Upgraded community health services, including checkups
by phone or in person with a local nurse practitioner at a
neighborhood clinic, and free charge cards for medications
are almost nine times more likely to benefit black
Americans at greater risk of heart disease than
full-service physician care alone. The analysis by
researchers at Johns Hopkins, published in the journal
Circulation online March 16, is the first to test
which model works best when patients have equal and
unrestricted access to health care services.
"Despite physicians' best attempts, current treatment
programs have not contained the disproportionately higher
number of black Americans, especially women, who have the
leading risk factors for coronary heart disease, including
high blood pressure, elevated levels of cholesterol, high
rates of smoking and diabetes, and a sedentary lifestyle,"
said lead investigator Diane Becker, a professor at the
schools of Medicine and Public Health. "Our results show
that direct involvement from a nurse practitioner and a
community health worker is far more effective at helping
patients lower their risk factors than the standard in
which patients are on their own to follow — or not
follow — their doctors' orders."
The Johns Hopkins findings offer an effective strategy
for reducing racial disparities in health status, which is
quite pronounced in heart disease, the researchers say.
Whites have the lowest rate of premature deaths from heart
disease of all racial groups in the United States, at 14.7
percent of deaths before age 65, while blacks have among
the highest, at 31.5 percent. According to the latest
statistics from the American Heart Association, in 2002,
50,000 blacks died from coronary heart disease, which
affects 7.4 percent of black men and 7.5 percent of black
women, roughly five times the rates in the general
population.
According to Becker, the study's results challenge
conventional wisdom that resource inequities, such as
limited access to medical services, or lack of affordable
medications, educational resources and culturally
appropriate health care, are the root of the racial
disparities in health status in the United States.
For one year, the researchers analyzed how well
patients followed their physicians' advice by tracking
regular visits, changes in lifestyle routines, use of
medications and health outcomes in more than 350 black
American adults between the ages of 30 and 59. Study
participants had no known history of heart problems, but
all had at least one fixable major risk factor for coronary
artery disease. Every participant had at least one sibling
with premature coronary heart disease (such as blocked
arteries) that had required hospitalization, so family
history was a risk factor.
Blood tests and physical exams were conducted at the
beginning and end of the study to assess changes in each
individual's risk factors. The researchers also used the
Framingham Risk Score, an estimate of the likelihood of
developing major heart problems, such as a heart attack,
within 10 years.
Roughly half (196) the participants were provided with
community-based care, and the rest (168) were provided with
enhanced primary care. Participants from the same family
were assigned to the same care group. In the community care
group, participants continued their regular checkups with
their physician, but all services and care for heart
disease risk factors were provided by a nurse practitioner
or a community health worker. For example, a patient in the
primary care group who needed to lower her blood pressure
and required regular checkups first had to schedule an
appointment with her physician. If that patient wanted to
quit smoking, her physician would mail out information
about local quit-smoking programs.
A patient in the community care group, however, was
taught how to measure and control her own blood pressure,
given one-on-one advice on how to quit smoking and received
follow-up calls from a nurse practitioner or community
health worker.
All participants in both groups had access to free
medication in the form of a charge card good at the local
pharmacy. Free access to risk-factor-reduction programs and
health services, including educational materials and
seminars, diet and exercise programs, and smoking cessation
classes, was afforded to both groups. The primary-care
group received coupons for free YMCA exercise programs, and
the community care group could attend classes in water
aerobics, line dancing and basketball led by a community
health worker.
Throughout the study, all decisions about risk-factor
reduction and care by the nurse practitioner were checked
twice monthly with a physician. For issues unrelated to
risk-factor reduction, the patients continued to see their
physician or a specialist as required.
Results showed that both groups significantly reduced
their overall risk of developing coronary heart disease,
but the community care group did significantly better than
the enhanced primary care group for overall risk, blood
pressure control and reducing cholesterol levels. Overall,
Framingham Risk Scores decreased 26 percent and 3 percent,
respectively. Blood pressure control was better in the
community group, at 60 percent, compared to 40 percent for
the primary-care group at the end of the study. (On
average, only 30 percent of blacks have controlled blood
pressure.)
For cholesterol levels, the community group had 50
percent control, compared with more than 20 percent of the
primary group; the average control rate for adult black
Americans is 10 percent. Among community group
participants, 8 percent quit smoking; 4 percent is the
average among black Americans.
Overall, community care group participants were twice
as likely to reach cholesterol and blood pressure levels
considered "safe," as measured against national standards
for these risk factors, than members of the primary-care
group. These results were strongly tied to the community
group's taking medications as prescribed.
While the Johns Hopkins findings favor enhanced
community-based care for blacks, they do not explain why
blacks suffer from higher rates of heart disease than white
Americans or why 100 percent control of risk factors was
not achieved, the researchers said.
"The solution is far more complex than simply a
structural problem of resources and delivery systems, where
adding tests, medications and services will do the trick,
Becker said. "Our study's results help solve part of the
problem, but still missing are explanations of the cultural
and social factors underlying the inequities and what
actions are necessary to achieve parity in health
status.
"The next step has to be a sincere dialogue with the
black community as to what they need to resolve health
inequities. More resources are not the only answer."
Becker attributes the success of the Johns Hopkins
model of community care to early input from the local black
community in East Baltimore. Prior to the start of the
study, two local pastors, a community health worker and
local residents helped design the types of services and
activities offered. Specific requests included a welcoming,
nonclinical look to the community care center, which
resembled a living room and kitchen and contained an
exercise center for testing that participants used
regularly. The center also had flexible scheduling,
allowing participants to phone in for checkups and
counseling, or to schedule appointments with as little as
24 to 48 hours' notice.
The study, which took five years to complete (1999 to
2003), was part of a larger long-term study of familial
relationships in heart disease called the Sibling Family
Heart Study. Funding was provided by the National
Institutes of Health and the Johns Hopkins Clinical
Research Center. Additional support came from
GlaxoSmithKline, Merck, Novartis and Pfizer, which provided
the charge cards for medications. Free gym memberships were
provided by the Druid Hill Family YMCA.
Other investigators in this research were Lisa Yanek,
Wallace Johnson Jr., Taryn Moy, Stacia Stott Reynolds,
Roger Blumenthal, Dhananjay Vaidya and Lewis Becker.