Health Coaching to Improve Hypertension Treatment in a Low-Income, Minority Population

The article by Dr. Margolius and colleagues provides tantalizing clues to address a significant public health scrooge, poor blood pressure control. 1The Affordable Care Act (ACA) will offer access to care for some 30 million Americans. In anticipation of the ACA, Medicare and other large health care insurers have been exploring the patient-centered medical home (PCMH) as a way to improve quality, satisfaction, and outcomes for patients with chronic medical illnesses. The Joint Principles of the Patient-Centered Medical Home consists of individuals having a personal physician who provides first contact care; this care should be continuous, comprehensive, accessible, and coordinated across providers.2 Such strategies require an evidence base to understand which components should be included to maximize benefit, yet limit cost. Thus, studies like this, that test innovative ways to improve access to quality of care, are needed.

In addition to supporting and encouraging similar innovative projects that "push the envelope" of where and how care is provided, it is important to consider two fundamentally important issues. First, evaluation of programs needs to ensure a high level of rigor to address the likely nay-sayers. In the current project, without a control arm, one wonders how much of the effect observed is not simply attributed to regression to the mean or possibly simply better identifying individuals who have been disenfranchised and not previously engaged in quality improvement programs for hypertension. While a control arm would alleviate some of these issues, the authors could have also considered examining if trends existed among individuals with similar characteristics but were not involved in the actual project. Thus, while the findings were impressive in terms of absolute decrease in systolic blood pressure, unanswered questions regarding relative changes in systolic blood pressure may still exist.

Second, research examining innovative programs such as this one need to consider implementation. The current program may be selected by a health care system for implementation and details regarding cost - cost of the program in terms of resources and personnel and patient time, and cost in terms of savings of health care use and prevention of downstream events like strokes and myocardial infractions - need to be considered. Importantly, in the current study, blood pressure control was achieved without added physician time and there was indication of the actual number of physician visits dropping over the 6 months.

Lastly, we need to consider examining ways to ensure the financial viability of these programs. In a capitated system like the VA or Medicaid, there is a push to be innovative and provide care outside the typical structure because provider reimbursement is less of an issue. Models of healthcare like this in a fee for service may be more challenging, and thoughtful ways of how these innovative interventions can be an incentive and incorporated into clinical care are needed.

1. Margolius D, Bodenheimer T, Bennett H, Wong J, Ngo V, Padilla G, et al. Health coaching to improve hypertension treatment in a low-income, minority population. Annals of family medicine. 2012; 10(3): 199-205.

2. American College of Physicians. Joint principles of the patient- centered medical home. March 2007; Available from: http://www.acponline.org/advocacy/where_we_stand/medical_home/approve_jp.pdf.

Competing interests:   None declared

Competing interests:   None declared