Determinants of JNC VI Guideline Adherence, Intensity of Drug Therapy, and Blood Pressure Control by Race and Ethnicity

Same-Day Primary Care Referral Versus Usual Care for Patients With Elevated Blood Pressures Seen in a Preoperative Clinic

Background While several studies have suggested that anesthesia and surgical care episodes provide an opportunity to improve the diagnosis and treatment of hypertension, few studies have implemented and tested pragmatic care coordination efforts for this population. The present study aimed to examine the effects of same-day primary care referral vs. usual care on outpatient hypertension treatment among patients with elevated preoperative clinic blood pressure (BP). Methodology With institutional review board approval of the project as a quality improvement (QI) initiative not requiring consent, we conducted a prospective QI project comparing same-day preoperative primary care referral vs. usual care within comparable cohorts of US Veterans presenting to a preoperative evaluation clinic with elevated BP for whom treatment assignment was based on prior primary care clinic affiliation. Outpatient BP, antihypertensive medications, and antihypertensive dosages at the initial visit and for one year after the initial preoperative clinic visit were followed in the electronic health record. Results Between June 1, 2018, and June 1, 2019, one of the two on-site primary care groups (Firm A) at our facility agreed to accommodate same-day BP referrals. Patients in the second primary care group received standard preoperative care (Firm B). Charts for the pseudo-randomized cohort of Firm A and B patients were compared after 12 months to assess for changes in BP and hypertension treatment. Firm A and B patients were similar in demographics. Overall, 68 (91%) Firm A patients were correctly referred for primary care appointments. Moreover, 28 of 68 (41.2%) patients adhered to the same-day referral recommendation, with the remainder declining to attend the primary care visit. BPs were similar between Firm A and Firm B groups at 3, 6, 9, and 12 months post-intervention. Firm A adherent patients (i.e., those attending the referral) received hypertension treatment intensification sooner than Firm A non-adherent and Firm B patients (median (interquartile range) days to intensification = 21 (0.5-103.5) vs. 154 (45.5-239) and 170 (48-220), respectively; p = 0.038 and p = 0.048, respectively). Conclusions Our protocol achieved a high degree of same-day primary care referral (91%) in hypertensive patients presenting at the preoperative clinic. Although this limited study did not demonstrate improved BP control in patients who received same-day primary care, this group did show increased rates of rapid treatment intensification which may infer improved long-term health outcomes. Further work examining logistical barriers to patients attending same-day referrals is warranted.

A glimpse into the future: modelling global prevalence of hypertension

BACKGROUND

Hypertension is a major risk factor for cardiovascular diseases. Insights and foresights on trends of hypertension prevalence are crucial to informing health policymaking. We examined and projected the patterns of hypertension prevalence among sexes.

METHODS

Using annual hypertension prevalence (18 + years) data sourced from WHO Global Health Observatory data repository from 1975 to 2015, Prophet models were developed to forecast the 2040 prevalence of hypertension in males, females, and both sexes. We used k-means clustering and self-organising maps to determine the clusters of hypertension prevalence concerning both sexes among 176 countries.

RESULTS

Worldwide, Croatia is estimated to have the highest prevalence of hypertension in males by 2040, while that of females is in Niger. Among the world's most populated countries, Pakistan and India are likely to increase by 7.7% and 4.0% respectively in both sexes. South-East Asia is projected to experience the largest hypertension prevalence in males, whereas Africa is estimated to have the highest prevalence of hypertension in females. Low-income countries are projected to have the highest prevalence of hypertension in both sexes. By 2040, the prevalence of hypertension worldwide is expected to be higher in the male population than in female. Globally, the prevalence of hypertension is projected to decrease from 22.1% in 2015 to 20.3% (20.2 - 20.4%) in 2040. We also identified three patterns of hypertension prevalence in 2040, cluster one countries are estimated to have the highest prevalence of hypertension in males (29.6%, 22.2 - 41.1%) and females (29.6%, 19.4 - 38.7%).

CONCLUSION

These findings emphasise the need for new and effective approaches toward the prevention and control of hypertension in Africa, South-East Asia, and Low-income countries.

Compliance With Guidelines of Hypertension Management, and Associated Factors Among the Health Practitioners

The consequences of uncontrolled hypertension such as stroke, myocardial infarction, retinal damage and others are significantly affecting individual and the community in large. The patients are suffering from compromised quality of life, permanent disability, and premature death in developing countries. The reason for the existence of the gap hasn't been clear yet. An institutional-based retrospective cross-sectional study designed from patient medical record data was used to assess compliance with the federal democratic and republic of Ethiopia ministry of health hypertension management guideline. Medical records of adult Patients treated for hypertension from March 2019 to March 2020 were reviewed. Systematic sampling technique from patients' medical records every 10th interval was taken to reach the total sample size. The collected data were checked for completeness, consistency, and accuracy before analysis. Data were coded, entered, and cleaned using Epi-data 7 and exported to SPSS version 25 for analysis. Overall compliance with the hypertension guideline was found to be poor; only 75 (19.5%) patients managed according to the guideline in these institutions. The majority of health practitioners complied with the pharmacological Antihypertensive treatment protocols for 238 (62.0%) patients, while for 146 (38.0%) of the patients the guideline was not followed. Combining the lifestyle modification recommendations and pharmacological antihypertensive treatment to assess compliance with the hypertension management guideline, only 75 (19.5%) patients managed as per the guideline, while 309 (80.5%) did not. Nearly more than two-thirds of the patients were not managed following the national hypertension guideline, and health practitioners are failed to recommend lifestyle modifications for most of the patients, as a result, the majority of the hypertensive patients are being exposed to complications and urgent intervention is demanded against the gap.

Prevalence of hypertension and diabetes in the population of Kosovo

Objectives

To observe the prevalence of arterial pressure and glycemia in Kosovo and to provide free screening service through health promotion.

Methods

This prospective study was conducted over a 3-year period, during 2017–2019. All data were collected by AAB College staff in 11 Kosovo cities prior to a random sample with 7254 observations. Data included demographic information as well as blood pressure and glycemic level measurements.

Results

The overall prevalence of arterial pressure was registered at 27.6% and diabetes mellitus at 9.2%. Arterial pressure in females had a tendency to increase with age (r = 0.3552, P < 0.001), as well as the glycemic index (r = 0.1997, P < 0.001). Nevertheless, age had a stronger impact on males than in females, with regard to higher arterial pressure in the year 2017 (P < 0.001). In the following years, 2018 and 2019, the ratio had reversed. Glycemia had strong correlation with systolic arterial pressure value (P < 0.001). For a 1 mmol/L increase in glycemia, the diastolic value increased by 0.19 mmHg on average.

Conclusions

This study concluded that at younger ages the values of arterial pressure and glycemia remain within the commonly observed range, but over the years the probability for higher blood pressure or glicemia increases. Through continuous control of arterial pressure and glycemia at an early age, it is possible to identify abnormal diagnostics, in order to address them in time. Educational initiatives and screenings should take place in order to increase awareness of the citizens for checking themselves regularly.

Prevalence, Awareness, and Treatment of Hypertension in Hispanics/Latinos With CKD in the Hispanic Community Health Study/Study of Latinos

Rationale & Objective

Lower rates of hypertension awareness, treatment, and control have been observed in Hispanics/Latinos compared with non-Hispanic whites. These factors have not been studied in Hispanics/Latinos with chronic kidney disease (CKD). We sought to describe the prevalence, awareness, treatment, and control of hypertension in Hispanic/Latino adults with CKD.

Study Design

Cross-sectional cohort.

Setting & Participants

US.Hispanics/Latinos aged 18 to 74 years enrolled in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) with CKD. Comparisons were made with the National Health and Nutrition Examination Survey (NHANES) 2007 to 2010.

