Race-Specific Patterns of Treatment Intensification Among Hypertensive Patients Using Home Blood Pressure Monitoring: Analysis Using Defined Daily Doses in the Heart Healthy Lenoir Study.

BACKGROUND: Racial disparities in blood pressure (BP) control persist, but whether differences by race in antihypertensive medication intensification (AMI) contribute is unknown. OBJECTIVE: To compare AMI by race for patients with elevated home BP readings. METHODS: This prospective cohort study followed adult patients from 6 rural primary care practices who used home BP monitoring (HBPM) and recorded/reported values. For providers, AMI was encouraged when mean HBPM systolic blood pressure (SBP) values were ⩾135 mm Hg; patients received phone-based coaching on HBPM technique and sharing HBPM findings. AMI was assessed between baseline and 12 months using defined daily dose (DDD) and summed to create a total antihypertensive DDD value. RESULTS: A total of 217 patients (mean age = 61.4 ± 10.2 years; 66% female; 57% black) provided usable HBPM data. Among 90 (41%) intensification-eligible hypertensive patients (ie, mean HBPM SBP values for 6-months ⩾135 mm Hg), mean total antihypertensive DDD was increased in 61% at 12 months. Blacks had significantly higher mean DDD at baseline and 12 months, but intensification (+0.72 vs +0.65; P = 0.83) was similar by race. However, intensification was greater in males than females (+1.1 vs +0.39; P = 0.031). Reduction in mean SBP following intensification was greater in white versus black patients (-8.2 vs -3.9 mm Hg; P = 0.14). Conclusion/Relevance: Treatment intensification in HBPM users was similar by race, differed significantly by gender, and may produce a greater response in white patients. Differential AMI in HBPM users does not appear to contribute to persistent racial disparities in BP control.

The association of health literacy and blood pressure reduction in a cohort of patients with hypertension: The heart healthy lenoir trial.

OBJECTIVE: Lower health literacy is associated with poorer health outcomes. Few interventions poised to mitigate the impact of health literacy in hypertensive patients have been published. We tested if a multi-level quality improvement intervention could differentially improve Systolic Blood Pressure (SBP) more so in patients with low vs. higher health literacy. METHODS: We conducted a non-randomized prospective cohort trial of 525 patients referred with uncontrolled hypertension. Stakeholder informed and health literacy sensitive strategies were implemented at the practice and patient level. Outcomes were assessed at 0, 6, 12, 18 and 24 months. RESULTS: At 12 months, the low and higher health literacy groups had statistically significant decreases in mean SBP (6.6 and 5.3mmHg, respectively), but the between group difference was not significant (Δ 1.3mmHg, P=0.067). At 24 months, the low and higher health literacy groups reductions were 8.1 and 4.6mmHg, respectively, again the between group difference was not significant (Δ 3.5mmHg, p=0.25). CONCLUSIONS/PRACTICE IMPLICATIONS: A health literacy sensitive multi-level intervention may equally lower SBP in patients with low and higher health literacy. Practical health literacy appropriate tools and methods can be implemented in primary care settings using a quality improvement approach.

A multicomponent quality improvement intervention to improve blood pressure and reduce racial disparities in rural primary care practices.

The Southeastern United States has the highest prevalence of hypertension and African Americans have disproportionately worse blood pressure control. The authors sought to evaluate the effect of a multicomponent practice-based quality improvement intervention on lowering mean systolic blood pressure (SBP) at 12 and 24 months compared with baseline among 525 patients, and to assess for a differential effect of the intervention by race (African Americans vs white). At 12 months, both African Americans (-5.0 mm Hg) and whites (-7.8 mm Hg) had a significant decrease in mean SBP compared with baseline, with no significant between-group difference. Similarly, at 24 months, mean SBP decreased in both African Americans (-6.0 mm Hg) and whites (-7.2 mm Hg), with no significant difference between groups. Notably, no significant racial disparity in mean SBP at baseline was shown. The intervention was effective in lowering mean SBP in both African Americans and whites but there was no differential effect of the intervention by race.

Lessons Learned From Implementing Health Coaching in The Heart Healthy Lenoir Hypertension Study.

BACKGROUND: Health coaching is increasingly important in patient-centered medical homes. OBJECTIVES: Describe formative evaluation results and lessons learned from implementing health coaching to improve hypertension self-management in rural primary care. METHODS: A hypertension collaborative was formed consisting of six primary care sites. Twelve monthly health coaching phone calls were attempted for 487 participants with hypertension. LESSONS LEARNED: Participant engagement was challenging; 58% remained engaged, missing fewer than three consecutive calls. Multivariate analyses revealed that older age (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.01-1.05), African American race (O,R 1.73; 95% CI, 1.15-2.60), greater number of comorbidities (OR, 1.17; 95% CI, 1.05-1.30) and receiving coaching closer to enrollment (OR, 5.03; 95% CI, 2.53-9.99) were correlated independently with engagement. Participants reported the coaching valuable; 96% would recommend health coaching to others. CONCLUSIONS: Health coaching in hypertension care can be successful strategy for engaging more vulnerable groups. A more tailored approach may improve engagement with counseling.

