Evaluating the efficacy of telephone-based outreach in addressing hypertension control among black men with severe hypertension: An observational study.

BACKGROUND: The high prevalence of uncontrolled hypertension (systolic blood pressure [SBP] ≥140 mmHg or diastolic blood pressure [DBP] ≥90 mmHg) in Black patients represents a significant racial health disparity in the United States. AIMS: This study evaluated the efficacy of a telephone-based strategy for inviting high-risk patients with severe hypertension to weekly self-management education classes. Further, the study assessed how the outreach intervention correlated with relevant quality improvement outcomes, including improved blood pressure and primary care follow-up among our clinic population of Black men with severe hypertension. METHODS: A cohort of 265 Black men aged ≥18 years with SBP ≥160 mmHg or DBP ≥100 mmHg at the most recent clinic visit were identified using Epic reports formatted for Federal Uniformed Data Set annual reporting. Telephone outreach was used to invite the cohort to attend weekly in-person classes facilitated by various healthcare professionals. Logistic regression was performed to determine the associations between being reached by phone with (1) class attendance and (2) follow-up appointment attendance. RESULTS: Most of the Black men were single (57.4%, n = 152), 49.1% had history of alcohol or substance use (n = 130), and 35.8% (n = 95) was uninsured. The average age was 55.6 years (SD = 11.6). After controlling for sociodemographic factors, being reached by phone was significantly associated with an increased likelihood of patient attendance at follow-up appointments (OR = 1.91, p = .038) but not with class attendance (OR = 2.45, p = .155). Patients who attended a follow-up appointment experienced significant reductions in both SBP and DBP at 9 months. LINKING EVIDENCE TO ACTION: Telephone outreach was labor-intensive but effective in keeping under-resourced patient populations engaged in primary care. Future work should aim to develop more efficient strategies for engaging high-risk patients in self-monitoring education to manage hypertension.

Patient expectations and preferences for community-based hypertension classes with implications for action.

BACKGROUND: Uncontrolled hypertension disproportionately affects Black men. Patient engagement with health promotion and health behavior programs for hypertension control is low. We held evidence-based hypertension classes at a Federally Qualified Health Center. AIMS: The aim of this project was to elicit patient preferences and expectations for community-based hypertension classes. METHODS: Group hypertension classes were held at a Federally Qualified Health Center. The priority population was Black men with hypertension. Semi-structured interviews were conducted with the group class attendees. Two independent coders performed content analysis using field notes from the interviews. RESULTS: Seven group class attendees were interviewed. Six interviewees were Black males, one was a Black female, and the mean age was 65.7 years. Content analysis of the interview field notes revealed five content areas: (1) Recommendation of Group Classes to a Friend, (2) Expectations for the Group Classes, (3) Reasons for Continued Attendance, (4) Lifestyle Changes and Adopting the Group Class Lessons, and (5) Feedback and Recommendations to Improve Group Classes. Findings suggest that creating a cultural context in which open, transparent discussion of blood pressure occur can be achieved. Thus, regarding acceptability, classes fulfilled and often exceeded the attendees' expectations and needs. LINKING EVIDENCE TO ACTION: Our findings suggest that community-based group classes are a viable intervention to contribute toward addressing the disparity of hypertension control among Black men. When designing peer-group interventions, taking patient preferences and expectations into account increases the effectiveness of these interventions. The qualitative narrative provided in this paper contributes to the development of similar community-based group classes for the management of severe hypertension.

Efficacy of Hypertension Self-Management Classes Among Patients at a Federally Qualified Health Center.

Structural racism has contributed to persistent racial disparities in hypertension control, with Black men suffering the highest prevalence of uncontrolled hypertension. Lincoln Community Health Center, our urban Federally Qualified Health Center (FQHC), aimed to use hypertension self-management classes to improve hypertension control among our clinic patients, particularly Black men. Patients attending classes learned about hypertension, were given blood pressure cuffs to use at home, and had the opportunity to speak to physicians in a group setting. We used a nonexperimental quality improvement intervention design to identify baseline differences between participants who attended multiple classes and those who attended only 1 class. Participants who attended multiple classes, most of whom were Black men, achieved an average blood pressure reduction of 19.1/14.8 mm Hg. Although the classes were effective, current policies around health insurance reimbursement and federal quality reporting standards hamper the ability of health care providers to implement such patient education initiatives.