Exposure

CKD was defined as estimated glomerular filtration rate < 60 mL/min/1.73 m² or urinry albumin-creatinine ratio ≥ 30 mg/g creatinine.

Outcomes

Hypertension was defined as systolic blood pressure (BP) ≥ 140 or diastolic BP ≥ 90 mm Hg or use of antihypertensives. For hypertension control, 2 thresholds were examined: <140/90 and <130/80 mm Hg.

Results

The prevalence of hypertension was 51.5%; among those with hypertension, hypertension awareness and treatment were present in 78.1% and 70.4%, respectively. A low prevalence of BP control was observed (32.6% with BP < 140/90 mm Hg; 17.9% with BP < 130/80 mm Hg). Health insurance coverage was associated with higher odds of BP < 140/90 mm Hg (OR, 1.98; 95% CI, 1.15-3.43). Compared with non-Hispanic whites with CKD in NHANES, HCHS/SOL participants with CKD had a lower prevalence of hypertension but a lower rate of BP control (32.6% vs 48.6% for BP < 140/90 mm Hg).

Limitations

Use of a single measurement of creatinine, cystatin C, and urinary albumin excretion to define CKD. Single-visit measurement of BP.

Conclusions

Hispanics/Latinos with CKD residing in the United States have very low rates of BP control. The association of health insurance coverage with hypertension control suggests that improved access to health care may improve outcomes for this growing population.

Prevalence and associated factors of uncontrolled hypertension among hypertensive patients: a nation-wide survey in Thailand

Objectives

The objectives of the research were to determine the prevalence and factors associated of uncontrolled blood pressure among Thai hypertensive patients in a nationwide survey.

Results

A total of 65,667 patients with hypertension were included in this study. The greater proportion of participants, 40,834 (62.2%), were females. The average age of participants was 63.9 ± 11.1 years. Uncontrolled hypertension was detected among 16,122 patients (24.6%; 95% CI 24.2–24.9). Among males and females, uncontrolled hypertension was 25.6% (95% CI 25.1–26.2) and 23.9% (95% CI 23.5–24.3) respectively. Multivariate analysis showed that the uncontrolled hypertension was significantly associated with being male, age, regions, hospital levels, diabetes comorbidity, higher body mass index, low density lipoprotein cholesterol level and the number of antihypertensive medications.

Hypertension, knowledge, attitudes, and practices of primary care physicians in Ulaanbaatar, Mongolia

We examined the knowledge, attitudes, and practices of primary care doctors in Ulaanbaatar, Mongolia using a recently developed World Hypertension League survey. The survey was administered as part of a quality assurance initiative to enhance hypertension control. A total of 577 surveys were distributed and 467 were completed (81% response rate). The respondents had an average age of 35 years and 90.1% were female. Knowledge of hypertension epidemiology was low (13.5% of questions answered correctly); 31% of clinical practice questions had correct answers and confidence in performing specific tasks to improve hypertension control had 63.2% "desirable/correct" answers. Primary care doctors mostly had a positive attitude toward hypertension management (76.5% desirable/correct answers) and highly prioritized hypertension management activities (85.7% desirable/correct answers). Some important highlights included the majority (> 80%) overestimating hypertension awareness, treatment, and control rates; 78.2% used aneroid blood pressure manometers; 15% systematically screened adults for hypertension in their clinics; 21.8% reported 2 or more drugs were required to control hypertension in most people; and 16.1% reported most people could be controlled by lifestyle changes alone. 55% of respondents were not comfortable prescribing more than 1 or 2 antihypertensive drugs in a patient and the percentage of desirable/correct responses to treating various high-risk patients was low. Most (53%-74%) supported task shifting to nonphysician health care providers except for drug prescribing, which only 13.9% supported. A hypertension clinical education program is currently being designed based on the specific needs identified in the survey.

Racial/ethnic disparity in the associations of smoking status with uncontrolled hypertension subtypes among hypertensive subjects

Background

Racial/ethnic differences in the associations of smoking with uncontrolled blood pressure (BP) and its subtypes (isolated uncontrolled systolic BP (SBP), uncontrolled systolic-diastolic BP, and isolated uncontrolled diastolic BP (DBP)) have not been investigated among diagnosed hypertensive subjects.

Methods

A sample of 7,586 hypertensive patients aged ≥18 years were selected from the National Health and Nutrition Examination Survey 1999–2010. Race/ethnicity was classified into Hispanic, non-Hispanic white, and non-Hispanic black. Smoking was categorized as never smoking, ex-smoking, and current smoking. Uncontrolled BP was determined as SBP≥140 or DBP≥90 mm Hg. Isolated uncontrolled SBP was defined as SBP≥140 and DBP<90 mm Hg, uncontrolled SDBP as SBP≥140 and DBP≥90 mm Hg, and isolated uncontrolled DBP as SBP<140 and DBP≥90 mm Hg. Adjusted odds ratios (ORs) with 95% confidence intervals (CIs) of uncontrolled BP and its subtypes were calculated using weighted logistic regression models.

Results

The interaction effect of race and smoking was significant after adjustment for the full potential confounding covariates (Adjusted p = 0.0412). Compared to never smokers, current smokers were 29% less likely to have uncontrolled BP in non-Hispanic whites (OR = 0.71, 95% CI = 0.56–0.90), although the likelihood for uncontrolled BP is the same for smokers and never smokers in Hispanics and non-Hispanic blacks. Current smokers were 26% less likely than never smokers to have isolated uncontrolled SBP in non-Hispanic whites (OR = 0.74, 95% CI = 0.58–0.95). However, current smoking is associated with an increased likelihood of uncontrolled systolic-diastolic BP in non-Hispanic blacks, and current smokers in this group were 70% more likely to have uncontrolled systolic-diastolic BP than never smokers (OR = 1.70, 95% CI = 1.10–2.65).

Conclusion

The associations between current smoking and uncontrolled BP differed over race/ethnicity. Health practitioners may need to be especially vigilant with non-Hispanic black smokers with diagnosed hypertension.

Patient, Physician, and Practice Characteristics Associated with Cardiovascular Disease Preventive Care for Women

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death for American women. Although CVD preventive care has the potential to reduce a significant number of these deaths, the degree to which healthcare providers deliver such care is unknown. The purpose of this study was to identify patient, physician, and practice characteristics that significantly influence the provision of CVD preventive care during ambulatory care visits for female patients.

METHODS

The National Ambulatory Medical Care Survey datasets from 2005 to 2010 were utilized. The study sample included female patients ≥20 years of age whose healthcare provider performed CVD preventive care and who had visits for a new health problem, a routine chronic problem, management of a chronic condition, and preventive care. Binary logistic regression models estimated the association of patient, physician, and practice characteristics and CVD preventive care; cholesterol testing, body mass index (BMI) screening, and tobacco education.

RESULTS

Of the 32,009 visits, 15.9% involved cholesterol testing, 50.3% involved BMI screening, and 3.20% involved tobacco education. Obstetricians/gynecologists were less likely to perform cholesterol testing (aOR: 0.39; 95% CI: 0.25-0.61) and tobacco education (aOR: 0.56; 95% CI: 0.32-0.98) than general/family physicians.

CONCLUSION

The delivery of CVD preventive care varied by healthcare provider type, with obstetricians/gynecologists having lower odds of providing two of the three services. The amount of time a physician spent with a patient was a significant predictor for the provision of all three services. These findings demonstrate the need to implement multifaceted approaches to address predicting characteristics of CVD preventive care.

