Assessing Patients' Perceptions of Clinician Communication: Acceptability of Brief Point-of-Care Surveys in Primary Care.

BACKGROUND: Improving patient-centered (PC) communication is a priority in many healthcare organizations. Most PC communication metrics are distal to the care encounter and lack clear attribution, thereby reducing relevance for leaders and clinicians. OBJECTIVE: We assessed the acceptability of measuring PC communication at the point-of-care. DESIGN: A brief patient survey was conducted immediately post-primary care appointments at one Veterans Affairs Medical Center. Audit-feedback reports were created for clinicians and discussed in qualitative interviews. PARTICIPANTS: A total of 485 patients completed the survey. Thirteen interviews were conducted with clinicians and hospital leaders. MAIN MEASURE(S): Measures included collaboRATE (a 3-item tool measuring PC communication), a question about how well needs were met, and overall visit satisfaction. Data were analyzed using descriptive statistics to characterize the mean and distribution of collaboRATE scores and determine the proportion of patients giving clinicians a "top score" on each item. Associations among responses were examined. Interviews focused on the value of measuring PC communication and were analyzed using a framework approach. KEY RESULTS: The proportion of patients giving PC communication "top scores" ranged from 41 to 92% for 16 clinicians who had ≥ 25 completed surveys. Among patients who gave "top scores" for PC communication, the odds of reporting that needs were "completely met" were 10.8 times higher (p < .001) and the odds of reporting being "very satisfied" with their care were 13.3 times higher (p < .001) compared with patients who did not give "top scores." Interviewees found clinician-specific feedback useful; concerns included prioritizing this data when other measures are used to evaluate clinicians' performance. Difficulties improving PC communication given organizational structures were noted. Recommendations for interventions included peer-to-peer education and mentoring by top-scoring clinicians. CONCLUSIONS: Assessing provider communication at the point-of-care is acceptable and useful to clinicians. Challenges remain to properly incentivize and support the use of this data for improving PC communication.

African American Veterans Storytelling: A Multisite Randomized Trial to Improve Hypertension.

BACKGROUND: Disparities in hypertension control persist for African American Veterans. OBJECTIVE: To enhance cultural relevance of hypertension control self-management education, in a multisite, stratified randomized trial, we tested an interactive Veteran-to-Veteran storytelling digital video disk (DVD) intervention created with Veteran partners, versus an education-only DVD comparison. METHODS: At 3 VA facilities, African American Veterans with uncontrolled hypertension were randomized to storytelling DVD intervention or didactic comparison DVD and followed for 6 months. We hypothesized that follow-up blood pressure (BP) would be lower among Veterans in the intervention group. RESULTS: African American Veterans (N=619) were 92% male, 39% over age 65, most had a high-school education, over 50% of both the intervention and comparison group reported a household income of <$20,000, and 40% had less than adequate health literacy. At baseline, mean intervention and comparison group BPs were 138/80 and 139/81 mm Hg, respectively; at 6 months, mean systolic BP (SBP) increased by 0.1 in the intervention group and by 1.9 for the comparison group; diastolic BP fell by 0.1 in the intervention group and rose by 0.2 in the comparison group. No differences between the intervention and control groups were statistically significant (all P>0.3). Site differences were large; at one, the intervention group improved while the comparison groups deteriorated, resulting in 6.3 and 3.9 mm Hg more improvement for the intervention group in SBP and diastolic BP (P=0.06 and 0.04), respectively; at the other 2 sites, there were positive and negative changes, all small, in the 2 measures, with minimal differences-one site favored the comparison group and the other, the intervention (these comparisons did not approach statistical significance (all P>0.20). In a secondary analysis stratified by baseline BP, there was no intervention effect among those with uncontrolled BP, but intervention patients who were in control at baseline were more likely to stay in control, compared with comparison [SBP increase by 6.3 mm Hg (SD=14.4) among intervention, and by 10.9 mm Hg (SD=16.9) in comparison, P=0.02]. CONCLUSIONS: In this multisite trial, we did not find a significant overall storytelling intervention effect (Clinicaltrials.gov Reg. #NCT01276197).

