Dataset Information

Impact of a Patient-Centered Behavioral Economics Intervention on Hypertension Control in a Highly Disadvantaged Population: a Randomized Trial.

ABSTRACT:

Background

Uncontrolled hypertension contributes to disparities in cardiovascular outcomes. Patient intervention strategies informed by behavioral economics and social psychology could improve blood pressure (BP) control in disadvantaged minority populations.

Objective

To assess the impact on BP control of an intervention combining short-term financial incentives with promotion of intrinsic motivation among highly disadvantaged patients.

Design

Randomized controlled trial.

Participants

Two hundred seven adults (98% African American or Latino) aged 18 or older with uncontrolled hypertension attending Federally Qualified Health Centers.

Intervention

Six-month intervention, combining financial incentives for measuring home BP, recording medication use, BP improvement, and achieving target BP values with counseling linking hypertension control efforts to participants' personal reasons to stay healthy.

Main measures

Primary outcomes: percentage achieving systolic BP (SBP) Key resultsAfter 6 months, rates of achieving target BP values for intervention and control subjects respectively was 57.1% vs. 40.2% for SBP ConclusionsThe intervention achieved short-term improvement in SBP control in a highly disadvantaged population. Despite attempts to enhance intrinsic motivation, the effect was not sustained after incentives were withdrawn. Future research should evaluate combined patient/provider strategies to enhance such interventions and sustain their benefit.

Trial registration

NCT01402453; http://clinicaltrials.gov/show/NCT01402453.

SUBMITTER: Shapiro MF

PROVIDER: S-EPMC6958561 | biostudies-literature | 2020 Jan

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Impact of a Patient-Centered Behavioral Economics Intervention on Hypertension Control in a Highly Disadvantaged Population: a Randomized Trial.

Shapiro Martin F MF Shu Suzanne B SB Goldstein Noah J NJ Victor Ronald G RG Fox Craig R CR Tseng Chi-Hong CH Vangala Sitaram S Mogler Braden K BK Reed Stewart B SB Villa Estivali E Escarce José J JJ

Journal of general internal medicine 20190912 1

<h4>Background</h4>Uncontrolled hypertension contributes to disparities in cardiovascular outcomes. Patient intervention strategies informed by behavioral economics and social psychology could improve blood pressure (BP) control in disadvantaged minority populations.<h4>Objective</h4>To assess the impact on BP control of an intervention combining short-term financial incentives with promotion of intrinsic motivation among highly disadvantaged patients.<h4>Design</h4>Randomized controlled trial.< ...[more]

PMID: 31515735

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Project description:IntroductionAs part of the Centers for Medicare and Medicaid Innovation Practice Transformation Network, an integrated healthcare system implemented a multimodal, population health-based hypertension clinical pathway program (HCPP) focused on hypertension management.AimTo determine whether the HCPP was associated with changes in hypertension control or process-of-care measures and whether associations varied for sites serving higher versus lower proportions of historically underserved patients.SettingAn integrated academic health system encompassing 5 clinic networks and 85 primary and specialty care sites.Program descriptionThe HCPP was implemented at some sites (adopters) but not others (non-adopters) and had four components: (1) stakeholder engagement; (2) clinical staff retraining; (3) electronic health record-based prompts; and (4) performance monitoring and feedback. Program goals were to encourage clinical teams to increase the frequency of follow up visits and adopt standardized approaches to blood pressure (BP) measurements and antihypertensive medication regimen advancement defined as adding or titrating existing medication.Program evaluationThis quasi-experimental study used 2017-2019 data from 63,497 patients with hypertension and multivariable difference-in-differences analyses to evaluate changes in outcomes at 19 adopter versus 39 non-adopter sites before and after HCPP implementation. Adoption was associated with 3.5 times differentially greater odds of a BP reassessment (OR 3.5, 95% CI 3.3-3.8), 11% differentially greater odds of BP control (BP<140/90 mmHg) (OR 1.11, 95% CI 1.07-1.15), and 12% differentially greater odds of having non-severely elevated BP (systolic BP < 155 mmHg) (OR 1.12, 95% CI 1.05-1.19). HCPP adoption was not associated with differential changes in 90-day follow-up BP measurement. Adoption was associated with 23% differentially greater odds of appropriate medication advancement (OR 1.23, 95% CI 1.04-1.46). A similar pattern was observed when limiting comparisons to sites caring for a higher proportion of historically underserved populations.DiscussionA multimodal population health approach to transforming hypertension care was associated with improved BP outcomes.

