Results from the Trial Using Motivational Interviewing, Positive Affect, and Self-Affirmation in African Americans with Hypertension (TRIUMPH).

OBJECTIVE: Our objective was to determine the effectiveness of combining positive affect and self-affirmation strategies with motivational interviewing in achieving blood pressure control among hypertensive African Americans (AA) compared with AA hypertensives in an education-only control group. DESIGN: Randomized trial. SETTING: Ambulatory practices in the South Bronx and Harlem, New York City. PARTICIPANTS: African American adults with uncontrolled hypertension. INTERVENTIONS: Participants were randomized to a positive affect and self-affirmation intervention or an education control group. The positive affect and self-affirmation intervention involved having participants think about things that made them happy and that reminded them of their core values on a daily basis. These strategies were reinforced every two months through motivational interviewing. The control arm received a workbook of strategies on blood pressure control. All participants were called every two months for one year. MAIN OUTCOMES: Blood pressure control rate. RESULTS: A total of 238 participants were randomized. The average age was 56 ± 11 years, approximately 70% were female, 80% were not married, and up to 70% had completed high school. There was no difference in control rates between the intervention and the control group. However, at one year, female participants were more likely to be controlled. Participants with high depressive symptoms or high perceived stress at baseline were less likely to be controlled. CONCLUSIONS: While this study did not demonstrate an intervention effect, it does provide important insight into the psychosocial factors that may underlie blood pressure control in African Americans. Implications for future behavioral intervention trials are discussed.

Medicaid managed care: how to target efforts to reduce costs.

BACKGROUND: To be successful, cost control efforts must target Medicaid Managed Care (MMC) beneficiaries likely to incur high costs. The critical question is how to identify potential high cost beneficiaries with simple, reproducible, transparent, auditable criteria. Our objective in this analysis was to evaluate whether the total burden of comorbidity, assessed by the Charlson comorbidity index, could identify MMC beneficiaries who incurred high health care costs. METHODS: The MetroPlus MMC claims database was use to analyze six months of claims data from 07/07-12/07; the analysis focused on the total amount paid. Age, gender, Charlson comorbidity score, serious mental illness and pregnancy were analyzed as predictors of total costs. RESULTS: We evaluated the cost profile of 4,614 beneficiaries enrolled at MetroPlus, an MMC plan. As hypothesized, the comorbidity index was a key correlate of total costs (p < .01). Yearly costs were more related to the total burden of comorbidity than any specific comorbid disease. For adults, in addition to comorbidity (p < .01) both serious mental illness (p < .01) and pregnancy (p < .01) were also related to total costs, while age, drug addiction and gender were not. The model with age, gender, comorbidity, serious mental illness, pregnancy and addiction explained 20% of the variance in total costs. In children, comorbidity (p < .01), serious mental illness (p < .01), addiction (p < .03) and pregnancy (p < .01) were associated with log cost; the model with those variables explained 6% of the variance in costs. CONCLUSIONS: Comorbidity can be used to identify MMC beneficiaries most likely to have high costs.

Ethical considerations for conducting health disparities research in community health centers: a social-ecological perspective.

Community health centers (CHCs) provide optimal research settings. They serve a high-risk, medically underserved population in the greatest need of intervention. Low socioeconomic status renders this population particularly vulnerable to research misconduct. Traditional principles of research ethics are often applied to participants only. The social-ecological model offers a comprehensive framework for applying these principles across multiple levels (participants, providers, organizations, communities, and policy). Our experience with the Trial Using Motivational Interviewing, Positive Affect and Self-Affirmation in African-Americans with Hypertension, a randomized trial conducted in CHCs, led us to propose a new platform for discussing research ethics; examine the social, community, and political factors surrounding research conducted in CHCs; and recommend how future research should be conducted in such settings.

The Trial Using Motivational Interviewing and Positive Affect and Self-Affirmation in African-Americans with Hypertension (TRIUMPH): from theory to clinical trial implementation.

This paper describes the application of a translational research model in developing The Trial Using Motivational Interviewing and Positive Affect and Self-Affirmation in African-Americans with Hypertension (TRIUMPH), a theoretically-based, randomized controlled trial. TRIUMPH targets blood pressure control among African-Americans with hypertension in a community health center and public hospital setting. TRIUMPH applies positive affect, self-affirmation, and motivational interviewing as strategies to increase medication adherence and blood pressure control. A total of 220 participants were recruited in TRIUMPH and are currently being followed. This paper provides a detailed description of the theoretical framework and study design of TRIUMPH and concludes with a critical reflection of the lessons learned in the process of implementing a health behavior intervention in a community-based setting. TRIUMPH provides a model for incorporating the translational science research paradigm to conducting pragmatic behavioral trials in a real-world setting in a vulnerable population. Lessons learned through interactions with our community partners reinforce the value of community engagement in research.

Associations between posttraumatic stress disorder and hemoglobin A1(C) in low-income minority patients with diabetes.

