Translational Science Highlight
- NCATS’ Clinical and Translational Science Awards (CTSA) Program engages communities in research and promotes the integration of underserved populations to strengthen the quality and adoption of research results.
When is a haircut more than a haircut? When it’s also the first step to cutting high blood pressure.
Black men are more likely to die from complications of high blood pressure than any other group in the U.S. To tackle this disparity, researchers from the Smidt Heart Institute at Cedars-Sinai and the University of California, Los Angeles (UCLA), are pairing pharmacists with barbershops to offer high blood pressure care for customers. The results from a recent study published in the New England Journal of Medicine show this approach can dramatically lower blood pressure.
“If we could expand and maintain this kind of blood pressure reduction for years, it would prevent an enormous number of strokes and heart attacks,” said Ronald Victor, M.D., a cardiologist and the director of the Hypertension Center in the Smidt Heart Institute. Victor led the six-month study with other investigators at UCLA’s Clinical and Translational Science Institute (CTSI), an NCATS Clinical and Translational Science Awards (CTSA) Program hub.
A Previous Attempt
Health outreach through barbershops is not new. In fact, Victor had tried a similar approach in Dallas, where barbers measured their customers’ blood pressure and encouraged those with high numbers to see their doctor.
“There was a meager improvement in blood pressure,” Victor said. “It was really disappointing, and I wanted to understand why.”
It turned out that when men in the study did see their doctors, blood pressure medication was rarely prescribed or increased. Despite decades of evidence about the benefits of these medications, many barriers to prescribing them persist, such as overwhelmed primary care offices and patients who are hesitant to start a new medication.
Adding a Twist
Victor suspected that pharmacists might be the missing link in his barbershop outreach. In most states, primary care providers can partner with pharmacists to care for patients through collaborative practice agreements. The agreements enable a pharmacist to prescribe or adjust certain medications on behalf of a doctor, and studies have shown this approach can improve health for people with high blood pressure.
Victor took this model and added a twist in his latest study: Instead of sending barbershop patrons to pharmacists, he sent the pharmacists to the barbershop. The goal was to overcome yet another obstacle for black men: They are less likely than other groups to visit a doctor.
“Mistrust of the medical system is alive and well today,” said C. Adair Blyler, Pharm.D., a pharmacist and co-author on the study. “We knew that if we wanted to stamp out this disparity, we had to bring the care to the men.”
A Powerful Endorsement for the Pharmacists
Some of the barbers in the study had watched their customers grow up. On average, the barbers had cut the men’s hair every two weeks for the past 10 years.
“I’ve seen some of my patients over the course of many years, but not every two weeks,” Victor said. “The barbers’ endorsement was instrumental in encouraging men to participate and also encouraging them to stay with the program for its duration. None of this would have been possible without the trust the men had in their barbers — and the relationship they developed over time with the pharmacists.”
CTSI’s Community Engagement Unit helped Victor and his colleagues recruit the first few barbershop owners. Fortunately, one of the first recruited was Eric Muhammad, who reached out to other barbers in the area to share his positive experience in the study. Muhammad and a postbaccalaureate student from UCLA ultimately recruited more than 50 black barbers who owned shops in the Los Angeles area.
“Some of the barbers, and especially Eric, felt it was their mission to help take care of their community,” Blyler said.
Muhammad’s work was so critical that he was included as a co-author on Victor’s study.
A Lasting Change
With 52 barbershops on board, the researchers randomly assigned each shop into the test group or the control group. As in the Dallas study, barbers in the control group talked to customers with high blood pressure about lifestyle changes and encouraged the men to see a doctor. In the test group, customers with high blood pressure met with a pharmacist at the shop. The pharmacists then prescribed high blood pressure medications as appropriate and followed up with the participants at future haircut appointments to check that the medications were working and not causing problems.
“As health care workers in neighborhoods that we don’t live in, there was some wariness about our intentions,” Blyler said. “But pretty quickly, we were able to establish a rapport with patients.”
The research team tracked both the control and test group participants’ blood pressure over the next six months. Men in the control group, who were encouraged to see their doctor, had slight improvements in blood pressure, although on average their blood pressure was still high after six months. But men in the test group, who met with a pharmacist at a barbershop, had large drops in their systolic blood pressure, from an average of 153 mmHg at the beginning of the study to 126 mmHg after six months. Normal systolic blood pressure is less than 120 mmHg.
Translating Results to the Real World
The initial pilot study in a Los Angeles suburb received support through the UCLA CTSI, and the promising results enabled Victor to obtain more funding from the National Heart, Lung, and Blood Institute for the larger study. Biostatisticians from CTSI also offered crucial input on designing both the pilot and the larger study and determining how to analyze the results.
Victor now wants to see if his approach can lead to equally impressive results in other real-world settings. This includes determining the approach’s cost-effectiveness, which would be key to national implementation. To proceed, he is collaborating with insurers to conduct more pilot studies. He also believes the CTSA Program network of hubs provides a great opportunity to test the model with diverse populations across the country.
This study offers valuable lessons on the potential impact of directly engaging communities and utilizing alternative health care delivery, through pharmacists, in nontraditional settings.
Posted August 2018