Overcoming barriers to hypertension control in African Americans

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Overcoming barriers to hypertension control in African Americans
Author(s)
Taiye Odedosu, MD
Antoinette Sschoenthaler, EdD
Dorice L. Vieira, MLS, MPH, MA
Charles Agyemang, PhD
Gbenga Ogedegbe, MD

High blood pressure takes a devastating toll on African Americans. Better control can go a long way to closing the “mortality gap” between African Americans and white Americans. But which strategies are best to address this complex problem?

In this report, we review the evidence on practice-based approaches to improving blood pressure control, from new styles of patient education to home blood pressure monitoring, focusing on studies in African Americans (Table 1).1–11

BETTER CONTROL IS NEEDED

Better control of hypertension is certainly needed. In the United States, African Americans have disparately high rates of cardiovascular disease and death from cardiovascular disease.12 (In this review, “African American” refers to non-Hispanic blacks, and “whites” refers to non-Hispanic whites.) According to the National Health and Nutrition Examination Survey (NHANES), from 1988 to 2008 the overall age-adjusted prevalence of hypertension in African Americans was 40%, vs 30% in whites.13 Partly because of this, African Americans have worse hypertension-related outcomes, including higher rates of fatal stroke, heart disease, end-stage kidney disease, and death compared with whites.14–18 Thus, hypertension is the single most common contributor to the mortality gap between African Americans and white Americans.19

Fortunately, clinical research has shown that better control of blood pressure produces cardiovascular benefits in African Americans.20 To date, however, the primary care treatment of hypertension in African Americans is suboptimal due to patient-related factors, to physician practice factors, and also to barriers in the health care system (Table 2).21–23

PATIENT-RELATED BARRIERS

Patient-related barriers24–40 include:

  • Poor knowledge about hypertension and its consequences31,32
  • Poor adherence to drug therapy (a major factor,24–26 as African Americans have poorer adherence rates than whites,27–29 which may explain some of the racial disparity in blood pressure control30)
  • False health beliefs34–37
  • Inability to change one’s lifestyle
  • Side effects of antihypertensive drugs32
  • Unrealistic expectations of treatment (eg, a cure33)
  • Demographic factors (eg, socioeconomic status, educational level, age, sex).24,38–40

Perhaps the most salient and easily modifiable of these factors are patients’ reluctance to modify their lifestyle and their misconceptions about the causes, treatment, and prevention of hypertension. Patients whose beliefs are discordant with traditional biomedical concepts of hypertension have poorer blood pressure control than those whose beliefs are concordant.41 This may be more relevant to African Americans, since they are known to have cultural health beliefs that differ from those of Western culture (eg, that hypertension is a curable rather than a chronic illness, and that hypertension is a disease of nerves that often affects the blood and clogs the arteries).42

PHYSICIAN-RELATED BARRIERS

Barriers to effective blood pressure control at the physician level43–48 include:

  • Nonadherence to treatment guidelines44
  • Failure to intensify the regimen if goals are not met45
  • Failure to emphasize therapeutic lifestyle changes.43,46–48

When primary care physicians do not follow evidence-based guidelines, the reason may be that they are not aware of them or that they do not understand them. In a national survey of 1,029 physicians that was designed to explore how well physicians know the indications for specific antihypertensive drugs and how closely their opinions and practice agreed with national guidelines, only 37.3% correctly answered all of the knowledge-related questions.49

Other reasons for nonadherence are that physicians may disagree with the guidelines, may not be able to follow the guidelines, may not believe that following them will achieve the desired effect, or may have no motivation to change their practice.50

Whatever the reason, Hyman et al51 reported that as many as 30% of physicians did not recommend treatment for patients with diastolic blood pressures of 90 to 100 mm Hg, and a higher proportion did not treat patients with systolic blood pressures of 140 to 160 mm Hg.

BARRIERS IN HEALTH CARE SYSTEMS

Although health care systems present barriers to optimal blood pressure control,20,27,31,52 there is evidence that most cases of uncontrolled hypertension occur in patients with good access to care.32,53,54 For example, an NHANES study53 suggested that most patients with uncontrolled hypertension had in fact seen a physician on average at least three times in the previous year. And this may be more pervasive in African Americans: one survey found hypertension was uncontrolled in 75% of hypertensive African American patients despite free access to care, free medications, and regular follow-up visits.41

Thus, the most significant barriers to blood pressure control appear to be patient-related and physician-related.

INTERVENTIONS AIMED AT PATIENTS

The most common approaches to improving blood pressure control at the patient level, regardless of race, are patient education,55–61 home blood pressure monitoring,62–67 and behavioral counseling to address misconceptions about hypertension,68 to improve adherence to drug therapy,69–73 and to encourage lifestyle modifications.74–78

 

 

Patient education

Patient education can improve blood pressure control.58,79–82 Its aims are to increase patients’ understanding of the disease83 and to encourage them to be more active in their own care.80,84,85

Patient education has a moderate effect on blood pressure control. The average proportion of patients whose hypertension was under control in community-based trials of various interventions ranged from 60% to 70%, compared with 38% to 46% with usual care.56,80,81

However, these strategies largely did not address misconceptions patients have about hypertension. This issue is especially critical in African Americans, who may have different perceptions of hypertension and different expectations for care41: beliefs that hypertension is “curable,” not chronic, and that medication is needed only for hypertension-related symptoms may translate to poorer rates of medication adherence.

Levine et al1 evaluated the efficacy of home visits by trained community health advisory board workers in a neighborhood in Baltimore, MD, with a high prevalence of hypertension. Participants were randomized to receive either one visit or five visits during the 40-month study period. Both groups had a statistically significant reduction in blood pressure, and in both groups the proportion of patients with adequate blood pressure control increased significantly. The results support the use of a practice- and community-based partnership to improve blood pressure control in African American patients.

Ogedegbe et al2 randomized 190 hypertensive African American patients to receive usual care or quarterly counseling sessions that used motivational interviewing focused on medication adherence. The counseled patients stayed adherent to their medications, whereas adherence declined significantly in those receiving usual care. This effect was associated with a modest, nonsignificant trend toward a net reduction in systolic blood pressure with motivational interviewing.

A novel method of health education is the use of narrative communication—ie, storytelling. It has a good amount of evidence to support it, as culturally appropriate storytelling may allow patients to identify with a story as it relates to their own lives.86–89 Examples of educational storytelling include:

  • A woman with hypertension discussing what it means to have high blood pressure, and the benefits of controlling it, such as living long enough to see her grandchildren grow up
  • A man discussing the importance of involving family and friends to help control blood pressure, and how dietary modifications can be made to ensure that salt alternatives are used when the family does the cooking.

Storytelling should be done in a culturally appropriate context. For example, storytellers should have the same background as the patient (ie, similar socioeconomic status and ethnic background): patients are more likely to be influenced if they identify with the storyteller and imagine themselves in a similar situation.

Houston et al3 randomized 299 hypertensive African Americans to view either three DVDs that featured patients with hypertension or three “attention-control DVDs” on topics not related to hypertension. The intervention group’s DVDs focused on storytelling and “learning more.” In the storytelling section, patients told personal stories about what it meant to have hypertension and gave advice on how to best interact with health care providers and methods to improve medication adherence. A “learning more” section focused on what high blood pressure is, addressed therapeutic lifestyle changes, and encouraged patients to communicate with their health care providers. The patients who viewed the patient narratives had significantly lower blood pressure at 3 months than those assigned to usual care. Although blood pressure subsequently increased in both groups, the benefits of the intervention still existed at the end of follow-up.

Important to note about two of the above three studies1,3 is that the interventions were done by people other than physicians, thus emphasizing the importance of a team approach to blood pressure control.

Behavioral counseling

The effectiveness of lifestyle modifications such as diet, weight loss, and physical activity in preventing and treating hypertension is well established.74–78 For example:

  • In the Dietary Approaches to Stop Hypertension (DASH) trial,76 a healthy diet lowered blood pressure about as much as single drugs do, particularly in African Americans.
  • The Trial of Nonpharmacologic Interventions in the Elderly (TONE)74 showed that exercise can lower blood pressure in obese hypertensive patients.
  • The PREMIER trial (Lifestyle Interventions for Blood Pressure Control)75 showed that a single brief counseling session could produce substantial decreases in blood pressure in patients with stage 1 hypertension or high-normal blood pressure.

Unfortunately, these results have been hard to translate into primary care practice, especially for African American patients. Several studies have evaluated the impact of lifestyle interventions on blood pressure control in primary care practices with a large population of African American patients.

Bosworth et al,4 in a study of a practice in which almost half the patients were African American, randomized patients to receive usual care, nurse-administered tailored behavioral telephone counseling, home blood pressure monitoring, or home monitoring plus tailored behavioral telephone counseling. The combination of home monitoring and tailored behavioral telephone counseling led to a statistically significant improvement at 24 months compared with baseline.

