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-HL /30/01-09/30/06

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

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

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

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

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

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

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

Characteristics of Physicians by Intervention Assignment (N=41) CharacteristicIntensive, n=22Minimal, n=19 Mean age, yrs Practice experience, yrs Female gender, %5058 African-American, % Asian, % White, % Hispanic/Other, % Internal Medicine,%7784 US medical grad, %6879

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

Patient Enrollment ( September 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

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, yrs Mean education, yrs Women (%) African-American (%) Medicaid insurance (%) Employed (%) No significant differences across intervention assignment groups

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 Mean PCS score, SF Mean MCS score, SF BP controlled (%) Comorbid diabetes (%)* Comorbid depression (%) Chi-square p<0.05 for differences across intervention assignment groups

Patient Intervention Contacts StatusPatients due CompletedRefusedWithdrewUnable to contact 2-week (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%)

Patient Follow-Up Status Status/Assessment3 month12 month Completed in person 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

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 (%) Mean change in HBS Change in BP control, (%)+11%+16% +1% Mean change, SBP (mm Hg) Mean change, DBP (mm Hg) Hill-Bone Adherence Score (lower scores indicate better adherence); no significant differences

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

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