Mechanical Details:
- Discuss how you will evaluate the effectiveness of your program to determine if it is achieving the stated goals.
- The initial office visit would consist of attaining baseline blood pressures in addition to other valuable labwork/values, such as:
b. CBC panel
c. BMI
d. EKG
e. Smoking status
f. Lipid Panel
g. A1C and BG
h. UA (albumin)
i. Weight
j. Potassium (to address potential hyperkalemia)
k. Creatinine
l. GFR
- This blood work will be used, compared to the baseline, to determine effectivity over 10 year period. I will evaluate the effectiveness of the program through a 10 year longitudinal study in which patients will get baseline vitals and contrast/compare those vitals over time to their results after a 10 year interval with combination therapy of ARB and ACEI with a diuretic.
- The biggest determinant of success would be either a maintained decrease in average blood pressure to a systolic pressure less than or equal to 130 mmHg and/or a diastolic pressure less than or equal to 80 mmHg (Mutner et al.). A significant decrease in average blood pressure would also be an indicator of success.
- Significant- decreases in 2.0 mmHg on average for systolic/diastolic measures
- Scope of the Problem –
Describe the problem; include background information;
How to alleviate hypertension in uninsured Latinos, both natural born and immigrants, in the Queens community in Northwest Corona using Renin-Angiotensin-Aldosterone System Inhibitory therapy and a diuretic. Queens is popular area in which many immigrants settle; in 2013, Queens had the highest amount of immigrants, both undocumented and documented, in comparison to other burroughs (The Newest New Yorkers, pg. 3). Most new immigrants settled in the following areas from the following backgrounds (The Newest New Yorkers, pg. 3) :
a. North Queens- Chinese
b. Richmond Hill and South Ozone Park- Guyanese
c. Northwest Queens- Ecuadorians/Mexicans
In fact, Queens’ immigrant population has increased 5.9% from 2000-2011 for the following: (The Newest New Yorkers, pg. 24).
Queens Immigrant Population by Race:
a. Asian: 37%
b. Latin American: 31%
c. Caribbean (non-Hispanic): 17%
d. European: 13%
e. African: 2%
I decided to do my research on Northwest Queens because it has the highest Latino resident and immigrant presence, specifically northwest Queens’ Corona which is near Jackson Heights and Elmhurst. This area has a high number of Mexican (15,300) and Ecuadorian (14,000) and Dominican (11,200) immigrants (The Newest New Yorkers, pg. 55). Because many do not use preventative forms of healthcare, these chronic diseases are often managed with expensive, inefficient means like the ER of a local hospital. According to NYC Health, “Central and South Americans are over three times as likely and Mexicans are six times as likely as non-Latinos to be uninsured. A higher percentage of Latinos born outside of the US-especially recent immigrants-are uninsured compared with US-born Latinos” (NYC Health, pg. 16).
Primary hypertension is a chronic disease defined by a systolic pressure greater than or equal to 130 mmHg and/or a diastolic pressure greater than or equal to 80 mmHg associated with a variety of chronic diseases like CHF and CAD (Mutner et al.). Because many do not use preventative forms of healthcare, these chronic diseases are often managed with expensive, inefficient means like the ER of a local hospital. In the Latino population of NYC, high blood pressure is a main factor contributing to heart disease and stroke; heart disease is the leading cause of death for Latinos (139.5/100,000 people) and stroke is the fifth (18.5/100,000) (NYC Health, pg. 24). If an intervention is designed to alleviate the population of Latinos in Corona for hypertension, it may save the local healthcare organizations valuable resources.
Renin-Angiotensin-Aldosterone Inhibitor therapy (RAAS) has been proven to be effective in the Hispanic population and have been shown to be effective not only in lowering blood pressure in patients at risk for other chronic diseases including diabetes and obesity when prescribed alongside a diuretic (Guzman). Specifically, ACEI and ARB alongside a diuretic will be used for this intervention excluding patients with renal issues or a history of hyperkalemia.
2. Planning –
Identify the changes you would like to make (behavioral, environmental changes, etc) and assess whether or not these factors can be changed.
