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
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
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
Study Design
All
physicians
are
videotaped
with a
simulated
patient at
baseline
Communication Skills
Intervention
Physicians
N=25
Minimal Intervention
Physicians
N=25
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.
Intervention
Patient
N=125
Minimal
Intervention
Patient
N=125
Intervention
Patient
N=125
Minimal
Intervention
Patient
N=125
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 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
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
53
Physicians Agreed
51*
Physicians Randomized
41
Physicians with patients
enrolled in study
23
No Response
57
Refusals
2
Became Ineligible
9 Left Clinical site
1 Withdrew
*47% response rate
Characteristics of Physicians by
Intervention Assignment (N=41)
Characteristic
Mean age, yrs
Practice experience, yrs
Intensive, n=22 Minimal, n=19
41.8
9.5
44.3
12.6
Female gender, %
African-American, %
Asian, %
White, %
Hispanic/Other, %
Internal Medicine,%
50
23
18
45
14
77
58
37
16
42
5
84
US medical grad, %
68
79
Physician Intervention
Process Evaluation
Process measure
% of intervention
physicians
Completed intervention
88%
Found program worthwhile
73%
Would recommend program
73%
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
Demographic Characteristics of
Patients by Randomization Status
Demographic Characteristic Physician intensive Physician minimal
n=19
n=22
Patient
Patient
Patient Patient
intensive minimal intensive minimal
n=83
n=84
n=57
n=55
Mean age, yrs
59.7
60.5
63.7
62.4
Mean education, yrs
11.3
11.8
12.2
12.2
Women (%)
65
65
72
62
African-American (%)
63
61
67
58
Medicaid insurance (%)
34
27
27
35
Employed (%)
21
27
24
24
No significant differences across intervention assignment groups
Clinical Characteristics of Patients
by Randomization Status
Clinical Characteristic
Mean BMI, kg/m2
Physician intensive Physician minimal
n=19
n=22
Patient
Patient
Patient Patient
intensive minimal intensive minimal
n=83
n=84
n=57
n=55
33.6
31.8
33.9
32.3
Mean PCS score, SF12
39.8
40.4
40.5
40.4
Mean MCS score, SF12
51.6
50.2
49.5
50.0
BP controlled (%)
41
60
46
55
Comorbid diabetes (%)*
44
34
58
45
Comorbid depression (%)
24
23
13
33
Chi-square p<0.05 for differences across intervention assignment groups
Patient Intervention Contacts
Status
2-week
Patients Completed Refused
due
140 107 (76%) 3 (2%)
Withdrew
1 (0.7%)
Unable to
contact
29 (21%)
3-month
140
96 (66%)
0
6 (4%)
40 (29%)
6-month
140
82 (59%)
0
8 (6%)
50 (36%)
9-month
136
69 (51%) 1 (0.7%)
8 (6%)
58 (43%)
12-month
113
55 (49%) 1 (0.7%)
11 (8%)
46 (34%)
Patient Follow-Up Status
Status/Assessment
Completed in person
Completed by telephone
Completed at clinic
Missed
Withdrew
Total complete
Total due
3 month
12 month
167
17
133
31
1
80
14
185 (66%)
8
64
18
172 (73%)
279
236*
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 Measure
Satisfied with last visit (%)
Mean change in HBS1
Physician intensive Physician minimal
n=19
n=22
Patient Patient Patient Patient
intensive minimal intensive minimal
n=52
n=55
n=36
n=40
64
57
59
62
-1.4
-1.3
-1.3
-1.7
+11%
+16%
+16%
+1%
Mean change, SBP (mm Hg)
-6.0
-3.0
-4.5
-3.6
Mean change, DBP (mm Hg)
-1.6
-0.3
0.0
-0.7
Change in BP control, (%)
1 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 appointmentkeeping and prescriptions on subset of sample