Racial and Ethnic Disparities in the Quality of Health Care

The annual National Healthcare Quality and Disparities Reports document widespread and persistent racial and ethnic disparities. These disparities result from complex interactions between patient factors related to social disadvantage, clinicians, and organizational and health care system factors. Separate and unequal systems of health care between states, between health care systems, and between clinicians constrain the resources that are available to meet the needs of disadvantaged groups, contribute to unequal outcomes, and reinforce implicit bias. Recent data suggest slow progress in many areas but have documented a few notable successes in eliminating these disparities. To eliminate these disparities, continued progress will require a collective national will to ensure health care equity through expanded health insurance coverage, support for primary care, and public accountability based on progress toward defined, time-limited objectives using evidence-based, sufficiently resourced, multilevel quality improvement strategies that engage patients, clinicians, health care organizations, and communities.

Sex Disparity in Blood Pressure Levels Among Nigerian Health Workers

Sex disparity in hypertension prevalence is well established in developed nations; however, there is paucity of data on the distribution of hypertension prevalence between the sexes in developing countries. Therefore, the authors examined sex differences in hypertension prevalence and cardiovascular risk factors in a sample of 352 healthy hospital workers in Nigeria. The mean ages of the men and women were 37.2±7.9 and 44.7±9.1 years, respectively. Thirty-five percent of participants were hypertensive, with 54% on treatment and 70% with controlled blood pressure. Men had a higher prevalence of hypertension (38.4% vs 33.0%) and prehypertension (37.6% vs 29.7%). Women had significantly higher odds of developing hypertension and of being on treatment. Mean blood pressure and fasting plasma glucose values were higher in men, while women were more often older, obese, and dyslipidemic and had a lower mean estimated glomerular filtration rate (P<.0001). These findings indicate sex disparity in blood pressure among hospital employees. Sex-focused management of hypertension is therefore advocated for hospital employees.

New insights on the risk for cardiovascular disease in African Americans: the role of added sugars

African Americans are at increased risk for cardiovascular and metabolic diseases, including obesity, high BP, diabetes, CKD, myocardial infarction, and stroke. Here we summarize the current risks and provide an overview of the underlying risk factors that may account for these associations. By reviewing the relationship between cardiovascular and renal diseases and the African-American population during the early 20th century, the historic and recent associations of African heritage with cardiovascular disease, and modern population genetics, it is possible to assemble strong hypotheses for the primary underlying mechanisms driving the increased frequency of disease in African Americans. Our studies suggest that underlying genetic mechanisms may be responsible for the increased frequency of high BP and kidney disease in African Americans, with particular emphasis on the role of APOL1 polymorphisms in causing kidney disease. In contrast, the Western diet, particularly the relatively high intake of fructose-containing sugars and sweetened beverages, appears to be the dominant force driving the increased risk of diabetes, obesity, and downstream complications. Given that intake of added sugars is a remediable risk factor, we recommend clinical trials to examine the reduction of sweetened beverages as a primary means for reducing cardiovascular risk in African Americans.

Racial comparisons of diabetes care and intermediate outcomes in a patient-centered medical home

OBJECTIVE To assess racial differences in diabetes processes and intermediate outcomes of care in an internal medicine, patient-centered medical home (PCMH) group practice. RESEARCH DESIGN AND METHODS We conducted a retrospective cohort study of 1,457 adults with diabetes receiving care from 89 medical providers within a PCMH-designated academic practice between 1 July 2009 and 31 July 2010. We used mixed models to assess independent associations between patient race (non-Hispanic white or black) and 1) receipt of processes of care (A1C and LDL testing, foot and retinal examination, and influenza and pneumococcal vaccination) and 2) achievement of intermediate outcomes (LDL <100 mg/dL, blood pressure [BP] <140/90 mmHg, A1C <7.0% [<53 mmol/mol], and A1C >9.0% [>75 mmol/mol]), controlling for sociodemographic factors, health status, treatment intensity, and clinical continuity. RESULTS Compared with non-Hispanic white patients, black patients were younger, were more often single, had lower educational attainment, and were less likely to have commercial insurance. In unadjusted analyses, fewer black patients received a retinal examination and influenza vaccination during the study period or any lifetime pneumococcal vaccination (P < 0.05 [all comparisons]). Fewer black patients achieved an LDL <100 mg/dL, BP <140/90 mmHg, or A1C <7.0% (<53 mmol/mol), while more black patients had an A1C >9.0% (>75 mmol/mol) (P < 0.05 [all comparisons]). In multivariable models, black patients were less likely to receive A1C testing (odds ratio [OR] 0.57 [95% CI 0.34-0.95]) or influenza vaccination (OR 0.75 [95% CI 0.57-0.99]) or to achieve an LDL <100 mg/dL (OR 0.74 [95% CI 0.55-0.99]) or BP <140/90 mmHg (OR 0.64 [95% CI 0.49-0.84]). CONCLUSIONS Racial differences in processes and intermediate outcomes of diabetes care were present within this PCMH-designated practice, controlling for differences in sociodemographic, clinical, and treatment factors.

Barriers to achieving blood pressure treatment targets in elderly hypertensive individuals

High blood pressure (BP) is highly prevalent among the elderly, and even with pharmacological therapy BP is difficult to control to guideline recommended levels. Although poor compliance to therapy is associated with less BP control, little is known regarding other barriers to attaining on-treatment target BP. This study examined factors associated with achieving on-treatment target BP in 6010 hypertensive participants aged 65-84 years from the Second Australian National Blood Pressure study. Participants were followed for a median of 4.1 years, with BP monitored every 6 months. 'Target BP' was defined as a reduction of systolic/diastolic BP of at least 20/10 mm Hg and BP <160/90 mm Hg from randomization in two consecutive follow-up visits. Cox regression was used to identify factors associated with achieving target BP from a number of baseline and in-study factors. Mean BP at randomization was 168/91 mm Hg and patients had a median of 9 (range: 2-20) study visits. Target BP was achieved in 50% of patients. Demographic factors associated with achieving target BP were male gender, living in a regional area; and clinical factors included history of antihypertensive therapy, increased plasma creatinine, lower pretreatment pulse pressure and in-study use of multiple BP-lowering drugs. Those aged >80 years and seeking care from multiple doctors (hazard ratio 0.40, 95% confidence interval 0.36-0.45, P<0.001) were less likely to achieve target BP. These findings identify clinical markers that can be targeted for intervention, but also demographic factors related to service delivery, which may provide further opportunity for achieving better BP control in hypertensive elderly.

Rate and predictors of blood pressure control in a federal qualified health center in Michigan: a huge concern?

Hypertension (HTN) is particularly burdensome in low-income groups. Federal-qualified health centers (FQHCs) provide care for low-income and medically underserved populations. To assess the rates and predictors of blood pressure (BP) control in an FQHC in Michigan, a retrospective analysis of all patients with HTN, coronary artery disease, and/or diabetes mellitus (DM) seen between January 2006 and December 2008 was conducted. Of 212 patients identified, 154 had a history of HTN and 122 had DM. BP control was achieved in 38.2% of the entire cohort and in 31.1% of patients with DM. The mean age was lower in patients with controlled BP in both the total population (P=.05) and the DM subgroup (P=.02). A logistic regression model found only female sex (odds ratio, 2.27; P=.02) to be associated with BP control and a trend towards an association of age with uncontrolled BP (odds ratio, 0.97; P=.06). BP control in nondiabetics was 47.8% vs 31.1% in diabetic patients (P=.02). We found that patients who attended the FQHC had a lower rate of BP control compared with the national average. Our study revealed a male sex disparity and significantly lower rate of BP control among DM patients.

Predictors of blood pressure control among hypertensives in community health centers

BACKGROUND

The correlates of blood pressure (BP) control among hypertensive individuals who have access to care in community-based health-care settings are poorly characterized, particularly among minority and immigrant populations.