Home blood pressure monitoring

The effectiveness of self-monitoring in improving blood pressure control is also well documented.62,63,65–67,90–95

Pickering et al62 studied patients with poorly controlled hypertension in a managed-care setting and found a reduction of 7 mm Hg systolic and 5 mm Hg diastolic pressure after 3 to 6 months of home monitoring compared with usual care.

Mengden et al,94 in a similar study, found average blood pressure reductions at 6 months of 19.3/11.9 mm Hg in the home-monitoring group vs 10.6/8.8 mm Hg in the usual-care group.

The effect of home blood pressure monitoring may be greater in African Americans.

Rogers et al93 found it to be more effective at lowering blood pressure than usual care in a group of 121 patients with poorly controlled hypertension followed in primary care practices, and these reductions were twice as large in African American patients than in white patients.93

Bondmass,92 in a study of 33 African American patients with poorly controlled hypertension, reported a 53% control rate within 4 weeks of home monitoring. All patients in the study had uncontrolled blood pressure at baseline (> 140/90 mm Hg).

Artinian et al5 evaluated the effect of nurse-managed telemonitoring on blood pressure control vs enhanced usual care. All participants were African American. The monitored group had a significantly greater reduction in systolic pressure at 12 months compared with those who received enhanced usual care.

 

 

PHYSICIAN-LEVEL INTERVENTIONS

Most interventions to improve how physicians manage patients with hypertension are designed to improve adherence to treatment guidelines. In most cases, these interventions are based on continuous quality improvement and disease management concepts such as physician education and academic detailing, reminders, feedback on performance measures, and risk-assessment tools.96,97

Physician education

Interest is increasing in physician educational interventions for blood pressure control.24,98

Inui et al,99 in an early study in a primary care practice, found that patients of physicians who received tutorials on hypertension management were more compliant with their drug regimens and had better blood pressure control than patients of physicians in the control group.

Jennett et al,100 in a similar randomized clinical trial, found that physicians who participated in an education activity were more adherent to treatment guidelines at 6 and 12 months compared with those who did not participate.

Maue et al101 showed that rates of blood pressure control improved from 41% to 52% after a 6-month educational intervention for physicians in a managed-care setting.

Tu et al102 reviewed 12 studies in which seven different physician educational interventions were used either alone or in combination and concluded that physician education improves compliance with guidelines for managing hypertension.

Unfortunately, these studies did not report outcomes separately for African American and white patients.

Hicks et al6 found that disease management approaches that target physicians whose patients with hypertension are mostly African American did not yield clinically relevant improvement in these patients, and that minority patients were significantly less likely to have their blood pressure controlled at the end of the study compared with their non-Hispanic white counterparts.

Feedback to providers

Several studies have shown that, given reminders and feedback systems, physicians will change their practice.103–106

Mashru and Lant104 combined chart audits and physician education in primary care practices and found they improved physician performance measures such as accuracy of diagnosis, number of patients who received cardiovascular risk assessment, and number of patients whose treatment was based on clinical laboratory assessments.

Feedback takes many forms but consists mostly of computerized information107 or peer-to-peer academic detailing with opinion leaders.108–110

Dickinson et al,106 for instance, showed that computer-generated listings of patients’ blood pressures combined with a physician education program on clinical management of hypertension led to increased knowledge and better follow-up on their patients.

Again, however, these studies did not distinguish between African American and white patients, which makes it difficult to judge whether or not these approaches work differently for physicians with a large proportion of African American patients.

Computerized decision-support systems

Computerized decision-support systems have proliferated in primary care practices.111

McAlister et al103 found that general practitioners randomized to manage hypertension with the assistance of a computer obtained better outcomes than with usual care.

Montgomery and Fahey,107 in a systematic review, found improved blood pressure control in two of the three trials that compared computer-generated feedback reports and reminders to usual care. Specifically, 51% of patients whose physicians received reminders either had controlled blood pressure or were at least receiving treatment vs 33% in the control group at 12 months. This difference was even higher at 24 months.

Montgomery et al7 later randomized primary care practices to use a computer-based decision-support system and a cardiovascular risk chart, the risk chart alone, or to continue as usual. Results indicated no reduction in cardiovascular risk in the computer-system or the chart-only group, whereas patients in the chart-only group had a significant reduction in systolic pressure and were prescribed more cardiovascular drugs. This study indicates that use of a computerized decision-support system is not superior to chart review and audit feedback alone.

Evidence that computerized decision systems improve blood pressure control in African Americans is scant. However, when one looks at the evidence from studies of African Americans, the outcomes do not seem to differ between African American and white patients.

Hicks et al6 examined the effectiveness of computerized decision support in improving hypertension care in a racially diverse population. Physicians were randomized to receive computerized decision support or to provide usual care without computerized support. Both groups improved significantly in prescribing appropriate drugs but not in overall blood pressure control. Furthermore, the study showed no reduction in racial disparities of care and blood pressure control.

A potential explanation for the lack of improvement in blood pressure was that the intervention dealt with making sure the appropriate drugs were prescribed rather than making sure physicians also appropriately intensified antihypertensive management when necessary.

 

 

INTERVENTIONS TARGETING PATIENTS AND PHYSICIANS

Several studies have targeted both patient and physician-level barriers to blood pressure control in practice-based settings.

Roumie et al8 randomized physicians to one of three intervention groups:

  • “Provider education” consisting of an email message with a Web-based link to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7)
  • Provider education plus a computer alert with information about their patient’s blood pressure
  • Provider education, a computer alert, and patient education (ie, patients received a letter encouraging adherence to drug therapy, changing their lifestyle, and talking with their doctor about their blood pressure).

Patients whose providers were randomized to the third group had better blood pressure control. The report did not differentiate African American vs white patients. The data, however, did show the effectiveness of adding patient education to provider education to improve blood pressure control.

Bosworth et al,112 in a study in which 40% of patients were African American, randomized patients to usual care or to bimonthly nurse-delivered behavioral telephone counseling. They also randomized providers either to receive computer-generated decision support designed to improve adherence to guidelines or to receive no support.

There were no significant differences in rates of blood pressure control in the intervention groups compared with a control group. Although differences in blood pressure control between groups were not significant, patients randomized to behavioral intervention had significantly better blood pressure control at the 24-month follow-up than at baseline.

Svetkey et al9 evaluated the effects of physician intervention, patient intervention, and physician intervention plus patient intervention compared with control on systolic blood pressure at 6 months. They found that an intensive behavioral lifestyle intervention led to a significant reduction in systolic pressure at 6 months. By itself, the physician intervention did not have a meaningful effect, but patients in the combined physician-and-patient-intervention group experienced the greatest reduction (9.7 ± 12.7 mm Hg).

It takes a team

Physicians should not be the only focus in helping patients achieve blood pressure control. Although physician and patient factors need to be addressed to improve blood pressure control in African Americans, emphasis should also be placed on interdisciplinary, team-based care utilizing health care providers such as nurses, physician assistants, and pharmacists. Team-based care has been shown to have the greatest impact of all the strategies for improving blood pressure control.113 There is a good amount of evidence involving interventions with a focus on health care providers other than physicians, although the data lack a sufficient focus on African Americans.

Carter et al,10 in a randomized controlled trial in which 26.3% of the patients were African American, found that an intervention consisting of clinical pharmacists giving physicians drug therapy recommendations based on national guidelines resulted in a significantly lower blood pressure compared with a control group: the mean reduction was 20.7/9.7 mm Hg in the intervention group vs 6.8/4.5 mm Hg in the control group.

Carter et al114 performed a meta-analysis of 37 studies and found that two strategies led to a significant reduction in blood pressure: a pharmacist-led intervention with treatment recommendations to physicians resulted in a systolic pressure reduction of 9.30 mm Hg; and nurse-led interventions resulted in a systolic pressure reduction of 4.80 mm Hg. Again, many of the studies cited in this meta-analysis lacked a focus on African Americans.

Hunt et al11 conducted a randomized controlled trial in which pharmacists actively participated in the management of blood pressure. They were involved with every aspect of care, including reviewing medications and adverse drug reactions, assessing lifestyle behaviors and barriers to adherence, making dosing adjustments, and adding medications. Patients randomized to the intervention group achieved significantly lower systolic and diastolic pressures (137/75 vs 143/78 mm Hg in the control group). However, information about race was not included.

The above studies are just a few out of a large body of evidence demonstrating the value of team-based care to improve blood pressure control. It has yet to be determined whether these models can improve blood pressure control specifically in African Americans, since so many of these trials lacked a focus on this group. Promising is an ongoing randomized prospective trial by Carter et al115 evaluating a model of collaboration between physicians and pharmacists, with a focus on patients in underrepresented minorities.

SO WHAT WORKS?

Although there is a growing body of literature on interventions to try to reduce disparities in hypertension and blood pressure control between African Americans and whites, only a few randomized controlled trials have focused on African Americans, and several have not reported their results.116 So the question remains: How should we interpret the available data, which are aggregated across racial groups, and put it into practice when caring for hypertensive African American patients?

