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1.  Medication Adherence: A Call for Action 
American heart journal  2011;162(3):412-424.
Poor adherence to efficacious cardiovascular related medications has led to considerable morbidity, mortality, and avoidable health care costs. This paper provides results of a recent think tank meeting in which various stakeholder groups representing key experts from consumers, community health providers, the academic community, decision-making government officials (FDA, NIH, etc), and industry scientists met to evaluate the current status of medication adherence and provide recommendations for improving outcomes. Below, we review the magnitude of the problem of medication adherence, prevalence, impact, and cost. We then summarize proven effective approaches and conclude with a discussion of recommendations to address this growing and significant public health issue of medication non adherence.
PMCID: PMC3947508  PMID: 21884856
2.  Factors Associated with Non-Adherence to Three Hypertension Self-Management Behaviors: Preliminary Data for a New Instrument 
Clinicians have difficulty in identifying patients that are unlikely to adhere to hypertension self-management. Identifying non-adherence is essential to addressing suboptimal blood pressure control and high costs.
1) To identify risk factors associated with non-adherence to three key self-management behaviors in patients with hypertension: proper medication use, diet, and exercise; 2) To evaluate the extent to which an instrument designed to identify the number of risk factors present for non-adherence to each of the three hypertension self-management behaviors would be associated with self-management non-adherence and blood pressure.
Cross-sectional analysis of randomized trial data.
Six hundred and thirty-six primary care patients with hypertension.
1) Demographic, socioeconomic, psychosocial, and health belief-related factors; 2) measures of self-reported adherence to recommended medication use, diet recommendations, and exercise recommendations, all collected at baseline assessment; 3) systolic blood pressure (SBP) and diastolic blood pressure (DBP).
We identified patient factors associated with measures of non-adherence to medications, diet, and exercise in hypertension. We then combined risk factors associated with ≥1 adherence measure into an instrument that generated three composite variables (medication, diet, and exercise composites), reflecting the number of risk factors present for non-adherence to the corresponding self-management behavior. These composite variables identified subgroups with higher likelihood of medication non-adherence, difficulty following diet recommendations, and difficulty following exercise recommendations. Composite variable levels representing the highest number of self-management non-adherence risk factors were associated with higher SBP and DBP.
We identified factors associated with measures of non-adherence to recommended medication use, diet, and exercise in hypertension. We then developed an instrument that was associated with non-adherence to these self-management behaviors, as well as with blood pressure. With further study, this instrument has potential to improve identification of non-adherent patients with hypertension.
PMCID: PMC3539028  PMID: 22926634
hypertension; self-management; medication adherence; diet; exercise
3.  Racial Differences in the Effect of a Telephone-Delivered Hypertension Disease Management Program 
Journal of General Internal Medicine  2012;27(12):1682-1689.
African Americans are significantly more likely than whites to have uncontrolled hypertension, contributing to significant disparities in cardiovascular disease and events.
The goal of this study was to examine whether there were differences in change in blood pressure (BP) for African American and non-Hispanic white patients in response to a medication management and tailored nurse-delivered telephone behavioral program.
Five hundred and seventy-three patients (284 African American and 289 non-Hispanic white) primary care patients who participated in the Hypertension Intervention Nurse Telemedicine Study (HINTS) clinical trial.
Study arms included: 1) nurse-administered, physician-directed medication management intervention, utilizing a validated clinical decision support system; 2) nurse-administered, behavioral management intervention; 3) combined behavioral management and medication management intervention; and 4) usual care. All interventions were activated based on poorly controlled home BP values.
Post-hoc analysis of change in systolic and diastolic blood pressure. General linear models (PROC MIXED in SAS, version 9.2) were used to estimate predicted means at 6-month, 12-month, and 18-month time points, by intervention arm and race subgroups (separate models for systolic and diastolic blood pressure).