METHODS

Using data extracted from electronic medical records in four federally qualified health centers in New York, we investigated correlates of hypertension (HTN) control in cross-sectional analyses. The sample consisted of adult, nonobstetric patients with a diagnosis of HTN and a clinic visit between June 2007 and October 2008 (n = 2,585).

RESULTS

Forty-nine percent of hypertensive patients had controlled BP at their last visit. Blacks had a higher prevalence of HTN (B, 32.8%; W, 16.2%; H, 11.5%) and were less likely to have controlled BP (B, 42.2%; W, 50.9%; H, 50.8%) compared with Hispanics and whites. Medication intensification did not differ by race/ethnicity. In multivariate analyses higher body mass index (BMI), black race, diabetes, fewer clinical encounters, and male gender were associated with poor BP control. However, when we applied the Seventh Report of the Joint National Committee (JNC 7) definition for BP control for nondiabetic patients (systolic blood pressure (SBP) <140, diastolic blood pressure (DBP) <90) to all patients with HTN, we found no difference in BP control between those with and without diabetes.

CONCLUSIONS

Blacks had poorer HTN control compared with whites and Hispanics. Significant discrepancies in BP control between hypertensive patients with and without diabetes may be related to a lack of provider adherence to JNC 7 guidelines that define BP control in this population as <130/80. Further research is needed to understand racial disparities in BP control as well as factors influencing clinician's management of BP among patients with diabetes.

Cultural Considerations: Pharmacological and Nonpharmacological Means for Improving Blood Pressure Control among Hispanic Patients

Cardiovascular disease is a leading cause of morbidity and mortality in the United States, and its prevention and treatment remain a priority for the medical community. Ethnic variations account for some differences in the prevalence of hypertension and blood pressure (BP) control rates among Hispanics, indicating the need for culturally appropriate management models. Aggressive treatment strategies are key to achieving optimal BP control in high-risk Hispanic patients. Hypertension in this ethnic group continues to be a major health concern. Of note, when provided access to comprehensive care, Hispanics demonstrate similar response rates to treatment as the majority of non-Hispanic whites. This highlights the importance of effective, culturally responsive hypertension management among high-risk Hispanic patients for achieving observable, positive health outcomes.

Hypertension and type 2 diabetes: what family physicians can do to improve control of blood pressure--an observational study

BACKGROUND

The prevalence of type 2 diabetes is rising, and most of these patients also have hypertension, substantially increasing the risk of cardiovascular morbidity and mortality. The majority of these patients do not reach target blood pressure levels for a wide variety of reasons. When a literature review provided no clear focus for action when patients are not at target, we initiated a study to identify characteristics of patients and providers associated with achieving target BP levels in community-based practice.

METHODS

We conducted a practice-based, cross-sectional observational and mailed survey study. The setting was the practices of 27 family physicians and nurse practitioners in 3 eastern provinces in Canada. The participants were all patients with type 2 diabetes who could understand English, were able to give consent, and would be available for follow-up for more than one year. Data were collected from each patient's medical record and from each patient and physician/nurse practitioner by mailed survey. Our main outcome measures were overall blood pressure at target (< 130/80), systolic blood pressure at target, and diastolic blood pressure at target. Analysis included initial descriptive statistics, logistic regression models, and multivariate regression using hierarchical nonlinear modeling (HNLM).

RESULTS

Fifty-four percent were at target for both systolic and diastolic pressures. Sixty-two percent were at systolic target, and 79% were at diastolic target. Patients who reported eating food low in salt had higher odds of reaching target blood pressure. Similarly, patients reporting low adherence to their medication regimen had lower odds of reaching target blood pressure.

CONCLUSIONS

When primary care health professionals are dealing with blood pressures above target in a patient with type 2 diabetes, they should pay particular attention to two factors. They should inquire about dietary salt intake, strongly emphasize the importance of reduction, and refer for detailed counseling if necessary. Similarly, they should inquire about adherence to the medication regimen, and employ a variety of patient-oriented strategies to improve adherence.

Age-dependent gender differences in hypertension management

OBJECTIVE

Despite gender-neutral guidelines, prior studies suggest that women have lower rates of hypertension control and these differences may vary with age. Accordingly, we compared rates of hypertension control between women and men as a function of age.

METHODS

Within three integrated healthcare systems in the Cardiovascular Research Network, we studied all patients seen from 2001 to 2007 with incident hypertension. Within 1 year of cohort entry, patient's hypertension was categorized as controlled based upon achieving guideline-recommended blood pressure levels, recognized if hypertension was diagnosed or a hypertension medication dispensed, and treated based on hypertension medications dispensed. Multivariable logistic regression models assessed the association between gender and 1-year hypertension outcomes, adjusted for patient characteristics.

RESULTS

Among the 152,561 patients with incident hypertension, 55.6% were women. Compared to men, women were older, had more kidney disease and more blood pressure measures during follow-up. Overall, men tended to have lower rates of hypertension control compared to women (41.2 vs. 45.7%, adjusted odds ratio 0.93, 95% confidence interval 0.91-0.95). A significant gender by age interaction was found with men aged 18-49 having 17% lower odds of hypertension control and men aged at least 65 having 12% higher odds of hypertension control compared to women of similar ages (P<0.001).

CONCLUSION

In this incident hypertension cohort, younger men and older women had lower rates of hypertension control compared to similarly aged peers. Future studies should investigate why gender differences vary by age in order to plan appropriate means of improving hypertension management regardless of gender or age.

HEALS: A Faith-Based Hypertension Control and Prevention Program for African American Churches: Training of Church Leaders as Program Interventionists

Background. A 12-session church-based HEALS program (healthy eating and living spiritually) was developed for hypertension control and prevention program in African Americans (AAs). This study presents specifics of training lay health educators to effectively deliver HEALS to high-risk AAs. Methods. A one-day workshop was conducted by the research experts in an AA church. Five church members were recruited to be program interventionists called church health counselors (CHCs). Results. Using principles of adult education, a training protocol was developed with the intention of recognizing and supporting CHCs skills. CHCs received training on delivering HEALS program. The process of training emphasized action methods including role playing and hands-on experience with diet portion measurements. Conclusion. With adequate training, the community lay health educator can be an essential partner in a community-based hypertension control programs. This may motivate program participants more and encourages the individual to make the behavior modifications on a permanent basis.

Health behaviors and racial disparity in blood pressure control in the national health and nutrition examination survey

Minorities have a higher prevalence of hypertension, a major risk factor for cardiovascular disease, which contributes to racial/ethnic disparities in morbidity and mortality in the United States. Many modifiable health behaviors have been associated with improved blood pressure control, but it is unclear how racial/ethnic differences in these behaviors are related to the observed disparities in blood pressure control. Cross-sectional analyses were conducted among 21 489 US adults aged >20 years participating in the National Health and Nutrition Examination Survey from 2001 to 2006. Secondary analyses were conducted among those with a self-reported diagnosis of hypertension. Blood pressure control was defined as systolic values <140 mm Hg and diastolic values <90 mm Hg (or <130 mm Hg and <80 mm Hg among diabetics, respectively). In primary analyses, non-Hispanic blacks had 90% higher odds of poorly controlled blood pressure compared with non-Hispanic whites after adjustment for sociodemographic and clinical characteristics (P<0.001). In secondary analyses among hypertensive subjects, non-Hispanic blacks and Mexican Americans had 40% higher odds of uncontrolled blood pressure compared with non-Hispanic whites after adjustment for sociodemographic and clinical characteristics (P<0.001). For both analyses, the racial/ethnic differences in blood pressure control persisted even after further adjustment for modifiable health behaviors, which included medication adherence in secondary analyses (P<0.001 for both analyses). Although population-level adoption of healthy behaviors may contribute to reduction of the societal burden of cardiovascular disease in general, these findings suggest that racial/ethnic differences in some health behaviors do not explain the disparities in hypertension prevalence and control.

