Understanding contributors to racial disparities in blood pressure control

Design and Rationale of the Social Determinants of the Risk of Hypertension in Women of Reproductive Age (SAFE HEART) Study: An American Heart Association Research Goes Red Initiative

BACKGROUND

Cardiovascular health literacy (CVHL) and social determinants of health (SDoH) play interconnected and critical roles in shaping cardiovascular health (CVH) outcomes. However, awareness of CVH risk has declined markedly, from 65% of women being aware that cardiovascular disease (CVD) is the leading cause of death for women in 2009 to just 44% being aware in 2019. The American Heart Association Research Goes Red (RGR) initiative seeks to develop an open-source, longitudinal, dynamic registry that will help women to be aware of and participate in research studies, and to learn about CVD prevention. We proposed to leverage this platform, particularly among Black and Hispanic women of reproductive age, to address CVHL gaps and advance health equity.

METHODS

The primary objective of the study is to evaluate the cross-sectional association of cardiovascular health literacy (CVHL), SDoH using a polysocial score, and CVH in women of reproductive age at increased risk of developing hypertension (HTN). To achieve this we will use a cross-sectional study design, that engages women already enrolled in the RGR registry (registry-enrolled). To enhance the racial and ethnic/social economic diversity of the cohort, we will additionally enroll 300 women from the Baltimore and Washington D.C. community into the Social Determinants of the Risk of Hypertension in Women of Reproductive Age (SAFE HEART) Study. Community-enrolled and registry-enrolled women will undergo baseline social phenotyping including detailed SDoH questionnaire, CVH metrics assessment, and CVHL assessment. The secondary objective is to assess whether a 4-month active health education intervention will result in a change in CVHL in the 300 community-enrolled women.

DISCUSSION

The SAFE HEART study examines the association between CVHL, SDoH, and CVH, with a focus on racial and ethnic minority groups and socioeconomically disadvantaged women of reproductive age, and the ability to improve these parameters by an educational intervention. These findings will inform the future development of community-engaged strategies that address CVHL and SDoH among women of reproductive age.

Patient Adherence Following Knee Surgery: Evidence-Based Practices to Equip Patients for Success

Patient adherence with postoperative wound care, activity restrictions, rehabilitation, medication, and follow-up protocols is paramount to achieving optimal outcomes following knee surgery. However, the ability to adhere to prescribed postoperative protocols is dependent on multiple factors both in and out of the patient's control. The goals of this review article are (1) to outline key factors contributing to patient nonadherence with treatment protocols following knee surgery and (2) to synthesize current management strategies and tools for optimizing patient adherence in order to facilitate efficient and effective implementation by orthopaedic health care teams. Patient adherence is commonly impacted by both modifiable and nonmodifiable factors, including health literacy, social determinants of health, patient fear/stigma associated with nonadherence, surgical indication (elective vs. traumatic), and distrust of physicians or the health care system. In addition, health care team factors, such as poor communication strategies or failure to follow internal protocols, and health system factors, such as prior authorization delays, staffing shortages, or complex record management systems, impact patient's ability to be adherent. Because the majority of factors found to impact patient adherence are nonmodifiable, it is paramount that health care teams adjust to better equip patients for success. For health care teams to successfully optimize patient adherence, focus should be paid to education strategies, individualized protocols that consider patient enablers and barriers to adherence, and consistent communication methodologies for both team and patient-facing communication.

Racial disparities in surgical treatment of type A acute aortic dissection

Objective

To determine whether there are racial disparities associated with mortality, cost, and length of hospital stay after surgical repair of type A acute aortic dissection (TAAAD).

Methods

Patient data from 2015 to 2018 were collected using the National Inpatient Sample. In-hospital mortality was the primary outcome. Multivariable logistical modeling was used to identify factors independently associated with mortality.

Results

Among 3952 admissions, 2520 (63%) were White, 848 (21%) were Black/African American, 310 (8%) were Hispanic, 146 (4%) were Asian and Pacific Islander (API), and 128 (3%) were classified as Other. Black/African American and Hispanic admissions presented with TAAAD at a median age of 54 years and 55 years, respectively, whereas White and API admissions presented at a median age of 64 years and 63 years, respectively (P < .0001). Additionally, there were higher percentages of Black/African American (54%; n = 450) and Hispanic (32%; n = 94) admissions living in ZIP codes with the lowest median household income quartile. Despite these differences on presentation, when adjusting for age and comorbidity, there was no independent association between race and in-hospital mortality and no significant interactions between race and income on in-hospital mortality.

Conclusions

Black and Hispanic admissions present with TAAAD a decade earlier than White and API admissions. Additionally, Black and Hispanic TAAAD admissions are more likely to come from lower-income households. After adjusting for relevant cofactors, there was no independent association between race and in-hospital mortality after surgical treatment of TAAAD.

