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.

Overcoming Barriers to Sustaining Health Equity Interventions: Insights from the National Institutes of Health Centers for Population Health and Health Disparities.

We conducted qualitative semi-structured telephone interviews with the directors of the 10 National Institutes of Health Centers for Population Health and Health Disparities (NIH/CPHHD) to identify factors that were associated with the sustainability of 19 interventions developed to address cancer disparities and 17 interventions developed to address cardiovascular disease disparities in the United States. Interview transcripts were analyzed using the constant comparative method of analysis to identify key themes and synthesize findings. Directors at NIH/CPHHD reported that barriers to sustainability included uncertainty about future funding and insufficient resources to build and maintain diverse stakeholder partnerships. Strategies that helped to overcome these barriers included developing and engaging community partnerships with health care systems; early pursuit of multiple funding sources; and investments in infrastructure to address the social determinants of health. Sustainability planning should be incorporated during the early stages of intervention development to facilitate maintenance of successful programs that address health disparities.

From Kisiizi to Baltimore: cultivating knowledge brokers to support global innovation for community engagement in healthcare.

BACKGROUND: Reverse Innovation has been endorsed as a vehicle for promoting bidirectional learning and information flow between low- and middle-income countries and high-income countries, with the aim of tackling common unmet needs. One such need, which traverses international boundaries, is the development of strategies to initiate and sustain community engagement in health care delivery systems. OBJECTIVE: In this commentary, we discuss the Baltimore "Community-based Organizations Neighborhood Network: Enhancing Capacity Together" Study. This randomized controlled trial evaluated whether or not a community engagement strategy, developed to address patient safety in low- and middle-income countries throughout sub-Saharan Africa, could be successfully applied to create and implement strategies that would link community-based organizations to a local health care system in Baltimore, a city in the United States. Specifically, we explore the trial's activation of community knowledge brokers as the conduit through which community engagement, and innovation production, was achieved. Cultivating community knowledge brokers holds promise as a vehicle for advancing global innovation in the context of health care delivery systems. As such, further efforts to discern the ways in which they may promote the development and dissemination of innovations in health care systems is warranted. TRIAL REGISTRATION: Trial Registration Number: NCT02222909 . Trial Register Name: Reverse Innovation and Patient Engagement to Improve Quality of Care and Patient Outcomes (CONNECT). Date of Trial's Registration: August 22, 2014.

Identifying and Prioritizing the Barriers and Facilitators to the Self-Management of Type 2 Diabetes Mellitus: A Community-Centered Approach.

OBJECTIVE: Self-management of type 2 diabetes mellitus is crucial to controlling the disease and preventing harm. Multiple factors have been identified in the literature as potential barriers and facilitators to self-management, but the magnitude and directionality of these factors are seldom studied. We sought to develop and test an instrument to identify and quantify the barriers and facilitators to self-management of type 2 diabetes. METHODS: A community-centered approach was used to design, implement, and interpret the results of a stated-preference study. All activities were guided by a diverse stakeholder board. Based on previously reported development work, a novel survey instrument consisting of 13 potential barriers and facilitators was pretested and piloted in our local community. Participants were asked to discuss, rate, and rank each factor. A simple self-explicated method was used to quantify the data and Z scores were used for hypothesis testing. RESULTS: In total, 25 patients with self-reported type 2 diabetes (64% female; 92% minorities) participated in the pretest and pilot. Time commitments (Z = -3.72), lack of active support groups (Z = -3.39) and other resources in the local community (Z = -2.96), and language/culture (Z = -2.69) were identified as barriers to self-management. Access to healthy food (Z = +5.68), personal understanding (Z = +4.81), and communication with healthcare providers (Z = +4.62) were identified as facilitators. CONCLUSION: We demonstrate that factors impacting self-management can be quantified and categorized as barriers and facilitators. While further refinement to some factors and investigation into alternative prioritization methods is necessary, our stakeholder board endorsed moving this to a large nationally representative study to see how these factors vary across different people.

Tobacco policies and on-premise smoking in bars and clubs that cater to young African Americans following the Maryland Clean Indoor Air Act of 2007.

