Advances in controlling hypertension in low-income patients.

Since hypertension is the foremost problem in minority and low-income populations treated in our community health centers, in 1976 we introduced a protocol that standardized diagnostic criteria and a step-care approach to the treatment of hypertension. In 1980, we modified the original protocol with guidelines for dietary management and an outline for improving physician-patient communication and health education. We hypothesized that implementing the protocol (and later modifications) would be associated with improved identification and control of hypertension. We conducted a cross-sectional study of hypertensive patients' charts in three community health centers in 1973, 1978, and 1982, and determined the status of blood pressure (BP) control of those patients by the end of the year. In 1973 (before protocol), 4 percent of hypertensives were undiagnosed and untreated, and 20 percent were lost to follow-up. Among those who remained under care, only 33 percent were under control (BP less than 160/95 mm Hg). In 1978, two years after the protocol was introduced, there were fewer undiagnosed and untreated patients (2 percent), but the number lost to follow-up increased to 31 percent. The proportion of hypertensives under control increased to 70 percent. In 1982, two years after the modifications to the protocol were introduced, the proportion of patients lost to follow-up decreased to 28 percent, and the proportion of patients with controlled blood pressure increased to 79 percent. The improved level of control was statistically significant at p less than .0001 (chi-square test).(ABSTRACT TRUNCATED AT 250 WORDS)

AIDS knowledge in minorities: significance of locus of control.

A convenience sample of 587 subjects from the community health centers of Harris County, Texas, completed a structured interview that included questions on knowledge of AIDS transmission and prevention and on the Wallston Health Locus of Control (HLOC) Scale. HLOC score was a strong independent predictor of AIDS knowledge, with high externality associated with less knowledge. In a regression equation predicting AIDS knowledge, HLOC contributed 3% of the variance after education and ethnicity were accounted for. Hispanic and black individuals had a higher external orientation than white individuals. These findings suggest the need to address personal beliefs and perceptions concerning risk and to consider HLOC when educating patients and the public about AIDS.

Patient exposition and provider explanation in routine interviews and hypertensive patients' blood pressure control.

Hypertensive patients' expressing themselves in their own words (Exposition) and providers' giving information (Explanation) during medical interviews were hypothesized to be associated with subsequent blood pressure control. Transcripts of routine return visits to clinics in low-income areas of Houston, TX, were coded using the Verbal Response Modes (VRM) system. VRM indexes of Patient Exposition and Provider Explanation were tested in relation to systolic and diastolic blood pressure obtained during home interviews 2 weeks after the clinic visits. Patient Exposition was significantly correlated with reductions in systolic and diastolic blood pressure from clinic visit to home interview, and Provider Explanation was significantly correlated with lower diastolic blood pressure at home interview. The results suggest that patients' and providers' verbal behavior in medical interviews should be included in predictive models of blood pressure control.

PIP: Analysis of the transcriptions of 217 patients' visits to community health centers in low-income areas of Houston, Texas, for hypertension treatment suggests at least a partial correlation between patients' expressing themselves in their own words (exposition) and providers' giving information on the one hand and subsequent lowered blood pressure on the other hand. Verbal Response Mode indexes of Patient Exposition and Provider Explanation were tested in relation to systolic and diastolic blood pressure obtained during home visits 2 weeks after the medical interview. The patients' amount of talking using their own words in the medical history segment of the health center visit was significantly correlated with reductions in blood pressure from clinic to home visit, but not with blood pressure levels at the clinic or the home interview. Providers' percentage of giving objective information in the conclusion segment of the clinical interview was significantly associated with lower blood pressure at the home interview, but not with clinic levels or with change from clinic to home visit. These trends remained even after controlling for patient age, sex, ethnicity, and for provider differences. This is believed to be the 1st empirical evidence of an association between blood pressure and characteristics of the medical interview. Overall, they suggest that greater attention should be given to patient-provider verbal interaction variables in designing blood pressure control programs.

Hypertension control in multi-ethnic primary care clinics.

