Racial differences in blood pressure control: potential explanatory factors

The Renin-Angiotensin-Aldosterone System, Nitric Oxide, and Hydrogen Sulfide at the Crossroads of Hypertension and COVID-19: Racial Disparities and Outcomes

Coronavirus disease 2019 is caused by SARS-CoV-2 and is more severe in the elderly, racial minorities, and those with comorbidities such as hypertension and diabetes. These pathologies are often controlled with medications involving the renin-angiotensin-aldosterone system (RAAS). RAAS is an endocrine system involved in maintaining blood pressure and blood volume through components of the system. SARS-CoV-2 enters the cells through ACE2, a membrane-bound protein related to RAAS. Therefore, the use of RAAS inhibitors could worsen the severity of COVID-19's symptoms, especially amongst those with pre-existing comorbidities. Although a vaccine is currently available to prevent and reduce the symptom severity of COVID-19, other options, such as nitric oxide and hydrogen sulfide, may also have utility to prevent and treat this virus.

User preferences for and engagement with text messages to support antihypertensive medication adherence: Findings from a pilot study evaluating an emergency department-based behavioral intervention

OBJECTIVE

We examined users' preferences for and engagement with text messages delivered as part of an emergency department (ED)-based intervention to improve antihypertensive medication adherence.

METHODS

We recruited ED patients with elevated blood pressure for a pilot randomized trial evaluating a medication adherence intervention with text messages. Intervention participants chose text content and frequency, received texts for 45 days, and completed a feedback survey. We defined engagement via responses to texts. We examined participant characteristics associated with text preferences, engagement, and feedback.

RESULTS

Participants (N = 101) were 57% female and 46% non-White. Most participants (71%) chose to receive both reminder and informational texts; 94% chose reminder texts once per day and 97% chose informational texts three times per week. Median text message response rate was 56% (IQR 26-80%). Participants who were Black (p < 0.01), had lower income (p = 0.03), or had lower medication adherence (p < 0.01) rated the program as more helpful and wanted additional functionalities for adherence support.

CONCLUSIONS AND PRACTICE IMPLICATIONS

While overall engagement was modest, participants at risk of worse health outcomes expressed more value and interest in the program. Findings inform the design of text messaging interventions for antihypertensive medication adherence and support targeting vulnerable patients to reduce health disparities.

CLINICAL TRIALS REGISTRATION

NCT02672787.

Effect of Values Affirmation on Reducing Racial Differences in Adherence to Hypertension Medication: The HYVALUE Randomized Clinical Trial

IMPORTANCE

Stereotype threat, or the fear of confirming a negative stereotype about one's social group, may contribute to racial differences in adherence to medications by decreasing patient activation to manage chronic conditions.

OBJECTIVE

To examine whether a values affirmation writing exercise improves medication adherence and whether the effect differs by patient race.

DESIGN, SETTING, AND PARTICIPANTS

The Hypertension and Values trial, a patient-level, blinded randomized clinical trial, compared an intervention and a control writing exercise delivered immediately prior to a clinic appointment. Of 20 777 eligible, self-identified non-Hispanic Black and White patients with uncontrolled hypertension who were taking blood pressure (BP) medications, 3891 were approached and 960 enrolled. Block randomization by self-identified race ensured balanced randomization. Patients enrolled between February 1, 2017, and December 31, 2019, at 11 US safety-net and community primary care clinics, with outcomes assessed at 3 and 6 months. Analysis was performed on an intention-to-treat basis.

INTERVENTIONS

From a list of 11 values, intervention patients wrote about their most important values and control patients wrote about their least important values.

MAIN OUTCOMES AND MEASURES

The primary outcome of adherence to BP medications was measured using pharmacy fill data (proportion of days covered >90%) at baseline, 3 months, and 6 months. The secondary outcome was systolic and diastolic BP. Patient activation to manage their health was also measured.

RESULTS

Of 960 patients, 474 (286 women [60.3%]; 256 Black patients [54.0%]; mean [SD] age, 63.4 [11.9] years) were randomly assigned to the intervention group and 486 (288 women [59.3%]; 272 Black patients [56.0%]; mean [SD] age, 62.8 [12.0] years) to the control group. Baseline medication adherence was lower (318 of 482 [66.0%] vs 331 of 412 [80.3%]) and mean (SE) BP higher among Black patients compared with White patients (systolic BP, 140.6 [18.5] vs 137.3 [17.8] mm Hg; diastolic BP, 83.9 [12.6] vs 79.7 [11.3] mm Hg). Compared with baseline, pharmacy fill adherence did not differ between intervention and control groups at 3 months (odds ratio [OR], 0.91 [95% CI, 0.57-1.43]) or at 6 months (OR, 0.86 [95% CI, 0.53-1.38]). There were also no treatment effect differences in pharmacy fill adherence by patient race (Black patients at 3 months: OR, 1.08 [95% CI, 0.61-1.92]; at 6 months: OR, 1.04 [95% CI, 0.58-1.87]; White patients at 3 months: OR, 0.68 [95% CI, 0.33-1.44]; at 6 months: OR, 0.55 [95% CI, 0.24-1.27]). Immediately after the intervention, the median patient activation was higher in intervention patients than in control patients, but this difference was not statistically significant in an unadjusted comparison (75.0 [IQR, 65.5-84.8] vs 72.5 [IQR, 63.1-80.9]; P = .06). In adjusted models, the Patient Activation Measure score immediately after the intervention was significantly higher in the intervention patients than in control patients (mean difference, 2.3 [95% CI, 0.1-4.5]).

CONCLUSIONS AND RELEVANCE

A values affirmation intervention was associated with higher patient activation overall but did not improve adherence or blood pressure among Black and White patients with hypertension.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03028597.

Genetic aortic disease epidemiology, management principles, and disparities in care

Patients with syndromic and nonsyndromic heritable aortopathies (also known as genetic aortic disease) are a heterogeneous group of patients who present at younger ages with more rapid growth of aortic aneurysms and/or increased frequency of dissections compared with patients with atherosclerotic aortopathies. In this review, we describe the etiology, epidemiology, and appropriate care delivery for these conditions at each stage of management. Within each section, we discuss sex, gender, and race differences and highlight disparities in care and knowledge. We then discuss the role of the vascular team throughout the cycle of care and the evolving inclusion of patient input in research. This understanding is essential to the creation of effective health care policies that support equitable, appropriate, and patient-centered clinical practices.

Cumulative psychosocial factors are associated with cardiovascular disease risk factors and management among African Americans in the Jackson Heart Study

BACKGROUND

Racial disparities in cardiovascular disease (CVD) have been attributed in part to negative psychosocial factors. Prior studies have demonstrated associations between individual psychosocial factors and CVD risk factors, but little is known about their cumulative effects.

METHODS

Using the Jackson Heart Study, we examined the cross-sectional associations of cumulative psychosocial factors with CVD risk factors among 5306 African Americans. We utilized multivariable Poisson regression to estimate sex-stratified prevalence ratios (PR 95% confidence interval-CI) of obesity, hypertension and diabetes prevalence and hypertension and diabetes control with negative affect (cynicism, anger-in, anger-out, depressive symptoms and cumulative negative affect) and stress (global stress, weekly stress, major life events-MLEs and cumulative stress), adjusting for demographics, socioeconomic status, and behaviors.

RESULTS

After full adjustment, high (vs. low) cumulative negative affect was associated with prevalent obesity among men (PR 1.36 95% CI 1.16-1.60), while high (vs. low) cumulative stress was similarly associated with obesity among men and women (PR 1.24 95% CI 1.01-1.52 and PR 1.13 95% CI 1.03-1.23, respectively). Psychosocial factors were more strongly associated with prevalent hypertension and diabetes among men than women. For example, men who reported high cynicism had a 12% increased prevalence of hypertension (PR 1.12, 95% CI 1.03-1.23). Psychosocial factors were more strongly associated with lower hypertension and diabetes control for women than men. Women who reported high (vs. low) cynicism had a 38% lower prevalence of hypertension control (PR 0.62, 95% CI 0.46-0.84).

CONCLUSIONS

Cumulative psychosocial factors were associated with CVD risk factors and disease management among African Americans. The joint accumulation of psychosocial factors was more associated with risk factors for men than women.