African American young adults ages 18-25 smoke less than their Caucasian peers, yet the burden of tobacco-related illness is significantly higher in African Americans than in Caucasians across the lifespan. Little is known about how clean indoor air laws affect tobacco smoking among African American young adults. We conducted a systematic observation of bars and clubs with events targeted to African American adults 18-25 in Baltimore City at two timepoints (October and November of 2008 and 2010) after enforcement of the Maryland Clean Indoor Air Act (CIAA). Twenty venues-selected on the basis of youth reports of popular venues-were rated during peak hours. All surveillance checklist items were restricted to what was observable in the public domain. There was a significant decrease in observed indoor smoking after CIAA enforcement. Observed outdoor smoking also decreased, but this change was not significant. Facilities for smoking outdoors increased significantly. The statewide smoking ban became effective February 1, 2008, yet measurable changes in smoking behavior in bars were not evident until the City engaged in stringent enforcement of the ban several months later.

Reaching for Health Equity and Social Justice in Baltimore: The Evolution of an Academic-Community Partnership and Conceptual Framework to Address Hypertension Disparities.

Cardiovascular health disparities persist despite decades of recognition and the availability of evidence-based clinical and public health interventions. Racial and ethnic minorities and adults in urban and low-income communities are high-risk groups for uncontrolled hypertension (HTN), a major contributor to cardiovascular health disparities, in part due to inequitable social structures and economic systems that negatively impact daily environments and risk behaviors. This commentary presents the Johns Hopkins Center to Eliminate Cardiovascular Health Disparities as a case study for highlighting the evolution of an academic-community partnership to overcome HTN disparities. Key elements of the iterative development process of a Community Advisory Board (CAB) are summarized, and major CAB activities and engagement with the Baltimore community are highlighted. Using a conceptual framework adapted from O'Mara-Eves and colleagues, the authors discuss how different population groups and needs, motivations, types and intensity of community participation, contextual factors, and actions have shaped the Center's approach to stakeholder engagement in research and community outreach efforts to achieve health equity.

Community Health Workers Versus Nurses as Counselors or Case Managers in a Self-Help Diabetes Management Program.

OBJECTIVES: To confirm the effectiveness of community health workers' involvement as counselors or case managers in a self-help diabetes management program in 2009 to 2014. METHODS: Our open-label, randomized controlled trial determined the effectiveness of a self-help intervention among Korean Americans aged 35 to 80 years in the Baltimore-Washington metropolitan area with uncontrolled type 2 diabetes. We measured and analyzed physiological and psychobehavioral health outcomes of the community health worker-counseled (n = 54) and registered nurse (RN)-counseled (n = 51) intervention groups in comparison with the control group (n = 104). RESULTS: The community health workers' performance was comparable to that of the RNs for both psychobehavioral outcomes (e.g., self-efficacy, quality of life) and physiological outcomes. The community health worker-counseled group showed hemoglobin A1C reductions from baseline (-1.2%, -1.5%, -1.3%, and -1.6%, at months 3, 6, 9, and 12, respectively), all of which were greater than reductions in the RN-counseled (-0.7%, -0.9%, -0.9%, and -1.0%) or the control (-0.5%, -0.5%, -0.6%, and -0.7%) groups. CONCLUSIONS: Community health workers performed as well as or better than nurses as counselors or case managers in a self-help diabetes management program in a Korean American community.

The Effect of a Community-Based Self-Help Intervention: Korean Americans With Type 2 Diabetes.

INTRODUCTION: Korean Americans are one of the most underserved ethnic/linguistic minority groups owing to cultural and institutional barriers; there is an urgent need for culturally competent diabetes management programs in the Korean American community for those with type 2 diabetes. The purpose of this study was to test the effectiveness of a community-based, culturally tailored, multimodal behavioral intervention program in an ethnic/linguistic minority group with type 2 diabetes. DESIGN: An RCT with waitlist comparison based on the Predisposing, Reinforcing, and Enabling Constructs in Education/environmental Diagnosis and Evaluation (PRECEDE)-Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development (PROCEED) and self-help models. Data were collected between September 2010 and June 2013 and were analyzed in August-December 2014. Statistical significance was set at p<0.05. SETTING/PARTICIPANTS: In a naturally occurring community setting, a total of 250 Korean Americans with type 2 diabetes were randomized into an intervention group (n=120) or a control group (n=130). INTERVENTION: The intervention consisted of key self-management skill-building activities through 12 hours of group education sessions, followed by integrated counseling and behavioral coaching by a team of RNs and community health workers. MAIN OUTCOME MEASURES: Primary (clinical) outcomes were hemoglobin A1c, glucose, total cholesterol, and low-density lipoprotein at baseline and at 3, 6, 9, and 12 months. Secondary (psychosocial and behavioral) outcomes included diabetes-related quality of life, self-efficacy, adherence to diabetes management regimen, and health literacy. RESULTS: During the 12-month project, the intervention group demonstrated 1.0%-1.3% (10.9-14.2 mmol/mol) reductions in hemoglobin A1c, whereas the control group achieved reductions of 0.5%-0.7% (5.5-7.7 mmol/mol). The differences between the two groups were statistically significant. The intervention group showed statistically significant improvement in diabetes-related self-efficacy and quality of life when compared with the control group. CONCLUSIONS: RN/community health worker teams equipped with culturally tailored training can be effective in helping an ethnic/linguistic minority group manage diabetes in the community.