Patient education. In trying to overcome patient-related barriers, emphasis should be on patient education, in particular addressing misconceptions about hypertension and promoting adherence to antihypertensive therapy. This is evident from the narrative storytelling intervention by Houston et al.3 Although this is the first study of its kind, this strategy may be something to consider if future studies replicate these findings. Culturally appropriate storytelling may allow patients to identify with the stories as they relate to their own personal lives. It can be an effective way to address patient education and change behaviors.

Self-monitoring with a home blood pressure monitor has also proven effective in the management of hypertension in African Americans. Indeed, the few studies that reported findings in African Americans showed impressive reductions in blood pressure. The benefits of home monitoring are well documented, and the effect on physician-related barriers such as clinical inertia are also quite impressive.117 However, most of these studies did not assess the long-term impact or cost-effectiveness of home monitoring on blood pressure control.

Behavioral counseling. Although we have good evidence of the effectiveness of behavioral counseling, whether this is sustained long-term has been less studied in African Americans. Thus, while interventions that targeted African Americans have reported impressive reductions in blood pressure, the effect tends to be greatest during the first few months of implementation, with the benefits disappearing over time.

Physician-related interventions. With regard to physician-level interventions, research has focused on physician education, utilizing alerts and computerized clinical decision-support systems. Evidence is scant on whether the use of computerized systems results in improves hypertension care in African Americans. However, a closer look at the data from studies that report outcomes in African American and white patients shows that the results do not seem to differ between these groups. Still, there is insufficient information about the impact on hypertensive African Americans.6

Strategies that address both patient- and physician-related barriers can improve overall blood pressure control; however, there is a lack of data comparing outcomes in hypertensive African Americans with those of whites, making it difficult to know if this would be an effective strategy in African American patients alone.

More studies needed that focus on African Americans

Developing interventions to improve blood pressure control in African Americans should be an ongoing priority for research if we intend to address racial disparities in cardiovascular disease. Although it is reassuring that there is a growing body of evidence and research with this focus,118–121 more research is needed to determine effective strategies that address barriers related to physician practice and to the health care system overall as they relate to blood pressure control in African Americans. More importantly, these strategies should also emphasize a team-based approach that includes nurses, pharmacists, and physician assistants. Developing targeted interventions for hypertensive African Americans will help reduce disparities in the rates of cardiovascular illness and death in this patient population.

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  75. Appel LJ, Champagne CM, Harsha DW, et al; Writing Group of the PREMIER Collaborative Research Group. Effects of comprehensive lifestyle modification on blood pressure control: main results of the PREMIER clinical trial. JAMA 2003; 289:2083–2093.
  76. Appel LJ, Moore TJ, Obarzanek E, et al. A clinical trial of the effects of dietary patterns on blood pressure. DASH Collaborative Research Group. N Engl J Med 1997; 336:1117–1124.
  77. Moore TJ, Conlin PR, Ard J, Svetkey LP. DASH (Dietary Approaches to Stop Hypertension) diet is effective treatment for stage 1 isolated systolic hypertension. Hypertension 2001; 38:155–158.
  78. Stevens VJ, Obarzanek E, Cook NR, et al; Trials for the Hypertension Prevention Research Group. Long-term weight loss and changes in blood pressure: results of the Trials of Hypertension Prevention, phase II. Ann Intern Med 2001; 134:1–11.
  79. Sawicki PT, Mühlhauser I, Didjurgeit U, Berger M. Improvement of hypertension care by a structured treatment and teaching programme. J Hum Hypertens 1993; 7:571–573.
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  81. Levine DM, Green LW, Deeds SG, Chwalow J, Russell RP, Finlay J. Health education for hypertensive patients. JAMA 1979; 241:1700–1703.
  82. Iso H, Shimamoto T, Yokota K, Sankai T, Jacobs DR, Komachi Y. Community-based education classes for hypertension control. A 1.5-year randomized controlled trial. Hypertension 1996; 27:968–974.
  83. Cuspidi C, Sampieri L, Macca G, et al. Improvement of patients’ knowledge by a single educational meeting on hypertension. J Hum Hypertens 2001; 15:57–61.
  84. Nessman DG, Carnahan JE, Nugent CA. Increasing compliance. Patient-operated hypertension groups. Arch Intern Med 1980; 140:1427–1430.
  85. Casasanta L, Patel S. Outcomes of an educational component of a disease management program for hypertension. Manag Care Interface 1999; 12:70–73.
  86. McAdams DP. The Stories We Live By: Personal Myths and the Making of the Self. New York NY: The Guilford Press; 1993.
  87. Bruner J. Acts of Meaning. Cambridge, MA: Harvard Univ Pr; 1990.
  88. Slater MD, Rouner D. Entertainment—education and elaboration likelihood: Understanding the processing of narrative persuasion. Commun Theory 2002; 12:173–191.
  89. Dal CS, Zanna MP, Fong GT. Narrative persuasion and overcoming resistance. In:Knowles ES, Linn J, eds. Resistance and Persuasion. Mahwah, NJ: Lawrence Erlbaum Assoc; 2004:175–191.
  90. Artinian NT, Washington OG, Templin TN. Effects of home telemonitoring and community-based monitoring on blood pressure control in urban African Americans: a pilot study. Heart Lung 2001; 30:191–199.
  91. Bailey B, Carney SL, Gillies AA, Smith AJ. Antihypertensive drug treatment: a comparison of usual care with self blood pressure measurement. J Hum Hypertens 1999; 13:147–150.
  92. Bondmass M. The effect of home monitoring and telemanagement on blood pressure control among African Americans. Telemed J 2000; 6:15–23.
  93. Rogers MA, Small D, Buchan DA, et al. Home monitoring service improves mean arterial pressure in patients with essential hypertension. A randomized, controlled trial. Ann Intern Med 2001; 134:1024–1032.
  94. Mengden T, Uen S, Baulmann J, Vetter H. Significance of blood pressure self-measurement as compared with office blood pressure measurement and ambulatory 24-hour blood pressure measurement in pharmacological studies. Blood Press Monit 2003; 8:169–172.
  95. Friedman RH, Kazis LE, Jette A, et al. A telecommunications system for monitoring and counseling patients with hypertension. Impact on medication adherence and blood pressure control. Am J Hypertens 1996; 9:285–292.
  96. Oxman AD, Thomson MA, Davis DA, Haynes RB. No magic bullets: a systematic review of 102 trials of interventions to improve professional practice. CMAJ 1995; 153:1423–1431.
  97. Wensing M, van der Weijden T, Grol R. Implementing guidelines and innovations in general practice: which interventions are effective? Br J Gen Pract 1998; 48:991–997.
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  99. Inui TS, Yourtee EL, Williamson JW. Improved outcomes in hypertension after physician tutorials. A controlled trial. Ann Intern Med 1976; 84:646–651.
  100. Jennett PA, Wilson TW, Hayton RC, Mainprize GW, Laxdal OE. Desirable behaviours in the office management of hypertension addressed through continuing medical education. Can J Public Health 1989; 80:359–362.
  101. Maue SK, Rivo ML, Weiss B, Farrelly EW, Brower-Stenger S. Effect of a primary care physician-focused, population-based approach to blood pressure control. Fam Med 2002; 34:508–513.
  102. Tu K, Davis D. Can we alter physician behavior by educational methods? Lessons learned from studies of the management and follow-up of hypertension. J Contin Educ Health Prof 2002; 22:11–22.
  103. McAlister NH, Covvey HD, Tong C, Lee A, Wigle ED. Randomised controlled trial of computer assisted management of hypertension in primary care. Br Med J (Clin Res Ed) 1986; 293:670–674.
  104. Mashru M, Lant A. Interpractice audit of diagnosis and management of hypertension in primary care: educational intervention and review of medical records. BMJ 1997; 314:942–946.
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  107. Montgomery AA, Fahey T. A systematic review of the use of computers in the management of hypertension. J Epidemiol Community Health 1998; 52:520–525.
  108. Coleman MT, Lott JA, Sharma S. Use of continuous quality improvement to identify barriers in the management of hypertension. Am J Med Qual 2000; 15:72–77.
  109. Goldberg HI, Wagner EH, Fihn SD, et al. A randomized controlled trial of CQI teams and academic detailing: can they alter compliance with guidelines? Jt Comm J Qual Improv 1998; 24:130–142.
  110. Horowitz CR, Goldberg HI, Martin DP, et al. Conducting a randomized controlled trial of CQI and academic detailing to implement clinical guidelines. Jt Comm J Qual Improv 1996; 22:734–750.
  111. Johnson B, McNair D, Kailasam K, et al. Discern—an integrated prospective decision support system. Proc Annu Symp Comput Appl Med Care 1994; 969.
  112. Bosworth HB, Olsen MK, Dudley T, et al. Patient education and provider decision support to control blood pressure in primary care: a cluster randomized trial. Am Heart J 2009; 157:450–456.
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  114. Carter BL, Rogers M, Daly J, Zheng S, James PA. The potency of team-based care interventions for hypertension: a meta-analysis. Arch Intern Med 2009; 169:1748–1755.
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Taiye Odedosu, MD
Bellevue Adult Primary Care Practice, Bellevue Hospital Center, New York, NY