Association of West African ancestry and blood pressure control among African Americans taking antihypertensive medication in the Jackson Heart Study

African Americans have a wide range of continental genetic ancestry. It is unclear whether racial differences in blood pressure (BP) control are related to ancestral background. The authors analyzed data from the Jackson Heart Study, a cohort exclusively comprised of self-identified African Americans, to assess the association between estimated West African ancestry (WAA) and BP control (systolic and diastolic BP < 140/90 mm Hg). Three nested modified Poisson regression models were used to calculate prevalence ratios for BP control associated with the three upper quartiles, separately, vs the lowest quartile of West African ancestry. The authors analyzed data from 1658 participants with hypertension who reported taking all of their antihypertensive medications in the previous 24 hours. WAA was estimated using 389 ancestry informative markers and categorized into quartiles (Q1: <73.7%, Q2: >73.7%-81.0%, Q3: >81.0%-86.3%, and Q4: >86.3%). The proportion of participants with controlled BP in the lowest-to-highest WAA quartile was 75.2%, 76.1%, 76.6%, and 74.4%. The prevalence ratios (95% CI) for controlled BP comparing Q2, Q3, and Q4 to Q1 of WAA were 1.00 (0.93-1.08), 1.02 (0.94-1.10), and 0.99 (0.91-1.07), respectively. Among African Americans in the Jackson Heart Study taking antihypertensive medication, BP control rates did not differ across quartiles of WAA.

Baseline Predictors of Low-Density Lipoprotein Cholesterol and Systolic Blood Pressure Goal Attainment After 1 Year in the ISCHEMIA Trial

BACKGROUND

Risk factor control is the cornerstone of managing stable ischemic heart disease but is often not achieved. Predictors of risk factor control in a randomized clinical trial have not been described.

METHODS AND RESULTS

The ISCHEMIA trial (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) randomized individuals with at least moderate inducible ischemia and obstructive coronary artery disease to an initial invasive or conservative strategy in addition to optimal medical therapy. The primary aim of this analysis was to determine predictors of meeting trial goals for LDL-C (low-density lipoprotein cholesterol, goal <70 mg/dL) or systolic blood pressure (SBP, goal <140 mm Hg) at 1 year post-randomization. We included all randomized participants in the ISCHEMIA trial with baseline and 1-year LDL-C and SBP values by January 28, 2019. Among the 3984 ISCHEMIA participants (78% of 5179 randomized) with available data, 35% were at goal for LDL-C, and 65% were at goal for SBP at baseline. At 1 year, the percent at goal increased to 52% for LDL-C and 75% for SBP. Adjusted odds of 1-year LDL-C goal attainment were greater with older age (odds ratio [OR], 1.11 [95% CI, 1.03-1.20] per 10 years), lower baseline LDL-C (OR, 1.19 [95% CI, 1.17-1.22] per 10 mg/dL), high-intensity statin use (OR, 1.30 [95% CI, 1.12-1.51]), nonwhite race (OR, 1.32 [95% CI, 1.07-1.63]), and North American enrollment compared with other regions (OR, 1.32 [95% CI, 1.06-1.66]). Women were less likely than men to achieve 1-year LDL-C goal (OR, 0.68 [95% CI, 0.58-0.80]). Adjusted odds of 1-year SBP goal attainment were greater with lower baseline SBP (OR, 1.27 [95% CI, 1.22-1.33] per 10 mm Hg) and with North American enrollment (OR, 1.35 [95% CI, 1.04-1.76]).

CONCLUSIONS

In ISCHEMIA, older age, male sex, high-intensity statin use, lower baseline LDL-C, and North American location predicted 1-year LDL-C goal attainment, whereas lower baseline SBP and North American location predicted 1-year SBP goal attainment. Future studies should examine the effects of sex disparities, international practice patterns, and provider behavior on risk factor control.

Discriminative Ability of CHA2DS2-VASc and HAS-BLED Score in Whites and Nonwhites

The CHA₂DS₂-VASc and HAS-BLED scoring systems are used in patients with atrial fibrillation (AF) to estimate risk of stroke and bleeding, respectively. Both were developed in minimally diverse European populations and these scores have not yet been extensively studied in US whites and nonwhites. In a retrospective cohort study, we included patients with AF who received inpatient or outpatient care in a large integrated academic health system from 2011 to 2017. Cox proportional hazards were used to analyze associations between stroke and CHA₂DS₂-VASc score in AF patients not prescribed anticoagulation and between incident bleeding and HAS-BLED score in anticoagulated patients. After exclusions for previous stroke, the cohort included 21,648 patients with a mean age of 66.8 ± 15.8. Anticoagulation was prescribed in 52% of whites and 46% of nonwhites (p < 0.001) with a CHA₂DS₂-VASc score of ≥2. Mean CHA₂DS₂-VASc scores were 2.4 ± 1.6 in whites and 2.2 ± 1.6 in nonwhites and mean HAS-BLED scores was 1.5 ± 1.1 in whites and 1.3 ± 1.0 in nonwhites. After adjusting for baseline differences, the discriminative ability of CHA₂DS₂-VASc and HAS-BLED was similar in whites and nonwhites (p = 0.52, 0.33, respectively). The discriminative ability of HAS-BLED was similar in patients on vitamin K antagonists and direct oral anticoagulants. In conclusion, oral anticoagulation was prescribed less frequently in nonwhites. However, the discriminative ability of CHA₂DS₂-VASc and HAS-BLED were similar in whites and nonwhites.

Using Values Affirmation to Reduce the Effects of Stereotype Threat on Hypertension Disparities: Protocol for the Multicenter Randomized Hypertension and Values (HYVALUE) Trial

Background

Medication nonadherence is a significant, modifiable contributor to uncontrolled hypertension. Stereotype threat may contribute to racial disparities in adherence by hindering a patient’s ability to actively engage during a clinical encounter, resulting in reduced activation to adhere to prescribed therapies.

Objective

The Hypertension and Values (HYVALUE) trial aims to examine whether a values-affirmation intervention improves medication adherence (primary outcome) by targeting racial stereotype threat.

Methods

The HYVALUE trial is a patient-level, blinded randomized controlled trial comparing a brief values-affirmation writing exercise with a control writing exercise among black and white patients with uncontrolled hypertension. We are recruiting patients from 3 large health systems in the United States. The primary outcome is patients’ adherence to antihypertensive medications, with secondary outcomes of systolic and diastolic blood pressure over time, time for which blood pressure is under control, and treatment intensification. We are comparing the effects of the intervention among blacks and whites, exploring possible moderators (ie, patients’ prior experiences of discrimination and clinician racial bias) and mediators (ie, patient activation) of intervention effects on outcomes.

Results

This study was funded by the National Heart, Lung, and Blood Institute. Enrollment and follow-up are ongoing and data analysis is expected to begin in late 2020. Planned enrollment is 1130 patients. On the basis of evidence supporting the effectiveness of values affirmation in educational settings and our pilot work demonstrating improved patient-clinician communication, we hypothesize that values affirmation disrupts the negative effects of stereotype threat on the clinical interaction and can reduce racial disparities in medication adherence and subsequent health outcomes.

Conclusions

The HYVALUE study moves beyond documentation of race-based health disparities toward testing an intervention. We focus on a medical condition—hypertension, which is arguably the greatest contributor to mortality disparities for black patients. If successful, this study will be the first to provide evidence for a low-resource intervention that has the potential to substantially reduce health care disparities across a wide range of health care conditions and populations.

Trial Registration

ClinicalTrials.gov NCT03028597; https://clinicaltrials.gov/ct2/show/NCT03028597 (Archived by WebCite at http://www.webcitation.org/72vcZMzAB).

