaseline adherence was similar in both groups (56.2 and 56.6% for MINT and UC, respectively, P = 0.94). Based on intent-to-treat analysis using mixed-effects regression, a significant time x group interaction with model-predicted posttreatment adherence rates of 43 and 57% were found in the UC and MINT groups, respectively (P = 0.027), with a between-group difference of 14% (95% confidence interval, -0.2 to -27%). The between-group difference in systolic and diastolic BP was -6.1 mm Hg (P = 0.065) and -1.4 mm Hg (P = 0.465), respectively, in favor of the MINT group.ConclusionsA practice-based MINT counseling led to steady maintenance of medication adherence over time, compared to significant decline in adherence for UC patients. This effect was associated with a modest, nonsignificant trend toward a net reduction in systolic BP in favor of the MINT group.American Journal of Hypertension (2008). doi 10.1038/ajh.2008.240American Journal of Hypertension (2008). doi 10.1038/ajh.2008.240