Antoinette Sschoenthaler, EdD
Center for Healthful Behavior Change, Division of General Internal Medicine, New York University School of Medicine, New York, NY

Dorice L. Vieira, MLS, MPH, MA
NYU Langone Medical Center, New York University Health Sciences Library, New York, NY

Charles Agyemang, PhD
Amsterdam Medical Center, Department of Social Medicine, Amsterdam, Netherlands

Gbenga Ogedegbe, MD
Center for Healthful Behavior Change, Division of General Internal Medicine, New York University School of Medicine, New York, NY

Address: Gbenga Ogedegbe, MD, Center for Healthful Behavior Change, Division of General Internal Medicine, New York University School of Medicine, 227 East 30th Street, New York, NY 10016; e-mail: olugbenga.ogedegbe@nyumc.org

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Addressing Disparities in Health Care
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Taiye Odedosu, MD
Antoinette Sschoenthaler, EdD
Dorice L. Vieira, MLS, MPH, MA
Charles Agyemang, PhD
Gbenga Ogedegbe, MD
Author(s)
Taiye Odedosu, MD
Antoinette Sschoenthaler, EdD
Dorice L. Vieira, MLS, MPH, MA
Charles Agyemang, PhD
Gbenga Ogedegbe, MD
Author and Disclosure Information

Taiye Odedosu, MD
Bellevue Adult Primary Care Practice, Bellevue Hospital Center, New York, NY

Antoinette Sschoenthaler, EdD
Center for Healthful Behavior Change, Division of General Internal Medicine, New York University School of Medicine, New York, NY

Dorice L. Vieira, MLS, MPH, MA
NYU Langone Medical Center, New York University Health Sciences Library, New York, NY

Charles Agyemang, PhD
Amsterdam Medical Center, Department of Social Medicine, Amsterdam, Netherlands

Gbenga Ogedegbe, MD
Center for Healthful Behavior Change, Division of General Internal Medicine, New York University School of Medicine, New York, NY

Address: Gbenga Ogedegbe, MD, Center for Healthful Behavior Change, Division of General Internal Medicine, New York University School of Medicine, 227 East 30th Street, New York, NY 10016; e-mail: olugbenga.ogedegbe@nyumc.org

Author and Disclosure Information

Taiye Odedosu, MD
Bellevue Adult Primary Care Practice, Bellevue Hospital Center, New York, NY

Antoinette Sschoenthaler, EdD
Center for Healthful Behavior Change, Division of General Internal Medicine, New York University School of Medicine, New York, NY

Dorice L. Vieira, MLS, MPH, MA
NYU Langone Medical Center, New York University Health Sciences Library, New York, NY

Charles Agyemang, PhD
Amsterdam Medical Center, Department of Social Medicine, Amsterdam, Netherlands

Gbenga Ogedegbe, MD
Center for Healthful Behavior Change, Division of General Internal Medicine, New York University School of Medicine, New York, NY

Address: Gbenga Ogedegbe, MD, Center for Healthful Behavior Change, Division of General Internal Medicine, New York University School of Medicine, 227 East 30th Street, New York, NY 10016; e-mail: olugbenga.ogedegbe@nyumc.org

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High blood pressure takes a devastating toll on African Americans. Better control can go a long way to closing the “mortality gap” between African Americans and white Americans. But which strategies are best to address this complex problem?

In this report, we review the evidence on practice-based approaches to improving blood pressure control, from new styles of patient education to home blood pressure monitoring, focusing on studies in African Americans (Table 1).1–11

BETTER CONTROL IS NEEDED

Better control of hypertension is certainly needed. In the United States, African Americans have disparately high rates of cardiovascular disease and death from cardiovascular disease.12 (In this review, “African American” refers to non-Hispanic blacks, and “whites” refers to non-Hispanic whites.) According to the National Health and Nutrition Examination Survey (NHANES), from 1988 to 2008 the overall age-adjusted prevalence of hypertension in African Americans was 40%, vs 30% in whites.13 Partly because of this, African Americans have worse hypertension-related outcomes, including higher rates of fatal stroke, heart disease, end-stage kidney disease, and death compared with whites.14–18 Thus, hypertension is the single most common contributor to the mortality gap between African Americans and white Americans.19

Fortunately, clinical research has shown that better control of blood pressure produces cardiovascular benefits in African Americans.20 To date, however, the primary care treatment of hypertension in African Americans is suboptimal due to patient-related factors, to physician practice factors, and also to barriers in the health care system (Table 2).21–23

PATIENT-RELATED BARRIERS

Patient-related barriers24–40 include:

  • Poor knowledge about hypertension and its consequences31,32
  • Poor adherence to drug therapy (a major factor,24–26 as African Americans have poorer adherence rates than whites,27–29 which may explain some of the racial disparity in blood pressure control30)
  • False health beliefs34–37
  • Inability to change one’s lifestyle
  • Side effects of antihypertensive drugs32
  • Unrealistic expectations of treatment (eg, a cure33)
  • Demographic factors (eg, socioeconomic status, educational level, age, sex).24,38–40

Perhaps the most salient and easily modifiable of these factors are patients’ reluctance to modify their lifestyle and their misconceptions about the causes, treatment, and prevention of hypertension. Patients whose beliefs are discordant with traditional biomedical concepts of hypertension have poorer blood pressure control than those whose beliefs are concordant.41 This may be more relevant to African Americans, since they are known to have cultural health beliefs that differ from those of Western culture (eg, that hypertension is a curable rather than a chronic illness, and that hypertension is a disease of nerves that often affects the blood and clogs the arteries).42

PHYSICIAN-RELATED BARRIERS

Barriers to effective blood pressure control at the physician level43–48 include:

  • Nonadherence to treatment guidelines44
  • Failure to intensify the regimen if goals are not met45
  • Failure to emphasize therapeutic lifestyle changes.43,46–48

When primary care physicians do not follow evidence-based guidelines, the reason may be that they are not aware of them or that they do not understand them. In a national survey of 1,029 physicians that was designed to explore how well physicians know the indications for specific antihypertensive drugs and how closely their opinions and practice agreed with national guidelines, only 37.3% correctly answered all of the knowledge-related questions.49

Other reasons for nonadherence are that physicians may disagree with the guidelines, may not be able to follow the guidelines, may not believe that following them will achieve the desired effect, or may have no motivation to change their practice.50

Whatever the reason, Hyman et al51 reported that as many as 30% of physicians did not recommend treatment for patients with diastolic blood pressures of 90 to 100 mm Hg, and a higher proportion did not treat patients with systolic blood pressures of 140 to 160 mm Hg.

BARRIERS IN HEALTH CARE SYSTEMS

Although health care systems present barriers to optimal blood pressure control,20,27,31,52 there is evidence that most cases of uncontrolled hypertension occur in patients with good access to care.32,53,54 For example, an NHANES study53 suggested that most patients with uncontrolled hypertension had in fact seen a physician on average at least three times in the previous year. And this may be more pervasive in African Americans: one survey found hypertension was uncontrolled in 75% of hypertensive African American patients despite free access to care, free medications, and regular follow-up visits.41

Thus, the most significant barriers to blood pressure control appear to be patient-related and physician-related.

INTERVENTIONS AIMED AT PATIENTS

The most common approaches to improving blood pressure control at the patient level, regardless of race, are patient education,55–61 home blood pressure monitoring,62–67 and behavioral counseling to address misconceptions about hypertension,68 to improve adherence to drug therapy,69–73 and to encourage lifestyle modifications.74–78

 

 

Patient education

Patient education can improve blood pressure control.58,79–82 Its aims are to increase patients’ understanding of the disease83 and to encourage them to be more active in their own care.80,84,85

Patient education has a moderate effect on blood pressure control. The average proportion of patients whose hypertension was under control in community-based trials of various interventions ranged from 60% to 70%, compared with 38% to 46% with usual care.56,80,81

However, these strategies largely did not address misconceptions patients have about hypertension. This issue is especially critical in African Americans, who may have different perceptions of hypertension and different expectations for care41: beliefs that hypertension is “curable,” not chronic, and that medication is needed only for hypertension-related symptoms may translate to poorer rates of medication adherence.

Levine et al1 evaluated the efficacy of home visits by trained community health advisory board workers in a neighborhood in Baltimore, MD, with a high prevalence of hypertension. Participants were randomized to receive either one visit or five visits during the 40-month study period. Both groups had a statistically significant reduction in blood pressure, and in both groups the proportion of patients with adequate blood pressure control increased significantly. The results support the use of a practice- and community-based partnership to improve blood pressure control in African American patients.

