Critique

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  1. Write your evaluation in the Word document provided (Critique 1 answer sheet).  You can insert the cursor after each question, and type in your answers.  Use full sentences, with paragraph breaks, to describe each point.  Double space all writing; number pages.
  2. Provide rationales for your decisions (citing sources). For example, if you write that the theory framework is strong, describe how it is strong with at least one citation (Author, year) to a theory book, research book, or article.
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Authors, Title, and Abstract

  1. Discuss author(s) qualifications to conduct the study, including educational preparation and clinical experience of author[s].
  2. Discuss the clarity of the article title (type of study, variables, and population stated).
  3. Discuss the quality of the abstract (purpose, design, sample, intervention, and key results presented). (10 pts)

Literature Review/Background

  1. Briefly describe the clinical problem that prompted the study.  This is not the research question, but the clinical issue that needed investigation.
  2. Discuss the data provided for the significance of the clinical problem, and whether or not you believe it is an important problem for nursing science.
  3. Identify the major topics discussed in the background section and evaluate whether there were any missing ideas or topics.
  4. Briefly explain whether the background section included sources current at the time of the study (ie. within 5 years of publication).
  5. Discuss whether the studies were critically evaluated and synthesized to provide a clear summary of the current knowledge about the problem of interest.
  6. Evaluate whether or not the background section provided support for the current research study. In other words, whether a gap(s) in research knowledge was/were clearly described.  (20 pts)

Research Problem, Purpose, Research Questions/Hypotheses

  1. State the study purpose and evaluate whether or not the purpose clearly addresses the gap in nursing knowledge identified in the background section.
  2. If there are research questions and/or hypotheses, list them, and discuss whether they logically follow from the research problem and purpose. If questions/hypotheses were only implied, rather than explicitly stated, describe that. (10 pts)

Theoretical Framework

  1. Describe the theory/framework that supported the study, and list the important concepts in the theory framework. 
  2. Evaluate the clarity of the presentation of the framework. If it was vague or had missing elements, describe those.
  3. Discuss how well the theory’s concepts were linked to the study variables.  (10 pts)

Writing Style & Format

  1. Grammar: full sentences, precision, clarity, spelling, and punctuation.
  2. Use APA format throughout this paper, specifically citations and a reference list. (10 pts)

Effects of a Community Population Health Initiative on
Blood Pressure Control in Latinos
James R. Langabeer II, PhD, EdD; Timothy D. Henry, MD, FACC; Carlos Perez Aldana, MS; Larissa DeLuna; Nora Silva, MPA;
Tiffany Champagne-Langabeer, PhD, RD

Background-—Hypertension remains one of the most important, modifiable cardiovascular risk factors. Yet, the largest minority
ethnic group (Hispanics/Latinos) often have different health outcomes and behavior, making hypertension management more
difficult. We explored the effects of an American Heart Association–sponsored population health intervention aimed at modifying
behavior of Latinos living in Texas.

Methods and Results-—We enrolled 8071 patients, and 5714 (65.7%) completed the 90-day program (58.5 years �11.7; 59%
female) from July 2016 to June 2018. Navigators identified patients with risk factors; initial and final blood pressure (BP) readings
were performed in the physician’s office; and interim home measurements were recorded telephonically. The intervention
incorporated home BP monitoring, fitness and nutritional counseling, and regular follow-up. Primary outcomes were change in
systolic BP and health-related quality of life. Using a univariate paired-samples pre–post design, we found an average 5.5% (7.6-
mm Hg) improvement in systolic BP (139.1 versus 131.5, t=10.32, P<0.001). Quality of life measured by the European quality of life 5-dimension visual analog scale improved from 0.79 to 0.82 (t=31.03, P<0.001). After multivariate regression analyses, improvements in quality of life and overall body mass index were significantly associated with reductions in systolic BP.

Conclusions-—A noninvasive, population health initiative that encourages routine engagement in patients’ own BP control was
associated with improvements in systolic BP and quality of life for this largely Latino community. (J Am Heart Assoc. 2018;7:
e010282. DOI: 10.1161/JAHA.118.010282.)

Key Words: blood pressure measurement/monitoring • ethnicity • hypertension • population

H ypertension remains a major but modifiable risk factorfor cardiovascular disease (CVD) and stroke in the
United States. It is estimated that the hypertension preva-
lence rates based on current guidelines affect 46% of the
population, or nearly 115 million adults in the United States
alone.1 The American Heart Association (AHA) established
strategic impact goals aimed at reducing CVD and stroke
deaths by 20% by the year 2020.2 The strategy introduced a
concept for cardiovascular health that is characterized by 7
metrics known as “Life’s Simple 7.”3 These metrics focus on

the patient’s self-engagement in monitoring their health and
key measures and emphasizes 4 health behaviors and 3
health factors, including blood pressure (BP) reduction.

