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Patient-Physician Partnership to Improve HBP Adherence Lisa A. Cooper, MD, MPH Associate Professor of Medicine, Epidemiology, and Health Behavior & Society.

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Presentation on theme: "Patient-Physician Partnership to Improve HBP Adherence Lisa A. Cooper, MD, MPH Associate Professor of Medicine, Epidemiology, and Health Behavior & Society."— Presentation transcript:

1 Patient-Physician Partnership to Improve HBP Adherence Lisa A. Cooper, MD, MPH Associate Professor of Medicine, Epidemiology, and Health Behavior & Society Johns Hopkins University School of Medicine Johns Hopkins Bloomberg School of Public Health Supported by the National Heart, Lung, and Blood Institute Grant No: 1R01-HL69403-01 09/30/01-09/30/06

2 Design: Randomized controlled trial with 2x2 factorial design Population: 50 MDs and 500 ethnic minorities and poor persons with high blood pressure (HBP) Setting: 18 urban community-based clinics in Baltimore, MD (9 federally qualified health centers) Interventions: –Physicians: 2 hour individualized communication skills training program on interactive CD-ROM –Patients: one-on-one education and activation by community health worker in person and by telephone Methods

3 Outcomes* Health outcomes (BP and diabetes control) Patient-physician communication behaviors Patient adherence –Self-reported adherence to meds, diet, and exercise –Appointment-keeping (administrative data) –Prescription refill rates (automated pharmacy records) Patient ratings of care Appropriateness of hypertension care (JNC-7) Hospitalizations and ER visits * Assessed at index visit and at 3 months and 12 months of follow-up

4 Communication Skills Intervention Physicians N=25 Intervention Patient N=125 Intervention Patient N=125 Study Design CHW contacts are 20 minutes at enrollment, 2 wks, 3,6,9, and 12 mo. Intervention includes coaching by CHW and photo-novella. All patients receive newsletter. Minimal Intervention Physicians N=25 Minimal Intervention Patient N=125 Minimal Intervention Patient N=125 All physicians are videotaped with a simulated patient at baseline

5 Physician Intervention All physicians: Baseline videotaped encounter with simulated patient Enrollment visits audio-taped for ~5-10 patients Intensive intervention only: Interactive CD-ROM features video of the physician interviewing simulated patient Workbook with exercises to guide physician through self-assessment Video-glossary of illustrative behaviors Administration time: 2 hrs

6 Patient Intervention All patients: Receive a monthly newsletter featuring Q &A column, recipe exchange, health tips, and reminders Are paid $25 for completing each of three assessments at baseline, 3 months, and 12 months Intensive intervention patients only: 20-minute pre-visit coaching and 10-minute post-visit debriefing delivered by community health worker (CHW) at 1 st clinic visit Five telephone follow-ups at 2 wks, 3,6, 9, and 12 mo Photo-novella: dramatic storyline with embedded health messages; comic strip format, 5 th grade reading level

7 Community Health Worker Coaching Sessions Help patient to identify key concerns with regard to patient-physician relationship and disease management Build patient’s skills in joint decision-making Provide reinforcement and support; build confidence Topics covered include knowledge and beliefs about health and high blood pressure, treatment (with medications, diet, physical activity, weight loss), smoking cessation, alcohol reduction, stress reduction

8 Physician Enrollment (January 2002 – January 2003) 133 Physicians Contacted 110 Physicians Responded 23 No Response 53 Physicians Agreed 51* Physicians Randomized 57 Refusals 2 Became Ineligible *47% response rate 9 Left Clinical site 1 Withdrew 41 Physicians with patients enrolled in study

9 Characteristics of Physicians by Intervention Assignment (N=41) CharacteristicIntensive, n=22Minimal, n=19 Mean age, yrs41.844.3 Practice experience, yrs9.512.6 Female gender, %5058 African-American, % Asian, % White, % Hispanic/Other, % 23 18 45 14 37 16 42 5 Internal Medicine,%7784 US medical grad, %6879

10 Physician Intervention Process Evaluation Process measure % of intervention physicians Completed intervention88% Found program worthwhile73% Would recommend program73%

11 Patient Enrollment ( September 2003 - August 2005 ) 3,240 patients Age >18 years of age 2 prior ICD-9 claims for hypertension Mailed letter and attempted phone call 941 (29%) Contacted by phone 598 (64%) Eligible 533 (89%) Willing to participate 279 (52%) Randomized

12 Demographic Characteristics of Patients by Randomization Status Demographic CharacteristicPhysician intensive n=22 Physician minimal n=19 Patient intensive n=83 Patient minimal n=84 Patient intensive n=57 Patient minimal n=55 Mean age, yrs59.760.563.762.4 Mean education, yrs11.311.812.2 Women (%)65 7262 African-American (%)63616758 Medicaid insurance (%)3427 35 Employed (%)212724 No significant differences across intervention assignment groups

13 Clinical Characteristics of Patients by Randomization Status Clinical CharacteristicPhysician intensive n=22 Physician minimal n=19 Patient intensive n=83 Patient minimal n=84 Patient intensive n=57 Patient minimal n=55 Mean BMI, kg/m 2 33.631.833.932.3 Mean PCS score, SF1239.840.440.540.4 Mean MCS score, SF1251.650.249.550.0 BP controlled (%)41604655 Comorbid diabetes (%)*44345845 Comorbid depression (%)24231333 Chi-square p<0.05 for differences across intervention assignment groups

14 Patient Intervention Contacts StatusPatients due CompletedRefusedWithdrewUnable to contact 2-week140107 (76%)3 (2%)1 (0.7%)29 (21%) 3-month14096 (66%)06 (4%)40 (29%) 6-month14082 (59%)08 (6%)50 (36%) 9-month13669 (51%)1 (0.7%)8 (6%)58 (43%) 12-month11355 (49%)1 (0.7%)11 (8%)46 (34%)

15 Patient Follow-Up Status Status/Assessment3 month12 month Completed in person167133 Completed by telephone1731 Completed at clinic18 Missed8064 Withdrew1418 Total complete185 (66%)172 (73%) Total due279236* 279 total patients – ( 38 not due yet + 5 deceased) = 236 due for 12 month follow-up

16 Changes at 3-month follow-up from baseline by intervention status Outcome MeasurePhysician intensive n=22 Physician minimal n=19 Patient intensive n=52 Patient minimal n=55 Patient intensive n=36 Patient minimal n=40 Satisfied with last visit (%)64575962 Mean change in HBS 1 -1.4-1.3 -1.7 Change in BP control, (%)+11%+16% +1% Mean change, SBP (mm Hg)-6.0-3.0-4.5-3.6 Mean change, DBP (mm Hg)-1.6-0.30.0-0.7 1 Hill-Bone Adherence Score (lower scores indicate better adherence); no significant differences

17 Conclusions Recruiting PCPs from urban community-based clinics to participate in a communication skills intervention to reduce disparities is feasible Recruiting and retaining ethnic minority and low income patients with high blood pressure in a clinic-based patient activation intervention is challenging Interventions that target the patient-physician relationship: –are acceptable and worthwhile to most PCPs –may be promising strategies to reduce disparities in quality and outcomes of hypertension care

18 Next Steps Complete 12-month follow-up assessments Analyze audiotapes of patient index visits (occurs after physician intervention and after first patient intervention contact) Analyze hospitalization and ER utilization data Obtain administrative data on appointment- keeping and prescriptions on subset of sample


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