Reducing Health Disparities in Appalachians with Multiple - - PowerPoint PPT Presentation

Reducing Health Disparities in Appalachians with Multiple Cardiovascular Disease Risk Factors

Wayne Noble, Clinical Research Protocol Manager Debra Moser, Professor and Linda C Gill Chair of Cardiovascular Nursing

@DebraMoser dmoser@uky.edu

2

Wayne Noble and Debra Moser

• Have nothing to disclose.

Acknowledgements

• Patient Centered Outcomes Research Institute
• Community members and other stakeholders
• Advisory Board
• Center for Excellence in Rural Health-Hazard

CVD Health Disparities and Appalachia

• Appalachian Kentucky is in the top 1% of the nation in cardiovascular

disease (CVD) morbidity and mortality

• Individuals in Appalachian Kentucky have the highest rates of

multiple CVD risk factors seen in any state

• Problem amplified by the distressed environment
• County with the worst life expectancy in the U.S.
• Of 13 counties in the U.S with a decreased life expectancy (1980 to

2014), 8 are in Appalachian Kentucky

• Among the poorest counties in the U.S.
• There is a critical need to test sustainable CVD risk reducing

interventions appropriate for Appalachia

Approach

• Lifestyle interventions can reduce CVD risk by 44%
• Lifestyle change is most effective when patients are given the

tools to engage in self-care

• interventions individualized to patients’ needs and barriers are more

effective than interventions that are not

• Our central hypothesis was that to be successful in

socioeconomically austere environments, CVD risk reducing interventions must focus on lifestyle change that increases individuals’ abilities to engage in self-care, be culturally appropriate, and have components that overcome barriers in such environments.

Community-Engaged Research

Patient and Other Stakeholder Engagement

• Focus groups with community members, people in

target population, care providers, community leaders, business people prior and after study

• Advisory board composed of members of these

groups

• Advisory board members on the grant
• Advisory board members attend the monthly

research meetings

• Successes, problems, barriers
• Equal members
• Staff, community health workers (CHW) from

community of focus

Specific Aims

1.Compare 4 month (short-term) and 1 year (long-term) impact on CVD risk factors selected by patients (i.e., tobacco use, blood pressure, lipid profile, HgA1c for diabetics, body mass index, depressive symptoms, or physical activity level) 2.all CVD risk factors 3.quality of life 4.patient satisfaction 5.desirability and adoptability by assessing adherence to recommended CVD risk reduction protocols, and retention of recruited individuals

Design

• 2 group randomized controlled comparative effectiveness

trial

Study Design

Inclusion Criteria

• Do not have primary care provider or haven’t seen one > 1 year
• At risk for CVD as reflected by having two or more:
• 1. diagnosis of hypertension or taking medications diagnosed for hypertension or found to

be hypertensive by us

• 2. diagnosis of hyperlipidemia or taking medication for treating abnormal lipid levels, or any

lipid abnormality found on our screening

• 3. diagnosis of type 2 diabetes or HgA1c > 7% found on our screening
• 4. overweight or obese (body mass index ≥ 25 kg/m2)
• 5. clinical diagnosis of depression, on medications for depression or found to have

depressive symptoms (score of > 9 on the PHQ-9) on our screening

• 6. sedentary lifestyle; individual does not engage in at least 30 minutes of moderate activity

for at least 4 days per week

• 7. diet high in saturated fats and low in fruits and vegetables

Recruitment and Setting

• Community health workers
• Advertising in local newspapers and gazettes
• Advertising at local churches, community centers, agricultural extension
• ffices, senior centers, local business organizations, public health

departments, public fairs of all types, county court houses, beauty shops and barbers, convenience stores, gas stations, and drug stores

• Advertising on the local radio and television stations that have a specific

time set aside for local happenings

• Word of mouth
• Data collection and intervention at Center for Excellence in Rural Health-

Hazard sites

Oversight

• IRB approval – everyone who comes in contact with clients received Human

Subject training

• CHW and our research staff = team who do all aspects of protocol together
• Members of the team trained together in all aspects of measurement, protocol

maintenance and fidelity to the protocol

• All staff performing data collection trained and certified by the PI and other

expert clinician-researcher team members

• Fidelity assured by oversight, review of recruitment and intervention activities
• Monthly team meetings in which protocol and data overviews done

Interventions

• Standard of care
• Secure an appointment with a primary care provider
• all individuals enrolled in the study received referral to a primary care

provider for management of the CVD risk factors identified in our screening

• free or at a low cost depending on the resources of the patient
• did not otherwise influence the delivery of care

HeartHealth Intervention

• 6 interactive modules:

1) principles self-care, CVD risk reduction; 2) nutrition (portion control, diet high in fruits and vegetable and whole grains, reducing saturated and trans fats, reducing sodium intake, reducing total fat intake, good fats vs bad fats); 3) physical activity; 4) depression control and stress reduction; 5) managing multiple comorbid risk factors; 6) smoking cessation and/or medication adherence

• Delivered over 12-weeks by community

health workers to groups of 10 people using specific behavior change principles

• Whole health approach
• Promotion of self-care of CVD risk factors
• Skill-based
• Individualized
• Culturally sensitive

Summary of Study Measures

Endpoint Measure When Measured Screening

• cognitive function
• Mini-Cog

Prior to enrollment Specific Aims 1 and 2

• blood pressure
• lipid profile
• body mass index
• HgA1c
• depressive symptoms
• physical activity
• AHA guidelines
• Cholestech POC
• Height and weight
• Bayer POC
• PHQ-9
• Jawbone

