Behavioral support from peers and primary care office staff can help patients improve their blood pressure control by as much as starting a new drug, a new study found. Barbara J. Turner, M.D., M.S.Ed., M.A., M.A.C.P., of UT Medicine San Antonio, is the senior author.
The randomized, controlled trial examined whether six months of intervention behavioral support from peers and primary care office staff could benefit African-American patients who had poor control of systolic pressure despite one to two years of prescriptions and office visits. Systolic pressure is the force of the blood against vessels as the heart contracts.
"These patients had previously failed to have their blood pressure controlled despite physicians continuing to intensity their medications, so we decided that adding more medicine just wasn't going to work," Dr. Turner said. "You start to think, what other things could I do for this person rather than just pills?"
Population has greater risk
The team focused the behavior support intervention especially on lowering blood pressure because it can be severe, even deadly, in its consequences, particularly for older African Americans. They are more likely than whites to die of heart disease and are less likely to achieve blood pressure control even with similar treatment, Dr. Turner said.
Dr. Turner is professor in the School of Medicine at The University of Texas Health Science Center San Antonio and director of the REsearch to Advance Community Health (REACH) Center, a collaboration of the Health Science Center, the University Health System and The University of Texas School of Public Health. Researchers conducted the study in two urban academic internal medicine practices in Pennsylvania. Dr. Turner came to San Antonio from the University of Pennsylvania School of Medicine.
Lower systolic pressure
In the study, funded by the Robert Wood Johnson Foundation, systolic pressure was reduced by 7.2 mmHg (millimeters of mercury) in the intervention group versus 0.8 mmHg in the control group a 6.4 mmHg greater reduction for the peer- and primary care staff-based intervention. The study also aimed to reduce overall risk of a heart attack or death from heart disease in the next four years. The intervention group did reduce their heart disease risk more than the control group, but not enough to achieve a significant difference in that outcome compared with the controls.
The study was conducted in patients who were already affected by multiple diseases. More than half of the participants had diabetes, nearly 1 in every 5 had suffered a heart attack or other coronary heart disease (CHD) event, and more than 2 in every 5 had depressive symptoms. Average age of the participants was 62.
Grateful peer coaches
For the peer support intervention, the team trained African-American patients from the same practices as the study subjects. This training program was conducted in collaboration with the American Heart Association. The peer coaches were aged 50 or older and had high blood pressure that was now well-controlled. The peer coaches spoke on the phone with study participants several times over the course of the study about the serious nature of high blood pressure, why taking medications is important and practical ways to adopt a healthier lifestyle.
"Interestingly, the lead peer coach was an 85-year-old former wedding planner," Dr. Turner said. "She was incredible. The best peer coaches were grateful to their doctors for helping them. They wanted to pay back their so-called debt to the doctor and thought this was a way to do it."
Three African-American staff members (a medical assistant, a licensed nurse and a chronic disease educator) were also trained to offer culturally appropriate slideshows developed by the team on topics such as where to get healthy food and why the danger of stroke and heart attack requires taking blood pressure medication daily, even if the condition has no symptoms.
"We also created an online program to show patients their heart disease risk factors and what would happen to their risk of having a heart attack within four years if they reduced one or more of these risk factors," Dr. Turner said. "We could show that the risk could be reduced, sometimes a lot, by making a positive change."
Aspects of a patient-centered medical home were employed, such as using an electronic medical record to identify and then track the progress of the participants.
Dr. Turner said UT Medicine, the clinical practice of the School of Medicine at the UT Health Science Center, and other practices in San Antonio have patients who are also failing to achieve blood pressure control goals despite medications and office visits. Behavioral support may help them achieve a safer blood pressure. In addition, studies with patients who have diabetes have also shown a likely benefit from peer- and primary care office-based behavioral support, Dr. Turner said.
The research is reported in the Journal of General Internal Medicine.
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