Culturally Competent Disease Management Improves Self-Monitoring and Blood Pressure Control in Hypertensive African Americans
Culturally Competent Disease Management Improves Self-Monitoring and Blood Pressure Control in Hypertensive African Americans
As part of an ongoing effort to reduce racial and ethnic disparities in hypertension control, Aetna tested a disease management program targeting African Americans that combines home blood pressure monitoring with culturally appropriate counseling and education over a 12-month period. Compared with home monitoring alone, the program significantly improved self-monitoring and blood pressure control. Based on these positive findings, a modified form of the program was launched in March 2012 in partnership with two large national employers.
Date First Implemented
The initial randomized controlled trial (RCT) ran from March 2006-December 2007.
African Americans are more likely to have hypertension and less likely to have the condition under control than members of most other ethnic and racial groups. As a result, they more frequently suffer from common hypertension-related complications, including kidney disease, stroke, blindness, and heart disease.
- More likely to have hypertension: Roughly one-third of African Americans over the age of 18 have hypertension, making African Americans 40 percent more likely to have the condition than members of other racial and ethnic groups. A combination of genetic and environmental factors contributes to this high rate.
- Less likely to be controlled: Although awareness of hypertension has increased in the African-American community in recent decades, only 56 percent of black men and 40 percent of black women with hypertension report receiving medication for the condition, and only 30 percent of men and 21 percent of women with hypertension have their blood pressure under control. By contrast, 39 percent of hypertensive white men have their blood pressure under control.
- Poorer health outcomes: Uncontrolled hypertension can lead to heart disease and kidney disease, which are leading causes of death in the United States. Death rates from hypertensive disease are more than twice as high in African-American men than in white men.
Description of the Innovative Activity
As part of an ongoing effort to reduce racial and ethnic disparities in hypertension control, Aetna tested a disease management program targeting African Americans that combines home blood pressure monitoring with culturally appropriate lifestyle counseling and education over a 12-month period. Key elements of the program as used in the RCT are described below:
- Initial call to learn about home monitoring: Each patient received an automatic arm cuff blood pressure monitor and tracking tool to encourage regular home monitoring. Patients received instruction in the use of the equipment from an Aetna disease management nurse via telephone. Nurse and patient reviewed technique and patient reported blood pressure at the beginning and end of call. Patients received instructions to monitor their blood pressure weekly and record their readings with the tracking tool. At the same time as the initial monitoring instruction, nurses assessed patient knowledge of hypertension risk factors and consequences as well as target blood pressure (as determined by personal physician), healthy lifestyle, and use of antihypertension medications.
- Culturally appropriate educational materials: Patients received by mail a packet of educational materials developed specifically for African Americans with hypertension. These materials included the 7 Steps to a Healthy Heart for African Americans, the African American Health and Dairy Foods Nutritional Fact Sheet, and tips for health eating. The brochures used information specifically relevant to African Americans and offer diet and lifestyle tips based on the documented increased sodium sensitivity in many African Americans as well as foods often associated with African American culture. Materials were generally written at fifth-grade reading level.
- Periodic calls to support self-management: Nurses attempted to reach participants once a month by phone. During the 12-month trial, the average participant spoke with the nurse three times. During these 15- to 20-minute calls, the nurse reviewed monitoring techniques and the latest blood pressure readings, provided additional education on hypertension and treatment, and encouraged and supported lifestyle changes, such as quitting smoking, eating more healthfully, and exercising more regularly.
- Quarterly reports to primary care providers: Physicians received notification of their patients' involvement in the program and patients were instructed to contact their physician in the event of an abnormal reading and to share their recent readings at appointments. Each quarter, nurses prepared and sent patient-specific progress reports for the primary care physicians. The reports covered blood pressure readings and relevant information from the phone counseling sessions.
- Patient incentives: During the RCT, patients received gifts worth between $15 and $55 depending on their degree of participation (e.g., number of monthly phone calls, whether they completed the study).
Context of the Innovation
Aetna provides health, dental, pharmacy, disability, and other insurance products to employer groups in all 50 states, covering nearly 18.5 million medical members. In 2002, Aetna established an initiative to identify and address health disparities and improve health outcomes for African American and other minority members. Known as The Racial and Ethnic Equality Initiative and housed in the Office of the Chief Medical Officer, this comprehensive program captures racial and ethnic data provided voluntarily by members, trains Aetna clinical staff and providers on cross-cultural communication, and develops and tests care delivery innovations designed to address specific health disparities, such as higher rates of hypertension among African Americans, lower rates of breast cancer screening among Latina and African-American women, and higher rates of emergency room utilization for asthma among African Americans and Latinos.
Innovations come from either national or Aetna specific data, which helps identify potential disparities among Aetna's membership. The process facilitates a targeted approach using culturally appropriate, evidence-based methods to focus limited resources for maximum impact.
Compared to home monitoring alone, the program significantly improved self-monitoring and blood pressure control.