Improvement in mean systolic blood pressure post-baseline was greater for African American patients in the combined intervention, compared to African American patients in usual care, at 12 months (6.6 mmHg; 95 % CI: -12.5, -0.7; p = 0.03) and at 18 months (9.7 mmHg; -16.0, -3.4; p = 0.003). At 18 months, mean diastolic BP was 4.8 mmHg lower (95 % CI: -8.5, -1.0; p = 0.01) among African American patients in the combined intervention arm, compared to African American patients in usual care. There were no analogous differences for non-Hispanic white patients.
The combination of home BP monitoring, remote medication management, and telephone tailored behavioral self-management appears to be particularly effective for improving BP among African Americans. The effect was not seen among non-Hispanic white patients.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-012-2138-x) contains supplementary material, which is available to authorized users.
PMCID: PMC3509293  PMID: 22865016
hypertension; telemedicine; self-management; adherence; veterans
4.  Challenges facing translational research organizations in China: a qualitative multiple case study 
Translational medicine is attracting much attention worldwide and many translational research organizations (TROs) have been established. In China, translational medicine has developed rapidly, but faces many challenges. This study was aimed at exploring these challenges faced by emerging TROs in China.
A qualitative, multiple case study approach was used to assess the challenges faced by TROs in China. Data were collected between May and August 2012.
Eight cases were identified. Overall, four themes that characterized TROs in China emerged from analyses: 1. objectives, organizer, and funding resources, 2. participating partners and research teams, 3. management, and 4. achievements. All TROs had objectives related to translating basic discovery to clinic treatment and cultivating translational researchers. In terms of organizer and funding resources, 7 out of 8 TROs were launched only by universities and/or hospitals, and funded mostly through research grants. As for participating partners and multidisciplinary research teams, all but one of the TROs only involved biomedical research institutions who were interested in translational research, and characterized as clinical research centers; 7 out of 8 TROs involved only researchers from biomedicine and clinical disciplines and none involved disciplines related to education, ethnicity, and sociology, or engaged the community. Current management of the TROs were generally nested within the traditional research management paradigms, and failed to adapt to the tenets of translational research. Half of the TROs were at developmental stages defined as infrastructure construction and recruitment of translational researchers.
TROs in China face the challenge of attracting sustainable funding sources, widening multidisciplinary cooperation, cultivating multi-disciplinary translational researchers and adapting current research management to translational research. Greater emphasis should be placed on increasing multidisciplinary cooperation, and innovating in education programs to cultivate of translational researchers. Efforts should be made to reform research management in TROs, and establish sustainable funding resources.
PMCID: PMC3853359  PMID: 24119837
Translational medicine; Translational research organization; Translational medical center; Case study
5.  The Effect of a Hypertension Self-Management Intervention on the Unintended Targets of Diabetes and Cholesterol Control 
The American journal of medicine  2009;122(7):639-646.
Most patient chronic disease self-management interventions target single disease outcomes. We evaluated the effect of a tailored hypertension self-management intervention on the unintended targets of glycosylated hemoglobin (Hb A1c) and LDL cholesterol (LDL-C).
We examined 588 patients from the Veterans Study to Improve the Control of Hypertension (V-STITCH), a two year randomized controlled trial. Patients received either a hypertension self-management intervention delivered by a nurse over the telephone or usual care. Although the study focused on hypertension self-management, we compared changes in Hb A1c among a subgroup of 216 patients with diabetes and LDL-C among 528 patients with measurements during the study period. Changes in these lab values over time were compared between the two treatment groups using linear mixed-effects models.
For the patients with diabetes, the hypertension self-management intervention resulted in a 0.46% reduction in Hb A1c over two years compared to usual care (95% CI: 0.04% to 0.89%; p=0.03). For LDL-C, the self-management intervention arm resulted in a reduction of 0.9mg/dl over two years compared to usual care (95% CI: -7.3mg/dl to 5.6mg/dl; p=0.79).