Cardiovascular health has been shown to have ethnic and
racial variation due to genetic, culture, nutritional, socioeco-
nomic, and other factors.4,5 Hispanic and Latino people
(Latinos) compose the largest minority ethnic group in the
country and the fastest growing population in the United
States and will account for nearly a fifth of the total US
population by 2020.6 Understanding the cardiovascular health
of Latinos is a key concern for ambulatory population health.
Although Latinos have lower overall rates of heart disease
than non-Latinos, CVD is still the leading cause of death since
these patients seek treatment less often for cardiovascular
issues7 and are 40% less likely to achieve BP control.8

Community-based programs have begun to explore the use
of ambulatory and home-based BP monitoring (HBPM) to reach
specific populations.9–11 Although most hypertension diagno-
sis and monitoring has typically been carried out in office
settings, recent studies have shown that HBPM can be equally
as or more effective in diagnosing and managing hyper-
tension.12–14 Patient self-engagement and self-management
of their condition is associated with overall better physical,

From the School of Biomedical Informatics, The University of Texas Health
Science Center Houston, TX (J.R.L., C.P.A., T.C.-L.); Division of Cardiology,
Cedar-Sinai Smidt Heart Institute, Los Angeles, CA (T.D.H.); SouthWest Affiliate,
American Heart Association, San Antonio, TX (L.D., N.S.).

Correspondence to: James R. Langabeer, PhD, EdD, University of Texas,
7000 Fannin Street, Ste 1690, Houston, TX 77030. E-mails: james.r.langa
beer@uth.tmc.edu

Received July 9, 2018; accepted September 25, 2018.

ª 2018 The Authors. Published on behalf of the American Heart Association,
Inc., by Wiley. This is an open access article under the terms of the Creative
Commons Attribution-NonCommercial-NoDerivs License, which permits use
and distribution in any medium, provided the original work is properly cited,
the use is non-commercial and no modifications or adaptations are made.

DOI: 10.1161/JAHA.118.010282 Journal of the American Heart Association 1

ORIGINAL RESEARCH

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emotional, and social health outcomes.15 Patient-reported
measures via HBPM have also been shown to provide more
effective management of hypertension specifically when
combined with intensive therapeutic lifestyle interventions
such as fitness and nutritional counseling.16

Nevertheless, recent systematic reviews have noted
significant variability and contradictory findings relative to
the efficacy of HBPM and lifestyle interventions for CVD.17 In
this study, we explore the effects of a community-based
HBPM intervention targeted to a Latino population.

Methods

Study Design and Setting
This study was designed to identify primarily Latino patients
with CVD risk factors and to encourage home BP readings to
engage these patients actively in maintaining their own
health. This research was a population-based prospective
cohort study, and we utilized a pre–post study design to
assess changes in systolic BP (SBP) over time (90 days of
active engagement). The intervention incorporated lifestyle
interventions, routine follow-up from patient navigators, and
HBPM. The intervention was modeled after the AHA “Check.
Change. Control.” program.18 The initiative, called the Voel-
cker Hypertension Impact Project, was funded by the Max and
Minnie Tomerlin Voelcker Fund and organized by the AHA
SouthWest Affiliate. It was designed to explore whether a
noninvasive, ambulatory, quality-improvement program could
encourage patient engagement and effect change in control-
ling individual hypertension for the Latino population specif-
ically. The intervention used HBPM, multiple fitness and
nutritional counseling sessions, and routine follow-up by
patient navigators in a coordinated community population
health initiative. The study was conducted in San Antonio,
Texas (the seventh largest city in the United States, with

>56% Hispanic population). All patients were enrolled from 1
of 3 participating clinics in the University Health System, a
county-owned academic medical center in San Antonio.
Institutional review board approval was obtained from the
University of Texas Health Science Center at Houston.

Intervention
Nonclinical patient navigators provided patient screening,
consent, education, coaching, and follow-up. Navigators are
especially trained personnel who assist patients with the
process of care and are especially useful for overcoming
barriers and reducing disparities related to language or
cultural gaps.19 Eligibility criteria included adult Latino
patients with risk factors, including elevated, stage 1, or
stage 2 hypertension (>120/80 mm Hg). To complete the
program, the patient study duration required 90 consecutive
days and a minimum of 3 interim measurements. The first and
final BP readings were performed entirely in the clinic by the
provider. During the interim, home BP measurements were
obtained by navigators during follow-up phone calls with
patients (about 30% of all measurements) or follow-up visits
by the patients to the clinic.