Dental Care in an Equal Access System Valuing Equity: Are There Racial Disparities?

BACKGROUND: Racial disparities in dental care have previously been shown in the Veterans Health Administration (VA)-a controlled access setting valuing equitable, high-quality care. OBJECTIVES: The aim of this study is to examine current disparities in dental care by focusing on the receipt of root canal therapy (RCT) versus tooth extraction. RESEARCH DESIGN: This is a retrospective analysis of data contained in the VA's electronic health records. We performed logistic regressions on the independent measures along with a facility-specific random effect, using dependent binary variables that distinguished RCT from tooth extraction procedures. SUBJECTS: VA outpatients who had at least 1 tooth extraction or RCT visit in the VA in fiscal year 2011. MEASURES: A dependent binary measure of tooth extraction or RCT. Other measures are medical record data on medical comorbidities, dental morbidity, prior dental utilization, and demographic characteristics. RESULTS: The overall rate of preferred tooth-preserving RCT was 18.1% during the study period. Black and Asian patients were most dissimilar with respect to dental morbidity, medical and psychological disorders, and black patients had the least amount of eligibility for comprehensive dental care. After adjustment for known confounding factors of RCT, black patients had the lowest RCT rates, whereas Asians had the highest. CONCLUSIONS: Current quality improvement efforts and a value to improve the equity of care are not sufficient to address racial/ethnic disparities in VA dental care; rather more targeted efforts will be needed to achieve equity for all.

A Brief, Multifaceted, Generic Intervention to Improve Blood Pressure Control and Reduce Disparities Had Little Effect.

BACKGROUND: Poor blood pressure (BP) control and racial disparities therein may be a function of clinical inertia and ineffective communication about BP care. METHODS: We compared two different interventions (electronic medical record reminder for BP care (Reminder only, [RO]), and clinician training on BP care-related communication skills plus the reminder (Reminder + Training, [R+T]) with usual care in three primary care clinics, examining BP outcomes among 8,866 patients, and provider-patient communication and medication adherence among a subsample of 793. RESULTS: Clinician counseling improved most at R+T. BP improved overall; R+T had a small but significantly greater reduction in diastolic BP (DBP; -1.7 mm Hg). White patients at RO experienced greater overall improvements in BP control. Site and race disparities trends suggested that disparities decreased at R+T, either stayed the same or decreased at Control; and stayed the same or increased at RO. CONCLUSIONS: More substantial or racial/ethnically tailored interventions are needed.

Effectiveness of fluorides in root caries prevention, Department of Veterans Affairs (2009-2018).

AIMS: The aim of this study was to examine the effectiveness of topical fluorides in prevention of root caries-related treatment in high caries risk Veterans. METHODS: This retrospective analysis of longitudinal data examined the effectiveness of professionally applied or prescription (Rx) fluoride treatment, in VHA clinics from FY 2009-2018. Professional fluoride treatments included 5% Sodium Fluoride (NaF) varnish (22 600 ppm fluoride), 2% NaF gel/rinse (9050 ppm fluoride), and 1.23% APF gel (12 300 ppm fluoride). The Rx for daily home use was 1.1% NaF paste/gel (5000 ppm fluoride). Outcomes studied were new root caries restorations or extractions and percent of patients with treatment over 1 year. Logistic regressions were adjusted for age, gender, race, ethnicity, chronic medical or psychiatric conditions, number of medication classes, anticholinergic drugs, smoking, baseline root caries treatment, preventive care, and time between first-last restoration in the index year. RESULTS: Root caries at baseline was associated with a high risk for new root caries. Veterans without root caries during the index year who received a fluoride gel/rinse intervention were 32-40% less likely to receive caries-related treatment for root caries during the follow-up period. Once Veterans had root caries, fluorides did not exhibit a positive effect. CONCLUSION: In older adults with high caries risk, early fluoride prevention is key, before root caries requires treatment.

Validation of a Subjective Caries Risk Assessment Tool.

