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Community-Based Exercise Therapy Among African Americans With PAD
Study Questions:
Is motivational interviewing (MI) efficacious for improving walking distance among African American patients with peripheral artery disease (PAD)?
Methods:
African American patients were randomized 1:1:1 to MI, Patient-Centered Assessment and Counseling for Exercise (PACE), or control. The two counseling interventions were delivered biweekly for 3 months and then monthly for 3 months, followed by a 6-month phase with limited contact. Control participants received a mailing at 3 and 9 months. The primary outcome was 6-month change in 6-minute walking performance. Secondary outcomes included 12-month change in walking performance and 6- and 12-month changes in quality of life.
Results:
A total of 174 African American patients were randomized and studied at health care centers, churches, and health fairs. At 6 months, mean (SE) change in walking distance by group was -3.42 (4.55) m for MI, 2.74 (6.00) m for PACE, and -0.18 (4.40) m for control. Changes in walking distance at 12 months were -7.75 (5.50) m for MI, 13.75 (6.13) m for PACE, and -1.08 (5.73) m for control. No statistically significant increases in walking distance were found for either intervention versus control at 6 or 12 months. Compared with MI, PACE resulted in a significant increase in walking distance at 12 months of 19.8 m (95% confidence interval, 3.33-26.28 m). An exploratory analysis of participants who completed the study showed that those randomized to PACE who completed at least 7/9 counseling sessions had significantly increased walking distance at 6 and 12 months compared with control participants.
Conclusions:
MI was not efficacious in improving walking distance at 6 or 12 months in a cohort of African American patients with PAD. The results do not support use of MI to improve walking performance in African American patients with PAD.
Perspective:
Exercise therapy is unique among treatment options for claudication because success requires the patient to both accept and repeatedly self-administer the treatment over a sustained period. Revascularization and pharmacotherapy therefore are relatively passive or much less active, respectively, than exercise therapy in terms of the patient’s direct contribution to the treatment. Patient engagement is therefore essential for exercise therapy’s success; the question is not whether exercise works, but whether the individual patient will do it.
Given the well-documented disparities related to PAD prevalence, severity, and treatment outcomes among African American patients, there is a strong rationale for developing interventions targeted to this population. Minority-specific hypotheses, however, are seldom adequately tested when cohort studies lack adequate subgroup sample sizes. This study focused on African Americans and evaluated MI as an approach to improve walking distance within a structured, community-based exercise therapy program. The title refers to the study cohort as African American patients with PAD, but it is important to note that the study did not strictly require PAD or symptomatic PAD for participation. Inclusion criteria allowed enrollment of patients with borderline ankle-brachial index between 0.99-0.90 (therefore not meeting established criteria for PAD), and many of those with PAD were asymptomatic (<10% of participants had claudication symptoms).
Although MI has been effective for increasing physical activity in other studies, it was inferior to the comparison intervention (PACE) for walking distance at 12 months and was not better than the control alternative. The discussion speculated that the lack of efficacy with MI may have resulted from negative perceptions of MI among African Americans (previously observed in other studies) and possible patient preferences for more paternalistic approaches where physicians assume a larger role in decision making. PACE, for example, is more practitioner-driven than MI because providers do most of the talking and patients therefore spend more time listening to prescribed advice from an expert.
These findings do not support MI as an approach to improve exercise therapy outcomes for African Americans with PAD. Nonetheless, this study is a great example of approaching PAD treatment from a different perspective where the study design and cohort are selected to address disparities, rather than describe them.
Keywords: African Americans, Ankle Brachial Index, Exercise Therapy, Health Fairs, Intermittent Claudication, Motivational Interviewing, Myocardial Revascularization, Patient Participation, Peripheral Arterial Disease, Quality of Life, Secondary Prevention, Treatment Outcome, Vascular Diseases, Walking
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