- More frequent self-monitoring: Compared with those receiving only the home monitoring equipment and instructions on how to use it, those participating in the full program were 46 percent more likely to monitor and report their blood pressure at least once a week.
- Better blood pressure control: Participants were 50 percent more likely to attain blood pressure control than those receiving just home monitoring equipment. Although average blood pressure in both groups fell during the study, participants achieved a significantly lower level of systolic blood pressure.
Planning and Development Process
Key steps included the following :
- Training nurses and physicians through existing program: Aetna already had an online program (known as Quality Interactions ) in place for staff who required or desired cultural competency training. Because the curriculum also met the needs of the hypertension program, program leaders decided to use it to train the disease management nurses involved in the RCT. The 2.5-hour online course, entitled Quality Interactions: A Patient-Based Approach to Cross-Cultural Care (developed by Manhattan Cross Cultural Group), emphasizes culturally competent communication, including how to take a patient history, identify cultural issues, and discuss treatment options. Nurses also received special training in cardiac care. During the RCT, physicians of patients participating in the full program could also complete the course, for which they could receive continuing medical education credits.
- Partnering to accelerate launch: To speed up development and launch, Aetna staff identified partners to help with different aspects of the program. For example, the Association of Black Cardiologists had already developed educational materials specifically geared to African Americans with hypertension. Aetna licensed their use and worked with the association to develop additional materials. Other partners included the Morehouse School of Medicine, which reviewed the study protocol, and Health & Technology Vector, a population health consulting company that assisted with the design and execution of the study.
- Conducting RCT and publishing results: The initial RCT ran from 2006 to 2008, with results being published in 2010.
- Integrating into comprehensive program: Based on the success seen in the RCT and another similar program, program leaders decided to integrate the initiative into a comprehensive hypertension management program that Aetna will offer to large employers. The program launched in March 2012 for employees of two large national employers. To enhance its effectiveness, staff of the Racial and Ethnic Equality Initiative worked with the Association of Black Cardiologists to update educational materials, including adding specific recipes and information on how to read food labels. In addition, all patient education materials were made available in Spanish.
Resources Used and Skills Needed
- Staffing: No additional staff were hired for the program. As noted, existing staff received training in cross-cultural communication and competency.
- Costs: Although specific cost data are not available, major expenses during the RCT included blood pressure cuffs, incentive payments, and reproduction and mailing of educational materials. Training costs were minimal because Aetna already had the Quality Interactions program in place.
Tools and Resources
More information on the training program can be found in Quality Interactions: A Patient-Based Approach to Cross-Cultural Care, available at: http://www.qualityinteractions.com/.
Getting Started with This Innovation
- Obtain leadership commitment: Success in addressing ethnic and racial disparities will likely not occur in the absence of support from the very top of the organization. At Aetna, both the chief executive officer and chief medical officer continue to demonstrate a strong commitment to addressing racial and ethnic disparities and improving quality of care for Aetna members.
- Use local data to identify and analyze target population(s): The original program came into being in part based on national data showing the high rate of hypertension and related complications in African Americans. However, this national data did not necessarily reflect the profile of Aetna's members, who generally are employed and may not face some of the same barriers as low-income, uninsured or Medicaid- and Medicare-eligible individuals. Currently, program leaders use Aetna-specific data to populate a dashboard that helps determine the need for and monitor the effectiveness of specific programs to address health disparities.
- Use multi-layered, holistic approach: Effectively addressing health disparities requires a multifaceted approach that focuses on promoting medication adherence and healthy behaviors, reducing barriers to accessing care, and addressing other relevant factors in a manner that takes into consideration the cultural beliefs and habits of those being served.
Sustaining This Innovation
- Consider adaptations for other conditions and groups: This conceptual framework of this program can be adapted for other conditions and populations. Going forward, successful program elements will be leveraged for the broader Aetna population. Examples include targeted member education materials and tools.
- Consider geography: Along with race and ethnicity, where one lives can also influence culture, health beliefs, and health habits. For example, a program developed for patients in Nebraska may not work well in Alabama, where eating habits and other relevant factors may be quite different.
Ms. Toscano has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.
Brennan T, Spettell C, Villagra V, et al. Disease Management to Promote Blood Pressure Control Among African Americans. Popul Health Manag. 2010;13(2):65-72. [PubMed]
Centers for Disease Control and Prevention. A Closer Look at African American Men and High Blood Pressure Control: A Review of Psychosocial Factors and Systems-Level Interventions. Atlanta: U.S. Department of Health and Human Services; 2010.
The Office of Minority Health, Heart Disease and African Americans. Available at: http://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=19.
Centers for Disease Control and Prevention. A Closer Look at African American Men and High Blood Pressure Control: A Review of Psychosocial Factors and Systems-Level Interventions. Atlanta: U.S. Department of Health and Human Services; 2010. Available at: http://www.cdc.gov/bloodpressure/docs/African_American_Executive_Summary.pdf.