OBJECTIVE: The objective was to evaluate the predictive validity of the American Dental Association's caries risk assessment (CRA) tool, adapted with permission, and used by the U.S. Department of Veterans Affairs dental services within their electronic dental record. METHODS: This analytic epidemiologic study with a retrospective longitudinal design included Veterans who had a minimum of three years of available data. The primary outcome was caries-related treatment during the twelve-month predictive period following the CRA category identification. RESULTS: The sample included 57,675 Veterans; 50.1% classified as low, 33.2% as moderate and 16.8% as high caries risk. During the twelve-month predictive period, both teeth/person and teeth with caries-related treatment rose sequentially from low to high CRA categories. However, poor sensitivity (0.34-0.58) and better specificity (0.53-0.78) values were observed. Similarly, better negative predictive values (0.72-0.79) compared to positive predictive values (0.28-0.34) were found. Adjusted logistic regression models showed that current treated caries (caries detected at the time of the CRA exam) was more strongly associated with future caries-related treatment than the subjective CRA determination. CONCLUSIONS: The subjective CRA tool evaluated in this study is better at identifying patients at low risk of requiring future caries-related treatment versus those at higher risk. This makes it difficult to target the most caries susceptible patients with preventive measures. Furthermore, we found that the amount of caries treatment required at the time of the CRA exam had the strongest association with caries-related treatment during the subsequent twelve-month predictive period. CLINICAL SIGNIFICANCE: The amount of caries-related treatment required at the time of the caries risk classification is the strongest predictor of future caries.

Examining the Impact of a Peer-Led Group Program for Veteran Engagement and Well-Being.

Objectives: Veterans often suffer from multiple chronic illnesses, including mental health disorders, diabetes, obesity, and cardiovascular disease. The improvement of engagement in their own health care is critical for enhanced well-being and overall health. Peer-led group programs may be an important tool to provide support and skill development. We conducted a pilot study to explore the impact of a peer-led group-based program that teaches Veterans to become empowered to engage in their own health and well-being through mindful awareness practices, self-care strategies, and setting life goals. Design: Surveys were collected before and immediately after participation in the Taking Charge of My Life and Health (TCMLH) peer-led group program. Settings/location: Sessions were held in non-clinical settings within a VA medical center in the Midwest. Subjects: Our sample comprised 48 Veteran participants who were enrolled in TCMLH and completed a pretest and post-test survey. Intervention: TCMLH is a 9-week peer-led group program with an established curriculum that leverages the power of peer support to improve patient engagement, empowerment, health, and well-being among Veterans through Whole Health concepts, tools, and strategies. Programs were led by 1 of 12 trained Veteran peer facilitators. Outcome measures: Program impact on Veteran well-being was assessed by pre-post measures, including the Patient Activation Measure (PAM), the Perceived Stress Scale (PSS), the Patient-Reported Outcomes Measurement Information System Scale (PROMIS-10), the Perceived Health Competency Scale (PHCS), and the Life Engagement Test (LET). Results: There was a significant decrease in perceived stress (PSS score). Significant improvements were also seen in mental health and quality of life (PROMIS-10), participant accordance with the statement "I have a lot of reasons for living" (LET), and patient engagement (PAM score). Conclusions: As the Whole Health movement expands-both in VA and elsewhere-our findings suggest that guiding patients in an exploration of their personal values and life goals can help in key areas of patient engagement and mental and physical health outcomes. Further study is warranted, and expansion of the TCMLH program will allow for a more rigorous evaluation with a larger sample size.

The association of COVID-19 occurrence and severity with the use of angiotensin converting enzyme inhibitors or angiotensin-II receptor blockers in patients with hypertension.

