Lee R. Bone

Randomized controlled trial of the effects of nurse case manager and community health worker interventions on risk factors for diabetes-related complications in urban African Americans

BACKGROUND African Americans suffer disproportionately from diabetes complications, but little research has focused on how to improve diabetic control in this population. There are also few or no data on a combined primary care and community-based intervention approach. METHODS We randomly assigned 186 urban African Americans with type 2 diabetes (76% female, mean A SD age 59 A 9 years) to 1 of 4 parallel arms: (1) usual care only; (2) usual care + nurse case manager (NCM); (3) usual care + community health worker (CHW); (4) usual care + nurse case manager/community health worker team. Using the framework of the Precede-Proceed behavioral model, interventions included patient counseling regarding self-care practices and physician reminders. RESULTS The 2-year follow-up visit was completed by 149 individuals (84%). Compared to the Usual care group, the NCM group and the CHW group had modest declines in HbA(1c) over 2 years (0.3 and 0.3%, respectively), and the combined NCM/CHW group had a greater decline in HbA(1c) (0.8%. P = 0.137). After adjustment for baseline differences and/or follow-up time, the combined NCM/CHW group showed improvements in triglycerides (-35.5 mg/dl; P = 0.041) and diastolic blood pressure, compared to the usual care group (-5.6 mmHg; P = 0.042). CONCLUSIONS Combined NCM/CHW interventions may improve diabetic control in urban African Americans with type 2 diabetes. Although results were clinically important, they did not reach statistical significance. This approach deserves further attention as a means to reduce the excess risk of diabetic complications in African Americans.

The Effects of a Nurse Case Manager and a Community Health Worker Team on Diabetic Control, Emergency Department Visits, and Hospitalizations Among Urban African Americans With Type 2 Diabetes Mellitus: A Randomized Controlled Trial

BACKGROUND Although African American adults bear a disproportionate burden from diabetes mellitus (DM), few randomized controlled trials have tested culturally appropriate interventions to improve DM care. METHODS We randomly assigned 542 African Americans with type 2 DM enrolled in an urban managed care organization to either an intensive or minimal intervention group. The intensive intervention group consisted of all components of the minimal intervention plus individualized, culturally tailored care provided by a nurse case manager (NCM) and a community health worker (CHW), using evidence-based clinical algorithms with feedback to primary care providers (eg, physicians, nurse practitioners, or physician assistants). The minimal intervention consisted of mailings and telephone calls every 6 months to remind participants about preventive screenings. Data on diabetic control were collected at baseline and at 24 months by blind observers; data emergency department (ER) visits and hospitalizations were assessed using administrative data. RESULTS At baseline, participants had a mean age of 58 years, 73% were women, and 50% were living in poverty. At 24 months, compared with the minimal intervention group, those in the intensive intervention group were 23% less likely to have ER visits (rate difference [RD], -14.5; adjusted rate ratio [RR], 0.77; 95% confidence interval [CI], 0.59-1.00). In on-treatment analyses, the rate reduction was strongest for patients who received the most NCM and CHW visits (RD, -31.0; adjusted RR, 0.66; 95% CI, 0.43-1.00; rate reduction downward arrow 34%). CONCLUSION These data suggest that a culturally tailored intervention conducted by an NCM/CHW team reduced ER visits in urban African Americans with type 2 DM. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00022750.

Hypertension care and control in underserved urban African American men: behavioral and physiologic outcomes at 36 months*

BACKGROUND African American men with hypertension in low socioeconomic urban populations achieve poor rates of hypertension control and suffer early from its complications. METHODS In a randomized clinical trial with 309 hypertensive urban African American men aged 21 to 54 years, we evaluated the effectiveness of a more intensive comprehensive educational-behavioral-pharmacologic intervention by a nurse practitioner-community health worker-physician (NP/CHW/MD) team and a less intensive education and referral intervention in controlling blood pressure (BP) and minimizing progression of left ventricular hypertrophy (LVH) and renal insufficiency. Changes in BP, left ventricular mass (LVM), and serum creatinine from baseline to 36 months were compared between groups. RESULTS At 36 months, the mean systolic BP/diastolic BP change from baseline was -7.5/-10.1 mm Hg for the more intensive group and +3.4/-3.7 mm Hg for the less intensive group (P =.001 and.005 for between-group differences in systolic BP and diastolic BP, respectively). The proportion of men with controlled BP (<140/90 mm Hg) was 44% in the more intensive group and 31% in the less intensive group (P =.045). The LVM was significantly lower in the more intensive group than in the less intensive group (more intensive, 274 g; less intensive, 311 g; P =.004). There was a trend toward slowing of the progression of renal insufficiency (incidence of 50% increase in serum creatinine) in the more intensive group compared to the less intensive group (more intensive, 5.2%; less intensive, 8.0%; P =.08). CONCLUSIONS During 36 months, the more intensive intervention led to a lower BP and decreased progression of LVH in a sample of hypertensive young African American men.

Barriers to hypertension care and control in young urban black men.

