Impact of pre-dialysis nephrology care engagement and decision-making on provider and patient action toward permanent vascular access.

BACKGROUND: While catheters are often thought the result of emergency hemodialysis (HD) initiation among patients with little or no pre-dialysis nephrology care, the role of patient level of engagement in care and modality decision-making have not been fully explored. METHODS: This is a retrospective medical record review of adults (age 18-89 years) who received care in academically affiliated private practice, public hospital, or Veterans Administration settings prior to initiating HD with a catheter between 10/1/2011 and 9/30/2012. Primary predictors were level of patient engagement in nephrology care within 6 months of HD initiation and timing of modality decision-making. Primary outcomes were provider action (referral) and any patient action (evaluation by a vascular surgeon, vein mapping or vascular surgery) toward [arteriovenous fistula or graft, (AVF/AVG)] creation. RESULTS: Among 92 incident HD patients, 66% (n = 61) initiated HD via catheter, of whom 34% (n = 21) had ideal engagement in care but 42% (n = 25) had no documented decision. Providers referred 48% (n = 29) of patients for AVF/AVG, of whom 72% (n = 21) took any action. Ideal engagement in care predicted provider action (adjusted OR 13.7 [95% CI 1.08, 175.1], p = 0.04), but no level of engagement in care predicted patient action (p > 0.3). Compared to patients with no documented decision, those with documented decisions within 3, 3-12, or more than 12 months before initiating dialysis were more likely to have provider action toward AVF/AVG (adjusted OR [95% CI]: 9.0 [1.4,55.6], p = 0.2, 37.6 [3.3423.4] p = 0.003, and 4.8 [0.8, 30.6], p = 0.1, respectively); and patient action (adjusted OR [95% CI]: 18.7 [2.3, 149.0], p = 0.006, 20.4 [2.6, 160.0], p = 0.004, and 6.2 [0.9, 44.0], p = 0.07, respectively). CONCLUSIONS: Timing of patient modality decision-making, but not level of engagement in pre-dialysis nephrology care, was predictive of patient and provider action toward AVF/AVG Interventions addressing patients' psychological preparation for dialysis are needed.

Hypertension Self-management in Socially Disadvantaged African Americans: the Achieving Blood Pressure Control Together (ACT) Randomized Comparative Effectiveness Trial.

BACKGROUND: Effective hypertension self-management interventions are needed for socially disadvantaged African Americans, who have poorer blood pressure (BP) control compared to others. OBJECTIVE: We studied the incremental effectiveness of contextually adapted hypertension self-management interventions among socially disadvantaged African Americans. DESIGN: Randomized comparative effectiveness trial. PARTICIPANTS: One hundred fifty-nine African Americans at an urban primary care clinic. INTERVENTIONS: Participants were randomly assigned to receive (1) a community health worker ("CHW") intervention, including the provision of a home BP monitor; (2) the CHW plus additional training in shared decision-making skills ("DoMyPART"); or (3) the CHW plus additional training in self-management problem-solving ("Problem Solving"). MAIN MEASURES: We assessed group differences in BP control (systolic BP (SBP) < 140 mm Hg and diastolic BP (DBP) < 90 mmHg), over 12 months using generalized linear mixed models. We also assessed changes in SBP and DBP and participants' BP self-monitoring frequency, clinic visit patient-centeredness (i.e., extent of patient-physician discussions focused on patient emotional and psychosocial concerns), hypertension self-management behaviors, and self-efficacy. KEY RESULTS: BP control improved in all groups from baseline (36%) to 12 months (52%) with significant declines in SBP (estimated mean [95% CI] - 9.1 [- 15.1, - 3.1], - 7.4 [- 13.4, - 1.4], and - 11.3 [- 17.2, - 5.3] mmHg) and DBP (- 4.8 [- 8.3, - 1.3], - 4.0 [- 7.5, - 0.5], and - 5.4 [- 8.8, - 1.9] mmHg) for CHW, DoMyPART, and Problem Solving, respectively). There were no group differences in BP outcomes, BP self-monitor use, or clinic visit patient-centeredness. The Problem Solving group had higher odds of high hypertension self-care behaviors (OR [95% CI] 18.7 [4.0, 87.3]) and self-efficacy scores (OR [95% CI] 4.7 [1.5, 14.9]) at 12 months compared to baseline, while other groups did not. Compared to DoMyPART, the Problem Solving group had higher odds of high hypertension self-care behaviors (OR [95% CI] 5.7 [1.3, 25.5]) at 12 months. CONCLUSION: A context-adapted CHW intervention was correlated with improvements in BP control among socially disadvantaged African Americans. However, it is not clear whether improvements were the result of this intervention. Neither the addition of shared decision-making nor problem-solving self-management training to the CHW intervention further improved BP control. TRIAL REGISTRY: ClinicalTrials.gov Identifier: NCT01902719.

