Addressing Disparities in Health Care

Overcoming barriers to hypertension control in African Americans

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ABSTRACTBarriers to blood pressure control exist at the patient, physician, and system levels. We review the current evidence for interventions that target patient- and physician-related barriers, such as patient education, home blood pressure monitoring, and computerized decision-support systems for physicians, and we emphasize the need for more studies that address the effectiveness of these interventions in African American patients.

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.


 

References

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

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