Lessons from implementing community-based group classes for severe hypertension.

Due to the impact of persistent structural racism, Black men have low rates of hypertension treatment and control despite having high rates of hypertension-related mortality. Peer-based education can improve blood pressure monitoring and lower blood pressure in Black men with hypertension. To address this disparity, we implemented weekly community-based group classes for severe hypertension at a Federally Qualified Health Center. After 9 months, 28 classes were held and 96 individuals were served. Fifty-six percent of the person-hours of attendance have been by Black men. Seven individuals were interviewed about their perspectives and preferences for the classes. They reported that the peer-based model of the group classes was advantageous, and they would recommend the classes to a friend. Successes of implementation included (a) ability to facilitate medication adjustments for participants with blood pressure readings that were over target goal, (b) capacity to give participants take-home blood pressure monitors, (c) and the community-centered approach. Challenges included variability in attendance by participants and retention of individuals with uncontrolled hypertension in primary care. These findings have implications for other Federally Qualified Health Centers seeking to design similar health promotion programs and policy makers evaluating the funding and reimbursement models for community-based disease management programs.

Reducing high-risk medication use through pharmacist-led interventions in an outpatient setting.

OBJECTIVE: This study aimed to reduce high-risk medication (HRM) prescribing by direct electronic medical record messaging to providers. SETTING: Lincoln Community Health Center is a federally qualified health center in the southeast United States. PRACTICE DESCRIPTION: This was a single-center, observational study performed with quality improvement methodology including define, measure, analyze, improve, and control phases. A total of 89 patients, aged 65 years or older, received 115 HRM prescriptions from August 2016 to August 2018. Project follow-up period included September 2018 to April 2019, with 19 additional patients receiving 23 HRM prescriptions. PRACTICE INNOVATION: Shared electronic medical records allowed pharmacists to electronically communicate indication of HRM, possible alternatives to HRM, and pharmacy of choice to providers to reduce HRM prescribing. Pharmacists' recommendations were timed to appear in providers' inboxes 3 to 5 days before the patient's clinic visit. Patients not returning to the clinic in a timely manner were telephoned by pharmacists with medical provider approved HRM alternative recommendations. EVALUATION: Discontinuation of HRMs were verified by chart review and insurance claims. The Cochran-Armitage trend test was used to examine significance of change related to national benchmark prescribing rates. Two-sided z test was used to analyze significance of change from implementation to follow-up period. RESULTS: Fifty-two provider communications sent by clinical pharmacists resulted in a therapy modification rate of 71.2%. National benchmark data that reflected a peak HRM prescribing rate of 10.7% was reduced to 1.9% within 18 months (P = 0.014). The national benchmark goal of less than 3% HRM prescribing was achieved and sustained from February 2019 to May 2019. CONCLUSION: Using interdisciplinary access to electronic medical records resulted in significant rates of HRM discontinuation. Timing messages before patient clinic visits promotes shared decision making.

Addressing Diabetes and Poorly Controlled Hypertension: Pragmatic mHealth Self-Management Intervention.