Qualitative Assessment of a State Partner-Facilitated Health Care-Associated Infection Prevention National Collaborative.

Background: The Centers for Disease Control and Prevention (CDC) funded a 3-year national collaborative focused on facilitating relationships between health care-associated infection (HAI) prevention stakeholders within states and improving HAI prevention activities within hospitals. This program-STRIVE (States Targeting Reduction in Infections via Engagement)-targeted hospitals with elevated rates of common HAIs. Objective: To use qualitative methods to better understand STRIVE's effect on state partner relationships and HAI prevention efforts by hospitals. Design: Qualitative case study, by U.S. state. Setting: 7 of 22 eligible STRIVE state partnerships. Participants: Representatives from state hospital associations, state health departments, and other participating organizations (for example, Quality Innovation Networks-Quality Improvement Organizations), referred to as "state partners." Measurements: Phone interviews (n = 17) with each organization were conducted, recorded, and transcribed. Results: State partners reported that relationships with each other and with participating hospitals improved through STRIVE participation. The partners saw improvements in hospital-level HAI prevention activities, such as improved auditing and feedback practices and inclusion of environmental services in prevention efforts; however, some noted those improvements may not be reflected in HAI rates. Many partners outlined plans to sustain their partner relationships by working on future state-level initiatives, such as opioid abuse prevention and antimicrobial stewardship. Limitation: Only 7 participating states were included; direct feedback from participating hospitals was not available. Conclusion: Although there were no substantial changes in aggregate HAI rates, STRIVE achieved its goal of improving state partner relationships and coordination. This improved collaboration may lead to a more streamlined response to future HAI outbreaks and public health emergencies. Primary Funding Source: Centers for Disease Control and Prevention.

Quantitative Results of a National Intervention to Prevent Hospital-Acquired Catheter-Associated Urinary Tract Infection: A Pre-Post Observational Study.

Background: Many hospitals struggle to prevent catheter-associated urinary tract infection (CAUTI). Objective: To evaluate the effect of a multimodal initiative on CAUTI in hospitals with high burden of health care-associated infection (HAI). Design: Prospective, national, nonrandomized, clustered, externally facilitated, pre-post observational quality improvement initiative, for 3 cohorts active between November 2016 and May 2018. Setting: Acute care, long-term acute care, and critical access hospitals, including intensive care and non-intensive care wards. Participants: Target hospitals had a high burden of Clostridioides difficile infection plus central line-associated bloodstream infection, CAUTI, or hospital-onset methicillin-resistant Staphylococcus aureus bloodstream infection, defined as cumulative attributable differences above the first tertile in the Targeted Assessment for Prevention (TAP) strategy. Some additional nonrecruited hospitals also joined. Intervention: Multimodal intervention, including Practice Change Assessment tool to identify infection prevention and control (IPC) and HAI prevention gaps; Web-based, on-demand modules involving onboarding, foundational IPC practices, HAI-specific 2-tiered approach to prioritize and implement interventions, and TAP resources; monthly webinars; state partner-led in-person meetings; and feedback. State partners made site visits to at least 50% of their enrolled hospitals, to support self-assessments and coach. Measurements: Rates of CAUTI and urinary catheter device utilization ratio. Results: Of 387 participating hospitals from 23 states and the District of Columbia, 361 provided CAUTI data. Over the study period, the unadjusted CAUTI rate was low and relatively stable, decreasing slightly from 1.12 to 1.04 CAUTIs per 1000 catheter-days. Catheter utilization decreased from 21.46 to 19.83 catheter-days per 100 patient-days from the pre- to the postintervention period. Limitations: The intervention period was brief, with no assessment of fidelity. Baseline CAUTI rates were low. Patient characteristics were not assessed. Conclusion: This multimodal intervention yielded no substantial improvements in CAUTI or urinary catheter utilization. Primary Funding Source: Centers for Disease Control and Prevention.