Pharmacology for primary hypertension is only of the leading methods in maintaining/preventing primary hypertension due to factors such as patient noncompliance, cost, among others. Although behavioral changes focusing on a healthy lifestyle are important, pharmacological measures are more easily measured and, thus, empirically evaluated than behavioral modifications. I will provide patients with RAAS therapy and a diuretic as the primary forms of change.
3. Identify your key stakeholders and discuss how you would get their buy-in.
My key stakeholders would be the local health organizations which may be burdened by uninsured Latino patients. I would get their buy in by showing that this program would save them money, and that we would be managing other aspects of care which could alleviate their resources, especially in ER settings.
I would attract patients by providing free healthcare for the duration of the study, including those conditions that aren’t necessarily involved in it.
4. How do you plan on obtaining additional information within a certain population (e.g. surveys, focus groups, etc).
I will send Community Outreach Coordinators, trained from within the community, to recruit participants. I will recruit individuals with door to door recruitment in the dominant language (more than likely Spanish) of the specific Queens Latino Corona community. I will enlist the help of local medical facilities tailored to the Latino population for referral. I will have the Community Outreach Coordinators ensure that participants meet the following criteria:
a. Latino living in Corona Queens (proof of residential address preferred.
b. Age 18 or older
c. Uninsured status
d. Having hypertension (have the Community Coordinator either communicate with a provider, if available and also take a BP) as defined by: a systolic pressure over 130 mmHg and/or a diastolic pressure over 80 mmHg.
e. Not history of hyperkalemia
f. No history of impaired renal function
Once a patient has agreed and has met the above parameters, they will be provided transportation to a site complete with medical equipment every 3 months to attain the following lab results.
a. Blood pressure supine, standing, and sitting position
b. CBC panel
c. BMI
d. EKG
e. Smoking status
f. Lipid Panel
g. A1C and BG
h. UA (albumin)
i. Weight
j. Potassium (to address potential hyperkalemia)
k. Creatinine
l. GFR
In the 3 month assessments, I will have CMAs and providers proficient in the primary language to assess any major changes in between appointments alongside general medical health status.
How do you plan to fund/finance your program?
I am hoping to get grants from the community or even sponsorships from the drug company itself. Another alternative would be to consult the local healthcare systems because it is them that incurs cost due to undocumented chronic diseases like primary hypertension.
Do you think your program will be feasible in the long run?
I think it could be feasible in the long run. The biggest issue would be that undocumented immigrants may fear legal repercussions if they are involved. I would assure them that this isn’t the case, though I imagine that this would still be an issue. It would need additional funding and we would need to see the cost effective analysis over a period of time to really determine its effectivity.
3. Development & Dissemination of the Intervention –
What is your goal? What are you hoping to achieve?
My primary goal is to alleviate hypertension in the Latino uninsured Corona community:
a. using RAAS therapy and a diuretic to manage/alleviate hypertension. As a side bonus, or for further study, we could also examine the cost reduction benefits for participating healthcare systems, though this is not a primary focus of the study.
Describe your framework – what are your inputs? That is, everything you have to provide to make the intervention work, eg. Time, money, physical space, etc.
Describe the actual intervention, e.g: what exactly is involved; how may sessions; how many times per week/month/year, etc.
a. Demographical Statistics of Queens Corona Latino Community- Proper documentation of demographics of undocumented immigrants is difficult to assess in any community. Before implementing my intervention, I would need to compile all available data of residents in Queens to determine the extent of the issue, which languages I should use for recruitment, and which health systems are most effected. This would also give me an idea, generalizing this information to other American race populations, of which area I would have the best impact on.
b. Community Outreach- I would need individuals, preferably from said communities, to go door-to-door to explain the program and recruit possible participants. These individuals would be involved in the initial recruitment of participants and I would keep at least one of these individuals as a cornerstone for reference during my intervention as an additional resource.
c. Money- I would need money to finance my study. I would need to pay the Community Outreach Coordinators, all medical personnel, for medical resources such as lab equipment, and for creating and conducting analysis of findings.
