Overcoming barriers to hypertension control in African Americans

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.