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A Randomized Trial to Improve Patient-Centered Care and Hypertension Control in Underserved Primary Care Patients

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Abstract

BACKGROUND

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.

OBJECTIVE

To compare the effectiveness of patient-centered interventions targeting patients and physicians with the effectiveness of minimal interventions for underserved groups.

DESIGN

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.

PARTICIPANTS

Forty-one primary care physicians and 279 hypertension patients.

INTERVENTIONS

Physician communication skills training and patient coaching by community health workers.

MAIN MEASURES

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.

KEY RESULTS

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 (β = +6.20 vs. −5.24, p = 0.03) and PIC dimensions related to doctor facilitation (β = +0.22 vs. −0.17, p = 0.03) and information exchange (β = +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).

CONCLUSION

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.

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Contributors

The authors would like to thank all of the research staff (interviewers and data collectors, community health workers, and administrative assistants) at Johns Hopkins, the staff at all of the participating clinical sites, all of the participating physicians, the organizational leaders, and the patients, for making the successful completion of this study possible.

Funders

This work was supported by a grant from the National Heart, Lung, and Blood Institute (R01HL69403).

Prior Presentations

This work was presented, in part, at The AHRQ Practice-Based Research Network 2010 National Research Conference, June 18, 2010 and the American Academy on Communication in Healthcare Research and Teaching Forum, October 18, 2010.

Conflict of Interest

Drs. Cooper and Roter have served as consultants for Talaria, Inc. Dr. Roter and Mrs. Larson are owners of RIASWorks LLC, a company that provides Roter Interaction Analysis System coding services to clients outside of the Johns Hopkins University System. It may be possible that the company will benefit indirectly from dissemination of the current research. Dr. Barr has received grants from Pfizer, Inc, UnitedHealth Care, NovoNordisk, Merck, Wyeth, Sanofi, and Endo. All other authors declare that they have no conflicts to disclose.

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Corresponding author

Correspondence to Lisa A. Cooper MD, MPH.

Additional information

Trial registration information: Patient–Physician Partnership Study. Study Protocol NCT00123045. http://clinicaltrials.gov/ct2/show/NCT00123045?term=patient-physician+partnership&rank=1

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Cooper, L.A., Roter, D.L., Carson, K.A. et al. A Randomized Trial to Improve Patient-Centered Care and Hypertension Control in Underserved Primary Care Patients. J GEN INTERN MED 26, 1297–1304 (2011). https://doi.org/10.1007/s11606-011-1794-6

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  • DOI: https://doi.org/10.1007/s11606-011-1794-6

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