Dissecting Leapfrog: How Well Do Leapfrog Safe Practices Scores Correlate With Hospital Compare Ratings and Penalties, and How Much Do They Matter?

BACKGROUND: Voluntary Leapfrog Safe Practices Score (SPS) measures were among the first public reports of hospital performance. Recently, Medicare's Hospital Compare website has reported compulsory measures. Leapfrog's Hospital Safety Score (HSS) grades incorporate SPS and Medicare measures. We evaluate associations between Leapfrog SPS and Medicare measures, and the impact of SPS on HSS grades. METHODS: Using 2013 hospital data, we linked Leapfrog HSS data with central line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) standardized infection ratios (SIRs), and Hospital Readmission and Hospital-Acquired Condition (HAC) Reduction Program penalties incorporating 2013 performance. For SPS-providing hospitals, we used linear and logistic regression models to predict CLABSI/CAUTI SIRs and penalties as a function of SPS. For hospitals not reporting SPS, we simulated change in HSS grades after imputing a range of SPS. RESULTS: In total, 1089 hospitals reported SPS; >50% self-reported perfect scores for all but 1 measure. No SPS measures were associated with SIRs. One SPS (feedback) was associated with lower odds of HAC penalization (odds ratio, 0.86; 95% confidence interval, 0.76-0.97). Among hospitals not reporting SPS (N=1080), 98% and 54% saw grades decline by 1+ letters with first and 10th percentile SPS imputed, respectively; 49% and 54% saw grades improve by 1+ letter with median and highest SPS imputed. CONCLUSIONS: Voluntary Leapfrog SPS measures skew toward positive self-report and bear little association with compulsory Medicare outcomes and penalties. SPS significantly impacts HSS grades, particularly when lower SPS is reported. With increasing compulsory reporting, Leapfrog SPS seems limited for comparing hospital performance.

Specialist and primary care physicians' views on barriers to adequate preparation of patients for renal replacement therapy: a qualitative study.

BACKGROUND: Early preparation for renal replacement therapy (RRT) is recommended for patients with advanced chronic kidney disease (CKD), yet many patients initiate RRT urgently and/or are inadequately prepared. METHODS: We conducted audio-recorded, qualitative, directed telephone interviews of nephrology health care providers (n = 10, nephrologists, physician assistants, and nurses) and primary care physicians (PCPs, n = 4) to identify modifiable challenges to optimal RRT preparation to inform future interventions. We recruited providers from public safety-net hospital-based and community-based nephrology and primary care practices. We asked providers open-ended questions to assess their perceived challenges and their views on the role of PCPs and nephrologist-PCP collaboration in patients' RRT preparation. Two independent and trained abstractors coded transcribed audio-recorded interviews and identified major themes. RESULTS: Nephrology providers identified several factors contributing to patients' suboptimal RRT preparation, including health system resources (e.g., limited time for preparation, referral process delays, and poorly integrated nephrology and primary care), provider skills (e.g., their difficulty explaining CKD to patients), and patient attitudes and cultural differences (e.g., their poor understanding and acceptance of their CKD and its treatment options, their low perceived urgency for RRT preparation; their negative perceptions about RRT, lack of trust, or language differences). PCPs desired more involvement in preparation to ensure RRT transitions could be as "smooth as possible", including providing patients with emotional support, helping patients weigh RRT options, and affirming nephrologist recommendations. Both nephrology providers and PCPs desired improved collaboration, including better information exchange and delineation of roles during the RRT preparation process. CONCLUSIONS: Nephrology and primary care providers identified health system resources, provider skills, and patient attitudes and cultural differences as challenges to patients' optimal RRT preparation. Interventions to improve these factors may improve patients' preparation and initiation of optimal RRTs.

Concerns regarding the financial aspects of kidney transplantation: perspectives of pre-transplant patients and their family members.