There was no evidence of a hypertension self-management intervention effect on LDL-C, but there was a modest effect of the intervention on the unintended target of Hb A1c. This effect was similar to that seen in self-management interventions specifically targeting diabetes management. Chronic disease self-management interventions may spill over into patients’ co-morbid diagnoses.
PMCID: PMC3766525  PMID: 19559166
Self-management; telemedicine; chronic disease; randomized controlled trial
6.  Organizational factors associated with readiness to implement and translate a primary care based telemedicine behavioral program to improve blood pressure control: the HTN-IMPROVE study 
Hypertension is prevalent and often sub-optimally controlled; however, interventions to improve blood pressure control have had limited success.
Through implementation of an evidence-based nurse-delivered self-management phone intervention to facilitate hypertension management within large complex health systems, we sought to answer the following questions: What is the level of organizational readiness to implement the intervention? What are the specific facilitators, barriers, and contextual factors that may affect organizational readiness to change?
Study design
Each intervention site from three separate Veterans Integrated Service Networks (VISNs), which represent 21 geographic regions across the US, agreed to enroll 500 participants over a year with at least 0.5 full time equivalent employees of nursing time. Our mixed methods approach used a priori semi-structured interviews conducted with stakeholders (n = 27) including nurses, physicians, administrators, and information technology (IT) professionals between 2010 and 2011. Researchers iteratively identified facilitators and barriers of organizational readiness to change (ORC) and implementation. Additionally, an ORC survey was conducted with the stakeholders who were (n = 102) preparing for program implementation.
Key ORC facilitators included stakeholder buy-in and improving hypertension. Positive organizational characteristics likely to impact ORC included: other similar programs that support buy-in, adequate staff, and alignment with the existing site environment; improved patient outcomes; is positive for the professional nurse role, and is evidence-based; understanding of the intervention; IT infrastructure and support, and utilization of existing equipment and space.
The primary ORC barrier was unclear long-term commitment of nursing. Negative organizational characteristics likely to impact ORC included: added workload, competition with existing programs, implementation length, and limited available nurse staff time; buy-in is temporary until evidence shows improved outcomes; contacting patients and the logistics of integration into existing workflow is a challenge; and inadequate staffing is problematic. Findings were complementary across quantitative and qualitative analyses.
The model of organizational change identified key facilitators and barriers of organizational readiness to change and successful implementation. This study allows us to understand the needs and challenges of intervention implementation. Furthermore, examination of organizational facilitators and barriers to implementation of evidence-based interventions may inform dissemination in other chronic diseases.
PMCID: PMC3847033  PMID: 24010683
Implementation; Hypertension; Blood pressure control; Organization
7.  Patient Self-Management Support: Novel Strategies in Hypertension and Heart Disease 
Cardiology clinics  2010;28(4):655-663.
Cardiovascular diseases (CVD), has become the leading cause of death and disability in most countries in the world. In this paper, we address patient self-management of hypertension and CVD as a crucial component of effective, high quality health care for hypertension and cardiovascular disease care. The patient must be a collaborator in this process and methods of improving patients’ ability and confidence for self-management are needed. Successful self-management programs have often supplemented the traditional patient-physician encounter by using non-physician providers, remote patient encounters (telephone or internet), group settings, and peer support for promoting self-management. Factors to consider in self-management include ensuring the programs are patient-centered, staffing and training, content of the program, patient population served, supporting material, protocols for how staff members are to provide support, communication with patients, communication between health care providers and self-management support. Given our healthcare systems’ inability to achieve a number of quality indicators using traditional office-based physician visits, further consideration is needed to determine the degree to which these interventions and programs can be integrated into primary care, their effectiveness in different groups, and their sustainability for improving chronic disease care.
PMCID: PMC3763915  PMID: 20937448
11.  Baseline Medication Adherence and Blood Pressure in a 24-month Longitudinal Hypertension Study 
Journal of Clinical Nursing  2011;21(9-10):1401-1406.