Approximately 26% of the patients received BP cuffs
through the program (SmartHeart automatic arm digital
monitor; Veridian Healthcare). The remainder either were
given prescriptions to purchase the same monitor or stated
they had an existing digital arm cuff. All cuffs had to be for the
arm, and wrist monitor measurements were not permitted.
Patients were instructed to perform at least 2 repeated
measurements and to record all readings on paper for
subsequent follow-up with the navigator. Other specific
instructions to reduce measurement errors were provided,
including guidance on how to utilize monitoring devices,
proper arm and sitting position, timing, inflation techniques,
and the need for repeated measurements.20

During the office visit, brief (<5 minutes) nutritional and fitness counseling was provided by the patient navigator and the nurse. Nutritional patient resources were provided for the DASH (Dietary Approaches to Stop Hypertension) diet, as well as fitness, activity, and local wellness programs. The intervention focused primarily on engaging patients in mon- itoring their own BP and encouraging active participation in their own cardiovascular health.

Variables and Data Sources
The data, analytic methods, and study materials will not be
made available to other researchers for purposes of repro-
ducing the results or replicating the procedure.

The primary dependent variable was the change in SBP
reading between the first and last measurements. We also

Clinical Perspective

What Is New?

• Most hypertension guidelines suggest incorporating out-of-
office measurements, yet little evidence exists about the
effectiveness in overall systolic blood pressure improvement.

• The inclusion of home blood pressure monitoring and lifestyle
interventions was associated with a 5.5% positive change in
systolic blood pressure for a largely Latino population.

What Are the Clinical Implications?

• Patients who present with controlled hypertension can
benefit from the inclusion of home blood pressure monitoring
to provide additional data points for medication management.

DOI: 10.1161/JAHA.118.010282 Journal of the American Heart Association 2

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captured change in diastolic BP and quality of life (QOL), using
the European QOL 5-dimension (EQ-5D) visual analog scale.

Other variables included height and weight (to calculate
body mass index [BMI]; kg/m2), demographics (age, sex,
race, ethnicity), and medical history (prior stroke, diabetes
mellitus, and heart failure). Medication compliance was
measured as binary (1=yes, on antihypertensive medication;
0=no). Most clinical data were extracted from electronic
health records, including demographics, medications, medical
history, and BP measurements. A separate database was
maintained to track the fitness and nutritional counseling
activities by patient and date.

Statistical Analysis
Continuous variables are presented as mean�SD. Categorical
data are presented as percentages. Chi-square analyses were
used to assess differences between groups of categorical
data. Student t tests were used to examine univariate
differences between continuous variables. Baseline charac-
teristics were compared between compliant and noncompli-
ant participants (those who did not complete the
intervention), using t tests and chi-square tests. Multivariate
linear regression examined changes in SBP, controlling for the
demographic and patient baseline conditions. We modeled
the dependent variable (improvement in within-participant
SBP) as a positive number in the regression model, defined as
baseline SBP minus follow-up SBP. We assessed for multi-
collinearity between the variables using Pearson correlation
for continuous variables or Spearman correlation in the case
of binary variables. Using a cutoff of >0.7, we did not find
evidence of significant collinearity between any of the
variables. Statistical significance was defined as P<0.05. SPSS Statistics v25 (IBM Corp) was utilized to perform all data analyses.

Results
The study enrolled 8071 patients from July 2016 to June 2018
(24 months), and 5714 (65.7%) completed the program. The
average age for patients who completed the intervention was
58.5�11.7 years (range: 18–97 years), including 3353
women (58.7%), and 4069 patients (71.2%) identified as
Latino. Approximately 60% of the patients had a history of
diabetes mellitus, and 75% had a BMI greater than normal
ranges (ie, BMI >25), with a mean of 33.4 (considered obese
class I). The mean intervention time for participants was
98.1 days.

Before study initiation, no participants were adhering to
the AHA Life’s Simple 7 recommendations (including BP
management, diet, BP, fitness, and activity). The majority
(92.3%) were already placed on antihypertensive medication

before enrollment in the study and remained on medications
during the intervention. Unless complications were reported
in the interim, patients did not return to the physician’s office
until the completion of the program; therefore, changes to
medication were minimal. Only 110 patients (1.9%) had any
change in dosage recorded during the program. Of those
patients on medications, the majority had 1 primary medi-
cation for hypertension management including calcium
channel blocker in 30%, angiotensin-converting enzyme
inhibitors in 60%, and angiotensin II receptor blockers in
10%. The results from interim measurements provided
additional information for physicians to monitor medication
concordance and improve BP management following the
program’s completion. Table 1 summarizes the patient base-
line characteristics.