BACKGROUND: A number of studies have reported the association between the use of angiotensin-converting enzyme inhibitor (ACEI) and angiotensin-II receptor blocker (ARB) medications and the occurrence or severity of coronavirus disease 2019 (COVID-19). Published results are inconclusive, possibly due to differences in participant comorbidities and sociodemographic backgrounds. Since ACEI and ARB are frequently used anti-hypertension medications, we aim to determine whether the use of ACEI and ARB is associated with the occurrence and severity of COVID-19 in a large study of US Veterans with hypertension. METHODS: Data were collected from the Department of Veterans Affairs (VA) National Corporate Data Warehouse (VA-COVID-19 Shared Data Resource) between February 28, 2020 and August 18, 2020. Using data from 228,722 Veterans with a history of hypertension who received COVID-19 testing at the VA, we investigated whether the use of ACEI or ARB over the two years prior to the index date was associated with increased odds of (1) a positive COVID-19 test, and (2) a severe outcome (hospitalization, mortality, and use of intensive care unit (ICU) and/or mechanical ventilation) among COVID-19-positive patients. We used logistic regression with and without propensity score weighting (PSW) to estimate the odds ratio (OR) and 95% confidence interval (95% CI) for the association between ACEI/ARB use and a positive COVID-19 test result. The association between medication use and COVID-19 outcome severity was examined using multinomial logistic regression comparing participants who were not hospitalized to participants who were hospitalized, were admitted to the ICU, used a mechanical ventilator, or died. All models were adjusted for relevant covariates, including demographics (age, sex, race, ethnicity), selected comorbidities, and the Charlson Comorbidity Index (CCI). RESULTS: The use of ACEI significantly decreased the odds of a positive COVID-19 test among Veterans with hypertension (OR = 0.917, (0.887, 0.948) and OR = 0.926, (0.894, 0.958) with PSW). The use of ACEI, but not of ARB, was also associated with significantly increased odds of using mechanical ventilators (OR = 1.265, (1.010, 1.584) and OR = 1.210, (1.053, 1.39) with PSW) among all COVID-19 inpatients compared to outpatients. CONCLUSIONS: In this study of Veterans with hypertension, ACEI was significantly associated with decreased odds of testing positive for COVID-19. With the exception of the association of ACEI with a small non-clinically-important increase in the odds of using mechanical ventilators, neither ACEI nor ARB was found to be associated with clinical severity or mortality among COVID-19-positive Veterans. The results of this study need further corroboration and validation in other cohort samples outside the VA.

Understanding racial disparities in treatment intensification for hypertension management.

BACKGROUND: Disparities in blood pressure (BP) control may be a function of disparities in treatment intensification (TI). OBJECTIVE: To examine racial differences in TI, understand modifiable factors that may mediate this relationship, and explore the relative effects of TI and race on blood pressure. DESIGN: Prospective cohort study. PARTICIPANTS: Participants were 819 black and white patients with hypertension from an urban, safety-net hospital MAIN MEASURES: We sequentially explored the effects of patient race, sociodemographic and clinical characteristics, beliefs about BP/medications, perceptions of provider/discrimination, sodium intake, medication adherence, and provider counseling on TI, performing a series of random effects analyses. To assess the effects of race and TI on BP, we performed linear regressions, using systolic BP (SBP) as the outcome. KEY RESULTS: Unadjusted analyses and those including sociodemographic and clinical characteristics revealed that black patients had less TI than whites (-0.31 vs.-0.24, p < 0.001), but adjustment for patient beliefs and experiences eliminated the effects of race (beta =-0.02, p = 0.5). Increased patient concerns about BP medications were related to lower TI, as was more provider counseling (beta =-0.06, p = 0.02 and beta = -0.01, p = 0.001, respectively). In the unadjusted analysis, black race was a significant predictor of SBP (134 mm/Hg for blacks vs. 131 mm/Hg for whites, p = 0.009), but when both race and TI were included in the model, TI was a significant predictor of SBP (final SBP 2.0 mm/Hg lower for each additional therapy increase per 10 visits, p < 0.001), while race was not (Blacks 1.6 mm/Hg higher than whites, p = 0.17). CONCLUSIONS: Improved patient-provider communication targeted towards addressing patient concerns about medications may have the potential to reduce racial disparities in TI and ultimately, BP control.

Pediatric clinicians can help reduce rates of early childhood caries: effects of a practice based intervention.

