Ian Kronish, MD, MPH is a general internist and Assistant Professor in the Department of Medicine at the Mount Sinai School of Medicine. The candidate's long-term goal is to become and independent patient- oriented researcher in the field of behavioral cardiology, examining factors by which physician and patient behavior impact the prognosis and management of chronic cardiovascular illnesses. More specifically, the candidate is interested in developing, testing, and disseminating behavioral interventions that can improve adherence to recommended cardiovascular behaviors. The candidate became involved in this area during his fellowship in general medicine when he studied the association of depression with non-adherence among patients after acute coronary syndromes as well as the impact of non-adherence on clinical outcomes after acute coronary syndromes. The proposed career development plan combines a closely mentored patient- oriented research experience with multidisciplinary, didactic training in 1) clinical trial design, 2) biostatistics, 3) health behavior theory, and 4) specialized hypertension training. One of the most commonly encountered cardiovascular problems encountered by general internists is uncontrolled hypertension. Two important causes of uncontrolled hypertension relate to behavioral factors and include: 1) inadequate therapy intensification by clinicians, also known as clinical inertia and 2) patient non-adherence to medications. Under the mentorship of health psychologist Karina Davidson, PhD, and general internist Thomas McGinn, MD, MPH, the candidate aims to test whether providing clinicians with objective information about their patients'adherence to medications can improve clinician management of uncontrolled hypertension. To achieve this aim, the candidate will first enroll and randomize 30 primary care clinicians. Clinicians randomized to the intervention will later receive reports that summarize their patients'adherence to blood pressure medications. Clinicians randomized to the control arm will continue with usual care. He will then enroll 300 patients with uncontrolled hypertension from the same practice as the clinicians. These patients will have their adherence to blood pressure medications electronically monitored for one month. These patients will then return for visits with their clinicians who were previously enrolled in the study. At the time of the patient visit, clinicians in the intervention group will receive a quantitative report summarizing their patients'adherence to blood pressure medications in the prior month. Clinicians in the control arm will not receive this report and will treat their patients according to usual care. The candidate will then assess whether clinicians who receive the adherence information are more likely to 1) intensify treatment in adherent patients with uncontrolled blood pressure (i.e: increase dose or number of medications) and 2) counsel poorly adherent patients. These data will be used to calculate power for a larger, more definitive trial. Another goal of the proposed research will be to assess patient-related, provider-related, and health system factors that may be predictors of poor adherence to medication during the 1-month run-in period and to use these factors to develop a model for predicting non-adherence to blood pressure medications.
If providing clinicians with reports of their patients'electronically monitored adherence to blood pressure medications improves the management of hypertension, then electronically monitoring adherence may be a useful tool to reduce the proportion of patients with uncontrolled blood pressure. Further, the successful development of a model that can predict poor adherence to blood pressure medications may be helpful for informing the design of interventions targeted at patients with poor adherence and for identifying poorly adherent patients who do not have access to electronic medication monitoring.
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