Mainstream model of medical care may not be the answer for eliminating disparities in African American population

Mar 15 2005

Having a health clinic in the apartment next door may not be everyone's idea of a good neighbor. But a new study shows that such a clinic can be much more effective than a traditional one in improving African American's heart health.

Providing health care services in an easily accessible, community environment doubled the success rate of African-American patients achieving blood pressure and cholesterol goals, compared to those who received care at a traditional clinic, according to a report in a special disparities themed issue of Circulation: Journal of the American Heart Association.

"Attending to unique social and cultural needs of the African-American community means making a major change in the way you deliver care. But in exchange, you can markedly reduce risk," said lead author Diane Becker, Sc.D., a health researcher in the division of general internal medicine at Johns Hopkins Medical Institutions in Baltimore.

"A mainstream model of medical care may not be the answer for eliminating disparities in this population," she said.

The study included 364 people who had brothers or sisters with a history of premature coronary disease (before age 60), placing the study group at high risk for heart disease themselves. Participants, on average, were 49 years old with a high school education. None had a personal history of heart disease when they enrolled in the study.

Those who had risk factors for heart disease (for example, high blood pressure, high cholesterol, current smoking history) were randomly assigned to two groups.

One group of 196 people received care in a community-based setting developed from recommendations by an advisory board that included members of the local African-American community. The other 168 people received care at a traditional health care clinic. About two-thirds of both groups were women and 80 percent of both groups had health insurance.

The community-based clinic was in an apartment within walking distance of a large part of the community. It also was near bus and subway stops with free parking available nearby. The apartment living room held a reception area and a small play area for children and appointments were not necessary. It also had a treatment room and a small exercise room, where patients were instructed on how to exercise. The consultation room resembled a small office.

"The community clinic was set up in a more user-friendly way," Becker said. "We had a clinical room for drawing blood, but otherwise, it was like visiting someone's apartment."

A nurse practitioner and a community health worker familiar with the neighborhood staffed the clinic. Patients received care only for risk factors related to heart disease. An African-American physician who specializes in urban African-American health consulted with the nurse practitioner and community health worker once a month.

The traditional clinic setting was regular primary care by the person's usual physician, enhanced with the same materials provided at the community clinic and feedback about all risk factors measured and recommendations from cardiologists about how to manage them. Costs and access (public transportation, etc.) were similar to the community clinic. The primary physicians had everything but the community site and the community health worker.

The community clinic and the primary physicians could distribute prescription cards that allowed patients to receive free medication related to the treatment of coronary risk factors. Patients at both facilities had access to free exercise facilities at the neighborhood YMCA and to free smoking cessation programs.

After one year, patients in the community-based program were two times more likely than the traditional clinic patients to have achieved the cholesterol and blood pressure goals established for both groups.

In addition, patients who received care at the community clinic reduced their 10-year global risk of heart disease by 25 percent compared to a 3 percent reduction in patients who received care with their usual physician. Global risk indicates the predicted chance of having a heart disease event within the next 10 years based on all of a person's risk factors.

Becker said that no patient with enhanced primary care attended the smoking cessation program or used the YMCA exercise facilities.

Patients at the community-based clinic were more likely to receive a prescription card, and 13 times more likely to use cholesterol-lowering medication. Use of cholesterol and blood pressure-lowering medications increased in both groups, but more so in the community program.

"The community health worker was absolutely key in helping patients navigate systems to use their pharmacy card, go to the YMCA and understand their medications," Becker said. "My next task is to figure out if adding a community health worker to a regular care system has the same impact and lowers costs. I suspect it will."

Becker said that the results should encourage others to consider alternative systems, or at least more flexible systems to help reduce heart disease risk among African Americans.

Co-authors include Lisa R. Yanek, M.P.H.; Wallace R. Johnson, Jr., M.D.; Diane Garrett; Taryn F. Moy, M.S.; Stasia Stott Reynolds, M.D.; Roger Blumenthal, M.D.; Dhananjay Vaidya, M.D., Ph.D.; and Lewis C. Becker, M.D.