Morehouse Community Physicians Network (CPN) hypertension registry: Patterns of care and opportunities for targeted medical education

Article (PDF Available)inEthnicity & disease 15(4 Suppl 5):S5-120-3 · February 2005with36 Reads
Source: PubMed
Abstract
Provider-focused strategies for improving outcomes in hypertension have produced mixed results. Studies suggest that the effectiveness of a chosen strategy increases when it is tailored to the specific situation. The hypertension registry includes data on African-American hypertensives who receive care in community-based primary care settings. We examined the registry to identify patterns of care and opportunities for provider-focused interventions to improve patient outcomes. The registry will include all records of hypertensive patients from 50 community-based primary care practices at full enrollment. Data from nine practices were manually abstracted into an electronic database and analyzed. Seven hundred and ten records were included in this report. Approximately 70% are female, average age 47 +/- 13 years, 5.3% are uninsured, and more than 60% have at least a high school education. Registry patients have multiple co-morbid conditions: 28% are diabetic, 8% have left ventricular hypertrophy, 5% have congestive heart failure, 6.5% have renal insufficiency, 5% have cerebrovascular disease, 3.5% have previous myocardial infarction and 2% have peripheral vascular disease. Among those with diabetes, mean glycosylated hemoglobin was 7.4 +/- 2. Pattern of antihypertensive use showed 43% on diuretics, 28% on calcium channel blockers, 24% on angiotensin converting enzyme inhibitors, 20% on beta blockers and 16% on angiotensin receptor blockers. Overall, 37% were at goal blood pressure and among those with diabetes, only 16% reached goal blood pressure. We conclude that the blood pressure control rates of African Americans in the registry trail those of the general population. This provides a unique opportunity to study the underlying factors and design tailored interventions to address this disparity in health outcome.

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MOREHOUSE COMMUNITY PHYSICIANS NETWORK (CPN) HYPERTENSION REGISTRY:
P
ATTERNS OF CARE AND OPPORTUNITIES FOR TARGETED MEDICAL EDUCATION
Background: Provider-focused strategies for
improving outcomes in hypertension have
produced mixed results. Studies suggest that
the effectiveness of a chosen strategy increases
when it is tailored to the specific situation.
1
The hypertension registry includes data on
African-American hypertensives who receive
care in community-based primary care set-
tings. We examined the registry to identify
patterns of care and opportunities for provider-
focused interventions to improve patient out-
comes.
Methods and Results: The registry will include
all records of hypertensive patients from 50
community-based primary care practices at full
enrollment. Data from nine practices were
manually abstracted into an electronic data-
base and analyzed. Seven hundred and ten
records were included in this report. Approx-
imately 70% are female, average age 47 6
13 years, 5.3% are uninsured, and more than
60% have at least a high school education.
Registry patients have multiple co-morbid
conditions: 28% are diabetic, 8% have left
ventricular hypertrophy, 5% have congestive
heart failure, 6.5% have renal insufficiency, 5%
have cerebrovascular disease, 3.5% have pre-
vious myocardial infarction and 2% have
peripheral vascular disease. Among those with
diabetes, mean glycosylated hemoglobin was
7.4 6 2. Pattern of antihypertensive use
showed 43% on diuretics, 28% on calcium
channel blockers, 24% on angiotensin con-
verting enzyme inhibitors, 20% on beta block-
ers and 16% on angiotensin receptor blockers.
Overall, 37% were at goal blood pressure and
among those with diabetes, only 16% reached
goal blood pressure.
Conclusion: We conclude that the blood
pressure control rates of African Americans in
the registry trail those of the general popula-
tion. This provides a unique opportunity to
study the underlying factors and design tai-
lored interventions to address this disparity in
health outcome. (Ethn Dis. 2005;15 [suppl
5]:S5-120–S5-123)
Key Words: Hypertension, Outcomes, Phy-
sician Education, Quality Improvement, Dis-
parities
Priscilla Igho-Pemu, MD, MS; Alexander Quarshie, MD, MS;
Adefisayo Oduwole, MD; Rigobert Lapu-Bula, MD, PhD;
Robert Mayberry, PhD; Chamberlain Obialo, MD;
Gary H. Gibbons, MD; Elizabeth Ofili, MD, MPH
INTRODUCTION
Overall, between 50%–55% of
known and treated hypertensive patients
in the United Stat es are at goal blood
pressure.