OBJECTIVE: Early childhood caries (ECC) is a serious and preventable disease which pediatric clinicians can help address by counseling to reduce risk. RESEARCH DESIGN: We implemented a multifaceted practice-based intervention in a pediatric outpatient clinic treating children vulnerable to ECC (N = 635), comparing results to those from a similar nearby clinic providing usual care (N = 452). INTERVENTION: We provided communication skills training using the approach of patient centered counseling, edited the electronic medical record to prompt counseling, and provided parents/caregivers with an educational brochure. OUTCOME MEASURES: We assessed changes in provider knowledge about ECC after the intervention, and examined providers' counseling practices and incidence of ECC over time by site, controlling for baseline ECC, patient sociodemographics and parents'/caregivers' practice of risk factors (diet, oral hygiene, tooth-monitoring), among 1045 children with complete data. RESULTS: Provider knowledge about ECC increased after the intervention training (percentage correct answers improved from 66% to 79%). Providers at the intervention site used more counseling strategies, which persisted after adjustment for sociodemographic characteristics. Children at the intervention site had a 77% reduction in risk for developing ECC at follow up, after controlling for age and race/ethnicity, sociodemographics and ECC risk factors; P

Caries prevalence and associations with medications and medical comorbidities.

OBJECTIVES: To use extensive electronic dental, medical, and pharmacy databases to estimate the prevalence of dental caries in a cohort of new patients during a 5-year period (FY2010-FY2015) and determine whether medication use and medical comorbidities are associated with caries prevalence. METHODS: This was a retrospective analysis of existing data from the Department of Veterans Affairs (VA). The number of teeth treated due to a caries-related diagnosis was determined and outcomes were presented as number of teeth/person and proportion of patients receiving caries-related treatment. Logistic and negative binomial regression modeled teeth/person with caries-related treatment; covariates included age, gender, race, ethnicity, physical and mental comorbidities, and use of prescription medications and prescription drugs with strong anticholinergic properties. RESULTS: The study population included 95,850 dentate dental patients: 92.1 percent were male, mean age of 58.7 ± 12.6 years, 73.2 percent were White/Caucasian, and 21.3 percent were Black/African American. They were taking a mean of 10.6 ± 5.9 VA prescription drug classes, 0.6 ± 0.4 drugs with strong anticholinergic properties, and had 3.6 ± 2.2 physical and 1.4 ± 1.2 mental comorbidities. On average, 2.2 teeth/person received caries-related treatment and 58 percent of the study population received any caries-related treatment. An increase in the rate of caries-related treatment in Veterans was statistically significantly associated with increased prescription medication use; one or more drugs with strong anticholinergic properties and with 1+ mental comorbidities. Increased physical comorbidity was not statistically significantly associated with caries-related treatment. CONCLUSIONS: This study demonstrates a high prevalence of caries among Veteran dental patients, with an increased prevalence in those taking higher numbers of prescription medications.

Beyond Medication Adherence: The Role of Patients' Beliefs and Life Context in Blood Pressure Control.

Objective: Despite numerous interventions to address adherence to antihypertensive medications, continued high rates of uncontrolled blood pressure (BP) suggest a need to better understand patient factors beyond adherence associated with BP control. We examined how patients' BP-related beliefs, and aspects of life context affect BP control, beyond medication adherence. Methods: We conducted a cross-sectional telephone survey of primary care patients with hypertension between 2010 and 2011 (N=103; 93 had complete data on all variables and were included in the regression analyses). We assessed patient sociodemographics (including race/ethnicity), medication adherence, BP-related beliefs, aspects of life context, and used clinical BP assessments. Results: Regression models including sociodemographics, medication adherence, and either beliefs or context consistently predicted BP control. Adding context after beliefs added no predictive value while adding beliefs after context significantly predicted BP control. Practical Implications: Results suggest that when clinicians must choose a dimension on which to intervene, focusing on beliefs would be the most fruitful approach to effecting change in BP control.

Chronic kidney disease is associated with angiographic coronary artery disease.

