Hypertensive disease management community outreach program in Hispanics.

To the Editor: The Hispanic-American community is the fastest growing minority population in the United States. It is estimated that Hispanics will constitute the largest minority group in the United States by the year 2010. (1) This rapid growth has considerable implications for the health status of this medically under-served population of Americans. (2) Traditionally, neither prevention nor promotions are significantly valued in Hispanics; and this contributes to higher prevalence of chronic illnesses such as diabetes and hypertension, as well as resulting in preventable morbidity and mortality. However, in recent years there seems to be increasing attention to these concepts.

The aim of our study was to determine if the community pharmacy-based hypertension disease management program significantly improves clinical and health-related quality of life (HRQoL) outcomes in Hispanics.

A community outreach disease management program was conducted with patients with uncontrolled hypertension in a Hispanic community. The study was implemented at two primary care medical clinics and two community pharmacy settings located in South Florida. A quasi-experimental time series design was used for program evaluation. Health-related quality of life was assessed using a SF-12 questionnaire and analyzed by norm-based scoring methods. Paired t tests were used to compare the differences between baseline and endpoint of the study in systolic blood pressure, diastolic blood pressure, medication compliance, and home blood pressure monitoring with 0.05 alpha level.

A total of 53 patients (50.5%) completed the entire hypertension disease management program. Systolic blood pressure and diastolic blood pressure significantly declined from 150.5/95.5 mm Hg to 133.8/83.3 mm Hg on the second month and remained consistent throughout the study period. After a 9-month intervention, quality of life mental component summary scale/physical component summary scale scores slightly increased from 48.58/46.68 to 50.39/51.51. Approximately 96% of the medications were refilled on time. The number of patients monitoring blood pressure at home significantly increased.

The study demonstrates that this community outreach pharmacy-based disease management program had a significant impact on blood pressure control. The study results are consistent with other controlled studies examining pharmacist intervention. (3) However, the study shows very limited effects on patient's HRQoL. Similar results were reported that clinical pharmacists had no significant impact on HRQoL as measured by the SF-36 for veterans at high risk for medication-related problems. (4) The lack of significant findings may be due to the study's short time frame (9 months). Also, the insufficient power to detect significance is another potential reason for the lack of significant findings. The sample size (n = 53) was relatively small because approximately 50% of study subjects did not complete the entire program.

In this study, free electronic blood pressure monitors were provided to patients to encourage blood pressure screenings at home. The electronic blood pressure monitor was chosen because of its ease of management. Traditional manual sphygmomanometer blood pressure cuffs required more sufficient operational skills, and stethoscopes can be tricky to use. Electronic blood pressure monitors that do not require use of a stethoscope work easier for most people. The study results illustrate that patients dramatically increase the number of blood pressure measures at home. The frequent blood pressure screenings motivated patients' self-consciousness to their disease status and improved treatment compliance of high blood pressure. Another encouraging finding is the improvement on the adherence of prescription medications. Surprisingly, approximately 96% of the medications were refilled on time after 9 months of the intervention. This is especially important in the management of hypertension as well as other chronic diseases.

The study was unique by providing community outreach services to its exclusive population--Hispanics. Despite its clinical successes, the study concludes that understanding the broad parameters of a culture is essential to providing quality care to individuals, families, and communities. It requires an understanding of their social, cultural, economic, and physical environments. In this study, the health care providers including pharmacists, physicians, nurses, and staff were fluent in Spanish and recruited from the surrounding Hispanic communities. Communication and the relationship between patient and health care provider are essential for quality health care. Also, trust and interpersonal comfort is a critical component of the relationship between the person who is ill and the healer. (5) Note that community pharmacy-based disease management programs as demonstrated in the study are not only for successful treatment and intervention, but also for the way in which the intervention is provided.

L. Leanne Lai, PhD

Nova Southeastern University 

Ft. Lauderdale, FL

Gabriel Novoa, MD

Preferred Medical Plan

Coral Gables, FL

References

1. Spector RE. Cultural Diversity in Health and Illness, Appleton & LangePublication, Stamford, 4thed, 1996.

2. Gavagan T, Brodyaga L. Medical care for immigrants and refugees. American Family Physician 1998;57:1061-1068.

3. Cote I, Cregoire J, Moisan J, et al. A pharmacy-based health promotion program in hypertension--cost benefit analysis. Pharmacoeconomics 2003;21:415-428.

4. Malone DC, Carter BL, Blllups SJ, et al. Can clinical pharmacists affect SF-36 scores in veterans at high risk for medication-related problems? Med Care 2001;39:113-122.

5. Zapata J, Shippee-Rice R. The use of folk healing and healers by six Latinos living in New England. Journal of Transcultural Nursing 1999;10:136-142. Letters to the Editor