The most recent JNC-V guidelines for hypertension treatment call for control of blood pressure (BP) to < 140/90 mm Hg, with increased emphasis on control of systolic pressure. To determine the extent and determinants of BP control in a large multi-ethnic, low-income clinic population of diagnosed hypertensives immediately prior to issuance of the new guidelines, we reviewed the medical records of 2925 patients sampled from a population of over 14,000 hypertensives following in a network of nine primary care clinics operated by the Harris County Hospital District in Houston, Texas. Variables extracted from the medical record included: systolic (SBP) and diastolic (DBP) blood pressure at the initial clinic visit, average of all BP readings in the 12 months prior to the chart review (the measure of current control), antihypertensives prescribed at the most recent visit, and patient sociodemographic variables. The mean age of the sample was 61.6 +/- 12.8 years, and 67% were female. Average 12-month SBP and DBP were 141 +/- 14.7 and 83.6 +/- 8.5 respectively. Forty-nine per cent of patients had SBP controlled to < 140 mm Hg, 79.5% had DBP controlled to < 90 mm Hg, and 46% of patients achieved the criterion of < 140/90 mm Hg. In logistic regression analysis, age, baseline BP, body mass index and ethnicity, but not gender, were associated with current control. After adjustment for other covariates, Hispanics and Black people were significantly more likely to be in poor control than whites (ORHISP = 2.05, 95%Cl = 1.57-2.70; ORBlack = 1.48, 95%Cl = 1.21-1.81). Twelve per cent of patients were not receiving any antihypertensive medication. Of the remaining, the majority (52%) were on monotherapy. In the monotherapy group, 45% had SBP > or = 140 mm Hg and 16% had DBP > or = 90 mm Hg. We conclude that the achievement of new treatment recommendations will require education of primary care providers in more aggressive titration of antihypertensive medications to control SBP.

Hypertension awareness and control in an inner-city African-American sample.

African-Americans in the US are at high risk for hypertension-related morbidity and mortality. The majority of African-Americans live in central city areas, and lower socioeconomic status and health care utilization patterns have been hypothesized to contribute to higher blood pressure (BP) levels and poorer control of treated hypertension in this group. In order to plan an intervention to improve hypertension care for inner city African-Americans in Houston, Texas, we conducted a baseline survey of residents in 12 low-income ZIP code areas with a > 70% African-American population to determine the level of hypertension awareness, treatment and control, and associated sociodemographic, health care utilization, and medication compliance variables. Subjects were recruited to attend a BP measurement and assessment of knowledge, attitudes and behaviors through random digit phone dialing in the target ZIP code areas. Of the 962 subjects examined, 433 (45%) were hypertensive (systolic BP > or = 140 mm Hg or diastolic pressure > or = 90 mm Hg or taking antihypertensive medication). Among all hypertensives, 73% were aware, 64% were on treatment, and 28% were controlled to 140/90 mm Hg. Of hypertensives on treatment, 43% were controlled to 140/90 mm Hg, but 72% were controlled using the criterion of 160/95 mm Hg, and 75% were controlled using a diastolic pressure < 90 mm Hg only. These results are similar to those reported for African-Americans in the most recent US national health survey. Males were less likely to be aware, receiving treatment and controlled than were females. Although lack of awareness was associated with less frequent BP measurement, 77% of those unaware reported a measurement within the past 2 years. The majority of aware hypertensives reported frequent physician contact and high compliance with medication. We conclude that intervention to improve hypertension control in this population should focus on ensuring that health providers diagnose BP and establish treatment goals based on the current standard of 140/90 mm Hg.

Adult onset diabetes mellitus: glycemic control and family function.

To test the hypothesis that family function differs in patients according to their level of diabetes control, family function was assessed using the Family APGAR questionnaire in low-income patients with adult-onset diabetes who were under comprehensive care in five community health centers. From 3,000 active patients, a group of 385 with the following characteristics were randomly selected: mean age, 59.1 (range 25-93); M:F ratio, 1:4; and ethnic distribution (blacks: Hispanics: whites, 48%:31%:21%). Categorizing patients by their extent of diabetes control, good family function was found in 92% of patients in good control of their diabetes mellitus, in 66% of those in fair control, and only in 50% of those in poor control (p less than 0.005, chi 2 = 44.1, df = 2). Since these data point to the association between levels of family functioning and control of diabetes, further studies are needed to ascertain if an improvement in family functioning will lead to better diabetic control.