International Registered Report Identifier (IRRID)

DERR1-10.2196/12498

Rationale and study design of the MyHEART study: A young adult hypertension self-management randomized controlled trial

Young adults (18-39 year-olds) with hypertension have a higher lifetime risk for cardiovascular disease. However, less than 50% of young adults achieve hypertension control in the United States. Hypertension self-management programs are recommended to improve control, but have been targeted to middle-aged and older populations. Young adults need hypertension self-management programs (i.e., home blood pressure monitoring and lifestyle modifications) tailored to their unique needs to lower blood pressure and reduce the risks and medication burden they may face over a lifetime. To address the unmet need in hypertensive care for young adults, we developed MyHEART (My Hypertension Education And Reaching Target), a multi-component, theoretically-based intervention designed to achieve self-management among young adults with uncontrolled hypertension. MyHEART is a patient-centered program, based upon the Self-Determination Theory, that uses evidence-based health behavior approaches to lower blood pressure. Therefore, the objective of this study is to evaluate MyHEART's impact on changes in systolic and diastolic blood pressure compared to usual care after 6 and 12 months in 310 geographically and racially/ethnically diverse young adults with uncontrolled hypertension. Secondary outcomes include MyHEART's impact on behavioral outcomes at 6 and 12 months, compared to usual clinical care (increased physical activity, decreased sodium intake) and to examine whether MyHEART's effects on self-management behavior are mediated through variables of perceived competence, autonomy, motivation, and activation (mediation outcomes). MyHEART is one of the first multicenter, randomized controlled hypertension trials tailored to young adults with primary care. The design and methodology will maximize the generalizability of this study. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03158051.

Promoting Health Equity And Eliminating Disparities Through Performance Measurement And Payment

Current approaches to health care quality have failed to reduce health care disparities. Despite dramatic increases in the use of quality measurement and associated payment policies, there has been no notable implementation of measurement strategies to reduce health disparities. The National Quality Forum developed a road map to demonstrate how measurement and associated policies can contribute to eliminating disparities and promote health equity. Specifically, the road map presents a four-part strategy whose components are identifying and prioritizing areas to reduce health disparities, implementing evidence-based interventions to reduce disparities, investing in the development and use of health equity performance measures, and incentivizing the reduction of health disparities and achievement of health equity. To demonstrate how the road map can be applied, we present an example of how measurement and value-based payment can be used to reduce racial disparities in hypertension among African Americans.

Change in Cardiometabolic Risk Among Blacks, Whites, and Hispanics: Findings From the Health and Retirement Study

Background

Blacks experience greater multisystem physiological dysregulation, or cumulative biological risk, which is associated with poor cardiometabolic health and mortality. In this study, we assess race differences in change in risk over 4 years among older whites, blacks, and Hispanics.

Method

We examined race differences in 4-year change in individual biomarkers and a cumulative measure of risk-cardiometabolic risk (CMR)-using data for each respondent from two waves of the Health and Retirement Study's biomarker assessment (n = 5,512). CMR is a count of high-risk cardiovascular and metabolic biomarkers. We estimated mean CMR at baseline and follow-up by race/ethnicity, and used logistic regression to determine whether race differences exist in 4-year transitions between high- and low-risk states for individual biomarkers.

Results

Blacks had higher baseline CMR than whites and Hispanics and experienced an increase in risk over 4 years; conversely, CMR decreased among whites and Hispanics. Blacks were more likely to develop high-risk pulse pressure and high-risk hemoglobin A1c, which contributed to increases in CMR. Whites and Hispanics were more likely to become low-risk on C-reactive protein and high-density lipoprotein cholesterol which contributed to declines in CMR. Race differences in transitions between risk states remained after controlling for social, behavioral, and health care-related factors. However, the racial patterning of these differences was influenced by disease diagnosis and medication use.

Conclusions

We show that the cardiometabolic health of older blacks worsens as they age both absolutely and relative to that of whites and Hispanics because of poor blood pressure control and diabetes prevention.

Stress, adherence, and blood pressure control: A baseline examination of Black women with hypertension participating in the SisterTalk II intervention

The prevalence of hypertension is highest among Black women, but treatment adherence is reportedly low. Stress unique to the experiences of Black Americans may be associated with low adherence and poor blood pressure control, but few studies have examined the relationships between stress, adherence, and blood pressure control among hypertensive Black women. This study seeks to fill gaps in research by examining the association between stress, adherence, and blood pressure control. The baseline sample (n = 571) of at-risk or hypertensive Black women from the SisterTalk II RCT (Northeastern USA, 2004-2006) to improve adherence to recommendations for hypertension was analyzed. Participants self-reported stress, pharmacological adherence, non-pharmacological adherence (i.e. lifestyle management such as diet and exercise), and demographics. Blood pressure and anthropometrics (BMI and waist circumference) were measured. Statistical analysis included ANOVA, t-tests, linear regression. Tests of mediation examined if adherence mediated the relationship between stress and blood pressure control. This study found that stress was associated with lower age (p < .001) and being a single parent (p < .001). Stress was also associated with higher systolic blood pressure (p = .029), and poor blood pressure control (p = .043). Participants who reported higher stress also reported lower non-pharmacological adherence (p = .042). Non-pharmacological adherence was found to mediate the association between stress and blood pressure control. Hence, results document a relationship between stress with non-pharmacological adherence and blood pressure control among Black American women. More research is necessary to examine the relationship between stress and treatment adherence.

Chronotherapy for Hypertension

PURPOSE OF REVIEW

Given the emerging knowledge that circadian rhythmicity exists in every cell and all organ systems, there is increasing interest in the possible benefits of chronotherapy for many diseases. There is a well-documented 24-h pattern of blood pressure with a morning surge that may contribute to the observed morning increase in adverse cardiovascular events. Historically, antihypertensive therapy involves morning doses, usually aimed at reducing daytime blood pressure surges, but an absence of nocturnal dipping blood pressure is also associated with increased cardiovascular risk.

RECENT FINDINGS

To more effectively reduce nocturnal blood pressure and still counteract the morning surge in blood pressure, a number of studies have examined moving one or more antihypertensives from morning to bedtime dosing. More recently, such studies of chronotherapy have studied comorbid populations including obstructive sleep apnea, chronic kidney disease, or diabetes. Here, we summarize major findings from recent research in this area (2013-2017). In general, nighttime administration of antihypertensives improved overall 24-h blood pressure profiles regardless of disease comorbidity. However, inconsistencies between studies suggest a need for more prospective randomized controlled trials with sufficient statistical power. In addition, experimental studies to ascertain mechanisms by which chronotherapy is beneficial could aid drug design and guidelines for timed administration.

Risk Factors for Low Pharmacy Refill Adherence Among Older Hypertensive Men and Women by Race

BACKGROUND

Sex-race stratification may lead to identification of risk factors for low antihypertensive medication adherence that are not apparent when assessing risk factors in women and men without race stratification. We examined risk factors associated with low pharmacy refill adherence across sex-race subgroups (white women, black women, white men, black men) within the Cohort Study of Medication Adherence among Older Adults (n = 2,122).

METHODS

Pharmacy refill adherence was calculated as proportion of days covered using all antihypertensive prescriptions filled in the year prior to a baseline risk factor survey. Sex- and sex-race-stratified multivariable Poisson regression models with robust standard errors were used to estimate adjusted prevalence ratios and 95% confidence intervals for associations between participant characteristics and low adherence.

RESULTS

Prevalence of low adherence was 22.9% vs. 40.7% in white vs. black women (P < 0.001) and 26.3% vs. 37.2% in white vs. black men (P = 0.003). In multivariable models, reducing antihypertensive medication due to cost was associated with low adherence within each sex-race subgroup. Additional factors associated with low adherence included shorter hypertension duration and comorbidities in white women; not being married and depressive symptoms in white men; and ≥6 primary care visits/year and complementary and alternative medicine use in black men. Among men, not being married and reporting depressive symptoms were associated with low adherence for whites, but not blacks.

CONCLUSIONS

Identification of sex-race-specific risk factors for low antihypertensive medication adherence may guide development and implementation of tailored interventions to increase antihypertensive medication adherence and blood pressure control among older patients.

Health literacy and health outcomes in hypertension: An integrative review

OBJECTIVE

The aim of this study was to summarize the evidence of health literacy and health outcomes in hypertensive patients.

METHODS

Articles published in English were searched from six databases: MEDLINE, CINAHL, Embase, ERIC, psycINFO, and SCOPUS. The articles published up to September 2017 were included.