BACKGROUND: African American and non-African American pre-transplant patients' and their families' concerns about the financial costs of kidney transplantation have not been well studied. METHODS: We conducted structured group interviews among pre-transplant patients (seven African American, five non-African American) and their family members (six African American, five non-African American) to identify their concerns about transplant health insurance coverage, out-of-pocket expenses, and living donor expenses. We reviewed transcribed group audio recordings and identified common discussion themes. RESULTS: African American and non-African American patients and family members expressed uncertainty about which transplant-related costs were covered by health insurance and wanted information about how to choose insurance policies accordingly. Patients were particularly concerned about the impact of pre-existing illness on securing optimal health insurance, while family members wanted information about non-insurance-based financial resources. Both patients and family members expressed concern about paying for immunosuppressant medications and about gradual loss of insurance benefits after transplantation. Both patients and family members also expressed concern about potential financial hardships for living donors. CONCLUSION: African American and non-African American pre-transplant patients and families expressed a broad range of concerns about transplant health insurance policies, out-of-pocket expenses, non-insurance-based financial resources, and resources to address donors' financial burden. Efforts to improve education and develop more comprehensive transplant insurance policies are needed to facilitate informed decision-making for potential transplant recipients and donors.

Adapting hypertension self-management interventions to enhance their sustained effectiveness among urban African Americans.

African Americans suffer disproportionately poor hypertension control despite the availability of efficacious interventions. Using principles of community-based participatory research and implementation science, we adapted established hypertension self-management interventions to enhance interventions' cultural relevance and potential for sustained effectiveness among urban African Americans. We obtained input from patients and their family members, their health care providers, and community members. The process required substantial time and resources, and the adapted interventions will be tested in a randomized controlled trial.

Development of a decision aid to inform patients' and families' renal replacement therapy selection decisions.

BACKGROUND: Few educational resources have been developed to inform patients' renal replacement therapy (RRT) selection decisions. Patients progressing toward end stage renal disease (ESRD) must decide among multiple treatment options with varying characteristics. Complex information about treatments must be adequately conveyed to patients with different educational backgrounds and informational needs. Decisions about treatment options also require family input, as families often participate in patients' treatment and support patients' decisions. We describe the development, design, and preliminary evaluation of an informational, evidence-based, and patient-and family-centered decision aid for patients with ESRD and varying levels of health literacy, health numeracy, and cognitive function. METHODS: We designed a decision aid comprising a complementary video and informational handbook. We based our development process on data previously obtained from qualitative focus groups and systematic literature reviews. We simultaneously developed the video and handbook in "stages." For the video, stages included (1) directed interviews with culturally appropriate patients and families and preliminary script development, (2) video production, and (3) screening the video with patients and their families. For the handbook, stages comprised (1) preliminary content design, (2) a mixed-methods pilot study among diverse patients to assess comprehension of handbook material, and (3) screening the handbook with patients and their families. RESULTS: The video and handbook both addressed potential benefits and trade-offs of treatment selections. The 50-minute video consisted of demographically diverse patients and their families describing their positive and negative experiences with selecting a treatment option. The video also incorporated health professionals' testimonials regarding various considerations that might influence patients' and families' treatment selections. The handbook was comprised of written words, pictures of patients and health care providers, and diagrams describing the findings and quality of scientific studies comparing treatments. The handbook text was written at a 4th to 6th grade reading level. Pilot study results demonstrated that a majority of patients could understand information presented in the handbook. Patient and families screening the nearly completed video and handbook reviewed the materials favorably. CONCLUSIONS: This rigorously designed decision aid may help patients and families make informed decisions about their treatment options for RRT that are well aligned with their values.

A Practical Guide for Building Collaborations Between Clinical Researchers and Engineers: Lessons Learned From a Multidisciplinary Patient Safety Project.

OBJECTIVES: Engineering and operations research have much to contribute to improve patient safety, especially within complex, highly regulated, and constantly evolving hospital environments. Despite new technologies, clinical checklists, and alarm systems, basic challenges persist that impact patient safety, such as how to improve communication between healthcare providers to prevent hospital-acquired complications. Because these collaborations are often new territory for both clinical researchers and engineers, the aim of the study was to prepare research teams that are embarking on similar collaborations regarding common challenges and training needs to anticipate while developing multidisciplinary teams. METHODS: Using a specific patient safety project as a case study, we share lessons learned and research training tools developed in our experience from recent multidisciplinary collaborations between clinical and engineering teams, which included many nonclinical undergraduate and graduate students. RESULTS: We developed a practical guide to describe anticipated challenges and solutions to consider for developing successful partnerships between engineering and clinical researchers. To address the extensive clinical, regulatory, data collection, and laboratory education needed for orienting multidisciplinary team members to join research projects, we also developed and shared a checklist for project managers as well as the training materials as adaptable resources to facilitate other teams' initiation into these types of collaborations. These resources are appropriate and tailorable for orienting both clinical and nonclinical team members, including faculty and staff as well as undergraduate and graduate students. CONCLUSIONS: We shared a practical guide to prepare teams for new multidisciplinary collaborations between clinicians and engineers.

