"The most surprising finding was that racial differences in blood pressure control were in large part explained by practitioners' likelihood of increasing therapy for high blood pressure," Dr. Valy Fontil of the University of San Francisco and San Francisco General Hospital told Reuters Health by email. "Racial disparities in hypertension and other chronic diseases are not inevitable. Clinicians play a vitally important role and their treatment decisions matter...a lot!"
As reported in JAMA Cardiology, Dr. Fontil and colleagues used various modeling methods to estimate the likelihood of blood pressure control (systolic level <140 mm Hg) by race and ethnicity, including associations of treatment intensification; follow-up intervals; and missed visits.
More than 16,000 adults with hypertension (mean age, 58.6; 50%, women) were included in the study: 28.9% were Asian; 23.2%, Black; 22.9%, Latinx; 18.0%, white; and 6.9% were of other races/ethnicities.
Compared with patients from all racial/ethnic groups, Blacks had lower treatment intensification scores (mean, −0.33 vs. −0.29) and missed more visits (mean, 0.8 visits vs .0.4 visits).
In contrast, Asian patients had higher treatment intensification scores (mean, −0.26) and fewer missed visits (mean, 0.2).
Black patients were less likely (odds ratio, 0.82) and Asian patients, more likely (OR, 1.13) to achieve blood pressure control than patients from all other racial or ethnic groups.
Overall, treatment intensification and missed visits accounted for 21% and 14%, respectively, of the total difference in blood pressure control among Black patients and 26% and 13% of the difference among Asian patients.
Dr. Fontil noted, "One of the biggest obstacles to achieving more equitable hypertension treatment is clinical inertia - missed opportunities to prescribe medications for high blood pressure. Often doctors firmly believe that they know full well how to treat hypertension (and perhaps other chronic diseases) and that the major barriers are on the patient."
"Our findings re-emphasize the call for adoption of treatment protocols and clinical decision support systems to help standardize quality of care for chronic diseases and provide clinicians with personalized treatment recommendation for their patients."
Dr. Yvonne Commodore-Mensah of Johns Hopkins School of Nursing in Maryland, coauthor of a related editorial, commented in an email to Reuters Health that initiatives on several levels are needed to help overcome disparities.
"At the national level, incentives should be aligned to allow team-based care to be implemented consistently," she said. (https://bit.ly/3dNtqOo) "Team-based care...provides patients with additional support from different members of the healthcare team including nurses, pharmacists, and community health workers. However, our current payment models do not allow them to be adequately compensated for their time and expertise."
"All patients diagnosed with hypertension should be provided with validated blood pressure devices to allow them to self-monitor their condition," she said. "Although some health plans provide these devices at discounted rates, people who live in poverty and receive care at community health centers may not be able to afford them."
"Hypertension control should be a community-level vital sign," she noted. "We should be able to track blood pressure control at the local level and integrate hypertension control programs in local public health departments...Faith-based settings, community-based organizations, barbershops, and salons offer convenient options for patients diagnosed with hypertension to receive care where they live, work, play and pray."
Other strategies may include prescribing single-pill combinations of hypertension medications to improve adherence; assessment of social needs to address issues such as transportation and food security; and telehealth options, Dr. Commodore-Mensah suggested.
SOURCE: https://bit.ly/3pWMzTB and https://bit.ly/3pNOeL4 JAMA Cardiology, online December 8, 2021.
By Marilynn Larkin
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