BACKGROUND: Patients with diabetes and poorly controlled hypertension are at increased risk for adverse renal and cardiovascular outcomes. Identifying these patients early and addressing modifiable risk factors is central to delaying renal complications such as diabetic kidney disease. Mobile health (mHealth), a relatively inexpensive and easily scalable technology, can facilitate patient-centered care and promote engagement in self-management, particularly for patients of lower socioeconomic status. Thus, mHealth may be a cost-effective way to deliver self-management education and support. OBJECTIVE: This feasibility study aimed to build a population management program by identifying patients with diabetes and poorly controlled hypertension who were at risk for adverse renal outcomes and evaluate a multifactorial intervention to address medication self-management. We recruited patients from a federally qualified health center (FQHC) in an underserved, diverse county in the southeastern United States. METHODS: Patients were identified via electronic health record. Inclusion criteria were age between 18 and 75 years, diagnosis of type 2 diabetes, poorly controlled hypertension over the last 12 months (mean clinic systolic blood pressure [SBP] ≥140 mm Hg and/or diastolic blood pressure [DBP] ≥90 mm Hg), access to a mobile phone, and ability to receive text messages and emails. The intervention consisted of monthly telephone calls for 6 months by a case manager and weekly, one-way informational text messages. Engagement was defined as the number of phone calls completed during the intervention; individuals who completed 4 or more calls were considered engaged. The primary outcome was change in SBP at the conclusion of the intervention. RESULTS: Of the 141 patients enrolled, 84.0% (118/141) of patients completed 1 or more phone calls and had follow-up SBP measurements for analysis. These patients were on average 56.9 years of age, predominately female (73/118, 61.9%), and nonwhite by self-report (103/118, 87.3%). The proportion of participants with poor baseline SBP control (50/118, 42.4%) did not change significantly at study completion (53/118, 44.9%) (P=.64). Participants who completed 4 or more phone calls (98/118, 83.1%) did not experience a statistically significant decrease in SBP when compared to those who completed fewer calls. CONCLUSION: We did not reduce uncontrolled hypertension even among the more highly engaged. However, 83% of a predominately minority and low-income population completed at least 67% of the multimodal mHealth intervention. Findings suggest that combining an automated electronic health record system to identify at-risk patients with a tailored mHealth protocol can provide education to this population. While this intervention was insufficient to effect behavioral change resulting in better hypertension control, it does suggest that this FQHC population will engage in low-cost population health applications with a potentially promising impact. TRIAL REGISTRATION: ClinicalTrials.gov NCT02418091; https://clinicaltrials.gov/ct2/show/NCT02418091 (Archived by WebCite at http://www.webcitation.org/76RBvacVU).

Implementing standardized substance use disorder screening in primary care.

OBJECTIVES: This quality improvement initiative aimed to develop and implement a protocol for an alcohol and substance use disorder screening for primary care. METHODS: The Two Item Conjoint Screen was selected and a process was piloted by care teams. Quality improvement tools were used to improve the protocol. Primary care providers (PCPs) were surveyed about their use of the screening protocol in the primary care setting. Data on total number of screenings were collected through the electronic health record. RESULTS: Implementation resulted in more than 30,000 screenings completed in 2016. PCP survey results indicated that PCPs felt screening was helpful in identifying potential substance use problems (100%) and that most providers (76%) felt that overall patient care improved after screening was initiated. CONCLUSIONS: Brief alcohol and substance use disorder screenings can be easily implemented and well integrated into primary care settings. PCPs found screenings to be valuable in caring for patients.

Computed tomography utilization in the North Carolina Medicaid population with a focus on "high exposure" patients, 2007-2012.

BACKGROUND: We examined trends in utilization of computed tomography (CT) among Medicaid enrollees in North Carolina, the clinical setting in which those CT scans were performed, and the number of enrollees known to have undergone 10 or more scans in a given year. METHODS: North Carolina Medicaid claims were analyzed to determine the number of CT studies performed between January 1, 2007, and December 31, 2012. We assessed the number of "high exposure" patients--those who received 10 or more CT scans in a given calendar year--and divided this group into patients with a diagnosis of cancer and patients without a diagnosis of cancer. We also determined the type of site at which each CT scan was performed. RESULTS: Over the 6-year period 2007-2012, the percentage of all enrollees who underwent any CT study ranged from 8.0% to 9.6% (126,082-177,425 enrollees). The number of CT scans performed annually increased from 2007 to 2009 and then plateaued. The number of high-exposure patients increased gradually, from 2,171 in 2007 to 4,017 in 2012. The majority of CT scans of high--exposure patients--150,241 of 251,052 (59.8%)--were performed in non office outpatient settings, such as emergency departments or urgent care centers. CONCLUSION: Although the number of CT scans performed annually in the North Carolina Medicaid population stabilized in the late 2000s (as did CT use nationally), the percentage of high-exposure patients has continued to rise. Physicians and patients need to be further educated in order to promote radiation safety and to decrease unnecessary radiation exposure.