Using appropriateness criteria to identify opportunities to improve perioperative urinary catheter use.

BACKGROUND: The Michigan Appropriate Perioperative (MAP) criteria provide guidance regarding urinary catheter use. For Category A (e.g., laparoscopic cholecystectomy), B (e.g., hemicolectomy), and C (e.g., abdominoperineal resection) procedures, recommendations are to avoid catheter, remove POD 0 or 1, and remove POD 1-4, respectively. We applied MAP criteria to statewide registry data to identify improvement targets. METHODS: Retrospective cohort study of risk-adjusted catheter use and duration for appendectomy, cholecystectomy, and colorectal resections in 2014-2015 from 64 Michigan hospitals. RESULTS: 5.5% of 13,032 Category A cases used urinary catheters, including 26.9% of open appendectomies. 94.5% of 1,624 Category B cases used catheters (31.2% remained after POD 1). 98.3% of 700 Category C cases used catheters (4.6% remained POD5+). Variation in duration of use persisted after risk adjustment. CONCLUSIONS: Perioperative urinary catheter use was appropriate for most simple abdominal procedures, but duration of use varied in all categories.

Persistent Barriers to Timely Catheter Removal Identified from Clinical Observations and Interviews.

BACKGROUND: Indwelling urinary and vascular catheters are valuable devices in patient care, but prolonged or unnecessary use increases the risk of infectious and noninfectious catheter harms. METHODS: To understand persistent barriers to detecting and removing unnecessary catheters, researchers conducted a multimethod qualitative study that included observations and in-person interviews with clinicians working on a progressive care unit of a large hospital. Observations consisted of shadowing nurses during shift change and while admitting patients, and observing physicians during morning rounds. Observational data were gathered using unstructured field notes. Interviews were conducted using a semistructured guide, audio-recorded, and transcribed. Qualitative content analysis was conducted to identify main themes. RESULTS: Barriers to timely removal identified during 19 interviews with clinicians and 133 hours of field observations included physicians not routinely reviewing catheter necessity during rounds, catheters going unnoticed or hidden under clothing, common use of "Do Not Remove" orders, and little or no discussion of catheters among clinicians. Five overall themes emerged: (1) Catheter data are hard to find, not accurate, or not available; (2) Catheter removal is not a priority; (3) Confusion exists about who has authority to remove catheters; (4) There is a lack of agreement on, and awareness of, standard protocols and indications for removal; and (5) Communication barriers among clinicians create challenges. CONCLUSION: To address barriers and facilitate detection and timely removal, clinicians need ready access to accurate catheter data, more clearly delineated clinician roles for prompting removal, effective tools to facilitate discussions about catheter use, and standardized catheter removal protocols.

Contextual Barriers to Communication Between Physicians and Nurses About Appropriate Catheter Use.

BACKGROUND: Indwelling urinary and vascular catheters are a common cause of health care-associated infections. Interventions designed to reduce catheter use can be ineffective if they are not integrated into the workflow and communication streams of busy clinicians. OBJECTIVES: To characterize communication barriers between physicians and nurses and to understand how these barriers affect appropriate use and removal of indwelling urinary and vascular catheters. METHODS: Individual and small-group semistructured interviews were conducted with physicians and nurses in a progressive care unit of an academic hospital. Common themes were identified, analyzed, and then organized using a conceptual framework of contextual barriers to communication: organizational, cognitive, and social complexity. RESULTS: Several barriers to communication between physicians and nurses contributed to inappropriate use and delayed removal of catheters. Workflow misalignment between clinicians was a barrier associated with organizational complexity, issues with electronic medical records and pagers were associated with cognitive complexity, and strained relationships between clinicians and rigid hierarchies were associated with social complexity. CONCLUSIONS: Communication is contextual, and improving physician-nurse communication about appropriate catheter use may require innovations that address the identified contextual barriers.