RESULTS

Nineteen publications were included in the review. There was quality and consistent evidence that hypertensive patients with lower literacy had poorer knowledge. There was inconsistent evidence to show the relationship between health literacy and clinical outcomes, of systolic and diastolic blood pressure, and blood pressure control; behavioral outcomes, of self-care, self-efficacy, adherence; patient-physician interactions outcomes, of patient-physician communication, patient trust, involvement in decision making and other outcomes.

CONCLUSION

The person with low health literacy is likely to have poor knowledge of hypertension. However, there is insufficient evidence to suggest that health literacy is associated with outcomes of hypertension independently.

A Review of ACE Inhibitors and ARBs in Black Patients With Hypertension

Objective: To review current guidelines and recent data evaluating the efficacy and safety of angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) in black hypertensive patients. Data Sources: Articles evaluating race-specific outcomes in hypertension were gathered using a MEDLINE search with keywords black, African American, ACE inhibitor, angiotensin receptor blocker, angiotensin system, and hypertension. Studies published from 2000 through April 2018 were reviewed. Study Selection and Data Extraction: Six guidelines, 8 monotherapy publications, and 5 combination therapy publications included race-specific results and were included in the review. The authors individually compared and contrasted the results from each publication. Data Synthesis: Numerous monotherapy trials indicate that black patients may have a reduced blood pressure (BP) response with ACE inhibitors or ARBs compared with white patients. Conversely, additional studies propose that race may not be the primary predictor of BP response. Reduced efficacy is not observed in trials involving combination therapy. Some studies suggest increased cardiovascular and cerebrovascular morbidity and mortality with ACE inhibitor or ARB monotherapy in black patients; however, data are conflicting. Relevance to Patient Care and Clinical Practice: This article clarifies vague guideline statements and informs clinicians on the appropriate use of ACE inhibitors or ARBs for hypertension treatment in black patients through an in-depth look into the evidence. Conclusions: Potentially reduced efficacy and limited outcomes data indicate that ACE inhibitors or ARBs should not routinely be initiated as monotherapy in black hypertensive patients. Use in combination with a calcium channel blocker or thiazide diuretic is efficacious in black patients, and there are no data showing that this increases or decreases cardiovascular or cerebrovascular outcomes.

Racial disparities in the prevalence and control of hypertension among a cohort of HIV-infected patients in the southeastern United States

BACKGROUND

African Americans are disproportionately affected by both HIV and hypertension. Failure to modify risk factors for cardiovascular disease and chronic kidney disease such as hypertension among HIV-infected patients may attenuate the benefits conferred by combination antiretroviral therapy. In the general population, African Americans with hypertension are less likely to have controlled blood pressure than whites. However, racial differences in blood pressure control among HIV-infected patients are not well studied.

METHODS

We conducted a cross-sectional study evaluating racial differences in hypertension prevalence, treatment, and control among 1,664 patients attending the University of Alabama at Birmingham HIV Clinic in 2013. Multivariable analyses were performed to calculate prevalence ratios (PR) with 95% confidence intervals (CI) as the measure of association between race and hypertension prevalence and control while adjusting for other covariates.

RESULTS

The mean age of patients was 47 years, 77% were male and 54% African-American. The prevalence of hypertension was higher among African Americans compared with whites (49% vs. 43%; p = 0.02). Among those with hypertension, 91% of African Americans and 93% of whites were treated (p = 0.43). Among those treated, 50% of African Americans versus 60% of whites had controlled blood pressure (systolic blood pressure <140 mmHg and diastolic blood pressure <90 mmHg) (p = 0.007). After multivariable adjustment for potential confounders, prevalence of hypertension was higher among African Americans compared to whites (PR 1.25; 95% CI 1.12-1.39) and prevalence of BP control was lower (PR 0.80; 95% CI 0.69-0.93).

CONCLUSIONS

Despite comparable levels of hypertension treatment, African Americans in our HIV cohort were less likely to achieve blood pressure control. This may place them at increased risk for adverse outcomes that disproportionately impact HIV-infected patients, such as cardiovascular disease and chronic kidney disease, and thus attenuate the benefits conferred by combination antiretroviral therapy.

Financial strain is associated with medication nonadherence and worse self-rated health among cardiovascular patients

Non-traditional indicators of socioeconomic status (SES; e.g., home ownership) may be just as or even more predictive of health outcomes as traditional indicators of SES (e.g., income). This study tested whether financial strain (i.e., difficulty paying monthly bills) predicted medication non-adherence and worse self-rated health. Research assistants administered surveys to 1,527 patients with acute coronary syndromes or acute decom-pensated heart failure. In adjusted models, having a higher income was associated with being more adherent (p &lt; .001), but was non-significant when adjusted for financial strain. Education, income, less financial strain, and being employed were each associated with better self-rated health (p &lt; .001). Financial strain was associated with less adherence (β =-.17, p &lt; .001) and worse self-rated health (β = -.23, p &lt; .001), and mediated the effect of income on adherence (coeff = .078 [BCa 95% CI: .051 to .108]). Future research should further explore the nuanced link between SES and health behaviors and outcomes.

Racial/Ethnic Disparities in Quality of Care for Cardiovascular Disease in Ambulatory Settings: A Review

Racial and ethnic disparities in cardiovascular disease (CVD) outcomes are widely reported, but research has largely focused on differences in quality of inpatient and urgent care to explain these disparate outcomes. The objective of this review is to synthesize recent evidence on racial and ethnic disparities in management of CVD in the ambulatory setting. Database searches yielded 550 articles of which 25 studies met the inclusion criteria. Reviewed studies were categorized into non-interventional studies examining the association between race and receipt of ambulatory CVD services with observational designs, and interventional studies evaluating specific clinical courses of action intended to ameliorate disparities. Based on the Donabedian framework, this review demonstrates that significant racial/ethnic disparities persist in process and outcome measures of quality of ambulatory CVD care. Multimodal interventions were most effective in reducing disparities in CVD outcomes.

Ethnic and racial disparities in hypertension management among women

Hypertension is a major independent risk factor for cardiovascular disease for all ethnic and racial groups. Compared with other lifestyle and metabolic risk factors, hypertension is the leading cause of death in women. Women with preeclampsia are three times more likely to develop chronic hypertension and have an elevated risk of future cardiovascular disease. The objective of this article is to provide a review of the factors related to racial and ethnic disparities in blood pressure control. This is followed by a summary of contemporary clinical practice guidelines for the prevention, through lifestyle behavioral modification, and treatment of hypertension with pharmacotherapy.

Effect of Expectation of Care on Adherence to Antihypertensive Medications Among Hypertensive Blacks: Analysis of the Counseling African Americans to Control Hypertension (CAATCH) Trial

Novel ideas are needed to increase adherence to antihypertensive medication. The current study used data from the Counseling African Americans to Control Hypertension (CAATCH) study, a sample of 442 hypertensive African Americans, to investigate the mediating effects of expectation of hypertension care, social support, hypertension knowledge, and medication adherence, adjusting for age, sex, number of medications, diabetes, education, income, employment, insurance status, and intervention. Sixty-six percent of patients had an income of $20,000 or less and 56% had a high school education or less, with a mean age of 57 years. Greater expectation of care was associated with greater medication adherence (P=.007), and greater social support was also associated with greater medication adherence (P=.046). Analysis also showed that expectation of care mediated the relationship between hypertension knowledge and medication adherence (P<.05). Expectation of care and social support are important factors for developing interventions to increase medication adherence among blacks.

Primary Care Providers Perceptions of Racial/Ethnic and Socioeconomic Disparities in Hypertension Control

OBJECTIVE

To evaluate the attitudes and perceptions of primary care providers (PCPs) regarding the presence and underlying sources of racial/ethnic and socioeconomic disparities in hypertension control.

METHODS

We conducted a survey of 115 PCPs from 2 large academic centers in Colorado. We included physicians, nurse practitioners, and physician assistants. The survey assessed provider recognition and perceived contributors of disparities in hypertension control.