Disease management to promote blood pressure control among African Americans

African Americans have a higher prevalence of hypertension and poorer cardiovascular and renal outcomes than white Americans. The objective of this study was to determine whether a telephonic nurse disease management (DM) program designed for African Americans is more effective than a home monitoring program alone to increase blood pressure (BP) control among African Americans enrolled in a national health plan. A prospective randomized controlled study (March 2006-December 2007) was conducted, with 12 months of follow-up on each subject. A total of 5932 health plan members were randomly selected from the population of self-identified African Americans, age 23 and older, in health maintenance organization plans, with hypertension; 954 accepted, 638 completed initial assessment, and 485 completed follow-up assessment. The intervention consisted of telephonic nurse DM (intervention group) including educational materials, lifestyle and diet counseling, and home BP monitor vs. home BP monitor alone (control group). Measurements included proportion with BP < 120/80, mean systolic BP, mean diastolic BP, and frequency of BP self-monitoring. Results revealed that systolic BP was lower in the intervention group (adjusted means 123.6 vs. 126.7 mm Hg, P = 0.03); there was no difference for diastolic BP. The intervention group was 50% more likely to have BP in control (odds ratio [OR] = 1.50, 95% confidence interval [CI] 0.997-2.27, P = 0.052) and 46% more likely to monitor BP at least weekly (OR 1.46, 95% CI 1.07-2.00, P = 0.02) than the control group. A nurse DM program tailored for African Americans was effective at decreasing systolic BP and increasing the frequency of self-monitoring of BP to a greater extent than home monitoring alone. Recruitment and program completion rates could be improved for maximal impact.

Understanding racial disparities in treatment intensification for hypertension management

BACKGROUND

Disparities in blood pressure (BP) control may be a function of disparities in treatment intensification (TI).

OBJECTIVE

To examine racial differences in TI, understand modifiable factors that may mediate this relationship, and explore the relative effects of TI and race on blood pressure.

DESIGN

Prospective cohort study.

PARTICIPANTS

Participants were 819 black and white patients with hypertension from an urban, safety-net hospital

MAIN MEASURES

We sequentially explored the effects of patient race, sociodemographic and clinical characteristics, beliefs about BP/medications, perceptions of provider/discrimination, sodium intake, medication adherence, and provider counseling on TI, performing a series of random effects analyses. To assess the effects of race and TI on BP, we performed linear regressions, using systolic BP (SBP) as the outcome.

KEY RESULTS

Unadjusted analyses and those including sociodemographic and clinical characteristics revealed that black patients had less TI than whites (-0.31 vs.-0.24, p < 0.001), but adjustment for patient beliefs and experiences eliminated the effects of race (beta =-0.02, p = 0.5). Increased patient concerns about BP medications were related to lower TI, as was more provider counseling (beta =-0.06, p = 0.02 and beta = -0.01, p = 0.001, respectively). In the unadjusted analysis, black race was a significant predictor of SBP (134 mm/Hg for blacks vs. 131 mm/Hg for whites, p = 0.009), but when both race and TI were included in the model, TI was a significant predictor of SBP (final SBP 2.0 mm/Hg lower for each additional therapy increase per 10 visits, p < 0.001), while race was not (Blacks 1.6 mm/Hg higher than whites, p = 0.17).

CONCLUSIONS

Improved patient-provider communication targeted towards addressing patient concerns about medications may have the potential to reduce racial disparities in TI and ultimately, BP control.

Treatment of hypertension in rural Cambodia: results from a 6-year programme

This study was aimed to describe the outcomes of a hypertension treatment programme in two outpatient clinics in Cambodia. We determined proportions of patients who met the optimal targets for blood pressure (BP) control and assessed the evolution of mean systolic and diastolic BP (SBP/DBP) over time. Multivariate analyses were used to identify predictors of BP decrease and risk factors for LTFU. A total of 2858 patients were enrolled between March 2002 and June 2008 of whom 69.2% were female, 30.5% were aged ≥64 years and 32.6% were diabetic. The median follow-up time was 600 days. By the end of 2008, 1642 (57.4%) were alive-in-care, 8 (0.3%) had died and 1208 (42.3%) were lost to follow-up. On admission, mean SBP and DBP were 162 and 94 mm Hg, respectively. Among the patients treated, a significant SBP reduction of 26.8 mm Hg (95% CI: 28.4-25.3) was observed at 6 months. Overall, 36.5% of patients reached the BP targets at 24 months. The number of young adults, non-overweight patients and non-diabetics reaching the BP targets was more. Older age (>64 years), uncontrolled DBP (≥90 mm Hg) on last consultation and coming late for the last consultation were associated with LTFU, whereas non-diabetic patients were 1.5 times more likely to default than diabetics (95% CI: 1.3-1.7). Although the definite magnitude of the BP decrease due to antihypertension medication over time cannot be assessed definitely without a control group, our results suggest that BP reduction can be obtained with essential hypertension treatment in a large-scale programme in a resource-limited setting.

Understanding contributors to racial disparities in blood pressure control

BACKGROUND

Racial disparities in blood pressure (BP) control are well documented but poorly understood; prior studies have only included a limited range of potential explanatory factors. We examined a comprehensive set of putative factors related to blood pressure control, including patient clinical and sociodemographic characteristics, beliefs about BP and BP medications, medication adherence, and experiences of discrimination, to determine if the impact of race on BP control remains after accounting for such factors.

METHODS AND RESULTS

We recruited 806 white and black patients with hypertension from an urban safety-net hospital. From a questionnaire administered to patients after their clinic visits, electronic medical record and BP data, we assessed an array of patient factors. We then examined the association of patient factors with BP control by modeling it as a function of the covariates using random-effects logistic regression. Blacks indicated worse medication adherence, more discrimination, and more concerns about high BP and BP medications, compared with whites. After accounting for all factors, race was no longer a significant predictor of BP control.

CONCLUSIONS

Results suggest that equalizing patients' health beliefs, medication adherence, and experiences with care could ameliorate disparities in BP control. Additional attention must focus on the factors associated with race to identify, and ultimately intervene on, the causes of racial disparities in BP outcomes.

Racial disparities in hypertension control, but not treatment intensification

BACKGROUND

Racial disparities in hypertension control are well documented, yet the contribution of providers to these disparities remains unclear. The objective of this study was to examine whether provider management of uncontrolled hypertension differed by patient race.

METHODS

In a retrospective cohort of 16,881 hypertensive adults in six academic primary care practices from 1/2004 to 12/2006, we evaluated hypertension control in black vs. white patients according to expert guidelines and, among those with uncontrolled hypertension, whether antihypertensive drugs were intensified by providers. Generalized estimating equations accounted for clustering and adjusted sequentially and additively for patient, provider, and practice characteristics, as well as health-care utilization and antihypertensive medication potency.

RESULTS

Black patients' visits (55.5% of 132,730 visits) had a higher unadjusted odds (1.63, 95% confidence interval (CI) 1.57-1.69) of uncontrolled hypertension than white patients' visits; the fully adjusted odds ratio remained significant (1.40, CI 1.33-1.48, P < 0.001). Among 66,327 visits with uncontrolled hypertension, no intensification of antihypertensive drugs was less likely for blacks' visits before adjustment (0.80, CI 0.76-0.83, P < 0.001) but moderated in the fully adjusted model (adjusted odds ratio 0.93, CI 0.87-0.99, P < 0.05) compared with whites' visits. Accounting for provider race, intensification was more likely at black patients' visits compared with white patients' visits.

