[show abstract][hide abstract] ABSTRACT: BACKGROUND: Racial disparities in blood pressure control have been well documented in the United States. Research suggests that many factors contribute to this disparity, including barriers to care at patient, clinician, healthcare system, and community levels. To date, few interventions aimed at reducing hypertension disparities have addressed factors at all of these levels. This paper describes the design of Project ReD CHiP (Reducing Disparities and Controlling Hypertension in Primary Care), a multi-level system quality improvement project. By intervening on multiple levels, this project aims to reduce disparities in blood pressure control and improve guideline concordant hypertension care. METHODS: Using a pragmatic trial design, we are implementing three complementary multi-level interventions designed to improve blood pressure measurement, provide patient care management services and offer expanded provider education resources in six primary care clinics in Baltimore, Maryland. We are staggering the introduction of the interventions and will use Statistical Process Control (SPC) charting to determine if there are changes in outcomes at each clinic after implementation of each intervention. The main hypothesis is that each intervention will have an additive effect on improvements in guideline concordant care and reductions in hypertension disparities, but the combination of all three interventions will result in the greatest impact, followed by blood pressure measurement with care management support, blood pressure measurement with provider education, and blood pressure measurement only. This study also examines how organizational functioning and cultural competence affect the success of the interventions. DISCUSSION: As a quality improvement project, Project ReD CHiP employs a novel study design that specifically targets multi-level factors known to contribute to hypertension disparities. To facilitate its implementation and improve its sustainability, we have incorporated stakeholder input and tailored components of the interventions to meet the specific needs of the involved clinics and communities. Results from this study will provide knowledge about how integrated multi-level interventions can improve hypertension care and reduce disparities.Trial Registration: ClinicalTrials.gov NCT01566864.
[show abstract][hide abstract] ABSTRACT: Racial disparities in hypertension control contribute to higher rates of cardiovascular mortality among blacks. Patient-physician communication quality is associated with better health outcomes, including blood pressure (BP) control. Both race/ethnicity and BP control may adversely affect communication.
To determine whether being black and having poor BP control interact to adversely affect patient-physician communication more than either condition alone, a situation referred to as "double jeopardy."
Cross-sectional study of enrollment data from a randomized controlled trial of interventions to enhance patient adherence to therapy for hypertension. Participants included 226 hypertensive patients and 39 physicians from 15 primary care practices in Baltimore, MD.
Communication behaviors and visit length from coding of audiotapes.
After controlling for patient and physician characteristics, blacks with uncontrolled BP have shorter visits (B = -3.9 min, p < 0.01) with less biomedical (B = -24.0, p = 0.05), psychosocial (B = -19.4, p < 0.01), and rapport-building (B = -19.5, p = 0.01) statements than whites with controlled BP. Of all communication outcomes, blacks with uncontrolled BP are only in "double jeopardy" for a patient positive affect-coders give them lower ratings than all other patients. Blacks with controlled BP also experience shorter visits and less communication with physicians than whites with controlled BP. There are no significant communication differences between the visits of whites with uncontrolled versus controlled BP.
This study reveals that patient race is associated with the quality of patient-physician communication to a greater extent than BP control. Interventions that improve patient-physician communication should be tested as a strategy to reduce racial disparities in hypertension care and outcomes.
Journal of General Internal Medicine 08/2009; 24(9):1057-64. · 3.28 Impact Factor
[show abstract][hide abstract] ABSTRACT: Disparities 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.
This 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.
A 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.
The 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.