Effect of patient navigation on colorectal cancer screening in a community-based randomized controlled trial of urban African American adults.

PURPOSE: In recent years, colorectal cancer (CRC) screening rates have increased steadily in the USA, though racial and ethnic disparities persist. In a community-based randomized controlled trial, we investigated the effect of patient navigation on increasing CRC screening adherence among older African Americans. METHODS: Participants in the Cancer Prevention and Treatment Demonstration were randomized to either the control group, receiving only printed educational materials (PEM), or the intervention arm where they were assigned a patient navigator in addition to PEM. Navigators assisted participants with identifying and overcoming screening barriers. Logistic regression analyses were used to assess the effect of patient navigation on CRC screening adherence. Up-to-date with screening was defined as self-reported receipt of colonoscopy/sigmoidoscopy in the previous 10 years or fecal occult blood testing (FOBT) in the year prior to the exit interview. RESULTS: Compared with controls, the intervention group was more likely to report being up-to-date with CRC screening at the exit interview (OR 1.55, 95 % CI 1.07-2.23), after adjusting for select demographics. When examining the screening modalities separately, the patient navigator increased screening for colonoscopy/sigmoidoscopy (OR 1.53, 95 % CI 1.07-2.19), but not FOBT screening. Analyses of moderation revealed stronger effects of navigation among participants 65-69 years and those with an adequate health literacy level. CONCLUSIONS: In a population of older African Americans adults, patient navigation was effective in increasing the likelihood of CRC screening. However, more intensive navigation may be necessary for adults over 70 years and individuals with low literacy levels.

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.

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.

Out of view but in plain sight: the illegal sale of single cigarettes.

The practice of selling single cigarettes (loosies) through an informal economy is prevalent in urban, low socioeconomic (low SES) communities. Although US state and federal laws make this practice illegal, it may be occurring more frequently with the recent increase in taxes on cigarettes. This investigation provides information concerning the illegal practice of selling single cigarettes to better understand this behavior and to inform intervention programs and policymakers. A total of 488 African American young adults were recruited and surveyed at two education and employment training programs in Baltimore City from 2005 to 2008. Fifty-one percent of the sample reported smoking cigarettes in the past month; only 3.7% of the sample were former smokers. Approximately 65% of respondents reported seeing single cigarettes sold daily on the street. Multivariate logistic regression modeling found that respondents who reported seeing single cigarettes sold on the street several times a week were more than two times as likely to be current smokers compared to participants who reported that they never or infrequently saw single cigarettes being sold, after controlling for demographics (OR = 2.16; p = 0.034). Tax increases have led to an overall reduction in cigarette smoking. However, smoking rates in urban, low SES communities and among young adults remain high. Attention and resources are needed to address the environmental, normative, and behavioral conditions influencing tobacco use and the disparities it causes. Addressing these factors would help reduce future health care costs and save lives.

Cigarillo use among high-risk urban young adults.

In the U.S., cigar use doubled from 5.0 to 10.6 billion cigars consumed annually between 1997 and 2007, driven in large part by increased sales of cigarette-sized "little cigars" and narrow, mid-sized "cigarillos." The present study examined prevalence of cigarillo use as well as attitudes, knowledge and behaviors related to cigarillo use among a sample of predominantly urban African American young adults 18-24 not in school and not employed. Survey data were collected from 131 young adults attending education and job training centers in Baltimore, Maryland and from 78 young adults attending education, job training, or recreational programs in Washington, D.C. In Baltimore, 22% of young adults had smoked a cigarillo in the past 30 days, compared with nearly 63% in D.C. Both populations were heavily exposed to cigarillo advertising and marketing. Cigarillo use in this urban young adult population is a growing public health problem and undermines the progress made in decreasing cigarette use.