Reliance on high technology among senior medical students.

To gain a better understanding of senior medical students who perceive high-technology medicine as the desirable form of medical practice, we developed and evaluated a structural equation model. Intolerance to clinical uncertainty, Machiavellianism, and authoritarianism characterized students who scored higher on reliance on high-technology medicine. High scorers also tended to have a negative orientation toward patients' psychological problems and were unlikely to choose careers in primary care medicine. Students who perceive high technology as a panacea in clinical medicine share personal traits and attitudes toward patients that are not conducive to achieving the national goal of a 50:50 ratio between primary and non-primary care physicians.

Machiavellianism in medical students.

To be more responsive to the nation's health needs, medical educators should identify those personal qualities associated with effective primary medical care. For this research Machiavellianism was chosen as a tracer character trait opposed to the characteristics embodied in an ideal family physician. A survey was conducted of 167 freshmen from one medical school and 823 seniors from four medical schools, with Machiavellianism scores used to predict their professional role characteristics, attributional style toward patients, and choice of a career specialty. Results showed that 15% of all students scored positively on the Machiavellianism scale. Mean Machiavellianism scores for seniors did not differ from those for freshmen. Men had higher Machiavellianism scores than women. Those students with high Machiavellianism scores relied excessively on high-tech medicine and were externally controlled, intolerant of ambiguity, and authoritarian. Seniors' high Machiavellianism scores predicted a negative attributional style toward geriatric and hypochondriac patients, thereby validating the use of Machiavellianism to measure medical students' indifference to patients and their problems.

Physician communication to patients regarding medications.

An analysis of 11 physicians' speech content regarding medications was conducted on 267 encounters with hypertensive patients. Scored were categories for questions, instructions, directions to take and justifications for taking medications. The median inter-auditor agreement was 83%. The results indicate that the physicians asked few questions and gave few instructions for patients on stable drug regimens; however, for newly prescribed drugs and changed regimens the provided information doubled: there were instructions for 77%, medication-taking commands for 31% and justification for taking medications for 21% of all medications. Other results indicate that that physicians did not discriminate by age, sex or race in quantity of speech about medication, but they did ask more questions of patients who saw a different physician on the previous visit. The results suggest that the system of scoring speech was reliable and captured the physicians adjustments to their patients' and their own needs for information.

AIDS knowledge in low-income and minority populations.

A convenience sample of 587 subjects was selected from the waiting areas of community health centers in Harris County, TX. They completed a structured interview that included questions on their knowledge of acquired immunodeficiency syndrome (AIDS) transmission and prevention. Hispanic patients were interviewed in their preferred language. They were given a cumulative correct score for 10 questions on AIDS. An ANOVA showed significant differences in knowledge between each radial group. Cumulative scores were whites, 78 percent correct; blacks, 68 percent correct; and Hispanics, 61 percent correct. Only 58 percent of Hispanics reported that using a condom during sexual intercourse lowered the risk of contracting AIDS, compared with 84 percent of whites and 83 percent of blacks. A regression analysis showed significant effects for both education and racial group, but not for age and sex. These findings show that knowledge of AIDS can be predicted according to the race and education of the population using these community health centers. Additional attention should be focused on educating low-income blacks and Hispanics about AIDS.

A diabetes control program in a public health care setting.

The Houston Diabetes Control Program is part of an effort by the State of Texas and approximately 30 other programs throughout the United States to ensure that persons with diabetes-related complications receive ongoing state-of-the-art preventive care and treatment. For the past 5 years, this program has served an urban, high-risk patient population with special cultural, ethnic, and economic challenges. The intervention has included the development and implementation of protocols for the prevention and care of diabetes-related complications of the eyes, lower extremities, and cardiovascular system, as well as general management of diabetes and patient and professional education. The program is ongoing in nine community health centers located in low-income neighborhoods of a large metropolitan area. The results thus far indicate an increase in sensitive eye examinations from 8 percent to 26 percent of the patient population, a reduction in incidence of legal blindness from 9.5 to 2.7 per 1,000 during a 4-year period, an increase in foot examinations from 18 percent to 44 percent of the patient population, and 77 percent of hypertensive patients in good control of blood pressure at less than 160 over 95 mmHg (millimeters of mercury). On the average, there have not been significant long-term improvements in weight reduction or blood glucose control. The major challenges for this program are (a) improvement in control of glycemia, hypertension, and cholesterol; (b) more effective diet and physical activity interventions; and (c) more effective education approaches that help patients to understand metabolic and cardiovascular functions. These challenges will require collaboration of health care professionals in constructive and imaginative ways through their unselfish commitment toward common goals.