Barriers to high blood pressure (HBP) care and control have been reported in the literature for > 30 years. Few reports on barriers, however, have focused on the young black man with HBP, the age/sex/race group with the highest rates of early severe and complicated HBP and the lowest rates of awareness, treatment, and control. In a randomized clinical trial of comprehensive care for hypertensive young urban black men, factors potentially associated with care and control were assessed at baseline for the 309 enrolled men. A majority of the men encountered a variety of barriers including economic, social, and lifestyle obstacles to adequate BP care and control, including no current HBP care (49%), risk of alcoholism (62%), use of illicit drugs (45%), social isolation (47%), unemployment (40%), and lack of health insurance (51%). Having health insurance (odds ratio = 7.20, P = .00) and a negative urine drug screen (odds ratio = .56, P = .04) were significant predictors of being in HBP care. Low alcoholism risk and employment were identified as significant predictors of compliance with HBP medication-taking behavior. Men currently using illicit drugs were 2.64 times less likely to have controlled BP compared with their counterparts who did not use illicit drugs, and men currently taking HBP medication were 63 times more likely have controlled BP compared with men not taking HBP medication. Comprehensive interventions are needed to address socioeconomic and lifestyle issues as well as other barriers to care and treatment, if HBP care is to be salient and effective in this high risk group.

INTER-RATER RELIABILITY OF PREVENTABLE DEATH JUDGMENTS

This study examined the inter-rater reliability of preventable death judgments for trauma. A total of 130 deaths were reviewed for potential preventability by multiple panels of nationally chosen experts. Deaths involving a central nervous system (CNS) injury were reviewed by three panels, each consisting of a trauma surgeon, a neurosurgeon, and an emergency physician. Deaths not involving the CNS were reviewed by three panels, each consisting of two trauma surgeons and an emergency physician. Cases for review were sampled from all hospital trauma deaths occurring in Maryland during 1986. Panels were given prehospital and hospital records, medical examiner reports, and autopsy reports, and asked to independently classify deaths as not preventable (NP), possibly preventable (POSS), probably preventable (PROB), or definitely preventable (DEF). Cases in which there was disagreement about preventability were discussed by the panel as a group (via conference call). Results indicated that overall reliability was low. All three panels reviewing non-CNS deaths agreed in only 36% of the cases (kappa = 0.21). Agreement among panels reviewing CNS deaths was somewhat higher at 56% (kappa = 0.40). Most of the disagreements, however, were in judging whether deaths were NP or POSS. Agreement was higher for early deaths and less severely injured patients. For non-CNS deaths agreement was also higher for younger patients. When both autopsy results and prehospital care reports were available reliability increased across panels. A variety of approaches have been used to elicit judgments of preventability. This study provides information to guide recommendations for future studies involving implicit judgments of preventable death.

Community Outreach and Cardiovascular Health (COACH) Trial A Randomized, Controlled Trial of Nurse Practitioner/Community Health Worker Cardiovascular Disease Risk Reduction in Urban Community Health Centers

Background—Despite well-publicized guidelines on the appropriate management of cardiovascular disease and type 2 diabetes, the implementation of risk-reducing practices remains poor. This report describes the results of a randomized, controlled clinical trial evaluating the effectiveness of a comprehensive program of cardiovascular disease risk reduction delivered by nurse practitioner /community health worker (NP/CHW) teams versus enhanced usual care (EUC) to improve lipids, blood pressure, glycated hemoglobin (HbA1c), and patient perceptions of the quality of their chronic illness care in patients in urban community health centers. Methods and Results—A total of 525 patients with documented cardiovascular disease, type 2 diabetes, hypercholesterolemia, or hypertension and levels of LDL cholesterol, blood pressure, or HbA1c that exceeded goals established by national guidelines were randomly assigned to NP/CHW (n=261) or EUC (n=264) groups. The NP/CHW intervention included aggressive pharmacological management and tailored educational and behavioral counseling for lifestyle modification and problem solving to address barriers to adherence and control. Compared with EUC, patients in the NP/CHW group had significantly greater 12-month improvement in total cholesterol (difference, 19.7 mg/dL), LDL cholesterol (difference,15.9 mg/dL), triglycerides (difference, 16.3 mg/dL), systolic blood pressure (difference, 6.2 mm Hg), diastolic blood pressure (difference, 3.1 mm Hg), HbA1c (difference, 0.5%), and perceptions of the quality of their chronic illness care (difference, 1.2 points). Conclusions—An intervention delivered by an NP/CHW team using individualized treatment regimens based on treat-to-target algorithms can be an effective approach to improve risk factor status and perceptions of chronic illness care in high-risk patients. Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT00241904.

A clinical trial to improve high blood pressure care in young urban black men: recruitment, follow-up, and outcomes.