Aim and objectives
We sought to identify the feasibility and predictive validity of an easy and quick self-reported measure of medication adherence and to identify characteristics of people with hypertension that may warrant increase attentiveness by nurses to address hypertensive self-management needs.
Current control rates of hypertension are approximately 50%. Effective BP control can be achieved in most people with hypertension through antihypertensive medication. However, hypertension control can only be achieved if the patient is adherent with their medication regimen. Patients who are non-adherent may be in need of additional intervention.
This secondary analysis evaluated the systolic blood pressure (SBP) of patients who received usual hypertension management across 24 months at 6-month intervals.
A longitudinal study of 159 hypertensive patients in two primary care clinics.
In a sample of 159 patients receiving care in a primary care facility, baseline medication non-adherence was associated with a 6.3 mmHg increase in SBP (p< 0.05) at baseline, a 8.4 mmHg increase in SBP (p < 0.05) at 12 months and a 7.5 increase in SBP at 24 months (p< 0.05) compared with adherent patients, respectively. Results also indicate a significant increase in SBP across 24 months among people who identified as minority and of low financial status.
Non-adherence with antihypertensive medication at baseline was predictive of increased SBP up to 24 months post-baseline.
Relevance to clinical practice
This study demonstrates the use of an easy-to-use questionnaire to identify patients who are non-adherent. We recommend assessing medication adherence to identify patients who are non-adherent with their anti-hypertensive medication and to be especially vigilant with patients who are minority or are considered low income.
PMCID: PMC3291791  PMID: 22107599
Blood pressure; medication adherence; nursing; nurses; longitudinal
Ethnicity & disease  2012;22(1):51-57.
To pilot test a culturally adapted behavioral weight loss intervention in obese and overweight Latino adults.
Pilot study.
Latino community organization in Durham, North Carolina.
Overweight and obese, self-identified Latinos ≥18 years old.
Intervention consisted of 20 weekly group sessions (90–120 minutes each) incorporating motivational interviewing techniques. The intervention goal was weight loss by adopting the Dietary Approach to Stop Hypertension (DASH) dietary pattern, increasing physical activity, and reducing caloric intake. The cultural adaptation included foods and physical activities commonly used in the Latino culture, using a Spanish-speaking interventionist, and conducting the intervention at a local Latino community organization.
Main outcome measures
Weight, body mass index (BMI), blood pressure, dietary pattern, and physical activity were measured at baseline and at 20 weeks.
A total of 56 participants are included in the final analysis. The average weight loss was 5.1 lbs (95% CI −8.7 to −1.5; P=.006); and there was a reduction in BMI of 1.3 kg/m2 (95% CI −2.2 to −0.5; P=.002) at 20 weeks. Systolic blood pressure decreased by 2.6 mm Hg (95% CI −4.7 to −0.6; P=.013).
A culturally adapted behavioral intervention for the treatment of overweight and obesity is potentially effective in a diverse group of Latino adults.
PMCID: PMC3395222  PMID: 22774309
Obesity; Overweight; Latinos; Cultural; Intervention; Weight Loss
14.  Racial Differences in Two Self Management Hypertension Interventions 
The American journal of medicine  2011;124(5):468.e1-468.e8.
Only one-half of Americans have their blood pressure controlled and there continue to be significant racial differences in blood pressure control. The goal of this study was to examine the effectiveness of two patient-directed interventions designed to improve blood pressure control within white and non-white subgroups (49% African Americans).
Post-hoc analysis of a 2 by 2 randomized trial with two-year follow-up in 2 university-affiliated primary care clinics. Within white and non-white patients (n=634), four groups were examined: 1) usual care; 2) home blood pressure monitoring (three times per week); 3) tailored behavioral self-management intervention administered via telephone by a nurse every other month; or, 4) a combination of the two interventions.
