Overcoming barriers to hypertension control in African Americans
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.
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.