Response rates to random digit dialing for recruiting participants to an onsite health study.

OBJECTIVE: To evaluate the response rates when random digit dialing was used as a substitute for geographic area sampling and household interviews to recruit 2100 African Americans for a blood pressure measurement and hypertension-related knowledge and attitudes survey. METHODS: Random digit dialing was used to identify African American adults living in 12 low-income ZIP code areas of Houston, Texas. A brief survey of hypertension awareness and treatment was administered to all respondents. Those who self-identified as African American were invited to a community location for blood pressure measurement and an extended personal interview. An incentive of $10 was offered for the completed clinic visit. A substudy of nonrespondents was carried out to test the effectiveness of a $25 incentive in increasing the response rate. Data from the initial random telephone interview were used to identify differences between those who did and did not attend the measurement session. RESULTS: Ninety-four percent of eligible persons contacted completed the telephone survey, and 65% agreed to visit a central community site for blood pressure measurement. In spite of the financial incentive and multiple attempts to reschedule missed appointments, only 26% of the 65% who agreed to attend completed the scheduled visit. In the substudy of the higher financial incentive, all of those who missed the original appointment agreed to another appointment, and 85% of this subgroup kept it. Not being employed full-time and a history of hypertension were consistently associated with agreement to be measured and keeping an appointment. In spite of the low response rate for scheduled appointments, differences--other than in employment status and a history of hypertension--between responders and nonresponders were small and consistent with what is usually observed in health surveys. CONCLUSIONS: The use of random digit dialing as a substitute for area sampling and household screening resulted in unacceptably low response rates in the study population and should not be undertaken without further research on ways to increase response rates.

NIDDM incidence in a tri-ethnic population of diagnosed hypertensives.

OBJECTIVE: Significant racial/ethnic differences exist in the prevalence of hypertension (HTN) and non-insulin dependent diabetes mellitus (NIDDM). The purpose of this study was to determine if ethnicity (African-American, Hispanic and non-Hispanic white) was related to NIDDM incidence over a maximum follow-up period of 10 years. DESIGN: Retrospective cohort study. SETTING: A large, urban public health care system serving over 200,000 predominantly minority persons. The system includes nine primary care health centers. PATIENTS: African-American, Hispanic and non-Hispanic white patients with diagnosed hypertension who received primary care in the study setting. METHODS: Medical records of 2,941 hypertensives free of NIDDM at their baseline visit were reviewed to document incident NIDDM during follow-up. Sociodemographic characteristics and physiologic covariates consistently available in the medical record (blood pressure, height, weight, and blood glucose) were also abstracted. RESULTS: The mean age of patients at the baseline visit was 56 years; 67% were female, 63% were African-American. 17% Hispanic, and 20% non-Hispanic white. Two hundred thirty-six incident cases of NIDDM were identified in the cohort. In Cox proportional hazards analysis, the risk of developing NIDDM was not related to ethnicity either in univariate analysis or after adjusting for age, baseline blood glucose, and body mass index (adjusted RR for African Americans compared with whites = .82, 95% CI = .57-1.18; adjusted RR for Hispanics compared with whites = .84, 95% CI = .51-1.38). CONCLUSION: The lack of association between ethnicity and NIDDM risk among hypertensives is unexpected, and may indicate differences in the pathogenetic mechanisms that underlie the development of hypertension and NIDDM in these three ethnic groups.

Factors related to medical school application and acceptance in minority summer enrichment program students.

