Joel F. Handler

A Cluster-Randomized Trial of Blood-Pressure Reduction in Black Barbershops

BACKGROUND Uncontrolled hypertension is a major problem among non‐Hispanic black men, who are underrepresented in pharmacist intervention trials in traditional health care settings. METHODS We enrolled a cohort of 319 black male patrons with systolic blood pressure of 140 mm Hg or more from 52 black‐owned barbershops (nontraditional health care setting) in a cluster‐randomized trial in which barbershops were assigned to a pharmacist‐led intervention (in which barbers encouraged meetings in barbershops with specialty‐trained pharmacists who prescribed drug therapy under a collaborative practice agreement with the participants’ doctors) or to an active control approach (in which barbers encouraged lifestyle modification and doctor appointments). The primary outcome was reduction in systolic blood pressure at 6 months. RESULTS At baseline, the mean systolic blood pressure was 152.8 mm Hg in the intervention group and 154.6 mm Hg in the control group. At 6 months, the mean systolic blood pressure fell by 27.0 mm Hg (to 125.8 mm Hg) in the intervention group and by 9.3 mm Hg (to 145.4 mm Hg) in the control group; the mean reduction was 21.6 mm Hg greater with the intervention (95% confidence interval, 14.7 to 28.4; P<0.001). A blood‐pressure level of less than 130/80 mm Hg was achieved among 63.6% of the participants in the intervention group versus 11.7% of the participants in the control group (P<0.001). In the intervention group, the rate of cohort retention was 95%, and there were few adverse events (three cases of acute kidney injury). CONCLUSIONS Among black male barbershop patrons with uncontrolled hypertension, health promotion by barbers resulted in larger blood‐pressure reduction when coupled with medication management in barbershops by specialty‐trained pharmacists. (Funded by the National Heart, Lung, and Blood Institute and others; ClinicalTrials.gov number, NCT02321618.)

Justice for the Welfare Recipient: Fair Hearings in AFDC: The Wisconsin Experience

The research reported here was financed by funds granted to the Institute for Research on Poverty, University of Wisconsin, by the Office of Economic Opportunity, pursuant to the provisions of the Economic Opportunity Act of 1964. The opinions are those of the author and should not be construed as representing the opinions or policy of any agency of government. The author has expressed appreciation to Kenneth R. Kreiling and Ronald Pipkin who, while graduate students in the Russell Sage Sociology and Law Program at the University of Wisconsin, made the statistical analysis of fair-hearing decisions. The author is professor of law and assistant director of the Institute for Research on Poverty, University of Wisconsin.

Evidence-Based Guideline for the Management of High Blood Pressure in Adults

Hypertension is the most common condition seen in primary care and leads to myocardial infarction, stroke, renal failure, and death if not detected early and treated appropriately. Patients want to be assured that blood pressure (BP) treatment will reduce their disease burden, while clinicians want guidance on hypertension management using the best scientific evidence. This report takes a rigorous, evidence-based approach to recommend treatment thresholds, goals, and medications in the management of hypertension in adults. Evidence was drawn from randomized controlled trials, which represent the gold standard for determining efficacy and effectiveness. Evidence quality and recommendations were graded based on their effect on important outcomes. There is strong evidence to support treating hypertensive persons aged 60 years or older to a BP goal of less than 150/90 mm Hg and hypertensive persons 30 through 59 years of age to a diastolic goal of less than 90 mm Hg; however, there is insufficient evidence in hypertensive persons younger than 60 years for a systolic goal, or in those younger than 30 years for a diastolic goal, so the panel recommends a BP of less than 140/90 mm Hg for those groups based on expert opinion. The same thresholds and goals are recommended for hypertensive adults with diabetes or nondiabetic chronic kidney disease (CKD) as for the general hypertensive population younger than 60 years. There is moderate evidence to support initiating drug treatment with an angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, calcium channel blocker, or thiazide-type diuretic in the nonblack hypertensive population, including those with diabetes. In the black hypertensive population, including those with diabetes, a calcium channel blocker or thiazide-type diuretic is recommended as initial therapy. There is moderate evidence to support initial or add-on antihypertensive therapy with an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in persons with CKD to improve kidney outcomes. Although this guideline provides evidence-based recommendations for the management of high BP and should meet the clinical needs of most patients, these recommendations are not a substitute for clinical judgment, and decisions about care must carefully consider and incorporate the clinical characteristics and circumstances of each individual patient.