CONCLUSIONS

In our study, black patients had poorer hypertension control, and providers were more likely to intensify antihypertensive drugs at visits of black compared with white patients as appropriate. These data suggest that more research is needed to understand racial disparities in hypertension control.

The effect of patient race and blood pressure control on patient-physician communication

BACKGROUND

Racial disparities in hypertension control contribute to higher rates of cardiovascular mortality among blacks. Patient-physician communication quality is associated with better health outcomes, including blood pressure (BP) control. Both race/ethnicity and BP control may adversely affect communication.

OBJECTIVE

To determine whether being black and having poor BP control interact to adversely affect patient-physician communication more than either condition alone, a situation referred to as "double jeopardy."

DESIGN, SETTINGS, AND PATIENTS

Cross-sectional study of enrollment data from a randomized controlled trial of interventions to enhance patient adherence to therapy for hypertension. Participants included 226 hypertensive patients and 39 physicians from 15 primary care practices in Baltimore, MD.

MEASUREMENTS

Communication behaviors and visit length from coding of audiotapes.

RESULTS

After controlling for patient and physician characteristics, blacks with uncontrolled BP have shorter visits (B = -3.9 min, p < 0.01) with less biomedical (B = -24.0, p = 0.05), psychosocial (B = -19.4, p < 0.01), and rapport-building (B = -19.5, p = 0.01) statements than whites with controlled BP. Of all communication outcomes, blacks with uncontrolled BP are only in "double jeopardy" for a patient positive affect-coders give them lower ratings than all other patients. Blacks with controlled BP also experience shorter visits and less communication with physicians than whites with controlled BP. There are no significant communication differences between the visits of whites with uncontrolled versus controlled BP.

CONCLUSIONS

This study reveals that patient race is associated with the quality of patient-physician communication to a greater extent than BP control. Interventions that improve patient-physician communication should be tested as a strategy to reduce racial disparities in hypertension care and outcomes.

Differences in prevalence, awareness, treatment and control of hypertension between developing and developed countries

Objective To systematically review quantitative differences in the prevalence, awareness, treatment and control of hypertension between developed and developing countries over the past 6 years. Methods We searched Medline [prevalence AND awareness AND treatment AND control AND (hypertension OR high blood pressure)] for population-based surveys. Prevalence, awareness, treatment and control of hypertension were compared between men and women, and between developing and developed countries, adjusting for age. The proportions of awareness, treatment and control were defined relative to the total number of hypertensive patients. Results We identified 248 articles, of which 204 did not fulfill inclusion criteria. The remaining articles reported data from 35 countries. Among men, the mean prevalence, awareness, treatment and control of hypertension were 32.2, 40.6, 29.2 and 9.8%, respectively, in developing countries and 40.8, 49.2, 29.1 and 10.8%, respectively, in developed countries. Among women, the mean prevalence, awareness, treatment and control of hypertension were 30.5, 52.7, 40.5, and 16.2%, respectively, in developing countries and 33.0, 61.7, 40.6 and 17.3%, respectively, in developed countries. After adjusting for age, the prevalence of hypertension among men was lower in developing than in developed countries (difference, S6.5%; 95% confidence interval, S11.3 to S1.8%). Conclusion There were no significant differences in mean prevalence, awareness, treatment and control of hypertension between developed and developing countries, except for a higher prevalence among men in developed countries. The prevalence, awareness, treatment and control of hypertension in developing countries are coming closer to those in developed countries.

Hypertension guideline adherence among nursing home patients

BACKGROUND

Adherence to hypertension guidelines in the outpatient setting is low.

OBJECTIVE

To evaluate adherence to JNC VII guidelines in nursing home patients.

DESIGN

Data were obtained from the 2004 National Nursing Home Survey (NNHS), a nationally representative sample of US nursing homes. Patients with hypertension were identified using ICD-9 codes. Adherence to JNC VII guidelines was defined as the use of a thiazide diuretic in patients without a compelling indication for a different class of antihypertensive medication, such as diabetes, chronic kidney disease, coronary artery disease, congestive heart failure, or a history of stroke.

PARTICIPANTS

There were 13,507 patients in the 2004 NNHS survey, of whom 7,129 had hypertension.

MAIN RESULTS

Of these 7,129 hypertensive patients, only 12.6% were on a thiazide. Out of the 7,129 hypertensive patients, 3,113 did not have diabetes, chronic kidney disease, coronary artery disease, congestive heart failure, or a history of stroke. Of these 3,113 patients, only 13.9% were on a thiazide. After excluding patients with a potential contraindication to a diuretic, such as hospice care or incontinence, only 18% were prescribed a thiazide. Of the 3,113 patients, 1,148 were on a single class of antihypertensive and more were prescribed a beta blocker, ACE inhibitor, calcium channel blocker, loop diuretic, and ARB than a thiazide diuretic.

CONCLUSIONS

Adherence to hypertension guidelines among nursing home patients is low. The appropriate use of thiazide diuretics could reduce costs and improve blood pressure control and patient outcomes.

C-reactive protein and cardiac vagal activity following resistance exercise training in young African-American and white men

African Americans have a greater prevalence of hypertension and diabetes compared with white Americans, and both autonomic dysregulation and inflammation have been implicated in the etiology of these disease states. The purpose of this study was to examine the cardiac autonomic and systemic inflammatory response to resistance training in young African-American and white men. Linear (time and frequency domain) and nonlinear (sample entropy) heart rate variability, baroreflex sensitivity, tonic and reflex vagal activity, and postexercise heart rate recovery were used to assess cardiac vagal modulation. C-reactive protein (CRP) and white blood cell count were used as inflammatory markers. Twenty two white and 19 African-American men completed 6 wk of resistance training followed by 4 wk of exercise detraining (Post 2). Sample entropy, tonic and reflex vagal activity, and heart rate recovery were increased in white and African-American men following resistance training ( P < 0.05). Following detraining (Post 2), sample entropy, tonic and reflex vagal activity, and heart rate recovery returned to baseline values in white men but remained above baseline in African-American men. While there were no changes in white blood cell count or CRP in white men, these inflammatory markers decreased in African-American men following resistance training, with reductions being maintained following detraining ( P < 0.05). In conclusion, resistance training improves cardiac autonomic function and reduces inflammation in African-American men, and these adaptations remained after the cessation of training. Resistance training may be an important lifestyle modification for improving cardiac autonomic health and reducing inflammation in young African-American men.

A 41-year-old African American man with poorly controlled hypertension: review of patient and physician factors related to hypertension treatment adherence

Mr R is an African American man with a long history of poorly controlled hypertension and difficulties with adherence to recommended treatments. Despite serious complications such as hypertensive emergency requiring hospitalization and awareness of the seriousness of his illness, Mr R says at times he has ignored his high blood pressure and his physicians' recommendations. African Americans are disproportionately affected by hypertension and its complications. Although most pharmacological and dietary therapies for hypertension are similarly efficacious for African Americans and whites, disparities in hypertension treatment persist. Like many patients, Mr R faces several barriers to effective blood pressure control: societal, health system, individual, and interactions with health professionals. Moreover, evidence indicates that patients' cognitive, affective, and attitudinal factors and the patient-physician relationship play critical roles in improving outcomes and reducing racial disparities in hypertension control.

Lifestyle modification counseling for hypertensive patients: results from the National Health and Nutrition Examination Survey 1999-2004

BACKGROUND

Lifestyle modification is recommended for all patients with the diagnosis of hypertension.

METHODS

We examined 3,497 adult hypertensive participants (representing 42 million Americans), from the National Health and Nutrition Examination Survey (NHANES) 1999-2004. We analyzed the rate, demographic, and clinical factors of participants who reported receiving lifestyle counseling and their adherence.