The overall race by time by treatment group effect suggested differential intervention effects on blood pressure over time for whites and non-whites (systolic blood pressure, p=0.08; diastolic blood pressure, p=0.01). Estimated trajectories indicated that among the 308 whites, there was no significant effect on blood pressure at either 12 or 24 months for any intervention compared to control group. At 12 months, the non-whites (n=328) in all three intervention groups had systolic blood pressure decreases of 5.3–5.7 mm hg compared to usual care (p<0.05). At 24 months, in the combined intervention, non-whites had sustained lower systolic blood pressure as compared to usual care (7.5 mm hg; p<0.02). A similar pattern was observed for diastolic blood pressure.
Combined home blood pressure monitoring and a telephone tailored-behavioral intervention appeared to be particularly effective for improving blood pressure in non-white patients.
PMCID: PMC3086723  PMID: 21531237
Hypertension; Lifestyle; Clinical Trial; Self-management; Adherence; Disparities
15.  Patient and provider interventions for managing osteoarthritis in primary care: protocols for two randomized controlled trials 
Osteoarthritis (OA) of the hip and knee are among the most common chronic conditions, resulting in substantial pain and functional limitations. Adequate management of OA requires a combination of medical and behavioral strategies. However, some recommended therapies are under-utilized in clinical settings, and the majority of patients with hip and knee OA are overweight and physically inactive. Consequently, interventions at the provider-level and patient-level both have potential for improving outcomes. This manuscript describes two ongoing randomized clinical trials being conducted in two different health care systems, examining patient-based and provider-based interventions for managing hip and knee OA in primary care.
Methods / Design
One study is being conducted within the Department of Veterans Affairs (VA) health care system and will compare a Combined Patient and Provider intervention relative to usual care among n = 300 patients (10 from each of 30 primary care providers). Another study is being conducted within the Duke Primary Care Research Consortium and will compare Patient Only, Provider Only, and Combined (Patient + Provider) interventions relative to usual care among n = 560 patients across 10 clinics. Participants in these studies have clinical and / or radiographic evidence of hip or knee osteoarthritis, are overweight, and do not meet current physical activity guidelines. The 12-month, telephone-based patient intervention focuses on physical activity, weight management, and cognitive behavioral pain management. The provider intervention involves provision of patient-specific recommendations for care (e.g., referral to physical therapy, knee brace, joint injection), based on evidence-based guidelines. Outcomes are collected at baseline, 6-months, and 12-months. The primary outcome is the Western Ontario and McMasters Universities Osteoarthritis Index (self-reported pain, stiffness, and function), and secondary outcomes are the Short Physical Performance Test Protocol (objective physical function) and the Patient Health Questionnaire-8 (depressive symptoms). Cost effectiveness of the interventions will also be assessed.
Results of these two studies will further our understanding of the most effective strategies for improving hip and knee OA outcomes in primary care settings.
Trial registration
NCT01130740 (VA); NCT 01435109 (NIH)
PMCID: PMC3433311  PMID: 22530979
Osteoarthritis; Physical activity; Weight reduction program; Pain management; Intervention study
16.  Participant Evaluation of a Telephone-Based Osteoarthritis Self-Management Program, 2006-2009 
Self-management support interventions can help improve osteoarthritis outcomes but are underused. Little is known about how participants evaluate the helpfulness of these programs. We describe participants' evaluations of a telephone-based, osteoarthritis self-management support intervention that yielded improved outcomes in a clinical trial.
Participants were 140 people in the intervention arm of the trial who completed an end-of-trial survey. We used mixed methods to describe participants' perceived helpfulness of the program and its components. We compared ratings of helpfulness according to participant characteristics and analyzed themes from open-ended responses with a constant comparison approach. We calculated Pearson correlation coefficients between perceived helpfulness and changes in pain, function, affect, and self-efficacy.
