Clinician Counseling and Cultural Competency to Improve Hypertension Control and Therapy Adherence

BACKGROUND:

Hypertension affects nearly 50 million people in the U.S. and is related to increased
medical morbidity and mortality associated with a range of medical disorders. Despite the
availability of effective treatments for BP control, less than 25 percent of patients with
hypertension demonstrate such control, and researchers have found this to be related to
important patient factors associated with pharmacotherapy adherence. Further, research has
demonstrated that this adherence problem is greater among African Americans than among
Caucasians. The focus of the study is on improvements in adherence among patients with
hypertension. The study is most specifically targeted to reducing racial disparities in
medication adherence by including an interventional element that specifically targets
African American patients in its approach.

DESIGN NARRATIVE:

To improve patients' adherence with prescribed anti-hypertensive medication, BP control, and
doctor-patient communication, and to decrease racial disparities in each area, the
investigators will conduct a three-armed randomized controlled study in the general internal
medicine clinics of a large urban teaching hospital serving many poor African American and
white patients. Proven intervention strategies will be implemented by teaching clinicians to
use patient-centered counseling, enhancing skills that are known to help patients change
health-related behaviors, and enhancing cultural competency among clinicians, thereby
further improving clinician-patient communication. One group of clinicians will implement
only the patient-centered counseling program. A second group will implement the
patient-centered counseling education program, augmenting it with an established method for
cultural competency training. A third group (control group) will provide usual care. To
assess outcomes, the study will evaluate pre-intervention patient adherence to prescribed
medications through patient self-report and the use of electronic pill top monitoring,
clinicians' provision of advice and counseling about anti-hypertensive medications and use
of cultural competency skills, and the proportion of patients with controlled BP. Subsequent
to the interventions, each of these outcomes will be assessed.

The aims of this study are to: 1) improve patients' adherence to prescribed
anti-hypertensive therapy; 1a. examine adherence rates at baseline, and examine whether
there are racial differences in adherence; 1b. decrease racial disparities in patient
adherence with anti-hypertensive therapy from the baseline to the follow-up assessments; and
1c. evaluate the relative efficacy of the patient-centered counseling intervention compared
to patient-centered counseling augmented by cultural competency training on patients'
medication adherence; 2) increase the proportion of patients with controlled hypertension;
2a. examine the baseline proportion of patients with controlled hypertension, and whether
there are racial differences in rates of control; 2b. decrease racial disparities in the
proportion of patients with controlled hypertension from the baseline to the follow-up
assessments; and 2c. evaluate the relative efficacy of patient-centered counseling compared
to patient-centered counseling augmented by cultural competency training on patients' BP
control; and 3) improve clinicians' communication with patients regarding medication use, as
measured by increased frequency of clinicians' provision of advice and counseling about
anti-hypertensive medications and use of culturally competent communication styles; 3a.
examine whether there are racial disparities in clinicians' provision of advice and
counseling or culturally competent communication patterns about anti-hypertensive
medications at baseline; 3b. examine whether the proposed interventions decrease any
observed racial disparities in clinician communication over time; and 3c. evaluate the
relative efficacy of the patient-centered counseling intervention compared to
patient-centered counseling augmented by cultural competency training on clinicians'
communication patterns.

Inclusion Criteria:

- Presenting for care at least once in the General Internal Medicine clinic

- Diagnosis of hypertension, as listed on a medical problem list or elsewhere within
the medical record

- Already prescribed antihypertensive medications

Exclusion Criteria:

- Musculoskeletal problems preventing successful opening of the electronic pill tops

- Cognitive status limitations, including psychiatric disorders such as schizophrenia

- Active alcohol or substance abuse problems

- Does not speak English