Ogedegbe et al2 randomized 190 hypertensive African American patients to receive usual care or quarterly counseling sessions that used motivational interviewing focused on medication adherence. The counseled patients stayed adherent to their medications, whereas adherence declined significantly in those receiving usual care. This effect was associated with a modest, nonsignificant trend toward a net reduction in systolic blood pressure with motivational interviewing.

A novel method of health education is the use of narrative communication—ie, storytelling. It has a good amount of evidence to support it, as culturally appropriate storytelling may allow patients to identify with a story as it relates to their own lives.86–89 Examples of educational storytelling include:

  • A woman with hypertension discussing what it means to have high blood pressure, and the benefits of controlling it, such as living long enough to see her grandchildren grow up
  • A man discussing the importance of involving family and friends to help control blood pressure, and how dietary modifications can be made to ensure that salt alternatives are used when the family does the cooking.

Storytelling should be done in a culturally appropriate context. For example, storytellers should have the same background as the patient (ie, similar socioeconomic status and ethnic background): patients are more likely to be influenced if they identify with the storyteller and imagine themselves in a similar situation.

Houston et al3 randomized 299 hypertensive African Americans to view either three DVDs that featured patients with hypertension or three “attention-control DVDs” on topics not related to hypertension. The intervention group’s DVDs focused on storytelling and “learning more.” In the storytelling section, patients told personal stories about what it meant to have hypertension and gave advice on how to best interact with health care providers and methods to improve medication adherence. A “learning more” section focused on what high blood pressure is, addressed therapeutic lifestyle changes, and encouraged patients to communicate with their health care providers. The patients who viewed the patient narratives had significantly lower blood pressure at 3 months than those assigned to usual care. Although blood pressure subsequently increased in both groups, the benefits of the intervention still existed at the end of follow-up.

Important to note about two of the above three studies1,3 is that the interventions were done by people other than physicians, thus emphasizing the importance of a team approach to blood pressure control.

Behavioral counseling

The effectiveness of lifestyle modifications such as diet, weight loss, and physical activity in preventing and treating hypertension is well established.74–78 For example:

  • In the Dietary Approaches to Stop Hypertension (DASH) trial,76 a healthy diet lowered blood pressure about as much as single drugs do, particularly in African Americans.
  • The Trial of Nonpharmacologic Interventions in the Elderly (TONE)74 showed that exercise can lower blood pressure in obese hypertensive patients.
  • The PREMIER trial (Lifestyle Interventions for Blood Pressure Control)75 showed that a single brief counseling session could produce substantial decreases in blood pressure in patients with stage 1 hypertension or high-normal blood pressure.

Unfortunately, these results have been hard to translate into primary care practice, especially for African American patients. Several studies have evaluated the impact of lifestyle interventions on blood pressure control in primary care practices with a large population of African American patients.

Bosworth et al,4 in a study of a practice in which almost half the patients were African American, randomized patients to receive usual care, nurse-administered tailored behavioral telephone counseling, home blood pressure monitoring, or home monitoring plus tailored behavioral telephone counseling. The combination of home monitoring and tailored behavioral telephone counseling led to a statistically significant improvement at 24 months compared with baseline.

Home blood pressure monitoring

The effectiveness of self-monitoring in improving blood pressure control is also well documented.62,63,65–67,90–95

Pickering et al62 studied patients with poorly controlled hypertension in a managed-care setting and found a reduction of 7 mm Hg systolic and 5 mm Hg diastolic pressure after 3 to 6 months of home monitoring compared with usual care.

Mengden et al,94 in a similar study, found average blood pressure reductions at 6 months of 19.3/11.9 mm Hg in the home-monitoring group vs 10.6/8.8 mm Hg in the usual-care group.

The effect of home blood pressure monitoring may be greater in African Americans.

Rogers et al93 found it to be more effective at lowering blood pressure than usual care in a group of 121 patients with poorly controlled hypertension followed in primary care practices, and these reductions were twice as large in African American patients than in white patients.93

Bondmass,92 in a study of 33 African American patients with poorly controlled hypertension, reported a 53% control rate within 4 weeks of home monitoring. All patients in the study had uncontrolled blood pressure at baseline (> 140/90 mm Hg).

Artinian et al5 evaluated the effect of nurse-managed telemonitoring on blood pressure control vs enhanced usual care. All participants were African American. The monitored group had a significantly greater reduction in systolic pressure at 12 months compared with those who received enhanced usual care.

 

 

PHYSICIAN-LEVEL INTERVENTIONS

Most interventions to improve how physicians manage patients with hypertension are designed to improve adherence to treatment guidelines. In most cases, these interventions are based on continuous quality improvement and disease management concepts such as physician education and academic detailing, reminders, feedback on performance measures, and risk-assessment tools.96,97

Physician education

Interest is increasing in physician educational interventions for blood pressure control.24,98

Inui et al,99 in an early study in a primary care practice, found that patients of physicians who received tutorials on hypertension management were more compliant with their drug regimens and had better blood pressure control than patients of physicians in the control group.

Jennett et al,100 in a similar randomized clinical trial, found that physicians who participated in an education activity were more adherent to treatment guidelines at 6 and 12 months compared with those who did not participate.

Maue et al101 showed that rates of blood pressure control improved from 41% to 52% after a 6-month educational intervention for physicians in a managed-care setting.

Tu et al102 reviewed 12 studies in which seven different physician educational interventions were used either alone or in combination and concluded that physician education improves compliance with guidelines for managing hypertension.

Unfortunately, these studies did not report outcomes separately for African American and white patients.

Hicks et al6 found that disease management approaches that target physicians whose patients with hypertension are mostly African American did not yield clinically relevant improvement in these patients, and that minority patients were significantly less likely to have their blood pressure controlled at the end of the study compared with their non-Hispanic white counterparts.

Feedback to providers

Several studies have shown that, given reminders and feedback systems, physicians will change their practice.103–106

Mashru and Lant104 combined chart audits and physician education in primary care practices and found they improved physician performance measures such as accuracy of diagnosis, number of patients who received cardiovascular risk assessment, and number of patients whose treatment was based on clinical laboratory assessments.

Feedback takes many forms but consists mostly of computerized information107 or peer-to-peer academic detailing with opinion leaders.108–110

Dickinson et al,106 for instance, showed that computer-generated listings of patients’ blood pressures combined with a physician education program on clinical management of hypertension led to increased knowledge and better follow-up on their patients.

Again, however, these studies did not distinguish between African American and white patients, which makes it difficult to judge whether or not these approaches work differently for physicians with a large proportion of African American patients.

Computerized decision-support systems

Computerized decision-support systems have proliferated in primary care practices.111

McAlister et al103 found that general practitioners randomized to manage hypertension with the assistance of a computer obtained better outcomes than with usual care.

Montgomery and Fahey,107 in a systematic review, found improved blood pressure control in two of the three trials that compared computer-generated feedback reports and reminders to usual care. Specifically, 51% of patients whose physicians received reminders either had controlled blood pressure or were at least receiving treatment vs 33% in the control group at 12 months. This difference was even higher at 24 months.

Montgomery et al7 later randomized primary care practices to use a computer-based decision-support system and a cardiovascular risk chart, the risk chart alone, or to continue as usual. Results indicated no reduction in cardiovascular risk in the computer-system or the chart-only group, whereas patients in the chart-only group had a significant reduction in systolic pressure and were prescribed more cardiovascular drugs. This study indicates that use of a computerized decision-support system is not superior to chart review and audit feedback alone.

Evidence that computerized decision systems improve blood pressure control in African Americans is scant. However, when one looks at the evidence from studies of African Americans, the outcomes do not seem to differ between African American and white patients.

Hicks et al6 examined the effectiveness of computerized decision support in improving hypertension care in a racially diverse population. Physicians were randomized to receive computerized decision support or to provide usual care without computerized support. Both groups improved significantly in prescribing appropriate drugs but not in overall blood pressure control. Furthermore, the study showed no reduction in racial disparities of care and blood pressure control.

A potential explanation for the lack of improvement in blood pressure was that the intervention dealt with making sure the appropriate drugs were prescribed rather than making sure physicians also appropriately intensified antihypertensive management when necessary.

 

 

INTERVENTIONS TARGETING PATIENTS AND PHYSICIANS

Several studies have targeted both patient and physician-level barriers to blood pressure control in practice-based settings.

Roumie et al8 randomized physicians to one of three intervention groups:

  • “Provider education” consisting of an email message with a Web-based link to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7)
  • Provider education plus a computer alert with information about their patient’s blood pressure
  • Provider education, a computer alert, and patient education (ie, patients received a letter encouraging adherence to drug therapy, changing their lifestyle, and talking with their doctor about their blood pressure).

Patients whose providers were randomized to the third group had better blood pressure control. The report did not differentiate African American vs white patients. The data, however, did show the effectiveness of adding patient education to provider education to improve blood pressure control.