RESULTS

Of the 3,497 participants with hypertension, 84% reported receiving lifestyle modification counseling. After adjustment for demographic and clinical characteristics, non-Hispanic blacks were more likely to report receiving counseling (odds ratio (OR), 2.5; P < 0.001) when compared to whites. Men (OR, 1.5; P = 0.02) reported receiving counseling more often than women as well as those with Medicare insurance (OR, 1.5; P = 0.02) compared to the privately insured. Participants who were hypercholesterolemic (OR, 1.7; P < 0.001), diabetic (OR, 3.5; P < 0.001), overweight (OR, 1.5; P < 0.001), or obese (OR 3.0; P < 0.001) reported receiving lifestyle counseling more often than those without these conditions. Of those receiving counseling, 88% reported adhering to those recommendations. After adjustment for demographic and clinical characteristics, only non-Hispanic blacks (OR, 2.8; P < 0.001) and those aged >60 (OR, 1.9; P = 0.04) were more likely to report adhering when advised.

CONCLUSIONS

High cardiovascular risk hypertensive patients had high rates of lifestyle counseling. However, gaps exist in lifestyle counseling for young and low cardiovascular risk hypertensive patients. In addition, differences in rates of adherence exist especially in those with high cardiovascular risk comorbid conditions. Future work is needed to increase adherence to lifestyle counseling for all hypertensive patients.

Racial disparity in hypertension control: tallying the death toll

PURPOSE

Black Americans with hypertension have poorer blood pressure control than their white counterparts, but the impact of this disparity on mortality among black adults is not known. We assessed differences in systolic blood pressure (SBP) control among white and black adults with a diagnosis of hypertension, and measured the impact of that difference on cardiovascular and cerebrovascular mortality among blacks.

METHODS

Using SBP measurements from white and black adults participating in the National Health and Nutrition Examination Survey, 1999-2002, we modeled changes in mortality rates resulting from a reduction of mean SBP among blacks to that of whites. Our data source for mortality estimates of blacks with hypertension was a meta-analysis of observational studies of SBP; our data source for reduction in mortality rates was a meta-analysis of SBP treatment trials.

RESULTS

The final sample of participants for whom SBP measurements were available included 1,545 black adults and 1,335 white adults. The mean SBP among blacks with hypertension was approximately 6 mm Hg higher than that for the total adult black population and 7 mm Hg higher than that for whites with hypertension. Within the hypertensive population, a reduction in mean SBP among blacks to that of whites would reduce the annual number of deaths among blacks from heart disease by 5,480 and from stroke by 2,190.

CONCLUSIONS

Eliminating racial disparity in blood pressure control among adults with hypertension would substantially reduce the number of deaths among blacks from both heart disease and stroke. Primary care clinicians should be particularly diligent when managing hypertension in black patients.

Prescribing patterns in hypertension: the emerging role of fixed-dose combinations for attaining BP goals in hypertensive patients

BACKGROUND

The attainment of clinical blood pressure (BP) goals can markedly reduce cardiovascular morbidity and mortality, yet approximately two-thirds of treated hypertensive patients in the United States have uncontrolled BP. Consequently, more aggressive management of hypertension, frequently involving combination therapy (e.g., fixed-dose combination [FDC] therapy), is needed to achieve the recommended BP goals of <140/90 mmHg for most patients, and <130/80 mmHg for high-risk patients.

SCOPE

This article, based on data from an extensive Medline search ('hypertension' AND 'prescribe', 'prescribing' OR 'prescription', date range: 1995-2007), focuses on prescribing patterns for antihypertensive medication, and on the emerging role of combination therapy, specifically FDC therapy, in treating hypertensive patients to target BP levels.

FINDINGS

Although the use of antihypertensive combination therapy has increased substantially in US adults over the last 20 years, such therapy remains considerably underutilized. Numerous studies have shown that combination therapies, including FDCs, can markedly reduce BP and adverse events relative to monotherapies, and this paper overviews data for various combination therapies: angiotensin-receptor blocker (ARB) + diuretic; angiotensin-converting enzyme (ACE) inhibitor + diuretic; calcium-channel blocker (CCB) + ACE inhibitor; and CCB + ARB. Specifically, fixed-dose CCB/ARB combinations of amlodipine with losartan, valsartan, or olmesartan medoxomil have recently been developed, and combination therapy schedules of amlodipine plus one of these ARBs have shown greater BP-lowering efficacy compared with the constituent monotherapies. Furthermore, in two large studies in a total of >3000 patients, CCB + ARB combination therapy was associated with significantly lower incidences of headache and peripheral edema than CCB monotherapy.

CONCLUSION

Guidelines for hypertension management clearly support the greater use of multidrug therapy, especially in high-risk patients. FDCs (e.g., various emerging CCB/ARB combinations) are a valuable option for such high-risk patients, as these combinations offer the potential to reduce adverse events, increase compliance, lower treatment costs, and improve BP goal-attainment rates.

Clinical characteristics and outcomes in hypertensive patients of Hispanic descent

In the United States, patients of Hispanic descent have higher rates of hypertension-related morbidity and mortality than patients from other ethnic groups even though the prevalence of hypertension among Hispanics is lower. This discrepancy likely reflects lower rates of hypertension awareness and control among Hispanics as well as a higher prevalence of diabetes mellitus and other cardiovascular risk factors in this population. Although available data suggest that patients of Hispanic descent who receive antihypertensive therapy experience responses and treatment benefits similar to those achieved by other ethnic groups, clinical trials of antihypertensive therapy have typically enrolled only small numbers of Hispanic patients. Agents targeting the renin-angiotensin system, namely angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers, may be particularly useful in the Hispanic population given the ability of these drugs to protect against hypertension-related and diabetes-related end-organ damage independent of their blood pressure-lowering effects.

Impact of computerized decision support on blood pressure management and control: a randomized controlled trial

BACKGROUND

We conducted a cluster randomized controlled trial to examine the effectiveness of computerized decision support (CDS) designed to improve hypertension care and outcomes in a racially diverse sample of primary care patients.

METHODS

We randomized 2,027 adult patients receiving hypertension care in 14 primary care practices to either 18 months of their physicians receiving CDS for each hypertensive patient or to usual care without computerized support for the control group. We assessed prescribing of guideline-recommended drug therapy and levels of blood pressure control for patients in each group and examined if the effects of the intervention differed by patients' race/ethnicity using interaction terms.

MEASUREMENTS AND MAIN RESULTS

Rates of blood pressure control were 42% at baseline and 46% at the outcome visit with no significant differences between groups. After adjustment for patients' demographic and clinical characteristics, number of prior visits, and levels of baseline blood pressure control, there were no differences between intervention groups in the odds of outcome blood pressure control. The use of CDS to providers significantly improved Joint National Committee (JNC) guideline adherent medication prescribing compared to usual care (7% versus 5%, P < 0.001); the effects of the intervention remained after multivariable adjustment (odds ratio [OR] 1.39 [CI, 1.13-1.72]) and the effects of the intervention did not differ by patients' race and ethnicity.

CONCLUSIONS

CDS improved appropriate medication prescribing with no improvement in disparities in care and overall blood pressure control. Future work focusing on improvement of these interventions and the study of other practical interventions to reduce disparities in hypertension-related outcomes is needed.

Hypertension control at physicians' offices in the United States

BACKGROUND

Uncontrolled hypertension is a common and important risk factor for heart disease and stroke. Nevertheless, the control rate among patients taking prescribed medication and/or therapeutic lifestyle modification has remained about the same for the past several decades.