Project description:African Americans and persons with low socioeconomic status (SES) are disproportionately affected by hypertension and receive less patient-centered care than less vulnerable patient populations. Moreover, continuing medical education (CME) and patient-activation interventions have infrequently been directed to improve the processes of care for these populations.To compare the effectiveness of patient-centered interventions targeting patients and physicians with the effectiveness of minimal interventions for underserved groups.Randomized controlled trial conducted from January 2002 through August 2005, with patient follow-up at 3 and 12 months, in 14 urban, community-based practices in Baltimore, Maryland.Forty-one primary care physicians and 279 hypertension patients.Physician communication skills training and patient coaching by community health workers.Physician communication behaviors; patient ratings of physicians' participatory decision-making (PDM), patient involvement in care (PIC), reported adherence to medications; systolic and diastolic blood pressure (BP) and BP control.Visits of trained versus control group physicians demonstrated more positive communication change scores from baseline (-0.52 vs. -0.82, p = 0.04). At 12 months, the patient+physician intensive group compared to the minimal intervention group showed significantly greater improvements in patient report of physicians' PDM (? = +6.20 vs. -5.24, p = 0.03) and PIC dimensions related to doctor facilitation (? = +0.22 vs. -0.17, p = 0.03) and information exchange (? = +0.32 vs. -0.22, p = 0.005). Improvements in patient adherence and BP control did not differ across groups for the overall patient sample. However, among patients with uncontrolled hypertension at baseline, non-significant reductions in systolic BP were observed among patients in all intervention groups-the patient+physician intensive (-13.2 mmHg), physician intensive/patient minimal (-10.6 mmHg), and the patient intensive/physician minimal (-16.8 mmHg), compared to the patient+physician minimal group (-2.0 mmHg).Interventions that enhance physicians' communication skills and activate patients to participate in their care positively affect patient-centered communication, patient perceptions of engagement in care, and may improve systolic BP among urban African-American and low SES patients with uncontrolled hypertension.

Project description:Patient-shared electronic health records provide opportunities for care outside of office visits. However, those who might benefit may be unable to or choose not to use these resources, while others might not need them.Electronic Communications and Home Blood Pressure Monitoring (e-BP) was a randomized trial that demonstrated that Web-based pharmacist care led to improved blood pressure (BP) control. During recruitment we attempted to contact all patients with hypertension from 10 clinics to determine whether they were eligible and willing to participate. We wanted to know whether particular subgroups, particularly those from vulnerable populations, were less willing to participate or unable to because they lacked computer access.From 2005 to 2006, we sent invitation letters to and attempted to recruit 9298 patients with hypertension. Eligibility to participate in the trial included access to a computer and the Internet, an email address, and uncontrolled BP (BP ? 140/90 mmHg). Generalized linear models within a modified Poisson regression framework were used to estimate the relative risk (RR) of ineligibility due to lack of computer access and of having uncontrolled BP.We were able to contact 95.1% (8840/9298) of patients. Those refusing participation (3032/8840, 34.3%) were significantly more likely (P < .05) to be female, be nonwhite, have lower levels of education, and have Medicaid insurance. Among patients who answered survey questions, 22.8% (1673/7354) did not have computer access. Older age, minority race, and lower levels of education were risk factors for lack of computer access, with education as the strongest predictor (RR 2.63, 95% CI 2.30-3.01 for those with a high school degree compared to a college education). Among hypertensive patients with computer access who were willing to participate, African American race (RR 1.22, 95% CI 1.06-1.40), male sex (RR 1.28, 95% CI 1.18-1.38), and obesity (RR 1.53, 95% CI 1.31-1.79) were risk factors for uncontrolled BP.Older age, lower socioeconomic status, and lower levels of education were associated with decreased access to and willingness to participate in a Web-based intervention to improve hypertension control. Failure to ameliorate this may worsen health care disparities.Clinicaltrials.gov NCT00158639; http://www.clinicaltrials.gov/ct2/show/NCT00158639 (Archived by WebCite at http://www.webcitation.org/5v1jnHaeo).