Review of Strategies to Reduce Central Line-Associated Bloodstream Infection (CLABSI) and Catheter-Associated Urinary Tract Infection (CAUTI) in Adult ICUs.

Central line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) are costly and morbid. Despite evidence-based guidelines, Some intensive care units (ICUs) continue to have elevated infection rates. In October 2015, we performed a systematic search of the peer-reviewed literature within the PubMed and Cochrane databases for interventions to reduce CLABSI and/or CAUTI in adult ICUs and synthesized findings using a narrative review process. The interventions were categorized using a conceptual model, with stages applicable to both CAUTI and CLABSI prevention: (stage 0) avoid catheter if possible, (stage 1) ensure aseptic placement, (stage 2) maintain awareness and proper care of catheters in place, and (stage 3) promptly remove unnecessary catheters. We also looked for effective components that the 5 most successful (by reduction in infection rates) studies of each infection shared. Interventions that addressed multiple stages within the conceptual model were common in these successful studies. Assuring compliance with infection prevention efforts via auditing and timely feedback were also common. Hospitalists with patient safety interests may find this review informative for formulating quality improvement interventions to reduce these infections.

Improving urban African Americans' blood pressure control through multi-level interventions in the Achieving Blood Pressure Control Together (ACT) study: a randomized clinical trial.

BACKGROUND: Given their high rates of uncontrolled blood pressure, urban African Americans comprise a particularly vulnerable subgroup of persons with hypertension. Substantial evidence has demonstrated the important role of family and community support in improving patients' management of a variety of chronic illnesses. However, studies of multi-level interventions designed specifically to improve urban African American patients' blood pressure self-management by simultaneously leveraging patient, family, and community strengths are lacking. METHODS/DESIGN: We report the protocol of the Achieving Blood Pressure Control Together (ACT) study, a randomized controlled trial designed to study the effectiveness of interventions that engage patient, family, and community-level resources to facilitate urban African American hypertensive patients' improved hypertension self-management and subsequent hypertension control. African American patients with uncontrolled hypertension receiving health care in an urban primary care clinic will be randomly assigned to receive 1) an educational intervention led by a community health worker alone, 2) the community health worker intervention plus a patient and family communication activation intervention, or 3) the community health worker intervention plus a problem-solving intervention. All participants enrolled in the study will receive and be trained to use a digital home blood pressure machine. The primary outcome of the randomized controlled trial will be patients' blood pressure control at 12months. DISCUSSION: Results from the ACT study will provide needed evidence on the effectiveness of comprehensive multi-level interventions to improve urban African American patients' hypertension control.

Facilitators and barriers to hypertension self-management in urban African Americans: perspectives of patients and family members.

INTRODUCTION: We aimed to inform the design of behavioral interventions by identifying patients' and their family members' perceived facilitators and barriers to hypertension self-management. MATERIALS AND METHODS: We conducted focus groups of African American patients with hypertension and their family members to elicit their views about factors influencing patients' hypertension self-management. We recruited African American patients with hypertension (n = 18) and their family members (n = 12) from an urban, community-based clinical practice in Baltimore, Maryland. We conducted four separate 90-minute focus groups among patients with controlled (one group) and uncontrolled (one group) hypertension, as well as their family members (two groups). Trained moderators used open-ended questions to assess participants' perceptions regarding patient, family, clinic, and community-level factors influencing patients' effective hypertension self-management. RESULTS: Patient participants identified several facilitators (including family members' support and positive relationships with doctors) and barriers (including competing health priorities, lack of knowledge about hypertension, and poor access to community resources) that influence their hypertension self-management. Family members also identified several facilitators (including their participation in patients' doctor's visits and discussions with patients' doctors outside of visits) and barriers (including their own limited health knowledge and patients' lack of motivation to sustain hypertension self-management behaviors) that affect their efforts to support patients' hypertension self-management. CONCLUSION: African American patients with hypertension and their family members reported numerous patient, family, clinic, and community-level facilitators and barriers to patients' hypertension self-management. Patients' and their family members' views may help guide efforts to tailor behavioral interventions designed to improve hypertension self-management behaviors and hypertension control in minority populations.