Baseline, 4 months, 1 year Specific Aim 3

• quality of life
• SF-36 version2

Baseline, 4 months, 1 year Specific Aim 4

• patient satisfaction
• Patient care delivery satisfaction questionnaire

4 months, 1 year Specific Aim 5

• desirability and adoptability
• Adherence to CVD risk reducing

recommendations assessed by Medical Outcomes Study Specific Adherence Scale

• Patient retention

Baseline, 4 months, 1 year 4 months, 1 year

Flow Through the Study

Baseline Participant Characteristics Compared Between Intervention and Control

Total Sample (N=352) N (%) or mean + SD Control (n=168) N (%) or mean + SD Intervention (n=184) N (%) or mean + SD P Age, years 42.9 + 12.8 43.2 + 12.2 42.6 + 13.4 .652 Female gender 272 (77.3) 126 (75.0) 146 (79.3) .331 Caucasian ethnicity 338 (96.8) 158 (94.6) 180 (98.9) .022 Education, years 13.6 + 2.8 13.5 + 2.7 13.6 + 2.9 .607 Married, cohabitating 210 (60.2) 103 (61.7) 107 (58.8) .582 Yrs lived in Kentucky 39.2 + 13.9 39.3 + 13.8 39.1+14.2 .896 Financial stability Comfortable Make ends meet Not enough 45 (12.9) 213 (61.0) 91 (26.1) 21 (12.6) 95 (56.9) 51 (30.5) 24 (13.2) 118 (64.8) 40 (22.0) .185

Total Sample (N=352) N (%) or mean + SD Control (n=168) N (%) or mean + SD Intervention (n=184) N (%) or mean + SD P Charlson comorbidity score .39 + .86 .35 + .72 .42 + .98 .489 Adequate health literacy 270 (78%) 125 (76.2) 145 (79.7) .439 Smoker (based on urinary cotinine) 147 (41.8) 76 (45.2) 71 (38.6) .206 Body mass index, kg/m2 31.9 + 7.6 31 + 7 32 +8 .169 Framingham risk score, % 9.3 + 8.8 9.4 + 8.7 9.3 + 8.8 .872 Systolic blood pressure, mmHg 137.9 + 19.9 137.8 + 21.3 138.1 + 18.7 .885 Diastolic blood pressure, mmHg 88.3 + 14.7 88.7 +13.9 87.9 + 15.4 .600 Total cholesterol, mg/dL 188.6 + 43.2 185.7 + 41.0 191.3 + 45.1 .227 Low density lipoprotein, mg/dL 105.6 + 33.1 103.7 + 32.5 107.3 + 33.7 .333 High density lipoprotein, mg/dL 46.2 + 14.3 46.4 +14.8 46.1+ 13.9 .869 Triglycerides, mg/dL 187.6 + 121.1 184 + 121 191 +122 .603 Depression score 5.5 + 5.5 5.5 + 5.2 5.5 + 5.8 .966

Percentage of Participants Meeting CVD Risk Reduction Goals

Specific Aim 2: Comparison of Outcomes Across Time Between Intervention and Usual Care

Outcomes Groups Baseline 4-months 12-months P T x Grp Body mass index Intervention 32.6 ± 7.8 32.3 ± 7.9 32.2 ± 7.9 0.017 Control 31.4 ± 7.4 31.7 ± 7.4 31.9 ± 7.4 Framingham risk score, % Intervention 9.4 ± 8.7 8.3 ± 8.2 7.7 ± 7.4 0 .001 Control 9.8 ± 8.5 10.2 ± 9.3 10.8 ± 9.3 Systolic blood pressure, mmHg Intervention 137.5 ± 18.8 136.6 ± 19.6 128.4 ± 17.2 0 .002 Control 138.3 ± 21.2 131.8 ± 19.2 136.9 ± 22.0 Diastolic blood pressure mmHg Intervention 88.3 ± 13.4 83.3 ± 11.3 80.0 ± 10.5 0.001 Control 89.3 ± 14.0 87.7 ± 12.5 87.1 ± 13.9 Total cholesterol, mg/dL Intervention 191.4 ± 45.1 184.5 ± 44.6 177.9 ± 39.8 0.026 Control 189.9 ± 42.3 184.9 ± 41.3 186.5 ± 40.1 Low density lipoprotein, mg/dL Intervention 109.1 ± 35.6 111.0 ± 118.6 106.1 ± 87.6 0.29 Control 106.4 ± 31.9 99.9 ± 30.1 93.2±28.7 High density lipoprotein, mg/dL Intervention 47.2± 14.0 46.8 ± 13.7 50.2 ± 15.2 0 .022 Control 48.0 ±14.9 46.9 ± 15.5 47.3 ±16.3 Triglycerides, mg/dL Intervention 193.7 ± 124.0 182.1 ± 99.9 184.9 ± 130.7 0.477 Control 189.2 ± 120.8 193.1 ± 118.6 191.4 ± 123.6 Depression scores Intervention 5.4 ± 5.0 4.2 ± 4.4 4.2 ± 5.5 0.019 Control 5.1 ± 5.4 4.8 ± 4.8 5.5 ± 6.1

Conclusions

• Interventions like HeartHealth that focus on self-care of CVD risk

factors and that are derived from collaboration with the community

• f interest are effective in medically underserved, socioeconomically

distressed rural areas.

• The success of the intervention, ease of recruitment and high

retention in the face of traditional obstacles to retention suggest community-based approaches should be used to develop, refine and test other needed interventions in rural, medically underserved, socioeconomically distressed areas to reduce health disparities.

Questions?