With "big data" comes big responsibility: outreach to North Carolina Medicaid patients with 10 or more computed tomography scans in 12 months.

BACKGROUND: Patients are being exposed to increasing levels of ionizing radiation, much of it from computed tomography (CT) scans. METHODS: Adults without a cancer diagnosis who received 10 or more CT scans in 2010 were identified from North Carolina Medicaid claims data and were sent a letter in July 2011 informing them of their radiation exposure; those who had undergone 20 or more CT scans in 2010 were also telephoned. The CT scan exposure of these high-exposure patients during the 12 months following these interventions was compared with that of adult Medicaid patients without cancer who had at least 1 CT scan but were not in the intervention population. RESULTS: The average number of CT scans per month for the high-exposure population decreased over time, but most of that reduction occurred 6-9 months before our interventions took place. At about the same time, the number of CT scans per month also decreased in adult Medicaid patients without cancer who had at least 1 CT scan but were not in the intervention population. LIMITATIONS: Our data do not include information about CT scans that may have been performed during times when patients were not covered by Medicaid. Some of our letters may not have been received or understood. Some high-exposure patients were unintentionally excluded from our study because organization of data on Medicaid claims varies by setting of care. CONCLUSION: Our patient education intervention was not temporally associated with significant decreases in subsequent CT exposure. Effecting behavior change to reduce exposure to ionizing radiation requires more than an educational letter or telephone call.

Applying the RE-AIM framework to evaluate an educational model to "close the gap" and improve health equity in uncontrolled hypertension.

OBJECTIVES: To use the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework to evaluate an educational model addressing self-management of uncontrolled hypertension. METHODS: We used a pre-post single cohort design to identify minoritized patients with uncontrolled hypertension (systolic > 160 mmHg and/or diastolic > 100 mmHg). Trained Ambassadors provided telephone outreach, skill-based blood pressure (BP) monitoring, and goal-setting for 4 months. Follow-up occurred at 7 months. We evaluated the initiative using the RE-AIM framework and quantitative analysis for process and outcome measures post-intervention. RESULTS: Among Black patients (n = 345), the average age was 55.4 years (8.7), half identified as male (n = 173, 50.1 %); many were uninsured (n = 159, 46.1 %). Engagement in calls occurred for 67.8 % (n = 234) of the cohort; monitor distribution was 22.9 % (n = 79); and goal setting occurred for 64 patients. BP improved for 40 % of the cohort (mean pre: 168/98 mmHg, mean post: 150/89 mmHg; p < 0.0001) and 40 % of patients' last known BP was < 140/90. CONCLUSIONS: RE-AIM evaluation of the Closing the Gap initiative suggests that the model is associated with BP reduction in high-risk Black patients. PRACTICE IMPLICATIONS: An educational model for patient-centered hypertension management in low-income populations is feasible and addresses self-monitoring barriers.

Reaching the Hard-to-Reach: Outcomes of the Severe Hypertension Outreach Intervention.

INTRODUCTION: Severe hypertension (≥180 mmHg systolic or ≥110 mmHg diastolic) is associated with a twofold increase in the relative risk of death. At the authors' Federally Qualified Health Center in the Southeast, 39% of adults (n=8,695) had hypertension, and 3% (n=235) were severe. The purpose of this project was to lower blood pressure and improve the proportion of patients achieving the Agency for Healthcare Research and Quality goal for blood pressure. METHODS: This quality improvement project was performed in 2017 in three 3-month Plan, Do, Study, Act cycles using a multidisciplinary outreach model in a community-based primary care setting. A clinical team including physicians, nurses, patient navigators, behavioral health counselors, and pharmacists contacted adult patients with severe hypertension (≥180/110 mmHg), scheduled visits, and established blood pressure and medication management goals. The data review and analysis concluded in 2019. RESULTS: Among patients with blood pressure ≥180/110 mmHg (n=235), the average age was 57 years (SD=12 years), 37% (n=87) were male, 82% (n=193) were Black, and 46% (n=108) were uninsured. The majority of those contacted attended a follow-up appointment within the 9-month project (77%, n=181) and achieved an improved systolic blood pressure (87%, n=167) and diastolic blood pressure (76%, n=146). Target blood pressure of <140/90 mmHg was achieved in 29% of patients (n=53). Medication possession ratio improved from 23% to 40% among patients reached by pharmacists (n=30). Fewer deaths occurred in those reached by the intervention than in those not reached (n=1 vs n=3). CONCLUSIONS: Multidisciplinary outreach and use of evidence-based guidelines (Eighth Joint National Committee) were associated with lower blood pressure in patients with severe hypertension.