The average rating of overall helpfulness on a scale from 1 to 10 was 7.6 (standard deviation, 2.3), and more than 80% of participants agreed that each component (phone calls, educational material, setting goals and action plans) was helpful. Participants had better perceived helpfulness ratings than their counterparts if they were nonwhite, had limited health literacy, had no college education, had perceived inadequate income, were older, had a spouse or were living together in a committed relationship, and had greater symptom duration and less pain. Ratings of helpfulness increased with greater improvement in outcomes. Participants frequently mentioned the health educator's calls as being helpful for staying on task with self-management behaviors.
Participants viewed this intervention and each of its components as helpful for improving osteoarthritis symptoms. In addition to the improvements in objective outcomes seen in the clinical trial, these results provide further support for the dissemination of self-management support interventions.
PMCID: PMC3392090  PMID: 22440547
17.  Lessons learned when innovations go awry: a baseline description of a behavioral trial—the Enhancing Fitness in Older Overweight Veterans with Impaired Fasting Glucose study 
Individuals diagnosed with impaired glucose tolerance (i.e., prediabetes) are at increased risk for developing diabetes. We proposed a clinical trial with a novel adaptive randomization designed to examine the impact of a home-based physical activity (PA) counseling intervention on metabolic risk in prediabetic elders. This manuscript details the lessons learned relative to recruitment, study design, and implementation of a 12-month randomized controlled PA counseling trial. A detailed discussion on how we responded to unforeseen challenges is provided. A total of 302 older patients with prediabetes were randomly assigned to either PA counseling or usual care. A novel adaptive design that reallocated counseling intensity based on self-report of adherence to PA was initiated but revised when rates of non-response were lower than projected. This study presents baseline participant characteristics and discusses unwelcome adaptations to a highly innovative study design to increase PA and enhance glucose metabolism when the best-laid plans went awry.
PMCID: PMC3411119  PMID: 22866170
Prediabetes; Adaptive design; Randomized controlled trial; Telephone; Exercise; Aging
18.  A Re-conceptualization of Access for 21st Century Healthcare 
Journal of General Internal Medicine  2011;26(Suppl 2):639-647.
Many e-health technologies are available to promote virtual patient–provider communication outside the context of face-to-face clinical encounters. Current digital communication modalities include cell phones, smartphones, interactive voice response, text messages, e-mails, clinic-based interactive video, home-based web-cams, mobile smartphone two-way cameras, personal monitoring devices, kiosks, dashboards, personal health records, web-based portals, social networking sites, secure chat rooms, and on-line forums. Improvements in digital access could drastically diminish the geographical, temporal, and cultural access problems faced by many patients. Conversely, a growing digital divide could create greater access disparities for some populations. As the paradigm of healthcare delivery evolves towards greater reliance on non-encounter-based digital communications between patients and their care teams, it is critical that our theoretical conceptualization of access undergoes a concurrent paradigm shift to make it more relevant for the digital age. The traditional conceptualizations and indicators of access are not well adapted to measure access to health services that are delivered digitally outside the context of face-to-face encounters with providers. This paper provides an overview of digital “encounterless” utilization, discusses the weaknesses of traditional conceptual frameworks of access, presents a new access framework, provides recommendations for how to measure access in the new framework, and discusses future directions for research on access.
PMCID: PMC3191218  PMID: 21989616
access; e-health; digital; connectivity; veterans
19.  Individual Progress Toward Self-Selected Goals Among Older Adults Enrolled in a Physical Activity Counseling Intervention 
The purpose of this study was to examine what happens to goals over the course of a physical activity counseling trial in older veterans. At baseline, participants (N = 313) identified 1 health-related goal and 1 walking goal for their participation in the study and rated where they perceived themselves to be relative to that goal at the current time. They rated their current status on these same goals again at 6 and 12 mo. Growth-curve analyses were used to examine longitudinal change in perceived goal status. Although both the intervention and control groups demonstrated improvement in their perceived proximity to their health-related and walking goals (L = 1.19, p < .001), the rates of change were significantly greater in the intervention group (β = −.30, p < .05). Our results demonstrate that this physical activity counseling intervention had a positive impact on self-selected goals over the course of the intervention.