RESULTS

Respondents were primarily female (66%), non-Hispanic White (84%), and physicians (80%). Among respondents, 67% and 73% supported the collection of data on the patients' race/ethnicity and socioeconomic status (SES), respectively. Eighty-six percent and 89% agreed that disparities in race/ethnicity and SES existed in hypertension care within the US health system. However, only 33% and 44% thought racial/ethnic and socioeconomic disparities existed in the care of their own patients. Providers were more likely to perceive patient factors rather than provider or health system factors as mediators of disparities. However, most supported interventions such as improving provider communication skills (87%) and cultural competency training (89%) to reduce disparities in hypertension control.

CONCLUSIONS

Most providers acknowledged that racial/ethnic and socioeconomic disparities in hypertension control exist in the US health system, but only a minority reported disparities in care among patients they personally treat. Our study highlights the need for testing an intervention aimed at increasing provider awareness of disparities within the local health setting to improve hypertension control for minority patients.

Reducing racial and ethnic disparities in hypertension prevention and control: what will it take to translate research into practice and policy?

INTRODUCTION

Despite available, effective therapies, racial and ethnic disparities in care and outcomes of hypertension persist. Several interventions have been tested to reduce disparities; however, their translation into practice and policy is hampered by knowledge gaps and limited collaboration among stakeholders.

METHODS

We characterized factors influencing disparities in blood pressure (BP) control by levels of an ecological model. We then conducted a literature search using PubMed, Scopus, and CINAHL databases to identify interventions targeted toward reducing disparities in BP control, categorized them by the levels of the model at which they were primarily targeted, and summarized the evidence regarding their effectiveness.

RESULTS

We identified 39 interventions and several state and national policy initiatives targeted toward reducing racial and ethnic disparities in BP control, 5 of which are ongoing. Most had patient populations that were majority African-American. Of completed interventions, 27 demonstrated some improvement in BP control or related process measures, and 7 did not; of the 6 studies examining disparities, 3 reduced, 2 increased, and 1 had no effect on disparities.

CONCLUSIONS

Several effective interventions exist to improve BP in racial and ethnic minorities; however, evidence that they reduce disparities is limited, and many groups are understudied. To strengthen the evidence and translate it into practice and policy, we recommend rigorous evaluation of pragmatic, sustainable, multilevel interventions; institutional support for training implementation researchers and creating broad partnerships among payers, patients, providers, researchers, policymakers, and community-based organizations; and balance and alignment in the priorities and incentives of each stakeholder group.

Medication Routines and Adherence Among Hypertensive African Americans

Poor adherence to prescribed medication regimens remains an important challenge preventing successful treatment of cardiovascular diseases such as hypertension. While studies have documented differences in the time of day or weekday vs weekend on medication adherence, no study has examined whether having a medication-taking routine contributes to increased medication adherence. The purpose of this study was to: (1) identify patients' sociodemographic factors associated with consistent medication-taking routine; (2) examine associations between medication-taking consistency, medication adherence, and blood pressure (BP) control. The study included black patients with hypertension (n = 190; 22 men and 168 women; age, mean±standard deviation 54 ± 12.08 years) who completed a practice-based randomized controlled trial. Findings showed that medication-taking consistency was significantly associated with better medication adherence (F = 9.54, P = .002). Associations with the consistency index were not statistically significant for diastolic BP control (odds ratio, 1.319; 95% confidence interval, 0.410-4.246; P = .642) and systolic BP control (odds ratio, 0.621; 95% confidence interval, 0.195-1.974; P = .419).

Heart matters: Gender and racial differences cardiovascular disease risk factor control among veterans

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of mortality for U.S. women. Racial minorities are a particularly vulnerable population. The increasing female veteran population has an higher prevalence of certain cardiovascular risk factors compared with non-veteran women; however, little is known about gender and racial differences in cardiovascular risk factor control among veterans.

METHODS

We used analysis of variance, adjusting for age, to compare gender and racial differences in three risk factors that predispose to CVD (diabetes, hypertension, and hyperlipidemia) in a cohort of high-risk veterans eligible for enrollment in a clinical trial, including 23,955 men and 1,010 women.

FINDINGS

Low-density lipoprotein (LDL) values were higher in women veterans than men with age-adjusted estimated mean values of 111.7 versus 97.6 mg/dL (p < .01). Blood pressures (BPs) were higher among African-American than White female veterans with age-adjusted estimated mean systolic BPs of 136.3 versus 133.5 mmHg, respectively (p < .01), and diastolic BPs of 82.4 versus 78.9 mmHg (p < .01). African-American veterans with diabetes had worse BP, LDL values, and hemoglobin A1c levels, although the differences were only significant among men.

CONCLUSIONS

Female veterans have higher LDL cholesterol levels than male veterans and African-American veterans have higher BP, LDL cholesterol, and A1c levels than Whites after adjusting for age. Further examination of CVD gender and racial disparities in this population may help to develop targeted treatments and strategies applicable to the general population.

Racial and Ethnic Disparities in Cardiovascular Disease: An Assessment of Obstetrician-Gynecologists' Knowledge, Attitudes, and Practice Patterns

BACKGROUND

African American and Hispanic women are disproportionately affected by cardiovascular disease (CVD) and its many risk factors. Obstetrician-gynecologists (OB/GYNs) play an integral role in well-woman care and have a unique opportunity to provide CVD counseling and screening to these at-risk and underserved groups.

OBJECTIVE

To assess whether OB/GYN race/ethnicity and OB/GYN practices with increasing minority patient populations predicted differences in OB/GYNs' knowledge, attitudes, and practice patterns relevant to racial/ethnic disparities in CVD. This study also sought to determine provider and patient-related barriers to CVD care.

METHOD

A questionnaire on CVD was mailed to 273 members of The American College of Obstetricians and Gynecologists in March-July 2013.

RESULTS

African American and Hispanic OB/GYNs and OB/GYN practices with increasing minority patient populations were more knowledgeable of CVD disparities. These OB/GYNs reported greater concern for minority women's CVD risk relative to White OB/GYNs. Overall, OB/GYNs appear less knowledgeable and concerned with Hispanics' increased CVD risk relative to African Americans'. The most commonly reported provider and patient-related barriers to CVD care were time constraints, patient nonadherence to treatment recommendations, and inadequate training.

CONCLUSION

It is likely that minority OB/GYNs and those with practices with increasing minority patient populations have greater exposure to women at risk for CVD. Dissemination of educational information regarding Hispanic women's CVD risk profile may improve OB/GYN knowledge, counseling, and screening. Increased training in CVD and multicultural competency during medical school and residency should help OB/GYNs overcome what they report as primary barriers to CVD care.

Factors associated with appointment non-adherence among African-Americans with severe, poorly controlled hypertension

BACKGROUND

Missed appointments are associated with an increased risk of hospitalization and mortality. Despite its widespread prevalence, little data exists regarding factors related to appointment non-adherence among hypertensive African-Americans.

OBJECTIVE

To investigate factors associated with appointment non-adherence among African-Americans with severe, poorly controlled hypertension.

DESIGN AND PARTICIPANTS

A cross-sectional survey of 185 African-Americans admitted to an urban medical center in Maryland, with severe, poorly controlled hypertension from 1999-2004. Categorical and continuous variables were compared using chi-square and t-tests. Adjusted multivariable logistic regression was used to assess correlates of appointment non-adherence.

MAIN OUTCOME MEASURES

Appointment non-adherence was the primary outcome and was defined as patient-report of missing greater than 3 appointments out of 10 during their lifetime.

RESULTS

Twenty percent of participants (n = 37) reported missing more than 30% of their appointments. Patient characteristics independently associated with a higher odds of appointment non-adherence included not finishing high school (Odds ratio [OR]  = 3.23 95% confidence interval [CI] (1.33-7.69), hypertension knowledge ([OR]  = 1.20 95% CI: 1.01-1.42), lack of insurance ([OR]  = 6.02 95% CI: 1.83-19.88), insurance with no medication coverage ([OR]  = 5.08 95% CI: 1.05-24.63), cost of discharge medications ([OR]  = 1.20 95% CI: 1.01-1.42), belief that anti-hypertensive medications do not work ([OR]  = 3.67 95% CI: 1.16-11.7), experience of side effects ([OR]  = 3.63 95% CI: 1.24-10.62), medication non-adherence ([OR]  = 11.31 95% CI: 3.87-33.10). Substance abuse was not associated with appointment non-adherence ([OR]  = 1.05 95% CI: 0.43-2.57).