The end-of-life experience in long-term care: five themes identified from focus groups with residents, family members, and staff.

PURPOSE: We designed this study to examine the end-of-life (EOL) experience in long-term care (LTC) based on input from key stakeholders. DESIGN AND METHODS: The study consisted of 10 homogeneous focus groups drawn from a purposive sample of LTC residents (2 groups; total n = 11), family caregivers (2 groups; total n = 19), paraprofessional staff (3 groups; total n = 20), and licensed/registered staff (3 groups; total n = 15) from five nursing homes and eight residential care/assisted living communities in North Carolina. We analyzed data by using grounded theory techniques to elicit manifest and latent themes. RESULTS: Five overarching themes emerged: (a) components of a good death in LTC, (b) normalcy of dying in LTC, (c) the role of relationships in the provision and receipt of care, (d) hospice contributions to care at the EOL in LTC, and (e) stakeholder recommendations for enhancing EOL care in these settings. Underlying these themes was one central category, closeness, based on physical proximity and frequency of contact. IMPLICATIONS: Findings suggest that promoting collaborative relationships among the four stakeholder groups, increasing social worker involvement, and removing barriers to hospice may enhance the EOL experience in LTC.

Physician communication with family caregivers of long-term care residents at the end of life.

OBJECTIVES: To assess family perceptions of communication between physicians and family caregivers of individuals who spent their last month of life in long-term care (LTC) and to identify associations between characteristics of the family caregiver, LTC resident, facility, and physician care with these perceptions. DESIGN: Retrospective study of family caregivers of persons who died in LTC. SETTING: Thirty-one nursing homes (NHs) and 94 residential care/assisted living (RC/AL) facilities. PARTICIPANTS: One family caregiver for each of 440 LTC residents who died (response rate 66.0%) was interviewed 6 weeks to 6 months after the death. MEASUREMENTS: Demographic and facility characteristics and seven items rating the perception of family caregivers regarding physician-family caregiver communication at the end of life, aggregated into a summary scale, Family Perception of Physician-Family caregiver Communication (FPPFC) (Cronbach alpha=0.96). RESULTS: Almost half of respondents disagreed that they were kept informed (39.9%), received information about what to expect (49.8%), or understood the doctor (43.1%); the mean FPPFC score (1.73 on a scale from 0 to 3) was slightly above neutral. Linear mixed models showed that family caregivers reporting better FPPFC scores were more likely to have met the physician face to face and to have understood that death was imminent. Daughters and daughters-in-law tended to report poorer communication than other relatives, as did family caregivers of persons who died in NHs than of those who died in RC/AL facilities. CONCLUSION: Efforts to improve physician communication with families of LTC residents may be promoted using face-to-face meetings between the physician and family caregivers, explanation of the patient's prognosis, and timely conveyance of information about health status changes, especially when a patient is actively dying.

Preferences versus practice: life-sustaining treatments in last months of life in long-term care.