This randomized trial recruited and followed underserved, inner-city, hypertensive (HTN), young black men and investigated whether a nurse-community health worker team in combination with usual medical care (SI) increased entry into care and reduced high blood pressure (HBP), in comparison to usual medical care (UC) alone. Emergency department records, advertising, and BP screenings identified potential participants with HBP. Telephone calls and personal contacts tracked enrollees. Of 1391 potential participants, 803 (58%) responded to an invitation to be screened and scheduled a visit. Of these, 528 (66%) kept an appointment, 207 (35%) were BP eligible, and 204 (99%) consented to enroll. At 12 months 91% of men were accounted for and 85.8% (adjusted for death, in jail, or moved away) were seen. Mean BP changed from 153(16)/98(10) to 152(19)/94(11) mm Hg in the SI group and 151(18)/98(11) to 147(21)/92(14) mm Hg in the UC group (P = NS). High rates of participation are attainable in this population; however, culturally acceptable ways of delivering HBP care are needed.

A randomized controlled trial of interventions to enhance patient-physician partnership, patient adherence and high blood pressure control among ethnic minorities and poor persons: study protocol NCT00123045

BackgroundDisparities in health and healthcare are extensively documented across clinical conditions, settings, and dimensions of healthcare quality. In particular, studies show that ethnic minorities and persons with low socioeconomic status receive poorer quality of interpersonal or patient-centered care than whites and persons with higher socioeconomic status. Strong evidence links patient-centered care to improvements in patient adherence and health outcomes; therefore, interventions that enhance this dimension of care are promising strategies to improve adherence and overcome disparities in outcomes for ethnic minorities and poor persons.ObjectiveThis paper describes the design of the Patient-Physician Partnership (Triple P) Study. The goal of the study is to compare the relative effectiveness of the patient and physician intensive interventions, separately, and in combination with one another, with the effectiveness of minimal interventions. The main hypothesis is that patients in the intensive intervention groups will have better adherence to appointments, medication, and lifestyle recommendations at three and twelve months than patients in minimal intervention groups. The study also examines other process and outcome measures, including patient-physician communication behaviors, patient ratings of care, health service utilization, and blood pressure control.MethodsA total of 50 primary care physicians and 279 of their ethnic minority or poor patients with hypertension were recruited into a randomized controlled trial with a two by two factorial design. The study used a patient-centered, culturally tailored, education and activation intervention for patients with active follow-up delivered by a community health worker in the clinic. It also included a computerized, self-study communication skills training program for physicians, delivered via an interactive CD-ROM, with tailored feedback to address their individual communication skills needs.ConclusionThe Triple P study will provide new knowledge about how to improve patient adherence, quality of care, and cardiovascular outcomes, as well as how to reduce disparities in care and outcomes of ethnic minority and poor persons with hypertension.

Health‐related Quality of Life in Urban African Americans with Type 2 Diabetes

AbstractOBJECTIVE: To examine the association of socioeconomic barriers, familial barriers, and clinical variables with health-related quality of life (HRQL). METHODS: A cross-sectional study was conducted of 186 African Americans with type 2 diabetes recruited from 2 primary care clinics in East Baltimore, Maryland. Physical functioning, social functioning, mental health, and general health were measured using the Medical Outcomes Study 36-item short form. Socioeconomic (money, housing, street crime) and familial (family problems, caretaker responsibilities) barriers were assessed by standardized interview. Insulin use, comorbid disease, and measured abnormalities in body mass index, hemoglobin A1c (HbA1c), blood pressure, lipids, and renal function were investigated. RESULTS: Mean HRQL scores were: physical functioning, 61±29; social functioning, 76±26; mental health, 69±21; and general health, 48±21. Linear regression analyses revealed that each barrier to care was significantly associated with lower scores in 1 or more HRQL domain. As number of socioeconomic and familial barriers increased from 0 to 5, HRQL scores decreased by 18 for social functioning, 21 for general health, 23 for physical functioning, and 28 for mental health (all P for trend <.01). Clinical variables significantly associated with reduced HRQL were obesity, impaired renal function, insulin use, and comorbid disease. Blood pressure, lipids, and HbA1c were not significantly associated with HRQL. CONCLUSIONS: An independent, graded relationship was found between socioeconomic and familial barriers to care and HRQL. This relationship was at least as strong as the association between HRQL and the clinical variables more likely to be perceived by participants as causing symptomatic distress or impacting lifestyle.

Medication adherence and diabetes control in urban African Americans with type 2 diabetes.

In 181 urban African Americans with Type 2 diabetes, medication adherence was assessed using a measure designed specifically for an urban, impoverished sociodemographic population. Hemoglobin A-sub(1c), blood pressure and cholesterol levels, medication-related beliefs, and depression were assessed. Seventy-four percent of the sample reported adherence to diabetes medication. Adherence, adjusted for age, was associated with lower hemoglobin A-sub(1c). The specific behaviors associated with poorer diabetes control were forgetting to take medications and running out of medications. Knowledge of blood glucose goals differed for adherers and nonadherers. Blood pressure and cholesterol medication adherence rates were not associated with actual levels of blood pressure or lipids, respectively. These data suggest that specific medication-taking behaviors are important to diabetes control and constitute logical targets for interventions. ((c) 2005 APA, all rights reserved).