Project description:BackgroundLittle is known about how delivery of primary care in the patient-centered medical home (PCMH) influences outpatient specialty care use.ObjectiveTo describe changes in outpatient specialty use among patients with treated hypertension during and after PCMH practice transformation.DesignOne-group, 48-month interrupted time series across baseline, PCMH implementation and post-implementation periods.PatientsAdults aged 18-85 years with treated hypertension.InterventionSystem-wide PCMH redesign implemented across 26 clinics in an integrated health care delivery system, beginning in January 2009.Main measuresResource Utilization Band variables from the Adjusted Clinical Groups case mix software characterized overall morbidity burden (low, medium, high). Negative binomial regression models described adjusted annual differences in total specialty care visits. Poisson regression models described adjusted annual differences in any use (yes/no) of selected medical and surgical specialties.Key resultsCompared to baseline, the study population averaged 7% fewer adjusted specialty visits during implementation (P?<?0.001) and 4% fewer adjusted specialty visits in the first post-implementation year (P?=?0.02). Patients were 12% less likely to have any cardiology visits during implementation and 13% less likely during the first post-implementation year (P?<?0.001). In interaction analysis, patients with low morbidity had at least 27% fewer specialty visits during each of 3 years following baseline (P?<?0.001); medium morbidity patients had 9% fewer specialty visits during implementation (P?<?0.001) and 5% fewer specialty visits during the first post-implementation year (P?=?0.007); high morbidity patients had 3% (P?=?0.05) and 5% (P?=?0.009) higher specialty use during the first and second post-implementation years, respectively.ConclusionsResults suggest that more comprehensive primary care in this PCMH redesign enabled primary care teams to deliver more hypertension care, and that many needs of low morbidity patients were within the scope of primary care practice. New approaches to care coordination between primary care teams and specialists should prioritize high morbidity, clinically complex patients.

Project description:IntroductionFew studies have examined the impact of emergency department (ED) social interventions on patient outcomes and revisits, especially in underserved populations. Our objective in this study was to characterize a volunteer initiative that provided community medical and social resources at ED discharge and its effect on ED revisit rates and adherence to follow-up appointments at a large, county hospital ED.MethodsWe performed a cross-sectional analysis of ED patients who received medical and social resources and an educational intervention at discharge between September 2017-June 2018. Demographic information, the number of ED return visits, and outpatient follow-up appointment adherence within 30 and 90 days of ED discharge were obtained from electronic health records. We obtained data regarding patient utilization of resources via telephone follow-up communication. We used logistic regression analyses to evaluate associations between patient characteristics, reported resource utilization, and revisit outcomes.ResultsMost patients (55.3% of 494 participants) identified as Latino/Hispanic, and 49.4% received healthcare assistance through a local governmental program. A majority of patients (83.6%) received at least one medical or social resource, with most requesting more than one. Patients provided with a medical or social resource were associated with a higher 90-day follow-up appointment adherence (odds ratio [OR] 2.56; 95% confidence interval [CI] 1.05-6.25, and OR 4.75; 95% CI 1.49-15.20], respectively), and the provision of both resources was associated with lower odds of ED revisit within 30 days (OR 0.50; 95% CI 0.27-0.95). Males and those enrolled in the healthcare assistance program had higher odds of ED revisits, while Hispanic/Latino and Spanish-speaking patients had lower odds of revisits.ConclusionAn ED discharge intervention providing medical and social resources may be associated with improved follow-up adherence and reduced ED revisit rates in underserved populations.

Dataset Information

Impact of a Patient-Centered Behavioral Economics Intervention on Hypertension Control in a Highly Disadvantaged Population: a Randomized Trial.

Background

Objective

Design

Participants

Intervention

Main measures

Trial registration

Publications

Impact of a Patient-Centered Behavioral Economics Intervention on Hypertension Control in a Highly Disadvantaged Population: a Randomized Trial.

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