PURPOSE: To determine prevalence and correlates of decisions made about specific life-sustaining treatments (LSTs) among residents in long-term care (LTC) settings, including characteristics associated with having an LST performed when the resident reportedly did not desire the LST. DESIGN AND PARTICIPANTS: After-death interviews with 1 family caregiver and 1 staff caregiver for each of 327 LTC residents who died in the facility. SETTING: The setting included 27 nursing homes (NHs) and 85 residential care/assisted living (RC/AL) settings in 4 states. MEASUREMENTS: Decedent demographics, facility characteristics, prevalence of decisions made about specific LSTs, percentage of time LSTs were performed when reportedly not desired, and characteristics associated with that. RESULTS: Most family caregivers reported making a decision with a physician about resuscitation (89.1%), inserting a feeding tube (82.1%), administering antibiotics (64.3%), and hospital transfer (83.7%). Reported care was inconsistent with decisions made in 5 of 7 (71.4%) resuscitations, 1 of 7 feeding tube insertions (14.3%), 15 of 78 antibiotics courses (19.2%), and 26 of 87 hospital transfers (29.9%). Decedents who received antibiotics contrary to their wishes were older (mean age 92 versus 85, P=.014). More than half (53.8%) of decedents who had care discordant with their wishes about hospitalization lived in a NH compared with 32.8% of those whose decisions were concordant (P=.034). CONCLUSION: Most respondents reported decision making with a doctor about life-sustaining treatments, but those decisions were not consistently heeded. Being older and living in a NH were risk factors for decisions not being heeded.

Are there enough doctors in my rural community? Perceptions of the local physician supply.

PURPOSE: To assess whether people in the rural Southeast perceive that there is an adequate number of physicians in their communities, assess how these perceptions relate to county physician-to-population (PtP) ratios, and identify other factors associated with the perception that there are enough local physicians. METHODS: Adults (n = 4,879) from 150 rural counties in eight southeastern states responded through a telephone survey. Agreement or disagreement with the statement "I feel there are enough doctors in my community" constituted the principal outcome. Weighted chi-square analysis and a generalized estimating equation (GEE) assessed the strength of association between perceptions of an adequate physician workforce and county PtP ratios, individual characteristics, attitudes about and experiences with medical care, and other county characteristics. FINDINGS: Forty-nine percent of respondents agreed there were enough doctors in their communities, 46% did not agree, and 5% were undecided. Respondents of counties with higher PtP ratios were only somewhat more likely to agree that there were enough local doctors (Pearson's correlation coefficient = 0.09, P < .001). Multivariate analyses revealed that perceiving that there were enough local physicians was more common among men, those 65 and older, whites, and those with lower regard for physician care. Perceptions that the local physician supply was inadequate were more common for those who had longer travel distances, problems with affordability, and little confidence in their physicians. Perceptions of physician shortages were more common in counties with higher poverty rates. CONCLUSIONS: County PtP ratios only partially account for rural perceptions that there are or are not enough local physicians. Perceptions of an adequate local physician workforce are also related to how much people value physicians' care and whether they face other barriers to care.

Advance care planning in nursing homes and assisted living communities.

OBJECTIVES: To determine the prevalence and characteristics of advance care planning (ACP) among persons dying in long-term care (LTC) facilities, and to examine the relationship between respondent, facility, decedent, and family characteristics and ACP. DESIGN: After-death interviews of family members of decedents and facility liaisons where decedents received care. SETTING: Stratified sample of 164 residential care/assisted living facilities and nursing homes in Florida, Maryland, New Jersey, and North Carolina. SUBJECTS: Family members and facility liaisons who gave 446 and 1014 reports, respectively, on 1015 decedent residents. MEASUREMENTS: Reports of death/dying discussions, known treatment preferences, and reports and records of signed living wills (LW), health care powers of attorney (HCPOA), do-not-resuscitate orders, and do-not-hospitalize orders. RESULTS: Family respondents reported a higher prevalence, compared with facility reports, of HCPOAs (92% versus 49%) and LWs (84% versus 43%). In family reports, non-white race and no private insurance were significantly associated with lower prevalence of LWs and HCPOAs; additionally, residing in nursing homes (versus assisted living facilities) and in North Carolina were associated with lower prevalence of reported LWs. In facility reports, non-white race, unexpected death, and residing in North Carolina or Maryland were significantly associated with lower prevalence of LWs, whereas high Medicaid case mix, intact cognitive status, and high family involvement were associated with lower prevalence of HCPOAs. Concordance of family and facility reporting of HCPOAs was significantly greater in facilities with fewer than 120 beds. CONCLUSIONS: The prevalence of ACP in LTC is much higher than previously described, and there is marked variation in characteristics associated with ACP, despite moderately high concordance, when reported by the facility or family caregivers.