Creating a transdisciplinary research center to reduce cardiovascular health disparities in Baltimore, Maryland: lessons learned.

Cardiovascular disease (CVD) disparities continue to have a negative impact on African Americans in the United States, largely because of uncontrolled hypertension. Despite the availability of evidence-based interventions, their use has not been translated into clinical and public health practice. The Johns Hopkins Center to Eliminate Cardiovascular Health Disparities is a new transdisciplinary research program with a stated goal to lower the impact of CVD disparities on vulnerable populations in Baltimore, Maryland. By targeting multiple levels of influence on the core problem of disparities in Baltimore, the center leverages academic, community, and national partnerships and a novel structure to support 3 research studies and to train the next generation of CVD researchers. We also share the early lessons learned in the center's design.

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.

Building a navigation system to reduce cancer disparities among urban Black older adults.

BACKGROUND: Although cancer outcomes have improved in recent decades, substantial disparities by race, ethnicity, income, and education persist. Increasingly, patient navigation services are demonstrating success in improving cancer detection, treatment, and care and in reducing cancer health disparities. To advance progress in developing patient navigation programs, extensive descriptions of each component of the program must be made available to researchers and health service providers. OBJECTIVE: We sought to describe the components of a patient navigation program designed to improve cancer screening based on informed decision making on cancer screening and cancer treatment services among predominantly Black older adults in Baltimore City. METHODS: A community-academic participatory approach was used to develop a patient navigation program in Baltimore, Maryland. The components of the patient navigation system included the development of a community academic (advisory) committee (CAC); recruitment and selection of community health workers (CHWs)/navigators and supervisory staff, initial training and continuing education of the CHWs/navigators, and evaluation of CHWs/navigators. The study was approved by the Johns Hopkins Bloomberg School of Public Health Institutional Review Board. CONCLUSIONS: The incorporation of community-based participatory research principles into each facet of this patient navigation program facilitated the attainment of the intervention's objectives. This patient navigation program successfully delivered cancer navigation services to 1,302 urban Black older adults. Appropriately recruited, selected and trained CHWs monitored by an experienced supervisor and investigators are the key elements in a patient navigation program. This model has the potential to be adapted by research and health service providers.

Antihypertensive medication nonadherence in black men: direct and mediating effects of depressive symptoms, psychosocial stressors, and substance use.

Black men suffer disproportionately from hypertension. Antihypertensive medication nonadherence is a major contributor to poor blood pressure control, yet few studies consider how psychosocial functioning may impact black men's medication adherence. The authors examined the direct and mediating pathways between depressive symptoms, psychosocial stressors, and substance use on antihypertensive medication nonadherence in 196 black men enrolled in a clinical trial to improve hypertension care and control. The authors found that greater depressive symptoms were associated with more medication nonadherence (ß=0.05; standard error [SE], 0.01; P<.001). None of the psychosocial stressor variables were associated with antihypertensive medication nonadherence. Alcohol misuse was associated with increased medication nonadherence (ß=0.81; SE, 0.26; P<.01), but it did not mediate the association between depressive symptoms and medication nonadherence. Clinicians should consider screening for depressive symptoms and alcohol misuse if patients are found to be nonadherent and should treat or refer patients to appropriate resources to address those issues.

A randomized trial to improve patient-centered care and hypertension control in underserved primary care patients.