Discretion in Social Welfare: The Uneasy Position in the Rule of Law

Prior to the routinization and bureaucratization of public welfare, the system could be loosely described as discretionary, professional, and decentralized. In general, eligibility was not clear-cut; budgets were individually determined. But even in those days, there were rules. Professionalization was the ideal, but most workers were in fact not professionals. And there were efforts at centralization at both the federal and state levels. Certainly as compared to the present, however, the public assistance programs had far more play. What was that system like? Then, as now, there was great variety, but some generalizations can be made. Wisconsin was a benign, liberal system. Basic grants were relatively generous, there was an elaborate system of special grants to meet both emergency and rehabilitative goals, and there was a considerable degree of professionalism. In practice, however, the system was quite routinized. The special needs program was not utilized in any significant amount; it depended, for the most part, on client initiative and clients lacked information or were hesitant to ask. The caseworkers, a shifting sea of people who used their public assistance jobs as way stations, were not particularly interested in spending more agency resources or engaging in more paperwork. At that time, home visits were mandatory, but, for the overwhelming majority of recipients, the visit was pleasant and attitudes toward the caseworker were positive. For the most part, these were friendly, non-threatening social calls. But in the rare situation in which caseworkers did have control over something that the clients wanted, then negative feelings arose-feelings of dependency and coercion. The next example comes from Professor Mashaws empirical work in Virginia, but is a story that has been found many times over in many parts of the country. These are the depressing tales of refusals to take

Changes in the Continuation of Antihypertensive Drug Use After ALLHAT

An analysis was performed of the 1‐year continued use of various antihypertensive agents in a health maintenance organization following the 2002 publication of the Antihypertensive and Lipid‐Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Computer‐stored information was used from the health maintenance organizations prescription information system. Only patients newly started on antihypertensive medications in 2001 and the calendar year following the ALLHAT publication were analyzed. Patients were considered to be persistent with their first prescribed antihypertensive drug class if they obtained at least one refill for the same class of antihypertensive agents on or within 3 months of the end of the 1‐year follow‐up period. The overall 1‐year continuation rate decreased from 2001 to 2003. However, the continuation of thiazide‐type diuretic use after ALLHAT (2003) was higher than that before ALLHAT (2001) (p=0.004), whereas the continuation rate was lower for all other drug classes. We provide data to suggest that evidence from randomized trials is one factor influencing the continued use of antihypertensive medication.

The Nonpharmacologic Treatment of Hypertension: How Effective Is It?An Update

Following a hypertension symposium in Los Angeles, CA, in October 2006, a panel was convened to update information about lifestyle changes or the nonpharmacologic treatment of hypertension. Dr Marvin Moser, Clinical Professor of Medicine at the Yale University School of Medicine, moderated the panel. Dr Stanley S. Franklin, Clinical Professor of Medicine and Associate Medical Director of the Heart Disease Prevention Program at the University of California, Irvine, and Dr Joel Handler, Director of the Orange County Kaiser‐Permanente Hypertension Clinic and clinical hypertension leader of the Care Management Institute of Kaiser Permanente, participated in the discussion.

ACC/AHA Special Report: Clinical Practice Guideline Implementation Strategies: A Summary of Systematic Reviews by the NHLBI Implementation Science Work Group

Background: In 2008, the National Heart, Lung, and Blood Institute convened an Implementation Science Work Group to assess evidence-based strategies for effectively implementing clinical practice guidelines. This was part of a larger effort to update existing clinical practice guidelines on cholesterol, blood pressure, and overweight/obesity. Objectives: Review evidence from the published implementation science literature and identify effective or promising strategies to enhance the adoption and implementation of clinical practice guidelines. Methods: This systematic review was conducted on 4 critical questions, each focusing on the adoption and effectiveness of 4 intervention strategies: (1) reminders, (2) educational outreach visits, (3) audit and feedback, and (4) provider incentives. A scoping review of the Rx for Change database of systematic reviews was used to identify promising guideline implementation interventions aimed at providers. Inclusion and exclusion criteria were developed a priori for each question, and the published literature was initially searched up to 2012, and then updated with a supplemental search to 2015. Two independent reviewers screened the returned citations to identify relevant reviews and rated the quality of each included review. Results: Audit and feedback and educational outreach visits were generally effective in improving both process of care (15 of 21 reviews and 12 of 13 reviews, respectively) and clinical outcomes (7 of 12 reviews and 3 of 5 reviews, respectively). Provider incentives showed mixed effectiveness for improving both process of care (3 of 4 reviews) and clinical outcomes (3 reviews equally distributed between generally effective, mixed, and generally ineffective). Reminders showed mixed effectiveness for improving process of care outcomes (27 reviews with 11 mixed and 3 generally ineffective results) and were generally ineffective for clinical outcomes (18 reviews with 6 mixed and 9 generally ineffective results). Educational outreach visits (2 of 2 reviews), reminders (3 of 4 reviews), and provider incentives (1 of 1 review) were generally effective for cost reduction. Educational outreach visits (1 of 1 review) and provider incentives (1 of 1 review) were also generally effective for cost-effectiveness outcomes. Barriers to clinician adoption or adherence to guidelines included time constraints (8 reviews/overviews); limited staffing resources (2 overviews); timing (5 reviews/overviews); clinician skepticism (5 reviews/overviews); clinician knowledge of guidelines (4 reviews/overviews); and higher age of the clinician (1 overview). Facilitating factors included guideline characteristics such as format, resources, and end-user involvement (6 reviews/overviews); involving stakeholders (5 reviews/overviews); leadership support (5 reviews/overviews); scope of implementation (5 reviews/overviews); organizational culture such as multidisciplinary teams and low-baseline adherence (9 reviews/overviews); and electronic guidelines systems (3 reviews). Conclusion: The strategies of audit and feedback and educational outreach visits were generally effective in improving both process of care and clinical outcomes. Reminders and provider incentives showed mixed effectiveness, or were generally ineffective. No general conclusion could be reached about cost effectiveness, because of limitations in the evidence. Important gaps exist in the evidence on effectiveness of implementation interventions, especially regarding clinical outcomes, cost effectiveness and contextual issues affecting successful implementation.