Perceived Social Standing, Medication Nonadherence, and Systolic Blood Pressure in the Rural South.

PURPOSE: Little is known about how perceived social standing versus traditional socioeconomic characteristics influence medication adherence and blood pressure (BP) among African American and white patients with hypertension in the rural southeastern United States. METHODS: Perceived social standing, socioeconomic characteristics, self-reported antihypertensive medication adherence, and BP were measured at baseline in a cohort of rural African American and white patients (n = 495) with uncontrolled hypertension attending primary care practices. Multivariate models examined the relationship of perceived social standing and socioeconomic indicators with medication adherence and systolic BP. FINDINGS: Medication nonadherence was reported by 40% of patients. Younger age [ß = 0.20; P = .001], African American race [ß = -0.30; P = .03], and lower perceived social standing [ß = 0.08; P = .002] but not sex or traditional socioeconomic characteristics including education and household income, were significantly associated with lower medication adherence. Race-specific analyses revealed that this pattern was limited to African Americans and not observed in whites. In stepwise modeling, older age [ß = 0.57, P = .001], African American race [ß = 4.4; P = .03], and lower medication adherence [ß = -1.7, P = .01] but not gender, education, or household income, were significantly associated with higher systolic BP. CONCLUSIONS: Lower perceived social standing and age, but not traditional socioeconomic characteristics, were significantly associated with lower medication adherence in African Americans. Lower medication adherence was associated with higher systolic BP. These findings suggest the need for tailored, culturally relevant medication adherence interventions in rural communities.

Health coaching interventions with a heart-healthy lenoir project client.

The Heart-Healthy Lenoir Project is a multi-study project designed to reduce the risk burden of heart disease in Lenoir County, North Carolina. This case report examines one client's experience in this project and the impact of health coaching interventions that were used. The client presented with unhealthy lifestyle behaviors and a systolic blood pressure (BP) of more than 200 mmHg. After 1 year of educational group meetings and personalized health coaching, the client was able to reduce her BP to an acceptable range and has adopted many new lifestyle behaviors. This case report demonstrates one way health coaching is being integrated into educational programs and in collaboration with primary care practices.

Heart-Healthy Lenoir Project es un proyecto multiestudio diseñado para reducir la carga que supone el riesgo de cardiopatías en el condado de Lenoir, Carolina del Norte (EE. UU.). Este caso clínico examina la experiencia de una cliente de este proyecto y el impacto de las intervenciones de formación sanitaria empleadas. La cliente llevaba un estilo de vida insano y presentaba una presión arterial (PA) sistólica de más de 200 mmHg. Después de 1 año de reuniones con el grupo educativo y de formación sanitaria personalizada, la cliente fue capaz de reducir su PA hasta unos límites aceptables y ha adoptado muchas conductas de estilo de vida nuevas. Este caso clínico demuestra que la formación sanitaria unidireccional se está integrando en los programas educativos en colaboración con consultas de atención primaria.

The Heart Healthy Lenoir project--an intervention to reduce disparities in hypertension control: study protocol.

BACKGROUND: Racial disparities in blood pressure control are well established; however the impact of low health literacy (LHL) on blood pressure has garnered less attention. Office based interventions that are created with iterative patient, practice and community stakeholder input and are rolled out incrementally, may help address these disparities in hypertension control. This paper describes our study protocol. METHODS/DESIGN: Using a community based participatory research (CBPR) approach, we designed and implemented a cohort study that includes both a practice level and patient level intervention to enhance the care and support of patients with hypertension in primary care practices in a rural region of eastern North Carolina. The study is divided into a formative phase and an ongoing 2.5 year implementation phase. Our main care enhancement activities include the integration of a community health coach, using home blood pressure monitoring in clinical decision making, standardizing care delivery processes, and working to improve medication adherence. Main outcomes include overall blood pressure change, the differential change in blood pressure by race (African American vs. White) and health literacy level (low vs. higher health literacy). DISCUSSION: Using a community based participatory approach in primary care practice settings has helped to engage patients and practice staff and providers in the research effort and in making practice changes to support hypertension care. Practices have engaged at varying levels, but progress has been made in implementing and iteratively improving upon the interventions to date. TRIAL REGISTRATION: ClinicalTrials.gov NCT01425515.