METHODS

We analyzed 2003 and 2004 National Ambulatory Medical Care Survey (NAMCS) data to determine hypertension control in the physician offices in the United States. All visits for hypertension with measured blood pressure levels were included in the analyses. Survey weights were applied to obtain national estimates. Characteristics associated with hypertension control status were identified.

RESULTS

About 176 million hypertension-related office visits occurred (9.7% of total office visits) during 2003 and 2004. Of these, 17, 44, and 62% of visits had blood pressure <130/80 mm Hg, 140/90 mm Hg, and 145/95 mm Hg, respectively. The likelihood of hypertension control (<140/90 mm Hg) was associated with a diagnosis of coronary heart disease (odds ratio (OR) 1.54, 95% confidence interval (CI) = 1.01-2.35), visits with increased serum cholesterol (OR = 1.34, 95% CI = 1.09-1.65), visits with patients' primary care physician vs. those with non-primary care physicians (OR = 1.49, 95% CI = 1.05-2.10), and visits with internists (OR = 1.32, 95% CI = 1.05-1.67) or cardiologists (OR = 1.70, 95% CI = 1.17-2.471) vs. those with family physicians. Age, gender, race/ethnicity, health insurance status, and prescription of types of antihypertensive medicine were not associated with hypertension control in office visits.

CONCLUSIONS

The hypertension control rate of 44% in US office visits leaves substantial room for improvement. A strong emphasis on improving hypertension management is needed to reduce hypertension-related morbidity and mortality.

Blood Pressure Control in Hispanics in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial

Historically, blood pressure control in Hispanics has been considerably less than that of non-Hispanic whites and blacks. We compared determinants of blood pressure control among Hispanic white, Hispanic black, non-Hispanic white, and non-Hispanic black participants (N=32 642) during follow-up in a randomized, practice-based, active-controlled trial. Hispanic blacks and whites represented 3% and 16% of the cohort, respectively; 33% were non-Hispanic black and 48% were non-Hispanic white. Hispanics were less likely to be controlled (<140/90 mm Hg) at enrollment, but within 6 to 12 months of follow-up, Hispanics had a greater proportion <140/90 mm Hg compared with non-Hispanics. At 4 years of follow-up, blood pressure was controlled in 72% of Hispanic whites, 69% of Hispanic blacks, 67% of non-Hispanic whites, and 59% of non-Hispanic blacks. Compared with non-Hispanic whites, Hispanic whites had a 20% greater odds of achieving BP control by 2 years of follow-up (odds ratio: 1.20; 95% CI: 1.10 to 1.31) after controlling for demographic variables and comorbidities, Hispanic blacks had a similar odds of achieving BP control (odds ratio: 1.04; 95% CI: 0.86 to 1.25), and non-Hispanic blacks had a 27% lower odds (odds ratio: 0.73; 95% CI: 0.69 to 0.78). We conclude that in all patients high levels of blood pressure control can be achieved with commonly available medications and that Hispanic ethnicity is not associated with inferior control in the setting of a clinical trial in which hypertensive patients had equal access to medical care, and medication was provided at no cost.

Does participatory decision making improve hypertension self-care behaviors and outcomes?

This study examined patients' perceptions of their providers' participatory decision making (PDM) style and hypertension self-care behaviors and outcomes. Five hundred fifty-four veterans with hypertension enrolled in the Veterans' Study to Improve the Control of Hypertension rated providers' PDM styles using a validated 3-item instrument. Behaviors assessed included presence of a home blood pressure monitor, monitoring frequency, and self-reported antihypertensive medication adherence. Overall, veterans with hypertension rated providers as highly participatory. In adjusted analyses, a lower PDM score was associated with decreased odds of having a home monitor (odds ratio, 0.90 per 10-point decrement in PDM score; 95% confidence interval, 0.83-0.98) but not with monitoring frequency, adherence, or blood pressure control. Providers' involvement of patients in decision making, reflected in ratings of PDM style, may be important to securing patients' participation in their own care, but alone this factor seems insufficient. No relationship between PDM score and blood pressure control was observed.

The management of hypertension in African Americans

The prevalence of hypertension in blacks in the United States is among the highest in the world. Compared with whites, blacks develop hypertension at an earlier age, their average blood pressures are much higher and they experience worse disease severity. Consequently, blacks have a 1.3 times greater rate of nonfatal stroke, 1.8 times greater rate of fatal stroke, 1.5 times greater rate of heart disease death, 4.2 times greater rate of end-stage kidney disease, and a 50% higher frequency of heart failure; overall, mortality due to hypertension and its consequences is 4 to 5 times more likely in African Americans than in whites. The increased prevalence of hypertension and excessive target organ damage is due to a combination of genetic and, most likely, environmental factors. There are no clinical trial data at present to suggest that lower-than-usual BP targets should be set for high-risk demographic groups such as African Americans. The primary means of prevention and early treatment of hypertension in African Americans will be the appropriate use of lifestyle modification. The International Society of Hypertension in Blacks guidelines realize that most patients will require combination therapy, many of them first-line, to reach appropriate BP goals. Although certain classes and combinations of antihypertensive agents have been well-established to be effective, the choice of drugs for combination therapy in African American patients may be different. Within the African American group, the responsiveness to monotherapy with ACE inhibitors, angiotensin receptor blockers, and beta blockers may be less than the responsiveness to diuretics and calcium channel blockers, but these differences are corrected when diuretics are added to the neurohormonal antagonists. Of note, African American patients with systolic BP >15 mm Hg or a diastolic BP >10 mm Hg above goal should be treated with first-line combination therapy.

Current diagnosis and management of hypertensive emergency

The appropriate and timely evaluation and treatment of patients with severely elevated blood pressure is essential to avoid serious adverse outcomes. Most importantly, the distinction between a hypertensive emergency (crisis) and urgency needs to be made. A sudden elevation in systolic (SBP) and/or diastolic blood pressure (DBP) that is associated with acute end organ damage (cardiovascular, cerebrovascular, or renal) is defined as a hypertensive crisis or emergency. In contrast, acute elevation in SBP and/or DBP not associated with evidence of end organ damage is defined as hypertensive urgency. In patients with a hypertensive emergency, blood pressure control should be attained as expeditiously as possible with parenteral medications to prevent ongoing and potentially permanent end organ damage. In contrast, with hypertensive urgency, blood pressure control can be achieved with the use of oral medications within 24-48 hours. This paper reviews the management of hypertensive emergencies.

Variations in physicians' advice for managing hypertension in women: a study using NHANES III

OBJECTIVE

To examine the pattern of physician advice-giving to individuals with hypertension and to determine if advice-giving and adherence to advice vary by race.

METHODS

Frequency of physician recommendations and patient adherence to such advice were analyzed using data from the Third National Health and Nutrition Examination Survey conducted from 1988 to 1994. A total of 2066 women were included in the study.

RESULTS

The frequency of advice-giving and patient adherence to that advice varied as a function of the type of advice dispensed. Physician advice-giving and patient adherence also varied as a function of race; compared to Black women, White women were 60% less likely [OR (95% CI): 0.41 (0.25, 0.65)] to be told to take prescribed medicines and 56% less likely [OR (95% CI): 0.44 (0.26, 0.76)] to be told to exercise. Regarding patient adherence, compared to Black women, White women were 37% less likely [OR (95% CI): 0.63 (0.44, 0.91)] to use prescribed medicines, 59% less likely [OR (95% CI): 0.41 (0.26, 0.66)] to report reducing use of salt/sodium, and among overweight women, 50% less likely [OR (95% CI): 0.50 (0.31, 0.81)] to report efforts to control/lose weight.

CONCLUSIONS

The variability of physician advice and patient adherence as a function of race warrants further study.