OBJECTIVE: Posttraumatic Stress Disorder (PTSD) is prevalent among low-income minorities and is associated with poorer health. However, the association between PTSD and hemoglobin A1(C) (A1(C)) among patients with diabetes has not been fully described. The objective of this cross-sectional study was to evaluate associations between PTSD and A1(C) among low-income minorities with diabetes. METHOD: Adults with diabetes were recruited from a network of primary care clinics. Data were obtained from surveys and electronic medical records. Lifetime PTSD symptoms were assessed using the Structured Clinical Interview-DSM-IV and depressive symptoms with the Patient Health Questionnaire-9. A1(C) was obtained from chart review. RESULTS: Of 103 adults analyzed, 12% had lifetime full PTSD and 12% had subthreshold PTSD. On backward stepwise logistic regression, patients with any PTSD symptoms were significantly more likely to have an A1(C) >7% compared to patients without symptoms (OR(adj) 2.98, 95% CI 1.04-8.52, P=.04). An A1(C) >7% also was associated with an interaction between PTSD symptoms and longer diabetes duration (P<.05). CONCLUSION: In this cohort of low-income minorities with diabetes, lifetime PTSD symptoms were significantly associated with an A1(C) >7%.

Patient care outside of office visits: a primary care physician time study.

BACKGROUND: Patient care provided by primary care physicians outside of office visits is important for care coordination and may serve as a substitute for office visits. OBJECTIVES: To describe primary care physicians' ambulatory patient care activities outside of office visits ("AOVs") and their perceptions of the extent to which AOVs substitute for visits and may be performed by support staff. DESIGN: Cross-sectional direct observational study. PARTICIPANTS: Thirty-three general internists in 20 practices in two health care systems (one public, one private) in the New York metropolitan area. MAIN MEASURES: Duration of AOVs by type of activity and whether they pertain to a patient visit on the study day (visit specific) or not (non-visit specific). Physician perceptions of the: (1) extent that non-visit-specific AOVs substitute for visits that would have otherwise occurred, (2) extent that visits that occurred could have been substituted for by AOVs, and (3) potential role of support staff in AOVs. KEY RESULTS: Physicians spent 20% of their workday performing AOVs, 62% of which was for non-visit specific AOVs. They perceived that a median of 37% of non-visit-specific AOV time substituted for visits, representing a potential five visits saved per day. They also perceived that 15% of total AOV time (excluding charting) could be performed by support staff. Forty-two percent of physicians indicated that one or more visits during the study day could be substituted for by AOVs. CONCLUSIONS: Though time spent on AOVs is generally not reimbursed, primary care general internists spent significant time performing AOVs, much of which they perceived to substitute for visits that would otherwise have occurred. Policies supporting physician and staff time spent on AOVs may reduce health care costs, save time for patients and physicians, and improve care coordination.

The prevalence of cardiovascular risk conditions and awareness among a Latino subgroup: Dominicans in northern Manhattan.

OBJECTIVE: To determine the prevalence of cardiovascular risks and identify early opportunities for prevention among Dominican adults residing in New York City. STUDY DESIGN AND METHODS: A cross-sectional survey was conducted among a convenience sample of Dominicans recruited through extensive outreach in the community. All participants were interviewed and received an anthropometeric and laboratory examination pertaining to cardiovascular risk. RESULTS: 17% had diabetes; another 20% had impaired fasting glucose or impaired glucose tolerance; 56% had high cholesterol levels; 41% had hypertension upon examination; 75% were either overweight or obese. The Dominican diagnosed diabetes prevalence significantly exceeded comparable rates among US Latinos dominated by Mexican Americans, while their hypertension prevalence exceeded both US Latino and African American rates. Dominicans were more obese than either US Latino or African Americans, but they had the lowest proportion with high cholesterol. While >80% had a clinical encounter in the last 12 months, 29% were unaware that they had diabetes; 39% did not know they had hypertension, and 50% were unaware of their high cholesterol levels. CONCLUSIONS: The prevalence of cardiovascular risk conditions among Dominicans in New York is higher than the rate for US Latinos for selected but not all conditions. In addition, many missed opportunities exist for prevention and early diagnosis. Future research and cardiovascular risk prevention programs need to pay attention to differences of cardiovascular risk among Latino subgroups.

Reducing frequent flyer emergency department visits.

Accessing comprehensive and timely health care services in the U.S. continues to be a significant problem, particularly for low-income and socially marginalized groups in urban environments. To begin to address these problems, the Northern Manhattan Community Voices partners have turned to health priority specialists (HPSs) and community health workers (CHWs) to help reduce emergency department visits for care that would better be delivered in clinics or provider offices. This paper examines data collected from an emergency department (ED) diversion program between January 2003 and December 2004 and examines the effects of interventions by HPSs and CHWs in relationship to ED usage among 711 patients. At 6-month assessment, 3 interventions were significantly correlated with decreased ED usage: providing health education (pearson correlation = .299; p = .000; N = 177; mean = .02), teaching patients how to use the health care system (pearson correlation = .259; p = .001; N = 177; mean = .01), and providing counseling on social/emotional issues (pearson correlation = .408; p = .000; N = 177; mean = .01). This paper presents data that reflect the operations in a real-life clinical setting working with economically, socially, and linguistically marginalized populations.