BACKGROUND: African Americans and persons with low socioeconomic status (SES) are disproportionately affected by hypertension and receive less patient-centered care than less vulnerable patient populations. Moreover, continuing medical education (CME) and patient-activation interventions have infrequently been directed to improve the processes of care for these populations. OBJECTIVE: To compare the effectiveness of patient-centered interventions targeting patients and physicians with the effectiveness of minimal interventions for underserved groups. DESIGN: Randomized controlled trial conducted from January 2002 through August 2005, with patient follow-up at 3 and 12 months, in 14 urban, community-based practices in Baltimore, Maryland. PARTICIPANTS: Forty-one primary care physicians and 279 hypertension patients. INTERVENTIONS: Physician communication skills training and patient coaching by community health workers. MAIN MEASURES: Physician communication behaviors; patient ratings of physicians' participatory decision-making (PDM), patient involvement in care (PIC), reported adherence to medications; systolic and diastolic blood pressure (BP) and BP control. KEY RESULTS: Visits of trained versus control group physicians demonstrated more positive communication change scores from baseline (-0.52 vs. -0.82, p = 0.04). At 12 months, the patient+physician intensive group compared to the minimal intervention group showed significantly greater improvements in patient report of physicians' PDM (ß = +6.20 vs. -5.24, p = 0.03) and PIC dimensions related to doctor facilitation (ß = +0.22 vs. -0.17, p = 0.03) and information exchange (ß = +0.32 vs. -0.22, p = 0.005). Improvements in patient adherence and BP control did not differ across groups for the overall patient sample. However, among patients with uncontrolled hypertension at baseline, non-significant reductions in systolic BP were observed among patients in all intervention groups-the patient+physician intensive (-13.2 mmHg), physician intensive/patient minimal (-10.6 mmHg), and the patient intensive/physician minimal (-16.8 mmHg), compared to the patient+physician minimal group (-2.0 mmHg). CONCLUSION: Interventions that enhance physicians' communication skills and activate patients to participate in their care positively affect patient-centered communication, patient perceptions of engagement in care, and may improve systolic BP among urban African-American and low SES patients with uncontrolled hypertension.

Short Form (SF-36) Health Survey measures are associated with decreased adherence among urban African Americans with severe, poorly controlled hypertension.

The objective of this study was to determine whether an association exists between Short Form (SF-36) Health Survey measures and nonadherence among urban African Americans with poorly controlled hypertension. A total of 158 African Americans were admitted to an urban academic hospital for severe, uncontrolled hypertension. The main outcome measure was self-reported nonadherence to antihypertensive medications using a validated instrument. For every 10-point increase in Physical Component Summary (PCS) score, an individual was almost two times more likely to report being nonadherent (odds ratio, 1.94; 95% confidence interval, 1.30-2.90; P<.01). A significant interaction (P=.05) was observed between the physical functioning and mental health subscales. Individuals with high physical functioning and low mental health scores displayed the lowest adherence rate. These results suggest that high physical functioning, especially if associated with poor mental health, increases the likelihood of nonadherence to antihypertensive regimens among urban African Americans. The SF-36 may serve as an effective clinical tool that identifies patients at risk for nonadherence and, more importantly, may improve clinicians' understanding of nonadherence, allowing for discussions about antihypertensive medications to be tailored to individual patients.

The effects of a nurse case manager and a community health worker team on diabetic control, emergency department visits, and hospitalizations among urban African Americans with type 2 diabetes mellitus: a randomized controlled trial.

BACKGROUND: Although African American adults bear a disproportionate burden from diabetes mellitus (DM), few randomized controlled trials have tested culturally appropriate interventions to improve DM care. METHODS: We randomly assigned 542 African Americans with type 2 DM enrolled in an urban managed care organization to either an intensive or minimal intervention group. The intensive intervention group consisted of all components of the minimal intervention plus individualized, culturally tailored care provided by a nurse case manager (NCM) and a community health worker (CHW), using evidence-based clinical algorithms with feedback to primary care providers (eg, physicians, nurse practitioners, or physician assistants). The minimal intervention consisted of mailings and telephone calls every 6 months to remind participants about preventive screenings. Data on diabetic control were collected at baseline and at 24 months by blind observers; data emergency department (ER) visits and hospitalizations were assessed using administrative data. RESULTS: At baseline, participants had a mean age of 58 years, 73% were women, and 50% were living in poverty. At 24 months, compared with the minimal intervention group, those in the intensive intervention group were 23% less likely to have ER visits (rate difference [RD], -14.5; adjusted rate ratio [RR], 0.77; 95% confidence interval [CI], 0.59-1.00). In on-treatment analyses, the rate reduction was strongest for patients who received the most NCM and CHW visits (RD, -31.0; adjusted RR, 0.66; 95% CI, 0.43-1.00; rate reduction downward arrow 34%). CONCLUSION: These data suggest that a culturally tailored intervention conducted by an NCM/CHW team reduced ER visits in urban African Americans with type 2 DM. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00022750.