PMCID: PMC3108332  PMID: 20956844
goal setting; longitudinal; function; exercise behavior
20.  Hypertension Improvement Project (HIP) Latino: results of a pilot study of lifestyle intervention for lowering blood pressure in Latino adults 
Ethnicity & health  2010;15(3):269-282.
To assess the feasibility of a culturally tailored behavioral intervention for improving hypertension-related health behaviors in Hispanic/Latino adults.
Feasibility pilot study in a community health center and a Latino organization in Durham, North Carolina (NC).
The culturally adapted behavioral intervention consisted of 6 weekly group sessions incorporating motivational interviewing techniques. Goals included weight loss if overweight, adoption of the Dietary Approaches to Stop Hypertension (DASH) dietary pattern, and increased physical activity. Participants were also encouraged to monitor their daily intake of fruits, vegetables, dairy and fat, and to record physical activity. Cultural adaptations included conducting the study in familiar places, using Spanish-speaking interventionist, culturally-appropriate food choices, and physical activity.
Main outcomes
Systolic blood pressure, weight, body mass index (BMI), exercise, and dietary pattern were measured at baseline and at 6 weeks follow-up. Qualitative evaluations of the recruitment process and the intervention were also conducted.
There were 64 potential participants identified via health care provider referrals (33%), printed media (23%), and direct contact (44%). Seventeen participants completed the intervention and had main outcome data available. Participants “strongly agreed/ agreed” that the group sessions provided them with the tools they needed to achieve weight loss, blood pressure control, and the possibility of sustaining the lifestyle changes after completing the intervention. At the end of the intervention, all physiological, diet, and exercise outcomes were more favorable, with the exception of fat. After 6 weeks, systolic blood pressure decreased an average of −10.4 ± 10.6 mmHg, weight decreased 1.5 ± 3.2 lbs, BMI decreased 0.3 ± 0.5, and physical activity increased 40 minutes per week.
Our findings suggest that lifestyle interventions for preventing and treating hypertension are feasible and potentially effective in the Hispanic/Latino population.
PMCID: PMC2888677  PMID: 20379894
Hypertension; Hispanic; Latino; non pharmacologic interventions; blood pressure control; weight loss; DASH dietary pattern; lifestyle intervention
21.  The impact of self-reported arthritis and diabetes on response to a home-based physical activity counseling intervention 
Physical activity (PA) has potential to improve outcomes in both arthritis and diabetes, but these conditions are rarely examined together. Our objective was to explore whether persons with arthritis alone or those with both arthritis and diabetes could improve amounts of PA with a home-based counseling intervention.
As part of the Veterans LIFE Study, veterans ages 70–92 were randomized to usual care or a twelve month PA counseling program. Arthritis and diabetes were assessed via self-report. Mixed models were used to compare trajectories for minutes of endurance and strength training PA for persons with no arthritis (n=85), arthritis (n=178), and arthritis plus diabetes (n=84).
Recipients of PA counseling increased minutes of PA per week independent of disease status (treatment arm by time interaction P<0.05 for both; endurance training time P=0.0006 and strength training time P<0.0001). Although PA was lower at each wave among persons with arthritis, and even more so among persons with arthritis plus diabetes, the presence of these conditions did not significantly influence response to the intervention (Arthritis/Diabetes group X time interactions P>0.05 for both outcomes) as each group experienced a nearly two-fold or more increase in PA.
A home-based PA intervention was effective in increasing minutes of weekly moderate intensity endurance and strength training PA in older veterans, even among those with arthritis or arthritis plus diabetes. This program may serve as a useful model to improve outcomes in older persons with these pervasive diseases.
