Patient-Physician Partnership to Improve HBP Adherence

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. Methods • 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

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. Study Design Intervention Patient N=125 Communication Skills Intervention Physicians N=25 All physicians are videotaped with a simulated patient at baseline Minimal Intervention Patient N=125 Minimal Intervention Physicians N=25 Intervention Patient N=125 Minimal Intervention Patient N=125 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.

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. 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 1st 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, 5th grade reading level Patient Intervention

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

9. Characteristics of Physicians by Intervention Assignment (N=41)

10. Physician Intervention Process Evaluation

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 No significant differences across intervention assignment groups

13. Clinical Characteristics of Patients by Randomization Status Chi-square p<0.05 for differences across intervention assignment groups

14. Patient Intervention Contacts

15. Patient Follow-Up Status 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 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