There were minor differences in the demographics and
baseline characteristics between those who did and did not
complete the program, including higher rates of stroke,
diabetes mellitus, prior heart failure, and baseline antihyper-
tensive medications in patients who completed the program.
Most patients dropped out of the program between the second
and third BP readings. For compliant participants, we had full
compliance for all readings during the program, largely
because of proactive follow-up by the patient navigator.

There was a significant 5.5% improvement in mean SBP
from 139.1 mm Hg at baseline to a final reading of
131.5 mm Hg (7.6 mm Hg, t=10.32, P<0.001). There was a similar 6% improvement in diastolic BP. Average EQ-5D score increased from 0.79 to 0.82 (t=31.03, P<0.001). Table 2

Table 1. Patient Characteristics

Variable Compliant Noncompliant P Value

Patients, n 5714 2357

Age, y, mean (SD) 58.5 (11.7) 57.14 (12.41) 0.001

Sex, female, n (%) 3353 (58.7) 1350 (57.3) 0.245

Body mass index, mean (SD) 33.4 (9.6) 33.7 (10.1) 0.112

Hispanic or Latino
ethnicity, n (%)

4069 (71.2) 1697 (72.0) 0.010

Race, n (%)

White 4720 (82.6) 1968 (83.5) <0.001

Black 571 (10.0) 276 (11.7)

All others 423 (7.4) 113 (4.8)

Baseline characteristics, n (%)

Diabetes mellitus 3539 (61.9) 1335 (56.7) <0.001

Prior stroke 466 (8.1) 157 (6.6) <0.001

Prior heart failure 692 (12.1) 207 (8.7) <0.001

Antihypertensive medication 5277 (92.3) 2086 (88.6) <0.001

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summarizes the outcome differences between the initial and
final readings for those who completed the program.

For patients who completed the intervention, there was a
reduction in within-participant mean SBP at each reading
across this consistent sample. The box plot in Figure shows
trend reduction in participants’ SBP over 5 measurements
during the 90-day period.

There was no significant difference between sexes for
either outcome variable. With the dependent variable (im-
provement in within-participant SBP) measured as a positive
number, we fit a multivariate regression model. After control-
ling for patient baseline and demographic factors, only BMI
and change in QOL persisted as significant factors in SBP
change in the final model (R2=0.092, P<0.001). Higher BMI and greater improvement in QOL were factors positively associated with improved SBP. Age, race, sex, ethnicity, medication compliance, and prior medical history were not significantly associated with reductions in SBP after controls. Table 3 shows the regression results.

Discussion
We found that a targeted noninvasive intervention for Latinos,
incorporating HBPM and lifestyle counseling, was associated
with a reduction in mean SBP. We also observed an
improvement in reported QOL scores during the program
that were positively associated with SBP change. In addition,
after controls for patient and demographic factors, individuals
with greater BMI had the largest overall change. Cardiovas-
cular health has been shown to have ethnic and racial
variation, partially due to nutritional and cultural factors.
Better understanding of the link between BMI and BP control
is necessary, especially when focusing on the Latino commu-
nity. More frequent interim BP measurements can be used to
comprehensively augment patient medical management.

Other researchers have found similar results regarding the
relationship of targeted quality-improvement strategies in BP
control. In their review of 18 comparable interventional
programs across the United States, Anderson and colleagues
found that community interventions that include HBPM
resulted in BP improvements.21 Other quality-improvement
strategies have also been shown to result in positive change.

Walsh and colleagues conducted a systematic review of 54
previously published community quality-improvement pro-
grams and found a median reduction of 4.5 mm Hg in both
SBP and diastolic BP. They concluded that interventions in
which the physician care team is extended outside of the
office and to others (eg, navigators, nurse educators) result in
improvement in hypertension control.

Graarup and colleagues reported that involving patients in
effective education and communication surrounding their
condition results in improvement in patients’ quality of care.22

Similarly, Ivey and colleagues analyzed patients with both CVD
and diabetes mellitus and concluded that getting patients
involved in managing their own chronic conditions results in
better patient-reported outcomes, including emotional, phys-
ical, and social health.15 In contrast, Ryvicker and colleagues
conducted a randomized trial of 587 patients and did not find
that actively engaging the patient through similar mechanisms
resulted in a positive SBP change.11

Most hypertension guidelines suggest incorporating out-of-
office measurements, including those of the US Preventive
Task Force on Hypertension, the European Society for
Hypertension, and the World Hypertension League.23–25