Bosworth et al,112 in a study in which 40% of patients were African American, randomized patients to usual care or to bimonthly nurse-delivered behavioral telephone counseling. They also randomized providers either to receive computer-generated decision support designed to improve adherence to guidelines or to receive no support.

There were no significant differences in rates of blood pressure control in the intervention groups compared with a control group. Although differences in blood pressure control between groups were not significant, patients randomized to behavioral intervention had significantly better blood pressure control at the 24-month follow-up than at baseline.

Svetkey et al9 evaluated the effects of physician intervention, patient intervention, and physician intervention plus patient intervention compared with control on systolic blood pressure at 6 months. They found that an intensive behavioral lifestyle intervention led to a significant reduction in systolic pressure at 6 months. By itself, the physician intervention did not have a meaningful effect, but patients in the combined physician-and-patient-intervention group experienced the greatest reduction (9.7 ± 12.7 mm Hg).

It takes a team

Physicians should not be the only focus in helping patients achieve blood pressure control. Although physician and patient factors need to be addressed to improve blood pressure control in African Americans, emphasis should also be placed on interdisciplinary, team-based care utilizing health care providers such as nurses, physician assistants, and pharmacists. Team-based care has been shown to have the greatest impact of all the strategies for improving blood pressure control.113 There is a good amount of evidence involving interventions with a focus on health care providers other than physicians, although the data lack a sufficient focus on African Americans.

Carter et al,10 in a randomized controlled trial in which 26.3% of the patients were African American, found that an intervention consisting of clinical pharmacists giving physicians drug therapy recommendations based on national guidelines resulted in a significantly lower blood pressure compared with a control group: the mean reduction was 20.7/9.7 mm Hg in the intervention group vs 6.8/4.5 mm Hg in the control group.

Carter et al114 performed a meta-analysis of 37 studies and found that two strategies led to a significant reduction in blood pressure: a pharmacist-led intervention with treatment recommendations to physicians resulted in a systolic pressure reduction of 9.30 mm Hg; and nurse-led interventions resulted in a systolic pressure reduction of 4.80 mm Hg. Again, many of the studies cited in this meta-analysis lacked a focus on African Americans.

Hunt et al11 conducted a randomized controlled trial in which pharmacists actively participated in the management of blood pressure. They were involved with every aspect of care, including reviewing medications and adverse drug reactions, assessing lifestyle behaviors and barriers to adherence, making dosing adjustments, and adding medications. Patients randomized to the intervention group achieved significantly lower systolic and diastolic pressures (137/75 vs 143/78 mm Hg in the control group). However, information about race was not included.

The above studies are just a few out of a large body of evidence demonstrating the value of team-based care to improve blood pressure control. It has yet to be determined whether these models can improve blood pressure control specifically in African Americans, since so many of these trials lacked a focus on this group. Promising is an ongoing randomized prospective trial by Carter et al115 evaluating a model of collaboration between physicians and pharmacists, with a focus on patients in underrepresented minorities.

SO WHAT WORKS?

Although there is a growing body of literature on interventions to try to reduce disparities in hypertension and blood pressure control between African Americans and whites, only a few randomized controlled trials have focused on African Americans, and several have not reported their results.116 So the question remains: How should we interpret the available data, which are aggregated across racial groups, and put it into practice when caring for hypertensive African American patients?

Patient education. In trying to overcome patient-related barriers, emphasis should be on patient education, in particular addressing misconceptions about hypertension and promoting adherence to antihypertensive therapy. This is evident from the narrative storytelling intervention by Houston et al.3 Although this is the first study of its kind, this strategy may be something to consider if future studies replicate these findings. Culturally appropriate storytelling may allow patients to identify with the stories as they relate to their own personal lives. It can be an effective way to address patient education and change behaviors.

Self-monitoring with a home blood pressure monitor has also proven effective in the management of hypertension in African Americans. Indeed, the few studies that reported findings in African Americans showed impressive reductions in blood pressure. The benefits of home monitoring are well documented, and the effect on physician-related barriers such as clinical inertia are also quite impressive.117 However, most of these studies did not assess the long-term impact or cost-effectiveness of home monitoring on blood pressure control.

Behavioral counseling. Although we have good evidence of the effectiveness of behavioral counseling, whether this is sustained long-term has been less studied in African Americans. Thus, while interventions that targeted African Americans have reported impressive reductions in blood pressure, the effect tends to be greatest during the first few months of implementation, with the benefits disappearing over time.

Physician-related interventions. With regard to physician-level interventions, research has focused on physician education, utilizing alerts and computerized clinical decision-support systems. Evidence is scant on whether the use of computerized systems results in improves hypertension care in African Americans. However, a closer look at the data from studies that report outcomes in African American and white patients shows that the results do not seem to differ between these groups. Still, there is insufficient information about the impact on hypertensive African Americans.6

Strategies that address both patient- and physician-related barriers can improve overall blood pressure control; however, there is a lack of data comparing outcomes in hypertensive African Americans with those of whites, making it difficult to know if this would be an effective strategy in African American patients alone.

More studies needed that focus on African Americans

Developing interventions to improve blood pressure control in African Americans should be an ongoing priority for research if we intend to address racial disparities in cardiovascular disease. Although it is reassuring that there is a growing body of evidence and research with this focus,118–121 more research is needed to determine effective strategies that address barriers related to physician practice and to the health care system overall as they relate to blood pressure control in African Americans. More importantly, these strategies should also emphasize a team-based approach that includes nurses, pharmacists, and physician assistants. Developing targeted interventions for hypertensive African Americans will help reduce disparities in the rates of cardiovascular illness and death in this patient population.

High blood pressure takes a devastating toll on African Americans. Better control can go a long way to closing the “mortality gap” between African Americans and white Americans. But which strategies are best to address this complex problem?

In this report, we review the evidence on practice-based approaches to improving blood pressure control, from new styles of patient education to home blood pressure monitoring, focusing on studies in African Americans (Table 1).1–11

BETTER CONTROL IS NEEDED

Better control of hypertension is certainly needed. In the United States, African Americans have disparately high rates of cardiovascular disease and death from cardiovascular disease.12 (In this review, “African American” refers to non-Hispanic blacks, and “whites” refers to non-Hispanic whites.) According to the National Health and Nutrition Examination Survey (NHANES), from 1988 to 2008 the overall age-adjusted prevalence of hypertension in African Americans was 40%, vs 30% in whites.13 Partly because of this, African Americans have worse hypertension-related outcomes, including higher rates of fatal stroke, heart disease, end-stage kidney disease, and death compared with whites.14–18 Thus, hypertension is the single most common contributor to the mortality gap between African Americans and white Americans.19

Fortunately, clinical research has shown that better control of blood pressure produces cardiovascular benefits in African Americans.20 To date, however, the primary care treatment of hypertension in African Americans is suboptimal due to patient-related factors, to physician practice factors, and also to barriers in the health care system (Table 2).21–23

PATIENT-RELATED BARRIERS

Patient-related barriers24–40 include:

  • Poor knowledge about hypertension and its consequences31,32
  • Poor adherence to drug therapy (a major factor,24–26 as African Americans have poorer adherence rates than whites,27–29 which may explain some of the racial disparity in blood pressure control30)
  • False health beliefs34–37
  • Inability to change one’s lifestyle
  • Side effects of antihypertensive drugs32
  • Unrealistic expectations of treatment (eg, a cure33)
  • Demographic factors (eg, socioeconomic status, educational level, age, sex).24,38–40

Perhaps the most salient and easily modifiable of these factors are patients’ reluctance to modify their lifestyle and their misconceptions about the causes, treatment, and prevention of hypertension. Patients whose beliefs are discordant with traditional biomedical concepts of hypertension have poorer blood pressure control than those whose beliefs are concordant.41 This may be more relevant to African Americans, since they are known to have cultural health beliefs that differ from those of Western culture (eg, that hypertension is a curable rather than a chronic illness, and that hypertension is a disease of nerves that often affects the blood and clogs the arteries).42

PHYSICIAN-RELATED BARRIERS

Barriers to effective blood pressure control at the physician level43–48 include:

  • Nonadherence to treatment guidelines44
  • Failure to intensify the regimen if goals are not met45
  • Failure to emphasize therapeutic lifestyle changes.43,46–48

When primary care physicians do not follow evidence-based guidelines, the reason may be that they are not aware of them or that they do not understand them. In a national survey of 1,029 physicians that was designed to explore how well physicians know the indications for specific antihypertensive drugs and how closely their opinions and practice agreed with national guidelines, only 37.3% correctly answered all of the knowledge-related questions.49

Other reasons for nonadherence are that physicians may disagree with the guidelines, may not be able to follow the guidelines, may not believe that following them will achieve the desired effect, or may have no motivation to change their practice.50

Whatever the reason, Hyman et al51 reported that as many as 30% of physicians did not recommend treatment for patients with diastolic blood pressures of 90 to 100 mm Hg, and a higher proportion did not treat patients with systolic blood pressures of 140 to 160 mm Hg.

