"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," says lead investigator Diane Becker, M.P.H., Sc.D., a professor at The Johns Hopkins University School of Medicine and Bloomberg School of 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 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 of them 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) of 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 local 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 rates 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 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 say.
"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," says Becker. "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 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 - who 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, M.P.H.; Wallace Johnson Jr., M.D.; Taryn Moy, M.S.; Stacia Stott Reynolds, M.D.; Roger Blumenthal, M.D.; Dhananjay Vaidya, M.D., Ph.D.; and Lewis Becker, M.D.