BACKGROUND/AIMS: Patients with chronic kidney disease (CKD) have a dramatically increased risk for cardiovascular mortality. Few prior studies have examined the independent association of CKD with coronary anatomy. METHODS: We evaluated the relationship between CKD and severe coronary artery disease (CAD) in 261 male veterans with nuclear perfusion imaging tests suggesting coronary ischemia. We used chart review and patient and provider interviews to collect demographics, clinical characteristics, and coronary anatomy results. We defined CKD as an estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73 m2, based on the creatinine obtained prior to angiography. We defined significant coronary obstruction as at least one 70% or greater stenosis. We used logistic regression to determine whether CKD was independently associated with significant coronary obstruction. RESULTS: The likelihood of CAD increased monotonically with decreasing eGFR, from 51% among patients with eGFR or = 90 ml/min/1.73 m2 to 84% in those with eGFR < 30 ml/min/1.73 m2 (p = 0.0046). Patients with CKD were more likely than those without CKD to have at least one significant coronary obstruction (75.9 vs. 60.7%, p = 0.016). Patients with CKD also had more significant CAD, that is, were more likely to have three-vessel and/or left main disease than those without CKD (34.9 vs. 16.9%, p = 0.0035). In logistic regression analysis, controlling for demographics and comorbidity, CKD continued to be independently associated with the presence of significant CAD (p = 0.0071). CONCLUSION: CKD patients have a high prevalence of obstructive coronary disease, which may contribute to their high cardiovascular mortality.

A new brief measure of oral quality of life.

INTRODUCTION: We developed a brief measure of the impact of oral conditions on individual functioning and well-being, known as oral quality of life. METHODS: Among older male veterans (N = 827) and community dental patients (N = 113), we administered surveys consisting of extant oral quality of life items, using clinical dental data from the veteran samples. We assigned each oral quality of life item to a theoretical dimension, conducted an iterative series of multitrait scaling analyses to examine the item-fit with the dimensions, reduced the number of items, and examined the psychometric characteristics of new scales and their association with clinical indices. RESULTS: We developed two brief oral quality of life scales, one consisting of 12 items and the other of 6, the latter a subset of the former. Each demonstrated sound psychometric properties and was sensitive to clinical indices. CONCLUSION: The two brief oral quality of life scales can be used to assess the population-based impact of oral conditions as well as outcomes of dental care.

Functional status outcomes among white and African-American cardiac patients in an equal access system.

BACKGROUND: Racial disparities exist in invasive cardiac procedure use and, sometimes, in subsequent functional status outcomes. We explored whether racial differences in functional outcomes occur in settings where differences in access and treatment are minimized. METHODS: We conducted a prospective observational cohort study of 1022 white and African-American cardiac patients with positive nuclear imaging studies in 5 VA hospitals. Patients' functional status was assessed at baseline, 6, and 12 months later using the Seattle Angina Questionnaire and the SF-12, controlling for treatment received, clinical, sociodemographic, and psychological characteristics. RESULTS: There were no significant baseline effects of race on functional status, after adjusting for sociodemographics, comorbid conditions, maximal medical therapy, severity of ischemia on nuclear imaging study, personal attitudes, and beliefs. Although there were no race differences in percutaneous transluminal coronary angioplasty use, there was a trend of African Americans being less likely to undergo coronary artery bypass graft, after 6 months (1.4% vs 6.5%) and 1 year (1.9 vs 6.9%). After adjustment, the decline in the SF12 Physical Component Summary from baseline to 6 months was, on average, 2.4 points less for African Americans than for whites, and at 12 months, Anginal Stability improved 8.4 points more for African Americans. The relative strength and direction of both findings persisted after removing covariates that might be confounded with race, and African Americans decreased less than whites on Physical Limitations, and improved more on Treatment Satisfaction, Anginal Frequency, and Disease Perceptions. CONCLUSIONS: In a setting where differences in access are minimized, so are racial differences in functional status outcomes.

Hypertensive patients' race, health beliefs, process of care, and medication adherence.

BACKGROUND: African Americans have higher rates of hypertension and worse blood pressure (BP) control than Whites, and poorer medication adherence may contribute to this phenomenon. We explored associations among patients' race, self-reported experiences with clinicians, attitudes and beliefs about hypertension, and ultimately, medication adherence, among a sample with no racial disparities in BP control, to determine what lessons we could learn from patients and providers in this setting. METHODS: We recruited 793 White and African-American (58%) patients previously diagnosed with hypertension from 3 VA medical centers to participate in survey assessments of each of the above dimensions, subsequent to a primary care clinic visit. RESULTS: African-American patients' providers were significantly more active in advising and counseling about hypertension care and medication adherence. African-American patients indicated greater knowledge or heightened awareness of the importance of controlling their BP, but there were no race differences on a summary adherence measure. In multivariate models modeling medication adherence, race was not significant, but having been told to split one's pills, believing one's BP continues to be high, and having one's provider discuss things to do to make it easier to take BP medications were each significantly associated with worse adherence, whereas having more confidence in one's ability to take BP medications as prescribed was associated with better adherence (all p's < or = .02). CONCLUSION: When both physicians and patients take BP management seriously, disparities in BP adherence and control may be reduced.