BARRIERS IN HEALTH CARE SYSTEMS

Although health care systems present barriers to optimal blood pressure control,20,27,31,52 there is evidence that most cases of uncontrolled hypertension occur in patients with good access to care.32,53,54 For example, an NHANES study53 suggested that most patients with uncontrolled hypertension had in fact seen a physician on average at least three times in the previous year. And this may be more pervasive in African Americans: one survey found hypertension was uncontrolled in 75% of hypertensive African American patients despite free access to care, free medications, and regular follow-up visits.41

Thus, the most significant barriers to blood pressure control appear to be patient-related and physician-related.

INTERVENTIONS AIMED AT PATIENTS

The most common approaches to improving blood pressure control at the patient level, regardless of race, are patient education,55–61 home blood pressure monitoring,62–67 and behavioral counseling to address misconceptions about hypertension,68 to improve adherence to drug therapy,69–73 and to encourage lifestyle modifications.74–78

 

 

Patient education

Patient education can improve blood pressure control.58,79–82 Its aims are to increase patients’ understanding of the disease83 and to encourage them to be more active in their own care.80,84,85

Patient education has a moderate effect on blood pressure control. The average proportion of patients whose hypertension was under control in community-based trials of various interventions ranged from 60% to 70%, compared with 38% to 46% with usual care.56,80,81

However, these strategies largely did not address misconceptions patients have about hypertension. This issue is especially critical in African Americans, who may have different perceptions of hypertension and different expectations for care41: beliefs that hypertension is “curable,” not chronic, and that medication is needed only for hypertension-related symptoms may translate to poorer rates of medication adherence.

Levine et al1 evaluated the efficacy of home visits by trained community health advisory board workers in a neighborhood in Baltimore, MD, with a high prevalence of hypertension. Participants were randomized to receive either one visit or five visits during the 40-month study period. Both groups had a statistically significant reduction in blood pressure, and in both groups the proportion of patients with adequate blood pressure control increased significantly. The results support the use of a practice- and community-based partnership to improve blood pressure control in African American patients.

Ogedegbe et al2 randomized 190 hypertensive African American patients to receive usual care or quarterly counseling sessions that used motivational interviewing focused on medication adherence. The counseled patients stayed adherent to their medications, whereas adherence declined significantly in those receiving usual care. This effect was associated with a modest, nonsignificant trend toward a net reduction in systolic blood pressure with motivational interviewing.

A novel method of health education is the use of narrative communication—ie, storytelling. It has a good amount of evidence to support it, as culturally appropriate storytelling may allow patients to identify with a story as it relates to their own lives.86–89 Examples of educational storytelling include:

  • A woman with hypertension discussing what it means to have high blood pressure, and the benefits of controlling it, such as living long enough to see her grandchildren grow up
  • A man discussing the importance of involving family and friends to help control blood pressure, and how dietary modifications can be made to ensure that salt alternatives are used when the family does the cooking.

Storytelling should be done in a culturally appropriate context. For example, storytellers should have the same background as the patient (ie, similar socioeconomic status and ethnic background): patients are more likely to be influenced if they identify with the storyteller and imagine themselves in a similar situation.

Houston et al3 randomized 299 hypertensive African Americans to view either three DVDs that featured patients with hypertension or three “attention-control DVDs” on topics not related to hypertension. The intervention group’s DVDs focused on storytelling and “learning more.” In the storytelling section, patients told personal stories about what it meant to have hypertension and gave advice on how to best interact with health care providers and methods to improve medication adherence. A “learning more” section focused on what high blood pressure is, addressed therapeutic lifestyle changes, and encouraged patients to communicate with their health care providers. The patients who viewed the patient narratives had significantly lower blood pressure at 3 months than those assigned to usual care. Although blood pressure subsequently increased in both groups, the benefits of the intervention still existed at the end of follow-up.

Important to note about two of the above three studies1,3 is that the interventions were done by people other than physicians, thus emphasizing the importance of a team approach to blood pressure control.

Behavioral counseling

The effectiveness of lifestyle modifications such as diet, weight loss, and physical activity in preventing and treating hypertension is well established.74–78 For example:

  • In the Dietary Approaches to Stop Hypertension (DASH) trial,76 a healthy diet lowered blood pressure about as much as single drugs do, particularly in African Americans.
  • The Trial of Nonpharmacologic Interventions in the Elderly (TONE)74 showed that exercise can lower blood pressure in obese hypertensive patients.
  • The PREMIER trial (Lifestyle Interventions for Blood Pressure Control)75 showed that a single brief counseling session could produce substantial decreases in blood pressure in patients with stage 1 hypertension or high-normal blood pressure.

Unfortunately, these results have been hard to translate into primary care practice, especially for African American patients. Several studies have evaluated the impact of lifestyle interventions on blood pressure control in primary care practices with a large population of African American patients.

Bosworth et al,4 in a study of a practice in which almost half the patients were African American, randomized patients to receive usual care, nurse-administered tailored behavioral telephone counseling, home blood pressure monitoring, or home monitoring plus tailored behavioral telephone counseling. The combination of home monitoring and tailored behavioral telephone counseling led to a statistically significant improvement at 24 months compared with baseline.

Home blood pressure monitoring

The effectiveness of self-monitoring in improving blood pressure control is also well documented.62,63,65–67,90–95

Pickering et al62 studied patients with poorly controlled hypertension in a managed-care setting and found a reduction of 7 mm Hg systolic and 5 mm Hg diastolic pressure after 3 to 6 months of home monitoring compared with usual care.

Mengden et al,94 in a similar study, found average blood pressure reductions at 6 months of 19.3/11.9 mm Hg in the home-monitoring group vs 10.6/8.8 mm Hg in the usual-care group.

The effect of home blood pressure monitoring may be greater in African Americans.

Rogers et al93 found it to be more effective at lowering blood pressure than usual care in a group of 121 patients with poorly controlled hypertension followed in primary care practices, and these reductions were twice as large in African American patients than in white patients.93

Bondmass,92 in a study of 33 African American patients with poorly controlled hypertension, reported a 53% control rate within 4 weeks of home monitoring. All patients in the study had uncontrolled blood pressure at baseline (> 140/90 mm Hg).

Artinian et al5 evaluated the effect of nurse-managed telemonitoring on blood pressure control vs enhanced usual care. All participants were African American. The monitored group had a significantly greater reduction in systolic pressure at 12 months compared with those who received enhanced usual care.

 

 

PHYSICIAN-LEVEL INTERVENTIONS

Most interventions to improve how physicians manage patients with hypertension are designed to improve adherence to treatment guidelines. In most cases, these interventions are based on continuous quality improvement and disease management concepts such as physician education and academic detailing, reminders, feedback on performance measures, and risk-assessment tools.96,97

Physician education

Interest is increasing in physician educational interventions for blood pressure control.24,98

Inui et al,99 in an early study in a primary care practice, found that patients of physicians who received tutorials on hypertension management were more compliant with their drug regimens and had better blood pressure control than patients of physicians in the control group.

Jennett et al,100 in a similar randomized clinical trial, found that physicians who participated in an education activity were more adherent to treatment guidelines at 6 and 12 months compared with those who did not participate.

Maue et al101 showed that rates of blood pressure control improved from 41% to 52% after a 6-month educational intervention for physicians in a managed-care setting.

Tu et al102 reviewed 12 studies in which seven different physician educational interventions were used either alone or in combination and concluded that physician education improves compliance with guidelines for managing hypertension.

Unfortunately, these studies did not report outcomes separately for African American and white patients.

Hicks et al6 found that disease management approaches that target physicians whose patients with hypertension are mostly African American did not yield clinically relevant improvement in these patients, and that minority patients were significantly less likely to have their blood pressure controlled at the end of the study compared with their non-Hispanic white counterparts.

Feedback to providers

Several studies have shown that, given reminders and feedback systems, physicians will change their practice.103–106

Mashru and Lant104 combined chart audits and physician education in primary care practices and found they improved physician performance measures such as accuracy of diagnosis, number of patients who received cardiovascular risk assessment, and number of patients whose treatment was based on clinical laboratory assessments.

Feedback takes many forms but consists mostly of computerized information107 or peer-to-peer academic detailing with opinion leaders.108–110

Dickinson et al,106 for instance, showed that computer-generated listings of patients’ blood pressures combined with a physician education program on clinical management of hypertension led to increased knowledge and better follow-up on their patients.

Again, however, these studies did not distinguish between African American and white patients, which makes it difficult to judge whether or not these approaches work differently for physicians with a large proportion of African American patients.

Computerized decision-support systems

Computerized decision-support systems have proliferated in primary care practices.111

McAlister et al103 found that general practitioners randomized to manage hypertension with the assistance of a computer obtained better outcomes than with usual care.

