Faculty Bibliography

BACKGROUND: Stroke is a leading cause of adult disability and mortality. Intravenous thrombolysis can minimize disability when patients present to the emergency department for treatment within the 3 - 4(1/2) h of symptom onset. Blacks and Hispanics are more likely to die and suffer disability from stroke than whites, due in part to delayed hospital arrival and ineligibility for intravenous thrombolysis for acute stroke. Low stroke literacy (poor knowledge of stroke symptoms and when to call 911) among Blacks and Hispanics compared to whites may contribute to disparities in acute stroke treatment and outcomes. Improving stroke literacy may be a critical step along the pathway to reducing stroke disparities. The aim of the current study is to test a novel intervention to increase stroke literacy in minority populations in New York City. DESIGN AND METHODS: In a two-arm cluster randomized trial, we will evaluate the effectiveness of two culturally tailored stroke education films - one in English and one in Spanish - on changing behavioral intent to call 911 for suspected stroke, compared to usual care. These films will target knowledge of stroke symptoms, the range of severity of symptoms and the therapeutic benefit of calling 911, as well as address barriers to timely presentation to the hospital. Given the success of previous church-based programs targeting behavior change in minority populations, this trial will be conducted with 250 congregants across 14 churches (125 intervention; 125 control). Our proposed outcomes are (1) recognition of stroke symptoms and (2) behavioral intent to call 911 for suspected stroke, measured using the Stroke Action Test at the 6-month and 1-year follow-up. DISCUSSION: This is the first randomized trial of a church-placed narrative intervention to improve stroke outcomes in urban Black and Hispanic populations. A film intervention has the potential to make a significant public health impact, as film is a highly scalable and disseminable medium. Since there is at least one church in almost every neighborhood in the USA, churches have the ability and reach to play an important role in the dissemination and translation of stroke prevention programs in minority communities. TRIAL REGISTRATION: NCT01909271 ; July 22, 2013.

BACKGROUND: Black and Hispanic stroke survivors experience higher rates of recurrent stroke than whites. This disparity is partly explained by disproportionately higher rates of uncontrolled hypertension in these populations. Home blood pressure telemonitoring (HBPTM) and nurse case management (NCM) have proven efficacy in addressing the multilevel barriers to blood pressure (BP) control and reducing BP. However, the effectiveness of these interventions has not been evaluated in stroke patients. This study is designed to evaluate the comparative effectiveness, cost-effectiveness and sustainability of these two telehealth interventions in reducing BP and recurrent stroke among high-risk Black and Hispanic stroke survivors with uncontrolled hypertension. METHODS/DESIGN: A total of 450 Black and Hispanic patients with recent nondisabling stroke and uncontrolled hypertension are randomly assigned to one of two 12-month interventions: 1) HBPTM with wireless feedback to primary care providers or 2) HBPTM plus individualized, culturally-tailored, telephone-based NCM. Patients are recruited from stroke centers and primary care practices within the Health and Hospital Corporations (HHC) Network in New York City. Study visits occur at baseline, 6, 12 and 24 months. The primary outcomes are within-patient change in systolic BP at 12 months, and the rate of stroke recurrence at 24 months. The secondary outcome is the comparative cost-effectiveness of the interventions at 12 and 24 months; and exploratory outcomes include changes in stroke risk factors, health behaviors and treatment intensification. Recruitment for the stroke telemonitoring hypertension trial is currently ongoing. DISCUSSION: The combination of two established and effective interventions along with the utilization of health information technology supports the sustainability of the HBPTM + NCM intervention and feasibility of its widespread implementation. Results of this trial will provide strong empirical evidence to inform clinical guidelines for management of stroke in minority stroke survivors with uncontrolled hypertension. If effective among Black and Hispanic stroke survivors, these interventions have the potential to substantially mitigate racial and ethnic disparities in stroke recurrence. TRIAL REGISTRATION: ClinicalTrials.gov NCT02011685 . Registered 10 December 2013.