d. Time- Ideally, I would have a longitudinal study over 10 years (this is a rhetorical, ideal study). I would have participants come in for an initial assessment then have them come in every 3 months for additional assessment of the above listed values.
e. Physical Space- Hopefully, the affected healthcare organizations could allow me to use facilities or I could ask a teaching institution, if not, I would need physical space for lab analysis and to assess health status over time.
f. Medical Personnel- I would need to have personnel, like PCTs or CMAs, that speak the language of the immigrants, and are familiar with the cultural or other aspects of the studied population. This would be a difficult task, but would be the best way to have patient compliance and an insight into possible cultural issues at hand.
g. Data collection- I would need a system in which to document and analyze the information I attain over time.
h. Transportation- I will need to find a way to ensure patients can get to and from appointment times.
i. Equipment- I will need to get the correct drugs and associated equipment, like blood pressure devices.
Actual Intervention:
- I will evaluate the effectiveness of the program through a 10 year longitudinal study.
- Latino uninsured patients will be picked if they meet the guidelines above and if they have hypertension. Other factors, such as SES and comorbidities will be noted as well. They will then be compared, matching each variable as much as possible, to those in the community with the same parameters over time in addition to their initial baseline health.
– Patients will be provided transportation to the clinic and ideally, appointment times would be the same for each appointment to limit variability. Patients will be provided transportation to the facility for additional weekly follow ups and the lipid panel will be checked at this time.
– Patients will come in every 3 months to draw the above labs to assess intervention.
-Patients will receive RAAS ACE1 and ARB and a diuretic free of charge alongside and receive healthcare free of charge for the duration of the study, including drugs not affiliated with the study. I hope that this will increase compliance and give me a better idea of the relationship/variables that will exist for the disease.
4. Evaluation & Maintenance –
Discuss how you plan to evaluate your program to determine if it is working as planned. How often will you perform an evaluation (monthly, yearly, etc)?
– An initial intervention will address patient medical history and get the following values:
a. Blood pressure supine, standing, and sitting position
b. CBC panel
c. BMI
d. EKG
e. Smoking status
f. Lipid Panel
g. A1C and BG
h. UA (albumin)
i. Weight
j. Potassium (to address potential hyperkalemia)
k. Creatinine
l. GFR
For the first month, patients will receive the drugs and report 24 hours afterwards biweekly to assess blood pressure in the three positions. After the first month, patients will come in every 3 months to draw the above labs to assess intervention for a total of 10 years (remember, this is a rhetorical study). This could cause some issues, mainly patient retention over a long period of time but I feel as though 10 years gives sufficient time to address possible positive changes on the burden to local healthcare organizations as well.
What happens if your intervention is unsuccessful? Do you plan on changing anything for the future?
If my intervention was unsuccessful, I would interview the patients and look at different factors that led to the failures, such as did the patient come to each and every appointment time? Were they complaint with the medication? I would then use this information to change my intervention for the future.
How do you plan on maintaining your program over the next 5-10 years? Could provide timelines, and sources of funding?
This is designed to be a 10 year study. It will be difficult to retain participants, but I hope to get the resources by focusing on the cost/benefit analysis and inefficiencies on the burden of healthcare for the current systems as they pertain to undocumented immigrants in Queens. I will use statistics to argue for my position. I will also look for funding and participation from drug companies, non-profits, teaching institutions, or other sources.
References
Community Toolbox – developing an intervention. This site also has examples.
http://ctb.ku.edu/en/developing-intervention
Guzman, N. J. (2012, June). Epidemiology and Management of Hypertension in the Hispanic Population: A Review of the Available Literature. Retrieved January 20, 2018, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3624012/
NYC Dept of City Planning. “The Newest New Yorkers: Characteristics of the City’s Foreign-born Population”. 2013 edition. Accessed Jan. 16, 2018 at https://www1.nyc.gov/assets/planning/download/pdf/data-maps/nyc-population/nny2013/nny_2013.pdf
NYC Health. “Health of Latinos in New York