2
Control rates among treated
African Americans and other minorities
are under 45%. Control rates in the
presence of co-morbid diabetes, heart
disease or kidney disease is lower still.
3
Many studies have found the fol-
lowing barriers to be important in the
overall health outcome of an individual
or group:
N Access to health care
4
;
N Patient factors, such as health beliefs,
trust in the health care system and
socioeconomic status
5
;
N Provider factors, such as cultural
competence
6
;
N System of providing healthcare.
Improvements in access and patient
behavior are more dependent on policy
initiatives and comprehensive public
educational interventions that fit in the
larger social context. In the realm of the
clinical enc ounter, provider and organi-
zational factors are amenable to change
if adequately enumerated. A clear un-
derstanding of the specific barrie rs to
the translation of evidence into practice
for minority patients w ith chronic
disease who are cared for in the out-
patient setting is vital to the design and
implementation of appropriate quality
improvement efforts.
7
Although failure of routine practice
to replicate recommended care has been
ascribed to knowledge deficiencies and
recalcitrance on the part of physicians,
there is evidence that structural prob-
lems (financial disincentives, inappro-
priate skill mix, lack of facilities or
equipment); peer group effects (practice
patterns determined by local standards
and beliefs rather than evidence or
consensus statements); professional (is-
sues surrounding knowledge/skills, atti-
tudes and beliefs); and patient factors
(personal beliefs, trust in the health
system, s elf-management skills, etc.)
also play a role.
8
Quality improvement initiatives in
hypertens ion h ave deployed multiple
strategies directed at overcoming bar-
riers to the adoption of evidence-based
guidelines. The results of such interven-
tions have been mixed. Passive inter-
ventions, such as dissemination of
guidelines, are less successful than more
active interventions like audit and
feedback, reminder systems, financial
incentives, regulation and policy, as well
as organizational change. Overall, how-
ever, the value of these interventions on
hypertension care processes has been
modest at best, and outcomes vary based
on the underlying characteristics of the
group studied.
9
Therefore, as part of a comprehen-
sive effort to identify barriers to im-
proved hypertension outcomes among
participating practices of the More-
house Community Physicians Network
(CPN), we examined the registry to
identify patterns of care and opportu -
From the Divisions of General Internal
Medicine, Cardiology, Nephrology, Biosta-
tistics, the Cardiovascular Research Institute,
and the Clinical Research Center, More-
house School of Medicine, Atlanta, Georgia.
Address correspondence and reprint
requests to Priscilla Igho-Pemu, MD, MS;
Morehouse School of Medicine; 720 West-
view Drive SW; Atlanta, GA, 30310; 404-
756-6684; 404-756-8122 (fax); ighpemp@
msm.edu
S5-120 Ethnicity & Disease, Volume 15, Autumn 2005
nities for provider-focused interventions
to improve patient outcomes.
METHODS
At full enrollment, the hypertension
registry wi ll include all hypertensive
patients from 50 primary care practices.
Practices were eligible to participate if
they had a minimum of 30% African-
American patients and were located in the
metro-Atlanta area. Characteristics of
each practice were obtained from the
physicians by way of a practice demo-
graphic sheet, which described the
type and training of physicians in the
practice, practice structure, the number
of outpatient visits per year, presence of
electronic medical records and payer
mix.
The registry was used to collect data
on: administrative items such as payer
mix; patient characteristics, such as
educational attainment; co-morbid
medical conditions; anthropometrics;
biochemical variables; and patterns of
medication use. The registry was ap-
proved by the institutional review board
of Morehouse School of Medicine and
is HIPAA compliant.
The data was manually abstracted
from the patient charts by FO, CN, CO
and SO at each practice and entered
into a database. Each of these chart
abstractors is well trained and proficient
in medical chart abstraction and in the
use of the data entry form. Each
associate involved in data entry had
a unique identif ier assigned such that all
data was traceable to the individual who
entered it.