CONCLUSIONS

Appointment non-adherence among African-Americans with poorly controlled hypertension was associated with many markers of inadequate access to healthcare, knowledge, attitudes and beliefs.

Racial differences in hypertension: implications for high blood pressure management

The racial disparity in hypertension and hypertension-related outcomes has been recognized for decades with African Americans with greater risks than Caucasians. Blood pressure levels have consistently been higher for African Americans with an earlier onset of hypertension. Although awareness and treatment levels of high blood pressure have been similar, racial differences in control rates are evident. The higher blood pressure levels for African Americans are associated with higher rates of stroke, end-stage renal disease and congestive heart failure. The reasons for the racial disparities in elevated blood pressure and hypertension-related outcomes risk remain unclear. However, the implications of the disparities of hypertension for prevention and clinical management are substantial, identifying African American men and women with excel hypertension risk and warranting interventions focused on these differences. In addition, focused research to identify the factors attributed to these disparities in risk burden is an essential need to address the evidence gaps.

Lifestyles of Jamaican Men With Hypertension

Purpose: Determine the extent to which the lifestyles of Jamaican men with hypertension met the guidelines of the Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7). Design and Methods: Following informed consent, a convenience sample of Jamaican men with hypertension ( n = 48), of African ethnicity, attending a Type 5 Health Center was interviewed over a four week period, using a 31-item interview schedule. Results: Mean age of respondents was 65.2 (± 12.1) years (range = 35-89 years) with 33% having blood pressure (BP) controlled to 130/80 mmHg. Those meeting the guidelines were normal weight 23 (47.9%), DASH (dietary approaches to stop hypertension) diet zero, medication 7 (14.6%), exercise 14 (29.2%), alcohol restriction 38 (79.2%), and smoking cessation 40 (83.3%). Medication adherence was associated with BP control ( r = −0.30, p < .04). More than half of the respondents believed that hypertension could be cured and that they could stop all treatment if their BP was normal. Discussion and Conclusions: Only a third of the sample had BP controlled to ≤130/80 mmHg. Adherence to the JNC 7 lifestyle guidelines was inadequate. Implications for Practice: A nurse led intervention, focusing on perceptions and lifestyle practices, is indicated.

Hypertension detection, management, control and associated factors among residents accessing community health services in Beijing

The aim of this study was to analyse high blood pressure detection, management, control and associated factors among residents accessing community health services (CHSs) in Beijing. We screened for HBP in 9524 individuals aged 50 years or older who accessed care in four Beijing CHSs. Among the 9397 residents with questionnaire responses that qualified them for inclusion in the study, 5029 patients with HBP were identified, 1510 (i.e., 30% of the HBP patient group) of whom were newly identified cases. The rate of hypertension detection was 53.5%. Among the 5029 HBP patients, the rates of awareness, treatment and control of hypertension were 70.0%, 62.1% and 29.6%, respectively. In general, the rate of hypertension control was higher when the rates of hypertension awareness and treatment were higher in subgroups stratified by different sociodemographic and risk factors, except for the overweight and obesity subgroups. In conclusion, suboptimal HBP awareness, treatment, and control are still major problems confronting CHSs in Beijing. Control of hypertension in the population may be improved by increasing awareness and improving the treatment of hypertension in CHSs.

Vascular depression: overrepresented among African Americans?

OBJECTIVE

Our primary aim was to compare the rate of vascular depression among a clinical sample of African American and Caucasian depressed older adults. Secondary aims included characterizing the clinical and neuropsychological profile of vascular depression and comparing antidepressant response rates between patients with vascular and nonvascular depression.

METHODS

This was a two-site, multi-ethnic, open 8-week trial of antidepressant medication in older adults with depression. Men and women 50 years or older meeting DSM-IV criteria for nonpsychotic unipolar depression participated in this trial. Each participant underwent a comprehensive psychiatric and neuropsychological evaluation and a brain MRI, which were performed at baseline.

RESULTS

Forty-six patients met inclusion and exclusion criteria. Forty-two of those patients received an MRI at baseline. Sixteen patients met criteria for vascular depression. Patients with vascular depression were significantly more likely to be African American and have a higher likelihood of being female, a higher rate of hypertension and psychomotor retardation, a lower rate of family history of affective illness, and frontal systems dysfunction on neuropsychological testing. The difference in response rates between patients with vascular and nonvascular depression did not reach statistical significance.

CONCLUSIONS

This is the first study to document high rates of vascular depression in a clinical sample of African Americans and Caucasians. Our findings suggest that vascular depression may be overrepresented among African Americans, which is consistent with the high rates of cardiovascular disease, hypertension, and stroke in this population.

Perceived discrimination and medication adherence in black hypertensive patients: the role of stress and depression

OBJECTIVE

To examine the relationship between perceived discrimination and medication adherence among black people with hypertension and the role of stress and depressive symptoms in this relationship. Perceived racial discrimination has been associated with poor health outcomes in blacks; its relationship to medication adherence among hypertensive patients remains untested.

METHODS

We measured perceived racial discrimination at baseline, stress and depressive symptoms at 6 months, and medication adherence at 12 months among patients enrolled in a 30-site cluster-randomized controlled trial testing a patient and physician-targeted intervention to improve blood pressure. A mediational method with bootstrapping (stratified by site) confidence intervals was used to estimate the indirect association between perceived discrimination and medication adherence through stress and depression.

RESULTS

Of 1056 patients from 30 sites enrolled in the trial, 463 had complete data on all four measures at 6 and 12 months and were included in the analyses. Adjusting for clustering, perceived discrimination was associated with poor medication adherence (B = 0.138, p = .011) at 12 months, and with stress (B = 2.24, p = .001) and depression (B = 1.47, p = .001) at 6 months. When stress and depression were included in the model, there was a 65% reduction in the total association of perceived discrimination with medication adherence, and the relationship was no longer significant (B = 0.049, p = .35).

CONCLUSIONS

Perceived discrimination is associated with poor medication adherence among hypertensive blacks, and stress and depressive symptoms may account for this relationship.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00233220.

Characteristics of diabetic patients associated with achieving and maintaining blood pressure targets in the Adherence and Intensification of Medications program

OBJECTIVES

To determine patient characteristics associated with achieving and sustaining blood pressure (BP) targets in the Adherence and Intensification of Medications program, a program led by pharmacists trained in motivational interviewing and authorized to make BP medication changes.

METHODS

We conducted a retrospective cohort study of patients with diabetes and persistent hypertension in Kaiser Permanente and the Department of Veterans Affairs. Using two-level logistic regression, baseline survey data from 458 program participants were examined to determine patient characteristics associated with (1) discharge from the program with a target BP (short-term success) and (2) maintenance of the target BP over a nine-month period (long-term success).

RESULTS

In multivariable analyses, patients who screened positive for depression or had a higher baseline systolic BP were less likely to achieve short-term success (adjusted odds ratio (AOR) 0.42 [95% confidence interval (CI): 0.19-0.93], p = 0.03; AOR 0.94 [0.91-0.97], p < 0.01; respectively). Patients who reported at baseline one or more barriers to medication adherence were less likely to achieve long-term success (AOR 0.50 [0.26-0.94], p = 0.03).

CONCLUSIONS

Although almost 90% of patients achieved short-term success, only 28% achieved long-term success. Baseline barriers to adherence were associated with lack of long-term success and could be the target of maintenance programs for patients who achieve short-term success.