Baylor College of Medicine has conducted a summer enrichment program for minority/disadvantaged premedical students since 1969. Follow-up data on medical school application and acceptance for participants from 1980 through 1984 were analyzed in relation to selected preprogram variables--cumulative college grade point average, total Scholastic Aptitude Test score, competitiveness of undergraduate college, sex, and ethnicity. Results of univariate and multivariate analyses indicated that: 1) females were significantly less likely to apply to medical school than males, 2) females had significantly lower mean MCAT scores (5.9 vs 7.2) even though their preprogram academic performance was comparable to that of the males, and 3) after controlling for MCAT scores, none of the preprogram variables were significant in predicting medical school acceptance. These findings suggest the need for research to explain the discrepancy between male and female MCAT performance and frequency of medical school application in summer program participants. The findings also have implications for the type of counseling provided to female participants in summer enrichment programs.

Evolution of magnetic therapy from alternative to traditional medicine.

Static or electromagnetic fields have been used for centuries to control pain and other biologic problems, but scientific evidence of their effect had not been gathered until recently. This article explores the value of magnetic therapy in rehabilitation medicine in terms of static magnetic fields and time varying magnetic fields (electromagnetic). A historical review is given and the discussion covers the areas of scientific criteria, modalities of magnetic therapy, mechanisms of the biologic effects of magnetic fields, and perspectives on the future of magnetic therapy.

Self-esteem and caregivers' attitudes toward elderly persons.

A scale identifying 141 medical students who responded positively to geriatric patients was based on Rosenberg's Self-esteem Scale modified by adding a phrase about geriatric care. Personal and professional role traits that predicted a positive therapeutic attitude were high scores on social desirability or self-monitoring and low scores on thanatophobia and depression. Senior medical students who expressed the highest self-esteem toward caring for elderly people indicated family medicine as their first choice of residency.

Measuring social desirability among senior medical students.

The purpose of the study was to assess the role of medical students' social desirability scores on influencing their attitudes toward either a geriatric or hypochondriac patient. To carry out this investigation, we developed a social desirability scale that was domain-specific for medicine. Students' medical social desirability scores predicted negative attitudes and beliefs toward the geriatric but not the hypochondriac patient. This difference suggests that medical students find it acceptable to dislike the hypochondriac as a patient but not the elderly person. Social desirability scores were inversely related to Machiavellan scores, suggesting that medical students with a Machivellian response pattern tended to view their role as a physician in a less idealized way. Students who scored highest on social desirability tended to choose obstetrics-gynecology for their future career and those with the lowest scores either pathology or surgical subspecialties. Research with this scale should help access social desirability's role in medical students' in managing the impression they leave with patients.

Is obstetrics-gynecology a primary care specialty?

Suddenly everyone wants more primary care physicians. For several years, we collected data from senior medical students to relate their attitudes and beliefs about several clinical problems common to primary care to their choices of residencies. Because the Texas Medical Association's Special Committee on Primary Care included obstetrics-gynecology as a primary care specialty, we reviewed our data to see if the personal traits and professional role characteristics of seniors choosing obstetrics-gynecology differed materially from those of seniors choosing family medicine, internal medicine, or pediatrics. Results of this analysis put obstetrics-gynecology about as firmly in the primary care group as if the experimental design had planned it that way.

Advances in the community control of hypertension: from epidemiology to primary care practice.

PURPOSE: To review the progress in hypertension control in the United States since 1972, to examine the factors that contributed to that progress and to consider areas in which further improvement is required. METHODS: A review of epidemiological, clinical and health services research related to hypertension control was conducted. We report our experience in evaluating hypertension control in a multi-ethnic community clinic population as an illustration of the challenges of hypertension management in primary care practice. SUMMARY OF FINDINGS: Hypertension prevalence in the United States population has remained relatively stable, whereas actual blood pressure levels in the population have declined slightly. Most Americans (approximately 80%) have had a blood pressure check within the past year, but the rate of blood pressure control in treated hypertensives has been disappointing. The current diagnostic and therapeutic criterion of blood pressure < or = 140/90 mmHg, regardless of individual patient characteristics (e.g. age, race), should be re-evaluated.

[Medical technology: its impact on the physician-patient relationship]. / La tecnología médica: su impacto en la relación paciente-médico.

The Nuestra Señora del Remedio Clinic is celebrating the 75th anniversary of the arrival of the San José de Gerona order at the clinic. Dr. Vallbona was invited to present a conference which we transcribe in this article, superficially reviewing the problems which may compromise the doctor-patient relationship as well as the rights and responsibilities each member of this relationship has.