PMCID: PMC2963864  PMID: 20429674
Physical Activity; Arthritis; Diabetes; Counseling
22.  Does Diabetes Associate with Poorer Self-Efficacy and Motivation for Physical Activity in Older Adults with Arthritis? 
To explore 1) Whether arthritis associates with poorer self-efficacy and motivation for, and participation in, two specific types of physical activity (PA): Endurance training (ET) and strength training (ST), and 2) If the added burden of diabetes contributes to a further reduction in these PA determinants and types.
Self-efficacy and motivation for exercise and minutes per week of ET and ST were measured in 347 older Veterans enrolled in a home-based PA counseling intervention. Regression analyses were used to compare high versus low self-efficacy and motivation and PA minutes in persons without arthritis, with arthritis alone, and with arthritis plus diabetes.
Persons with arthritis alone reported lower self-efficacy for ET and ST than those without arthritis (Odds ratio[OR]ET 0.71 (0.39,1.20); ORST 0.69 (0.39,1.20)). A further reduction in self-efficacy for these two types of PA was observed for those with both arthritis and diabetes (ORET 0.65 (0.44,0.92); ORST 0.64 (0.44,0.93); trend P<0.001). There was no trend towards a reduction in motivation for PA in those with arthritis alone or arthritis and diabetes. Persons with arthritis exhibited higher motivation for ET than those without arthritis (ORET 1.85 (1.12,3.33). There were no significant differences between the three groups in minutes of ET (P=0.93), but persons with arthritis plus diabetes reported significantly less ST compared to individuals with arthritis only (P=0.03).
Despite reduced self-efficacy for ET and ST and less ST in older persons with arthritis, motivation for both PA types remains high, even in the presence of diabetes.
PMCID: PMC3058748  PMID: 20604671
exercise self-efficacy; co-morbidity; strength training
23.  Evaluation of a self-management implementation intervention to improve hypertension control among patients in Medicaid 
Elevated blood pressure can lead to serious patient morbidity and mortality. The aim of the study was to evaluate the implementation of a tailored multifaceted program, administered by care managers in a Medicaid setting to improve hypertension medication adherence. The program enrolled 558 Medicaid patients. Patients had at least one phone call by care managers. The individually tailored program focused on improving lifestyle and medication adherence. The primary outcome was the medication possession ratio (MPR), calculated using fill history from pharmacy claims. We observed an improvement of medication possession from 55% 9–12 months prior to program enrollment to 77% 9–12 months post initiation of the program. We demonstrated 12 month sustainability and increased MPR. Personal interaction by phone allows the intervention to be tailored to participants’ current concerns, health goals, and specific barriers to achieving these goals.
PMCID: PMC3717688  PMID: 24073040
Medication adherence; Hypertension; Medicaid; Health care disparities
24.  Long-Term Changes in Physical Activity Following a One-Year Home-Based Physical Activity Counseling Program in Older Adults with Multiple Morbidities 
Journal of Aging Research  2010;2011:308407.
This study assessed the sustained effect of a physical activity (PA) counseling intervention on PA one year after intervention, predictors of sustained PA participation, and three classes of post-intervention PA trajectories (improvers, maintainers, and decliners) in 238 older Veterans. Declines in minutes of PA from 12 to 24 months were observed for both the treatment and control arms of the study. PA at 12 months was the strongest predictor of post-intervention changes in PA. To our surprise, those who took up the intervention and increased PA levels the most, had significant declines in post-intervention PA. Analysis of the three post-intervention PA trajectories demonstrated that the maintenance group actually reflected a group of nonresponders to the intervention who had more comorbidities, lower self-efficacy, and worse physical function than the improvers or decliners. Results suggest that behavioral counseling/support must be ongoing to promote maintenance. Strategies to promote PA appropriately to subgroups of individuals are needed.
PMCID: PMC3014677  PMID: 21234104

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