Comprehensive High Blood Pressure Care for Young Urban Black Men

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DISTINGUISHED LECTURE FIGHTING THE
PRESSURE Multi-professional research to
improve high blood pressure care and
control Professor Martha Hill
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• WELCOME
• Professor John Daly
• Dean
• UTSNursing, Midwifery Health

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Multi-Professional Research to Improve High Blood
Pressure Care and Control

• Martha N. Hill, RN, PhD
• Principal Investigator
• Johns Hopkins University

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School of Nursing Co-Investigators Staff
Co-Investigators Cheryl Dennison, PhD, CRNP
Miyong Kim, PhD, RN Linda Rose, PhD,
RN Project Director Mary Roary, MHS Nurse
Practitioner Sue Hall, MSN, CRNP Community
Health Worker Dwyan Monroe Staff LaPricia
Lewis Sylvia Robinson Anthony
Weldon Cassia Lewis Jennifer Walker
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Schools of Public Health and Medicine
Co-Investigators Staff
Co-Investigators Lee Bone, MPH, RN Roger
Blumenthal, MD Gary Gerstenblith,
MD David Levine, MD, ScD Wendy Post,
MD, MS Eddie Rame, MD James Weiss,
MD Staff Ann Capriotti Bobby
Roary
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Support

• National Institutes of Health
• NINR R01 NR04119
• NCRR GCRC 5M01RR00052
• WA Baum and Co. Inc.
• Merck Co.

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Background

• Social, psychological, behavioral and genetic
  factors are associated with uncontrolled HBP
• Black men
• suffer earliest from severe complications
• have low rates of continuous HBP care
• achieve poor control of HBP
• are vastly under-studied
• Myths suggest that young urban black men are
  hard-to-reach and not interested in their
  health or participating in research

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Specific Aims

• Enroll 300 inner-city hypertensive black men,
  with and without controlled BPs, in a clinical
  trial comparing a comprehensive NP/CHW/MD team
  intervention to community care to lower BP over
  60 months
• Characterize HBP and lifestyle-related
  co-morbidities over 60 months

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Main Hypotheses

• Compared to the less intensive (LI) intervention
  group receiving HBP care in the community, the
  more intensive (MI) intervention group receiving
  comprehensive NP/CHW/MD HBP care over 60 months
  will have significantly
• greater lowering of mean BP
• greater BP control (lt 140/90 mm Hg)
• higher rates of being in HBP care and taking HBP
  medication

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Conceptual Framework

• Predisposing Factors
• Knowledge, Attitudes, Beliefs, Experiences

• Behavior Patterns
• Entry into Care
• Retention in Care
• Adherence to Treatment

• Outcomes
• ? Blood Pressure
• ? Complications
• ? Quality of Life

• Enabling Factors
• Health Care Resources
• Health Behavior Skills

• Reinforcing Factors
• Social Support

Green, L.W. and Kreuter, M.W. (2005). Health
Program Planning An Educational and Ecological
Approach, 4th Edition, New York McGraw-Hill.
Hill, M. N., Bone, L. R., Kim, M. T., Miller, D.
J., Dennison, C.R., Levine, D. M. (1999).
Barriers to hypertension care and control in
young urban black men. AJH, 12, 951-958.
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Methods Eligibility Criteria

• Black men, ages 18-54 years
• Residing in inner city Baltimore
• Hypertension
• SBP gt 140 and/or DBP gt 90 mm Hg on gt 2 occasions
• Mean of 2nd and 3rd random zero measurements on
  2nd eligibility visit gt 140 and/or gt 90 mm Hg or
• On HBP medication, with BP lt or gt 140/90
• Able to give verified names, addresses and
  telephone numbers for gt 3 contact persons

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Recruitment Yield
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Recruitment Source
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Randomized Clinical Trial Design and
Interventions
309 Men

• More Intensive
• Education
• Individualized NP-CHW-MD Team Care
• NP visits prn lt 2-3 months
• ARB Losartan 50 -100 mg (free)
• HCTZ gt 12.5 - 25mg (free)
• Other HBP meds prn
• Home visits annually
• Transportation
• Social services referrals prn

• Less Intensive
• Education
• Provided list of community
• HBP care sources

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Methods to Maximize Follow-Up in Both Groups

• Intensive tracking of vital status and residency
• Pre-appointment reminders for annual research
  visits
• Follow-up on missed appointments
• Mail, telephone, home visits
• 6 mo health status telephone call
• Feedback on BP control and test results
• Birthday and holiday cards
• 25 - 100 financial compensation for annual
  visits

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Baseline Sociodemographic Characteristics(n
309)