Understanding uncontrolled hypertension: is it the patient or the provider?

The relative contributions of adherence and treatment intensity to blood pressure (BP) control are not well understood. The authors studied patients with uncontrolled hypertension (N=410) from 3 primary care clinics in the Veterans Affairs (VA) medical system. A questionnaire was used to assess patient adherence to therapy, and VA system pharmacy fills were used to assess the intensity of the antihypertensive regimen. At baseline, an inadequate antihypertensive regimen was implicated as the most probable reason for uncontrolled BP in a majority of patients (72%), while nonadherence could only be implicated in 13%. In multivariate longitudinal analyses, patients who had an increase in their medical treatment during the study had lower final diastolic BP levels compared with the patients who did not (-3.70 mm Hg; P<.05). While patient adherence to therapy plays a role, vigorous clinical management by the clinician is a more important contributor to BP control.

Can stories influence African-American patients' intentions to change hypertension management behaviors? A randomized control trial.

OBJECTIVES: Information-only interventions for hypertension management have limited effectiveness, particularly among disadvantaged populations. We assessed the impact of viewing African-American patients' stories of successfully controlling hypertension on intention to change hypertension management behaviors and engagement with educational materials. METHODS: In a three-site randomized trial, 618 African-American Veterans with uncontrolled hypertension viewed an information-only DVD about hypertension (control) or a DVD adding videos of African-American Veterans telling stories about successful hypertension management (intervention). After viewing, patients were asked about their engagement with the DVD, and their intentions to change behavior. Mean scores were compared with two-sided t-tests. RESULTS: Results favored the Stories intervention, with significantly higher emotional engagement versus control (4.3 vs. 2.2 p<0.0001). Intervention patients reported significantly greater intentions to become more physically active (4.6 vs. 4.4, p=0.018), use salt substitutes (3.9 vs. 3.4, p=0.006), talk openly with their doctor about hypertension (4.6 vs. 4.5, p=0.049), and remember to take hypertension medication (4.8 vs. 4.6, p=0.04). CONCLUSION: Patients were more emotionally engaged and reported intentions to change behavior when watching real patient hypertension management success stories. PRACTICE IMPLICATIONS: Stories may be more influential than information alone, and represent a scalable approach to modifying behavioral intention.

Patient Decision Control and the Use of Cardiac Catheterization.

BACKGROUND: Shared decision-making is a key determinant of patient-centered care. A lack of patient involvement in treatment decisions may explain persistent racial disparities in rates of cardiac catheterization (CCATH). To date, limited evidence exists to demonstrate whether patients who engage in shared decision-makingare more or less likely to undergo non-emergency CCATH. OBJECTIVE: To assess the relationship between participation in the decision to undergo a CCATH and the use of CCATH. We also examined whether preference for or actual engagement in decision-making varied by patient race. METHODS: We analyzed data from 826 male Veterans Administration patients for whom CCATH was indicated and who participated in the Cardiac Decision Making Study. RESULTS: After controlling for confounders, patients reporting any degree of decision control were more likely to receive CCATH compared with those reporting no control (doctor made decision without patient input) (54% vs 39%, P<.0001). Across racial groups, patients were equally likely to report a preference for control over decision-making (P=.53) as well as to experience discordance between their preference for control and their perception of the actual decision-making process (P=.59). Therefore, these factors did not mediate racial disparities in rates of CCATH use. CONCLUSION: Shared decision-making is an essential feature of whole-person care. While participation in decision-making may not explain disparities in CCATH rates, further work is required to identify strategies to improve congruence between patients' desire for and actual control over decision-making to actualize patient-centered care.