The template for datapoints ob-
tained was similar to that used by the
Consortium of Southeastern Hyperten-
sion Control (COSEHC) centers of
excellence. All hypertensive patients in
every eligible practice are enrolled in the
registry unless they specifically request
not to be included. Once the data was
entered into the database, accuracy of
the data was confirmed by comparing it
with results of random chart audits
completed by the author and AQ; the
database was updated accordingly.
This analysis included all records
that are currently in the hypertension
registry. Analysis was done using Inter-
cooled StataH (V-8, Windows2000.
Statcorp, College Station, Texas). De-
scriptive data on the type of patients
were assessed. Continuous data were
describedusingmeanandstandard
deviation and categorical data using
frequencies and percentages. The main
outcome was blood pressure control
rates. Blood pressure control was de-
termined for each individual, based on
specific co-morbid conditions according
to recommendations of the Seventh
Report of the Joint National Commit-
tee on Prevention, Detection, Evalua-
tion, and Treatment of High Blood
Pressure (JNC-7).
10
Secondary outcomes included blood
glucose control rates based on glycosy-
lated hemoglobin values and lipid control
rates as described by the Third Report of
the Expert Panel on Detection, Evalua-
tion, and Treatment of High Blood
Cholesterol in Adults (Adult Treatment
Panel III) of the National Cholesterol
Education program (NCEP).
11
RESULTS
Many of the practices are solo or
small group practices that do not have
electronic patient records systems. Seven
hundred and ten records were obtained
from nine primary care practices. Nine-
ty-six percent of the patients were
African Am erican. Sixty-eight (68%)
were female. Average age was 476
13 years. Among the women, 68.7%
were post-menopausal. The patients in
the registry were well-educated, more
than 60% had a minimum of a high
school education and all but 5.3% had
private insurance. Distribution of health
insurance types is shown in Table 1.
Twenty percent had HMO insurance,
7% Medicaid, 5% Medicare HMO, 7%
with Medicare only, 7.6% with Medi-
care plus, and 32% with other private
health insurance.
Co-morbid diabetes was present in
27.8%, left ventricular hypertrophy in
8%, congestive heart failure in 5.22%,
renal insufficiency in 6.52%, cerebro-
vascular disease in 4.86%, angina in
2.82%, peripheral vascular disease in
2.12% and a history of myocardial
infarction in 3.53% of the hypertensive
patients in this registry (Table 2).
Mean and standard deviations of the
biochemical variables shown in Table 3
are as follows: low-density lipoprotein
cholesterol (LDL-C), 117.99 6 36 mg/dl;
Table 1. Type of health insurance
Type of Health Insurance Percentage (%)
Private health insurance 32
HMO 20
Medicare plus 7.6
Medicaid 7
Medicare only 7
Uninsured 5.3
Medicare HMO 5
Unknown 1.03
Military 0.3
Table 2. Co-Morbid conditions in
hypertensive patients
Comorbid Conditions Percent (%)
Diabetes mellitus 27.8
Left ventricular hypertrophy 8.07
Renal insufficiency 6.52
Congestive heart failure 5.22
Cerebrovascular disease 4.86
Myocardial infarction 3.53
Angina 2.82
Peripheral vascular disease 2.12
Table 3. Biochemical variables in
hypertensive patients
Biochemical
Variables Mean þ SD
Triglycerides 135.89 6 89 mg/dL
LDL cholesterol 117.99 6 35.96 mg/dL
HDL cholesterol 53.2 6 16.6 mg/dL
Fasting blood glucose 116 6 57 mg/dL
Glycosylated
hemoglobin
(HbA1C)
7.38 6 1.88
AA HYPERTENSION OUTCOMES OPPORTUNITIES FOR IMPROVEMENT - Igho-Pemu et al
Ethnicity & Disease, Volume 15, Autumn 2005 S5-121
fasting glucose, 116 6 57 mg/dl; and
glycosylated hemoglobin, 7.38 6 1.88.
