Title: Comprehensive High Blood Pressure Care for Young Urban Black Men
1 DISTINGUISHED LECTURE FIGHTING THE
PRESSURE Multi-professional research to
improve high blood pressure care and
control Professor Martha Hill
2 - WELCOME
- Professor John Daly
- Dean
- UTSNursing, Midwifery Health
3Multi-Professional Research to Improve High Blood
Pressure Care and Control
- Martha N. Hill, RN, PhD
- Principal Investigator
- Johns Hopkins University
4School 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
5Schools 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
6Support
- National Institutes of Health
- NINR R01 NR04119
- NCRR GCRC 5M01RR00052
- WA Baum and Co. Inc.
- Merck Co.
7Background
- 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
8Specific 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
9Main 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
10Conceptual 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.
11Methods 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
12Recruitment Yield
13Recruitment Source
14 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
15Methods 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
16Baseline 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
17Tracking 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
18Causes of Death (n53)
Primary cause of death listed on Death
Certificate
19Change in Sociodemographic Characteristics from
Baseline to 36 and 60 Months
- Statistically significant within group changes
from baseline to 36m or 60m, plt0.05
20Change in Lifestyle Risk Factors
Statistically significant within group changes
from baseline to 36m or 60m, plt0.05
21Change 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
22SBP 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
23Prevalence of BP Control (lt140/90 mmHg)
Statistically significant between group
difference, p lt 0.05
24Summary
- 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
25Summary, 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
26Conclusions
- 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
27Implications
- 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
28Selected 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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36SummaryAn 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
37The Continuum ofTransdisciplinary Science
Hospital
Laboratory
Ambulatory Care
Community