• Age (mean SD) 41 5.6
• Education (mean SD) 11 2.2
• Employment
• Unemployed, 40
• Disabled, 32
• Jail experience, 64
• Income lt 10,000/yr, 71
• No health insurance, 51

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Tracking and Follow-up




n264
n252
n231
n217
n200
Accounting for deceased (n3,9,16,19,22),
incarcerated (n6,4,8,6,8), moved out-of-state
(n1,1,1,3,4). Accounting for deceased (n5,
9,17,24,28), incarcerated (n10,9,13,17,17),
moved out-of-state (n3,5,4,4,5), in long-term
care facility (1,1,2,3,3) for 12,24,36,48,and 60
m follow-up respectively.
Statistically significant between group
difference for total sample f-u, p lt 0.05
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Causes of Death (n53)


Primary cause of death listed on Death
Certificate
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Change in Sociodemographic Characteristics from
Baseline to 36 and 60 Months

• Statistically significant within group changes
  from baseline to 36m or 60m, plt0.05

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Change in Lifestyle Risk Factors









Statistically significant within group changes
from baseline to 36m or 60m, plt0.05
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Change in HBP Care Behaviors











Statistically significant between group
difference at 36m or 60 m, p lt 0.001
Statistically significant within group changes
from baseline to 36m or 60m, plt0.05
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SBP and DBP Changes Over 5 Years
SBP
DBP
n264
n252
n231
n217
n200
n264
n252
n231
n217
n200
















Statistically significant between group
difference, p lt 0.001 Statistically
significant within group changes, plt0.05
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Prevalence of BP Control (lt140/90 mmHg)


Statistically significant between group
difference, p lt 0.05
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Summary

• Young urban black men with HTN were willing to
  participate in research, be randomized and be
  followed
• Mortality rates were high
• 1/3 of deaths caused by narcotic / alcohol
  intoxication
• 1/4 due to cardiovascular or cerebrovascular
  disease
• High risk profile for socio-economic, lifestyle,
  and HBP care behaviors
• Both groups showed improvements in selected
  variables

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Summary, continued

• Prevalence of cardiac and renal end organ damage
  was high in both groups
• LVH progression less in MI group
• MI group had significantly lower SBP and DBP at
  12, 36, and 48 months and greater BP control at
  36 months compared to LI group
• Proportion with BP control increased in both
  groups with significantly higher control rates
  seen in MI group at 36 months

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Conclusions

• A multidisciplinary research program including
  community members as staff can maintain contact
  every 6 months and facilitate BP lowering over
  time in a very high risk group
• Participating in a clinical trial with intensive
  tracking and follow-up was beneficial to both
  groups
• Sustaining BP lowering over time requires engaged
  patients and a dedicated staff

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Implications

• To further lower BP and reduce cardiovascular
  risk among this high risk group, we must
• develop comprehensive interventions to reduce
  other CV risk factors
• address social and economic challenges

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Selected Study Publications
Dennison CR, Post WS, Kim MT, Bone LR, Cohen D,
Blumenthal RS, Rame JE, Roary MC, Levine DM, Hill
MN. Underserved Urban African American Men
Hypertension Trial Outcomes and Mortality During
5 Years. AJHypertens 200720164-171. Hill MN,
Han HR, Dennison CR, Kim MT, Roary MC, Blumenthal
RS, Bone LR, Levine DM, Post WS. Hypertension
care and control in underserved urban African
American men Behavioral and physiologic outcomes
at 36 months. AJHypertens 200316(11)906-913. Kim
MT, Han HR, Hill MN, Rose LR, Roary MS.
Depression, substance use, adherence behaviors,
and blood pressure control in urban hypertensive
black men. Annals of Behavioral Medicine
200351(5) 309-316. Post W, Hill MN, Dennison
CR, Weiss JL, Gerstenblith G, Blumenthal RS. High
prevalence of target organ damage in young,
African-American inner-city men with
hypertension. JClinHypertens 20035(1)24-30. Kim,
M.T., Dennison, C.R. Hill, M.N., Bone, L.R.,
Levine, D.M. Relationship of alcohol and illicit
drug use with high blood pressure care and
control among urban hypertensive black men.
Ethnicity Disease 2000 10175-183. Hill MN,
Bone LR, Kim MT, Miller DJ, Dennison CR, Levine
DM. Barriers to hypertension care and control in
young urban black men. AJHypertens
199912951-958.
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SummaryAn Innovative Integrated Model

• Research Preventive Clinical
  Basic
• Health Services
• Science Behavioral Bio/Behavioral
  Biologic
• Setting Community Ambl. Care Laboratory
• Method Outreach Patient Care Testing
• Personnel CHW-NP NP-CHW-MD
  Geneticists

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The Continuum ofTransdisciplinary Science
Hospital
Laboratory
Ambulatory Care
Community