Montgomery and Fahey,107 in a systematic review, found improved blood pressure control in two of the three trials that compared computer-generated feedback reports and reminders to usual care. Specifically, 51% of patients whose physicians received reminders either had controlled blood pressure or were at least receiving treatment vs 33% in the control group at 12 months. This difference was even higher at 24 months.

Montgomery et al7 later randomized primary care practices to use a computer-based decision-support system and a cardiovascular risk chart, the risk chart alone, or to continue as usual. Results indicated no reduction in cardiovascular risk in the computer-system or the chart-only group, whereas patients in the chart-only group had a significant reduction in systolic pressure and were prescribed more cardiovascular drugs. This study indicates that use of a computerized decision-support system is not superior to chart review and audit feedback alone.

Evidence that computerized decision systems improve blood pressure control in African Americans is scant. However, when one looks at the evidence from studies of African Americans, the outcomes do not seem to differ between African American and white patients.

Hicks et al6 examined the effectiveness of computerized decision support in improving hypertension care in a racially diverse population. Physicians were randomized to receive computerized decision support or to provide usual care without computerized support. Both groups improved significantly in prescribing appropriate drugs but not in overall blood pressure control. Furthermore, the study showed no reduction in racial disparities of care and blood pressure control.

A potential explanation for the lack of improvement in blood pressure was that the intervention dealt with making sure the appropriate drugs were prescribed rather than making sure physicians also appropriately intensified antihypertensive management when necessary.

 

 

INTERVENTIONS TARGETING PATIENTS AND PHYSICIANS

Several studies have targeted both patient and physician-level barriers to blood pressure control in practice-based settings.

Roumie et al8 randomized physicians to one of three intervention groups:

  • “Provider education” consisting of an email message with a Web-based link to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7)
  • Provider education plus a computer alert with information about their patient’s blood pressure
  • Provider education, a computer alert, and patient education (ie, patients received a letter encouraging adherence to drug therapy, changing their lifestyle, and talking with their doctor about their blood pressure).

Patients whose providers were randomized to the third group had better blood pressure control. The report did not differentiate African American vs white patients. The data, however, did show the effectiveness of adding patient education to provider education to improve blood pressure control.

Bosworth et al,112 in a study in which 40% of patients were African American, randomized patients to usual care or to bimonthly nurse-delivered behavioral telephone counseling. They also randomized providers either to receive computer-generated decision support designed to improve adherence to guidelines or to receive no support.

There were no significant differences in rates of blood pressure control in the intervention groups compared with a control group. Although differences in blood pressure control between groups were not significant, patients randomized to behavioral intervention had significantly better blood pressure control at the 24-month follow-up than at baseline.

Svetkey et al9 evaluated the effects of physician intervention, patient intervention, and physician intervention plus patient intervention compared with control on systolic blood pressure at 6 months. They found that an intensive behavioral lifestyle intervention led to a significant reduction in systolic pressure at 6 months. By itself, the physician intervention did not have a meaningful effect, but patients in the combined physician-and-patient-intervention group experienced the greatest reduction (9.7 ± 12.7 mm Hg).

It takes a team

Physicians should not be the only focus in helping patients achieve blood pressure control. Although physician and patient factors need to be addressed to improve blood pressure control in African Americans, emphasis should also be placed on interdisciplinary, team-based care utilizing health care providers such as nurses, physician assistants, and pharmacists. Team-based care has been shown to have the greatest impact of all the strategies for improving blood pressure control.113 There is a good amount of evidence involving interventions with a focus on health care providers other than physicians, although the data lack a sufficient focus on African Americans.

Carter et al,10 in a randomized controlled trial in which 26.3% of the patients were African American, found that an intervention consisting of clinical pharmacists giving physicians drug therapy recommendations based on national guidelines resulted in a significantly lower blood pressure compared with a control group: the mean reduction was 20.7/9.7 mm Hg in the intervention group vs 6.8/4.5 mm Hg in the control group.

Carter et al114 performed a meta-analysis of 37 studies and found that two strategies led to a significant reduction in blood pressure: a pharmacist-led intervention with treatment recommendations to physicians resulted in a systolic pressure reduction of 9.30 mm Hg; and nurse-led interventions resulted in a systolic pressure reduction of 4.80 mm Hg. Again, many of the studies cited in this meta-analysis lacked a focus on African Americans.

Hunt et al11 conducted a randomized controlled trial in which pharmacists actively participated in the management of blood pressure. They were involved with every aspect of care, including reviewing medications and adverse drug reactions, assessing lifestyle behaviors and barriers to adherence, making dosing adjustments, and adding medications. Patients randomized to the intervention group achieved significantly lower systolic and diastolic pressures (137/75 vs 143/78 mm Hg in the control group). However, information about race was not included.

The above studies are just a few out of a large body of evidence demonstrating the value of team-based care to improve blood pressure control. It has yet to be determined whether these models can improve blood pressure control specifically in African Americans, since so many of these trials lacked a focus on this group. Promising is an ongoing randomized prospective trial by Carter et al115 evaluating a model of collaboration between physicians and pharmacists, with a focus on patients in underrepresented minorities.

SO WHAT WORKS?

Although there is a growing body of literature on interventions to try to reduce disparities in hypertension and blood pressure control between African Americans and whites, only a few randomized controlled trials have focused on African Americans, and several have not reported their results.116 So the question remains: How should we interpret the available data, which are aggregated across racial groups, and put it into practice when caring for hypertensive African American patients?

Patient education. In trying to overcome patient-related barriers, emphasis should be on patient education, in particular addressing misconceptions about hypertension and promoting adherence to antihypertensive therapy. This is evident from the narrative storytelling intervention by Houston et al.3 Although this is the first study of its kind, this strategy may be something to consider if future studies replicate these findings. Culturally appropriate storytelling may allow patients to identify with the stories as they relate to their own personal lives. It can be an effective way to address patient education and change behaviors.

Self-monitoring with a home blood pressure monitor has also proven effective in the management of hypertension in African Americans. Indeed, the few studies that reported findings in African Americans showed impressive reductions in blood pressure. The benefits of home monitoring are well documented, and the effect on physician-related barriers such as clinical inertia are also quite impressive.117 However, most of these studies did not assess the long-term impact or cost-effectiveness of home monitoring on blood pressure control.

Behavioral counseling. Although we have good evidence of the effectiveness of behavioral counseling, whether this is sustained long-term has been less studied in African Americans. Thus, while interventions that targeted African Americans have reported impressive reductions in blood pressure, the effect tends to be greatest during the first few months of implementation, with the benefits disappearing over time.

Physician-related interventions. With regard to physician-level interventions, research has focused on physician education, utilizing alerts and computerized clinical decision-support systems. Evidence is scant on whether the use of computerized systems results in improves hypertension care in African Americans. However, a closer look at the data from studies that report outcomes in African American and white patients shows that the results do not seem to differ between these groups. Still, there is insufficient information about the impact on hypertensive African Americans.6

Strategies that address both patient- and physician-related barriers can improve overall blood pressure control; however, there is a lack of data comparing outcomes in hypertensive African Americans with those of whites, making it difficult to know if this would be an effective strategy in African American patients alone.

More studies needed that focus on African Americans

Developing interventions to improve blood pressure control in African Americans should be an ongoing priority for research if we intend to address racial disparities in cardiovascular disease. Although it is reassuring that there is a growing body of evidence and research with this focus,118–121 more research is needed to determine effective strategies that address barriers related to physician practice and to the health care system overall as they relate to blood pressure control in African Americans. More importantly, these strategies should also emphasize a team-based approach that includes nurses, pharmacists, and physician assistants. Developing targeted interventions for hypertensive African Americans will help reduce disparities in the rates of cardiovascular illness and death in this patient population.

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Issue
Cleveland Clinic Journal of Medicine - 79(1)
Issue
Cleveland Clinic Journal of Medicine - 79(1)
Page Number
46-56
Page Number
46-56
Publications
Cleveland Clinic Journal of Medicine
Publications
Cleveland Clinic Journal of Medicine
Topics
Cardiology
Drug Therapy
Article Type
Article
Display Headline
Overcoming barriers to hypertension control in African Americans
Display Headline
Overcoming barriers to hypertension control in African Americans
Sections
Addressing Disparities in Health Care
Inside the Article

KEY POINTS

  • Rates of cardiovascular disease and related death are disparately high in African Americans.
  • Ways to improve how physicians manage blood pressure in this patient population may include chart audit with feedback, a computerized clinical decision-support system, and keeping up-to-date with treatment guidelines. However, more data are needed to determine the effectiveness of these interventions.
  • A novel method of health education is the use of narrative communication—ie, storytelling. Culturally appropriate storytelling may allow patients to identify with a story as it relates to their own lives.
  • A team-based approach to blood pressure control that involves nurses, pharmacists, and physician assistants should be emphasized, even though studies that have shown positive results did not focus specifically on African Americans.
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