Introduction: Many risk factors have been implicated in the pathophysiology of obstructive sleep apnea (OSA). Recent evidence suggests that medical risk factors, such as uncontrolled/high blood pressure (BP), high cholesterol, triglycerides, high body mass index, diabetes, and dyslipidemia (all indicators of metabolic syndrome) are highly comorbid with OSA. However, data on the relationships between these risk factors and OSA among blacks with metabolic syndrome are lacking. Methods: Data for the present study were collected from 340 participants from the Metabolic Syndrome Outcome (MetSO) study, a NIHfunded cohort study of 1,035 blacks with metabolic syndrome (mean age = 62 + 13 years, 69% female, and 43% with annual family income < $10K). During initial interviews, patients provided sociodemographic, health risks, and history of chronic diseases. Patients with a score > 6 on the Apnea Risk Evaluation System (ARES) were considered at high OSA risk. Logistic regression analyses were employed to investigate whether metabolic syndrome indicators, particularly uncontrolled blood pressure, increased the odds of OSA. Results: Of the sample, 77.1% was at risk for OSA and 16.8% had uncontrolled BP. Analysis also showed 60.4% were diabetic, 8.9% had a stroke history, 74.3% had dyslipidemia, 91.1% were either overweight or obese and 30.9% had heart disease. Mean systolic BP was 134.8 + 18.4; diastolic BP was 75.6 + 11.9; LDL cholesterol was 105.6 + 36.9; HDL cholesterol was 48.0 + 17.3; triglycerides was 135.8 + 81.2; glucose was 138.4 + 68.3; and HbA1c was 7.93 + 1.63. Logistic regression analysis showed that uncontrolled BP independently increased the odds of OSA risk (OR = 1.94, 95% CI = 1.12-3.32, p < 0.01). Conclusion: Our indings suggest that uncontrolled BP was associated with a twofold greater risk of OSA in blacks. The clinical implication of this inding is that blacks with metabolic syndrome and who have uncontrolled BP should be screened for the presence of OSA

OBJECTIVE: To examine the relationship between perceived discrimination and medication adherence among black people with hypertension and the role of stress and depressive symptoms in this relationship. Perceived racial discrimination has been associated with poor health outcomes in blacks; its relationship to medication adherence among hypertensive patients remains untested. METHODS: We measured perceived racial discrimination at baseline, stress and depressive symptoms at 6 months, and medication adherence at 12 months among patients enrolled in a 30-site cluster-randomized controlled trial testing a patient and physician-targeted intervention to improve blood pressure. A mediational method with bootstrapping (stratified by site) confidence intervals was used to estimate the indirect association between perceived discrimination and medication adherence through stress and depression. RESULTS: Of 1056 patients from 30 sites enrolled in the trial, 463 had complete data on all four measures at 6 and 12 months and were included in the analyses. Adjusting for clustering, perceived discrimination was associated with poor medication adherence (B = 0.138, p = .011) at 12 months, and with stress (B = 2.24, p = .001) and depression (B = 1.47, p = .001) at 6 months. When stress and depression were included in the model, there was a 65% reduction in the total association of perceived discrimination with medication adherence, and the relationship was no longer significant (B = 0.049, p = .35). CONCLUSIONS: Perceived discrimination is associated with poor medication adherence among hypertensive blacks, and stress and depressive symptoms may account for this relationship. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00233220.

BACKGROUND: Excessive daytime sleepiness (EDS) often occurs as a result of insufficient sleep, sleep apnea, illicit substance use, and other medical and psychiatric conditions. This study tested the hypothesis that blacks exhibiting EDS would have poorer self-reported adherence to hypertensive medication using cross-sectional data from the Counseling African-Americans to Control Hypertension (CAATCH) trial. METHODS: A total of 1,058 hypertensive blacks (average age 57+/-12 years) participated in CAATCH, a randomized controlled trial evaluating the effectiveness of a multilevel intervention for participants who receive care from community health centers in New York City. Data analyzed in this study included baseline sociodemographics, medical history, EDS, and medication adherence. We used the Epworth Sleepiness Scale, with a cutoff score of >/=10, to define EDS. Medication adherence was measured using an abbreviated Morisky Medication Adherence scale, with a score >0 indicating nonadherence. RESULTS: Of the sample, 71% were female, 72% received at least a high school education, 51% reported a history of smoking, and 33% had a history of alcohol consumption. Overall, 27% of the participants exhibited EDS, and 44% of those who exhibited EDS were classified as adherent to prescribed antihypertensive medications. Multivariable logistic regression analysis, adjusting for effects of age, body mass index, sex, education, and smoking and drinking history indicated that participants who exhibited EDS were more than twice as likely to be nonadherent (odds ratio 2.28, 95% confidence interval 1.42-3.67, P<0.001). CONCLUSION: Analysis of the CAATCH data showed a high prevalence of EDS among hypertensive blacks. EDS is a significant predictor of nonadherence to prescribed medications for hypertension. These findings point to a modifiable variable that can be targeted in future interventions focusing on medication adherence.

Background. Few studies examine psychosocial factors influencing the adoption of healthy behaviors among hypertensive patients. The effect of discrimination on health behaviors remains untested. Purpose. To examine the influence of discrimination on adoption of healthy behaviors among low-income Black hypertensive patients. Methods. Black patients (N = 930) in community-based primary care practices enrolled in the CAATCH trial. Mixed effects regressions examined associations between perceived discrimination and change in medication adherence, diet, and physical activity from baseline to 12 months, controlling for intervention, gender, age, income, and education. Results. Patients were low-income, high-school-educated, with a mean age of 57 years. Greater discrimination was associated with worse diet and lower medication adherence at baseline. Discrimination was associated with greater improvement in healthy eating behaviors over the course of the 12-month trial. Conclusions. Prior exposure to discrimination was associated with unhealthy behaviors at baseline, but did not negatively influence the adoption of health behaviors over time.