Determinants of CPAP Adherence in Hispanics with Obstructive Sleep Apnea

Purpose. We hypothesized that socioeconomic factors and a language barrier would impact adherence with continuous positive airway pressure (CPAP) among Hispanics with obstructive sleep apnea (OSA). Methods. Patients with OSA who were prescribed CPAP for at least 1 year and completed a questionnaire evaluating demographic data, socioeconomic status, and CPAP knowledge and adherence participated in the study. Results. Seventy-nine patients (26 males; 53 ± 11 yrs; body mass index (BMI) = 45 ± 9 kg/m²) with apnea-hypopnea index (AHI) 33 ± 30 events/hr completed the study. Included were 25 Hispanics, 39 African Americans, and 15 Caucasians, with no difference in age, AHI, CPAP use, or BMI between the groups. While there was a difference in educational level (P = 0.006), income level (P < 0.001), and employment status (P = 0.03) between the groups, these did not influence CPAP adherence. Instead, overall improvement in quality of life and health status and perceived benefit from CPAP influenced adherence, both for the group as a whole (P = 0.03, P = 0.004, and P = 0.001, resp.), as well as in Hispanics (P = 0.02, P = 0.02, P = 0.03, resp.). Conclusion. In Hispanic patients with OSA, perceived benefit with therapy, rather than socioeconomic status or a language barrier, appears to be the most important factor in determining CPAP adherence.

Association of race consciousness with the patient-physician relationship, medication adherence, and blood pressure in urban primary care patients

BACKGROUND

Race consciousness (the frequency with which one thinks about his or her own race) is a measure that may be useful in assessing whether racial discrimination negatively impacts blood pressure (BP). However, the relation between race consciousness and BP has yet to be empirically tested, especially within the context of the patient-physician relationship and medication adherence.

METHODS

Race-stratified generalized estimating equations were used to assess the relationship of race consciousness on BP, measures of the patient-physician relationship, and self-reported medication adherence, controlling for patients being nested within physicians and for patient age and sex.

RESULTS

The mean age of the patients was 61.3 years, 62% were black, and 65% were women. Black patients were more likely to ever think about race than were white patients (49% vs. 21%; P < 0.001). Race-conscious blacks had significantly higher diastolic BP (79.4 vs. 74.5 mm Hg; P = 0.004) and somewhat higher systolic BP (138.8 vs. 134.7 mm Hg; P = 0.13) than blacks who were not race conscious. Race-conscious whites were more likely to perceive respect from their physician (57.1% vs. 25.8%; P = 0.01) but had lower medication adherence (62.4% vs. 82.9%; P = 0.05) than whites who were not race-conscious.

CONCLUSIONS

Among blacks, race consciousness was associated with higher diastolic BP. In contrast, among whites, there was no association between race consciousness and BP, but race consciousness was associated with poor ratings of adherence, despite more favorable ratings of the patient-physician relationship. Future work should explore disparities in race consciousness and its impact on health and health-care disparities.

Facilitators and barriers to hypertension self-management in urban African Americans: perspectives of patients and family members

INTRODUCTION

We aimed to inform the design of behavioral interventions by identifying patients' and their family members' perceived facilitators and barriers to hypertension self-management.

MATERIALS AND METHODS

We conducted focus groups of African American patients with hypertension and their family members to elicit their views about factors influencing patients' hypertension self-management. We recruited African American patients with hypertension (n = 18) and their family members (n = 12) from an urban, community-based clinical practice in Baltimore, Maryland. We conducted four separate 90-minute focus groups among patients with controlled (one group) and uncontrolled (one group) hypertension, as well as their family members (two groups). Trained moderators used open-ended questions to assess participants' perceptions regarding patient, family, clinic, and community-level factors influencing patients' effective hypertension self-management.

RESULTS

Patient participants identified several facilitators (including family members' support and positive relationships with doctors) and barriers (including competing health priorities, lack of knowledge about hypertension, and poor access to community resources) that influence their hypertension self-management. Family members also identified several facilitators (including their participation in patients' doctor's visits and discussions with patients' doctors outside of visits) and barriers (including their own limited health knowledge and patients' lack of motivation to sustain hypertension self-management behaviors) that affect their efforts to support patients' hypertension self-management.

CONCLUSION

African American patients with hypertension and their family members reported numerous patient, family, clinic, and community-level facilitators and barriers to patients' hypertension self-management. Patients' and their family members' views may help guide efforts to tailor behavioral interventions designed to improve hypertension self-management behaviors and hypertension control in minority populations.

Disparities in antihypertensive medication adherence in adolescents

BACKGROUND

Hypertension affects up to 5 % of all children, but little is known about the role of medication adherence on blood pressure (BP) control. In this study we examined the association between adolescents' antihypertensive medication adherence and BP control, investigating for racial disparities.

METHODS

A total of 21 adolescents with essential hypertension [mean age 14.7 ± 2.0 years, 57 % male, 52 % African American] were recruited from a pediatric nephrology clinic. Objective medication adherence measures were obtained with Medication Event Monitoring System (MEMS) caps and pharmacy refill records to determine medication possession ratios (MPRs).

RESULTS

The African Americans adolescents had lower medication adherence than non-African Americans adolescents based on the MPR over the past 12 months (mean 0.54 ± 0.21 vs. 0.85 ± 0.16, respectively; p < 0.001) and a trend for less adherence measured by MEMS caps over the last 28 days (mean 0.75 ± 0.26 vs. 0.91 ± 0.04, respectively; p < 0.07). Seven of the eight participants with low adherence (MPR <0.65) had uncontrolled BP (systolic and/or diastolic BPs ≥ 95th percentile), and no participants with high adherence according to the MPR had uncontrolled BP (p < 0.001). There was no difference in BP control by race.

CONCLUSIONS

Antihypertensive medication adherence measured by pharmacy refills was associated with BP control. AAs were more likely to have lower medication adherence. Targeting medication adherence through the use of electronic medical records may be a potential mechanism to reduce health disparities.

The Trial Using Motivational Interviewing and Positive Affect and Self-Affirmation in African-Americans with Hypertension (TRIUMPH): from theory to clinical trial implementation

This paper describes the application of a translational research model in developing The Trial Using Motivational Interviewing and Positive Affect and Self-Affirmation in African-Americans with Hypertension (TRIUMPH), a theoretically-based, randomized controlled trial. TRIUMPH targets blood pressure control among African-Americans with hypertension in a community health center and public hospital setting. TRIUMPH applies positive affect, self-affirmation, and motivational interviewing as strategies to increase medication adherence and blood pressure control. A total of 220 participants were recruited in TRIUMPH and are currently being followed. This paper provides a detailed description of the theoretical framework and study design of TRIUMPH and concludes with a critical reflection of the lessons learned in the process of implementing a health behavior intervention in a community-based setting. TRIUMPH provides a model for incorporating the translational science research paradigm to conducting pragmatic behavioral trials in a real-world setting in a vulnerable population. Lessons learned through interactions with our community partners reinforce the value of community engagement in research.

Examining the association of health literacy and health behaviors in African American older adults: does health literacy affect adherence to antihypertensive regimens?

Health literacy is the degree to which individuals have the capacity to obtain, process, and understand the health information needed to make appropriate health decisions. The health behaviors of African American adults with inadequate health literacy skills affect their health outcomes. This study examined the association of health literacy and adherence behaviors in African American older adults (N = 121) with hypertension using a descriptive correlational design. Health literacy was measured using the Rapid Estimate of Adult Literacy in Medicine survey, and adherence was measured using the Hill-Bone Compliance Scale. Most of the participants were functioning with inadequate health literacy. No statistically significant association was found between health literacy and adherence, but regression analysis showed that age and health status significantly predicted adherence: Those who were younger and reported poor or fair health status were less likely to adhere to treatment.

[Factors associated with poor blood pressure control in hypertensive black Africans: cross-sectional study of 456 hypertensive patients from Burkina Faso]

INTRODUCTION

Hypertension in black is more frequent with early onset and clinically more severe. The blood pressure control and the decrease of global cardiovascular risk are two main goals of the treatment of hypertension. The objectives of this study were to determine the proportion of uncontrolled hypertension in hypertensive patients followed as outpatients and to investigate the factors associated with poor control.

PATIENTS AND METHODS

This is a descriptive cross-sectional study including 456 hypertensive patients known and followed as outpatients. Blood pressure measurement was performed between 8 am and 12 noon both arms in the supine position, after a compliance averaging 8 minutes of rest. We searched for conventional cardiovascular risk factors (age superior or equal to 45 years for men and superior or equal to 55 for women, physical inactivity, overweight/obesity, smoking, diabetes and dyslipidemia) and calculated the global cardiovascular risk according to the Framingham model. Was regarded as uncontrolled high blood pressure SBP superior or equal to 140 mmHg and/or DBP superior or equal to 90 mmHg. Univariate analysis and multivariate logistic regression (using SPSS program version 17) were conducted to look for factors associated with poor blood pressure control.