The Administration of Social Services and the Structure of Dependency: The Views of AFDC Recipients

Based on survey data collected in Wisconsin, the authors find in the Aid to Families with Dependent Children program a very low level of social service activity, mostly directed to- ward maintaining the status quo rather than improving or altering the lives of the clients. Clients discriminate between specific aid services, general discussions, and specific regula- tions. Only with specific aids do clients find social services helpful; but they also exhibit a high degree of dependency. Most expressed positive feelings toward the caseworker, perhaps in part because contacts were infrequent and discussions were general. Negative feelings were reported when there was more caseworker interaction and regulation. Reforms in the administration of social services are evaluated, particularly as to whether changes would reduce dependency.

on welfare reform's hollow victory

Dædalus Summer 2006 Almost a decade has passed since President Clinton ful1⁄2lled his pledge to “end welfare as we know it” by signing the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (prwora). prwora, commonly known as ‘welfare reform,’ replaced Aid to Families with Dependent Children (afdc), a government cash-aid program that primarily supported single mothers and their children, with Temporary Aid for Needy Families (tanf), a blockgrant program that increased state discretion substantially. The goal of the reform was to promote work in the paid labor force among welfare recipients. Within 1⁄2ve years, 80 percent of the states’ caseloads had to be working or searching for jobs. And for the 1⁄2rst time in welfare history, strict time limits were imposed on individual aid: a two-year limit on continuous aid and a cumulative lifetime limit of 1⁄2ve years. Most states adopted a ‘work 1⁄2rst’ strategy–recipients had to take any job, even a low-wage, entry-level one –rather than providing recipients opportunities for education and training 1⁄2rst. The assumption was that working would improve the economic and social outcomes of poor families: even workers who started at low-wage jobs would be able to work their way up the economic ladder. Policymakers believed that these mandatory requirements were necessary to move recipients off the rolls. Furthermore, they thought that the children of welfare recipients would gain a sense of pride and direction from seeing their parents working. Everyone has declared the reform a success. Caseloads have declined from 12.2 million to 5.3 million recipients. Labor-force participation has increased 15 to 20 percentage points among single mothers with children under the age of 1⁄2ve–the population most likely to be welfare recipients. Welfare reform, a burning political issue since the 1970s, has disappeared from the radar screen for almost a decade. But this reform has actually resulted in a hollow victory. While caseloads have declined and work participation has increased, most families are still living in poverty and enduring signi1⁄2cant hardship. Joel F. Handler, a Fellow of the American Academy since 2004, is Richard C. Maxwell Professor of Law and professor of policy studies at the University of California, Los Angeles. An authority on social-welfare law and poverty, he has conducted numerous studies on poverty, political participation, and administration of justice. He is the author of “The Poverty of Welfare Reform” (1995), “Down From Bureaucracy” (1996), “Social Citizenship and Workfare in the United States and Western Europe” (2004), and, most recently, “Blame Welfare, Ignore Poverty and Inequality” (with Yeheskel Hasenfeld, 2006). Joel F. Handler

The Modern Pauper

Ever since war and famine have occurred, there have been welfare policies to deal with the poor. Although these policies are complex and shift during various periods, some firm generalizations can be made. Often the immediate task of welfare policy was to help deal with disorder; throughout history, armies of the poor have posed threats to society. A second task was the relief of misery; despite the strong social control features of welfare policy, there has always been a humanitarian voice. The third task was preservation of labor markets; relief had to be given under such terms and conditions as would not encourage those who could work to seek welfare instead. This last point is known as the principle of “less eligibility”—that is, the terms of relief had to be less desirable than the conditions of the lowest-paid labor. This is the essence of the work requirement, which often conflicts with the other two principles.