The patterns of medication use are
showninFigure1,withthemost
commonly prescribed treatment being
diuretics (43%) followed by calcium
channel blockers (28%), beta blockers
(20.4%), and angiotensin receptor
blockers (16%). Figure 2 shows the
number of medications used by
blood pressure control status. Forty-two
percent of the patients in the registry
were treated with two or more antihy-
pertensive medica tions. Among dia-
betics, 42% were on two antihyperten-
sive medications or more (Figure 3).
Overall, 37.11 % of al l the hyper-
tensive patients in the registry reached
goal pressure by standards defined by
JNC 7. Among diabetics, the blood
pressure control rates dropped t o
15.87%.
DISCUSSION
This preliminary review of the
hypertension registry shows blood pres-
sure control rates of 37% among non-
diabetic African Americans, compared
with 44% reported in the National
Health and Nutrition Examination
Survey, NHANES 1999–2000.
1
How-
ever, this cohort is a high-risk group as
reflected in the high proportions of co-
morbid conditions. Forty percent of the
hypertensives in the registry were di-
abetic compared with 11% in the
general population. Similarly, conges-
tive heart failure was present in 9.13%
in the registry compared with 2.5% in
the general population.
The documentation of the treatment
and outcomes in the registry is signifi-
cant on several fronts. This registry of
hypertensive African-American patients,
drawn from the real world of private
practice in primary care presents a
unique opportunity to study and un-
derstand the barriers to optimal blood
pressure control as a model for other
chronic diseases manage d in the primary
care setting. The inherent value of the
results of such investigations lies in the
potential to inform interventions that
improve both the process of care as well
as overall outcomes in hypertension and
other chronic diseases for African-
American and other ethnic minorities.
The design and implementation of
interventions to improve health quality
without definin g the problems have
been suggested as an underlying reason
for the broad variation in effect that has
Fig 1. Patterns of antihypertensive medication use
Fig 2. Number of antihypertensive medications by blood pressure control status
AA HYPERTENSION OUTCOMES O PPORTUNITIES FOR IMPROVEMENT - Igho-Pemu et al
S5-122 Ethnicity & Disease, Volume 15, Autumn 2005
been observed with quality improve-
ment initiatives.
8
It is interesting that a gap in treatment
outcomes, when compared to the general
population, is present even though the
majority of patients (more than 90%)
have health insurance and more than
60% have at least a high school educa-
tion. Traditionally, gaps in treatment
outcomes have been attributed to issues
surrounding access to health care as well
as education (a surrogate for socio-
economic status).
4,5
If these initial results
hold when the registry is completed, they
indicate a need for a deeper analysis of the
following issues: patient factors such as
health beliefs, trust in the healthcare
system, transportation difficulties, self-
efficacy, provider and organizational
barriers, an d th e des ign of specific
interventions to address these problems.
CONCLUSION
We conclude that the African Amer-
icans in the registry have multiple
co-morbid conditions and that their
blood pressure control rates trail those
of the general population. The patients
with diabetes show poorer contr ol rates,
providing a unique opportunity to
study the underlying factors and design
tailored interventions to address this
disparity in health outcome.
Limitations
The registry is based on results of
a chart review in primary care offices;
therefore the rates of disease may not be
comparable to that of the gene ral
population as described in NHANES
data. This is a preliminary report from
the registry and it may not reflect the
overall control rates when the registry is
complete. Since this is observational, its
value is in the hypothesis generation for
further study.
A
CKNOWLEDGMENTS
This research effort was supported in part by
NIH Grants No U54RR14758 (CCRE),
5P20RR11104(CRC) and The Medtronic
Foundation.
We gratefully acknowledge all CPN phy-
sicians for their co-operation and commit-
ment to improving health outcomes of their
patients; CPN staff, Folake Ojutalayo, Sara
Obuobisa, Casmir Nwigwe, Ifeoma Imo-
nugo, Okeoma Chukwu, Pam Cooper,
Priscilla Johnson, Natasha Williams, Frances
Grant and all CRC staff for their assistance.
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Fig 3. Patterns of antihypertensive medication use by blood pressure control status
among patients with diabetes
AA HYPERTENSION OUTCOMES OPPORTUNITIES FOR IMPROVEMENT - Igho-Pemu et al
Ethnicity & Disease, Volume 15, Autumn 2005 S5-123
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