RESULTS

We recruited 456 hypertensive patients including 259 women (56.8%). Modifiable cardiovascular risk factors also hypertension were dominated by dyslipidemia (29.8%) and diabetes (24.6%). The global cardiovascular risk calculated using the Framingham model was low in 21.3%, moderate in 34.0%, high in 24.8% and very high in 19.9% of cases. The proportion of uncontrolled hypertension was 54.2% (n=247 including 126 women and 121 men). This poor blood pressure control was associated (multivariate analysis) at age superior or equal to 60 years, low socioeconomic status, high to very high cardiovascular risk, antihypertensive monotherapy, treatment duration superior or equal to 10 years, an associated treatment and non-compliance therapy.

CONCLUSION

More than half of hypertensive patients in our study were not adequately controlled on antihypertensive therapy. Factors of poor control were age superior or equal to 60 years, low socioeconomic status, high to very high cardiovascular risk, antihypertensive monotherapy, treatment duration superior or equal to 10 years, an associated treatment and non-compliance therapy.

Characterizing depression and comorbid medical conditions in African American women in a primary care setting

BACKGROUND

African American women are more likely to seek treatment for depression in primary care settings; however, few women receive guideline-concordant depression treatment in these settings. This investigation focused on the impact of depression on overall functioning in African American women in a primary care setting.

METHODS

Data was collected from a sample of 507 African American women in the waiting room of an urban primary care setting. The majority of women were well-educated, insured, and employed. The CESD-R was used to screen for depression, and participants completed the 36-Item Short-Form Survey to determine functional status.

RESULTS

Among the participants with depression, there was greater functional impairment for role-physical (z = -0.88, 95% CI = -1.13, -0.64) when compared to individuals with diabetes and hypertension. Individuals with depression also had greater role-emotional impairment (z = -1.12, 95% CI = -1.37, -0.87) than individuals with diabetes and hypertension. African American women with comorbid hypertension and depression had greater functional impairment in role-physical when compared to African American women with hypertension and no depression (t(124) = -4.22, p < 0.01).

CONCLUSION

African American women with depression are more likely to present with greater functional impairment in role function when compared to African American women with diabetes or hypertension. Because African American women often present to primary care settings for treatment of mental illness, primary care providers need to have a clear understanding of the population, as well as the most effective and appropriate interventions.

Factors associated with non-adherence to three hypertension self-management behaviors: preliminary data for a new instrument

BACKGROUND

Clinicians have difficulty in identifying patients that are unlikely to adhere to hypertension self-management. Identifying non-adherence is essential to addressing suboptimal blood pressure control and high costs.

OBJECTIVES

1) To identify risk factors associated with non-adherence to three key self-management behaviors in patients with hypertension: proper medication use, diet, and exercise; 2) To evaluate the extent to which an instrument designed to identify the number of risk factors present for non-adherence to each of the three hypertension self-management behaviors would be associated with self-management non-adherence and blood pressure.

DESIGN

Cross-sectional analysis of randomized trial data.

PATIENTS

Six hundred and thirty-six primary care patients with hypertension.

MEASUREMENTS

1) Demographic, socioeconomic, psychosocial, and health belief-related factors; 2) measures of self-reported adherence to recommended medication use, diet recommendations, and exercise recommendations, all collected at baseline assessment; 3) systolic blood pressure (SBP) and diastolic blood pressure (DBP).

RESULTS

We identified patient factors associated with measures of non-adherence to medications, diet, and exercise in hypertension. We then combined risk factors associated with ≥1 adherence measure into an instrument that generated three composite variables (medication, diet, and exercise composites), reflecting the number of risk factors present for non-adherence to the corresponding self-management behavior. These composite variables identified subgroups with higher likelihood of medication non-adherence, difficulty following diet recommendations, and difficulty following exercise recommendations. Composite variable levels representing the highest number of self-management non-adherence risk factors were associated with higher SBP and DBP.

CONCLUSIONS

We identified factors associated with measures of non-adherence to recommended medication use, diet, and exercise in hypertension. We then developed an instrument that was associated with non-adherence to these self-management behaviors, as well as with blood pressure. With further study, this instrument has potential to improve identification of non-adherent patients with hypertension.

A randomized trial of peer coach and office staff support to reduce coronary heart disease risk in African-Americans with uncontrolled hypertension

OBJECTIVE

Adopting features of the Chronic Care Model may reduce coronary heart disease risk and blood pressure in vulnerable populations. We evaluated a peer and practice team intervention on reduction in 4-year coronary heart disease risk and systolic blood pressure.

DESIGN AND SUBJECTS

A single blind, randomized, controlled trial in two adjacent urban university-affiliated primary care practices. Two hundred eighty African-American subjects aged 40 to 75 with uncontrolled hypertension.

INTERVENTION

Three monthly calls from trained peer patients with well-controlled hypertension and, on alternate months, two practice staff visits to review a personalized 4-year heart disease risk calculator and slide shows about heart disease risks. All subjects received usual physician care and brochures about healthy cooking and heart disease.

MAIN MEASURES

Change in 4-year coronary heart disease risk (primary) and change in systolic blood pressure, both assessed at 6 months.

KEY RESULTS

At baseline, the 136 intervention and 144 control subjects' mean 4-year coronary heart disease risk did not differ (intervention=5.8 % and control=6.4 %, P=0.39), and their mean systolic blood pressure was the same (140.5 mmHg, p=0.83). Endpoint data for coronary heart disease were obtained for 69 % of intervention and 82 % of control subjects. After multiple imputation for missing endpoint data, the reduction in risk among all 280 subjects favored the intervention, but was not statistically significant (difference -0.73 %, 95 % confidence interval: -1.54 % to 0.09 %, p=0.08). Among the 247 subjects with a systolic blood pressure endpoint (85 % of intervention and 91 % of control subjects), more intervention than control subjects achieved a >5 mmHg reduction (61 % versus 45 %, respectively, p=0.01). After multiple imputation, the absolute reduction in systolic blood pressure was also greater for the intervention group (difference -6.47 mmHg, 95 % confidence interval: -10.69 to -2.25, P=0.003). One patient died in each study arm.

CONCLUSIONS

Peer patient and office-based behavioral support for African-American patients with uncontrolled hypertension did not result in a significantly greater reduction in coronary heart disease risk but did significantly reduce systolic blood pressure.

The association between self-efficacy and hypertension self-care activities among African American adults

Chronic disease management requires the individual to perform varying forms of self-care behaviors. Self-efficacy, a widely used psychosocial concept, is associated with the ability to manage chronic disease. In this study, we examine the association between self-efficacy to manage hypertension and six clinically prescribed hypertension self-care behaviors. We interviewed 190 African Americans with hypertension who resided in the greater metropolitan Charlotte area about their self-efficacy and their hypertension self-care activities. Logistic regression for correlated observations was used to model the relationship between self-efficacy and adherence to hypertension self-care behaviors. Since the hypertension self-care behavior outcomes were not rare occurrences, an odds ratio correction method was used to provide a more reliable measure of the prevalence ratio (PR). Over half (59%) of participants reported having good self-efficacy to manage their hypertension. Good self-efficacy was statistically significantly associated with increased prevalence of adherence to medication (PR = 1.23, 95% CI: 1.08, 1.32), eating a low-salt diet (PR = 1.64, 95% CI: 1.07-2.20), engaging in physical activity (PR = 1.27, 95% CI: 1.08-1.39), not smoking (PR = 1.10, 95% CI: 1.01-1.15), and practicing weight management techniques (PR = 1.63, 95% CI: 1.30-1.87). Hypertension self-efficacy is strongly associated with adherence to five of six prescribed self-care activities among African Americans with hypertension. Ensuring that African Americans feel confident that hypertension is a manageable condition and that they are knowledgeable about appropriate self-care behaviors are important factors in improving hypertension self-care and blood pressure control. Health practitioners should assess individuals' self-care activities and direct them toward practical techniques to help boost their confidence in managing their blood pressure.