Objective: To examine the effectiveness of a comprehensive intervention by a nurse practitioner-community health worker-physician (NP/CHW/MD) team on hypertension (HBP) care utilization among urban young black men with HBP at 36-month follow-up.
Study Design: A randomized clinical trial over 36 months
Population, Sample, Setting, Years: The data for this analysis were derived from a sample of 309 hypertensive urban black men ages 18-54 years who were randomized in a clinical trial, which was designed to improve blood pressure outcomes in the population. At 36-month follow-up, a total of 231 men were included. The Outpatient General Clinical Research Center at the Johns Hopkins Hospital in Baltimore, Maryland was the data collection site. Randomization occurred from September 1996 to October 1997 and 36-month follow-up was completed in February 2000.
Concepts, Variables, Intervention, Outcomes: Important variables included: employment status, income, health insurance status, and illicit drug use. Our intervention consisted of NP visits every 1-3 months, free hypertensive medication, social services referral and annual home visit by the CHW, and MD consultation as needed, as compared to education and referral to sources of usual care available in the community of control group. Outcome variables included: having a regular health care provider (physician or nurse practitioner) for HBP care and being on antihypertensive medication.
Methods: Interviews were conducted to assess sociodemographic and HBP care utilization variables. Illicit drug use was assessed by urine test. Although not included in this analysis, blood specimens were collected to assess cardiovascular risk factors. Electrocardiogram, echocardiography, and carotid tonometry were also performed. Bivariate analyses were carried out to assess group difference on the health care utilization variables at baseline and 36-month follow-up, respectively. Logistic regression determined the degree of association of possible barriers to being in HBP care.
Findings: At baseline, a majority of the men encountered a variety of socioeconomic barriers to HBP care utilization, including unemployment (74%), annual incomes less than $10,000 (72%), lack of health insurance (51%), and use of illicit drugs (45%). Only 53% reported that they were on antihypertensive medication and 51% had a regular health care provider for HBP care. Having health insurance (odds ratio=7.2, 95% CI: 4.10-12.65) and a negative urine drug screen (odds ratio=0.6, 95% CI: 0.33-0.98) were significant predictors of being in HBP care at baseline. At 36 months, the proportion of men who were unemployed, with low income (< $10,000/year), and with no health insurance decreased to 58%, 58%, and 26%, respectively, in the intervention group and to 60%, 57%, and 25%, respectively, in the control group. However, the proportion of men with a positive urine drug screen for cocaine, metabolites, opiates, cannabinoids, barbiturates, or benzodiazepines remained essentially unchanged in both groups (45% in the intervention group and 40% in the control group, respectively). The proportion of men reporting having a regular physician or nurse for HBP care increased to 94% in the intervention group and 69% in the control group (x2=24.0, p £ 0.001). The proportion of men that reported being on HBP medications also increased to 91% in the intervention group and 65% in the control group (x2=4.5, p=0.035). Intervention group assignment was significantly associated with increased likelihood of being in HBP care at 36 months; men in the intervention group were 8.7 times (95% CI: 3.524-21.56) more likely to have a regular health care provider and 5.9 times (95% CI: 1.157-29.61) more likely to be on antihypertensive medication compared to those in the control group. Health insurance was another significant predictor of having a health care provider (odds ratio=3.7, 95% CI: 1.62-8.40). No other variables were associated with the utilization outcomes.
Conclusions: Our comprehensive intervention (i.e., open health care site operated by an NP, home visits by CHWs, and free antihypertensive medication provided in consultation with a physician) appeared to reduce barriers to HBP care in this sample. However, illicit drug use was a consistent problem among these men.
Implications: There are very limited systems in place to reduce health disparity and to support efforts to improve the care delivered to indigent urban black patients with HBP. Our community-based nurse-run clinic, as an alternative to traditional medical care, is likely to be a cost-effective approach in patient populations who experience a variety of psychosocial and environmental barriers to care. Given the high rate of illicit drug use and its known adverse effect on HBP care utilization, stronger lifestyle interventions, especially addressing the substance use problem in the population, are warranted.
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