However, studies involving the inclusion of HBPM have also
yielded conflicting results. Bosworth and colleagues con-
ducted a randomized trial of telemonitored HBPM and found
only moderate improvements in BP control.26 Alternatively, in
a 2-year study of older adults using nontelemonitored HBPM,
Tzourio and colleagues reported that routine HBPM resulted in
modest reductions of BP that improve significantly over
time.16 Band and colleagues suggest a comprehensive
approach to managing hypertension, including active patient
engagement and digital interventions such as HBPM.12

Legitimate concerns exist around the validity and accuracy
of HBPM equipment and the patient’s ability to monitor and
record readings correctly.20,27 Kronish and colleagues
reported that the level of patients’ experience and training
around proper use is a common problem. They further
established that the primary barriers to broader use of HBPM
include “compliance with the correct test protocol, accuracy
of tests results, out-of-pocket costs of home BP devices, and
time needed to instruct patients on home BP monitoring
problems.”28 They go on to report however that “white coat
hypertension” offers compelling evidence to support the
inclusion of repeated measurements outside the physician’s
office.26 Celis and colleagues recommend that clinics adopt
HBPM but conclude that it should not replace, but rather
complement, in-office and ambulatory measurements based
on concerns about the validity of readings.29

Lifestyle and nutritional counseling in the management of
patients with hypertension is considered level I evidence for
reducing cardiovascular risk.30 However, including such
counseling in clinic-based population health programs poses

Table 2. Quality Outcome by Phase

Measure Initial Final P Value

Systolic BP 139.1 (18.5) 131.5 (15.1) <0.001

Diastolic BP 76.8 (12.3) 72.2 (10.8) <0.001

Quality of life 0.79 (0.16) 0.82 (0.14) <0.001

Data shown as mean (SD). BP indicates blood pressure.

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administrative and personnel challenges that limit broader
utilization.31 Even if lifestyle counseling offers only minimal
positive change without the addition of antihypertensive
medication, most researchers recommend augmenting
patient management with these components.32,33

Prior studies have pointed to evidence gaps in the
diagnosis and treatment of CVD in the Latino community.34

In this study, we conclude that regular patient engagement
through their own HBPM, coupled with nutritional and fitness
counseling sessions, results in improvement in SBP control for
a Latino population.

Limitations and Future Research
First, this sample was not randomized, so it is possible that
our findings are partially based on inherent sample charac-
teristics or other factors for which we did not control. We
attempted to adjust for confounders by including patient
demographic and baseline characteristics in our models.
Future studies would benefit from randomization. In addition,
because this was a community intervention, we relied on
home-based BP readings, largely based on patients’ own
equipment. There are control, quality, and accuracy concerns
surrounding home readings, given equipment, timing, and
human factors. We attempted to control for these concerns
by doing all first and final readings in the clinic, providing cuffs
to >25% of the patients, and instructing patients on appro-
priate use and positioning. Furthermore, because most
patients came into the study already compliant with BP
medications, this study does not address the impact of
antihypertensive medication changes during the study. Finally,
white coat or masked hypertension could affect measurement

in the study. We are unable to determine whether these
issues played a role, but the point of key analysis was each
patient’s change from baseline to final reading.

Given our findings, future research should examine other
community-based programs across other racial and ethnic
populations. Subsequent studies could explore BMI and QOL
in more detail. We also recommend large-scale studies to
positively confirm these findings across other regions.

Conclusion
A noninvasive population health intervention that extended
hypertension management outside the physician’s office and
incorporated routine HBPM and lifestyle counseling was

80

100

120

140

160

180

Initial BP2 BP3 BP4 Final

Sy
st

ol
ic

B
P

(m
m

H
g)

BP Measurement

Figure. Mean systolic BP by measurement. BP indicates blood pressure.

Table 3. Regression Model Results

Variable D SBP b (95% CI) P Value

Age 0.045 (�0.001 to 0.091) 0.057
Sex 1.043 (�0.430 to 2.516) 0.165
Ethnicity �0.992 (�2.671 to 0.686) 0.246
BMI 0.118 (0.055–0.182) <0.001

Stroke �2.199 (�4.984 to 0.585) 0.122
Diabetes mellitus �0.284 (�1.854 to 1.286) 0.723
Heart failure �2.212 (�4.484 to 0.060) 0.056
Medication �2.405 (�4.939 to 0.129) 0.063
QOL change 0.315 (0.237–0.393) <0.001

BMI indicates body mass index; CI, confidence interval; QOL, quality of life; SBP, systolic
blood pressure.

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effective at improving BP control and QOL for a Latino
population.

Sources of Funding
This works was partially supported by a grant from the
American Heart Association.

Disclosures
None.

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