Racial Differences in Fatal Out-of-Hospital Coronary Heart Disease and the Role of Income in the Atherosclerosis Risk in Communities Cohort Study (1987 to 2017)

Black patients have higher incident fatal coronary heart disease (CHD) rates than do their White counterparts. Racial differences in out-of-hospital fatal CHD could explain the excess risk in fatal CHD among Black patients. We examined racial disparities in in- and out-of-hospital fatal CHD among participants with no history of CHD, and whether socioeconomic status might play a role in this association. We used data from the ARIC (Atherosclerosis Risk in Communities) study, including 4,095 Black and 10,884 White participants, followed between 1987 and 1989 until 2017. Race was self-reported. We examined racial differences in in- and out-of-hospital fatal CHD with hierarchical proportional hazard models. We then examined the role of income in these associations, using Cox marginal structural models for a mediation analysis. The incidence of out-of-hospital and in-hospital fatal CHD was 1.3 and 2.2 in Black participants, and 1.0 and 1.1 in White participants, respectively, per 1,000 person-years. The gender- and age-adjusted hazard ratios comparing out-of-hospital and in-hospital incident fatal CHD in Black with that in White participants were 1.65 (1.32 to 2.07) and 2.37 (1.96 to 2.86), respectively. The income-controlled direct effects of race in Black versus White participants decreased to 1.33 (1.01 to 1.74) for fatal out-of-hospital and to 2.03 (1.61 to 2.55) for fatal in-hospital CHD in Cox marginal structural models. In conclusion, higher rates of fatal in-hospital CHD in Black participants than in their White counterparts likely drive the overall racial differences in fatal CHD. Income largely explained racial differences in both fatal out-of-hospital CHD and fatal in-hospital CHD.

Perceived discrimination in primary care: Does Payer mix matter?

INTRODUCTION

Previous literature has explored patient perceptions of discrimination by race and insurance status, but little is known about whether the payer mix of the primary care clinic (i.e., that is majority public insurance vs. majority private insurance clinics) influences patient perceptions of race- or insurance-based discrimination.

METHODS

Between 2015-2017, we assessed patient satisfaction and perceived race- and insurance-based discrimination using a brief, anonymous post-clinic visit survey.

RESULTS

Participants included 3,721 patients from seven primary care clinics-three public clinics and four private clinics. Results from unadjusted logistic regression models suggest higher overall reports of race- and insurance-based discrimination in public clinics compared with private clinics. In mulvariate analyses, increasing age, Black race, lower education and Medicaid insurance were associated with higher odds of reporting race- and insurance-based discrimination in both public and private settings.

CONCLUSION

Reports of race and insurance discrimination are higher in public clinics than private clinics. Sociodemographic variables, such as age, Black race, education level, and type of insurance also influence reports of race- and insurance-based discrimination in primary care.

Parental Factors Affecting Pediatric Medication Management in Underserved Communities

BACKGROUND

Medication errors and adverse drug events are common in the pediatric population. Limited English proficiency and low health literacy have been associated with decreased medication adherence, increased medication errors, and worse health outcomes. This study explores parental factors affecting medication management in underserved communities.

METHODS

Using qualitative methods, we identified factors believed to affect medication management among parents. We conducted focus group discussions between December 2019 and September 2020. We recruited parents and health care professionals from local community partners and a tertiary care children's hospital. Sessions were recorded and transcribed. Three investigators created the coding scheme. Two investigators independently coded each focus group and organized results into themes using thematic analysis.

RESULTS

Eleven focus groups were held (n = 45): 4 English-speaking parent groups (n = 18), 3 Spanish-speaking parent groups (n = 11), and 4 health care professional groups (n = 16). We identified 4 main factors that could impact medication delivery: 1) limited health literacy among parents and feeling inadequate at medication administration (knowledge/skill gap), 2) poor communication between caregivers (regarding medication delivery, dosage, frequency, and purpose) and between providers (regarding what has been prescribed), 3) lack of pediatric medication education resources, and 4) personal attitudes and beliefs that influence one's medication-related decisions.

CONCLUSIONS

The compounding effect of these factors - knowledge, communication, resource, and personal belief - may put families living in underserved communities at greater risk for medication errors and suboptimal health outcomes. These findings can be used to guide future interventions and may help optimize medication delivery for pediatric patients.

A systematic search and review of the discrimination in health care measure, and its adaptations

BACKGROUND

Discrimination occurs in health care settings contributing to health inequities. Yet guidance on how best to measure discrimination in health care is still limited.

OBJECTIVES

We sought to (1) identify and describe the characteristics of published studies that used the Discrimination in Health Care Measure, a scale first published in 2001; (2) review how the measure has been used or adapted and summarize the measure's published psychometric properties and its variations; and (3) summarize associations between the measure and health-related variables.

METHODS

We performed a systematic search and review of the measure by searching PsycINFO, PubMed, Sociological Abstracts, and Web of Science from January 1, 2001 through January 31, 2017. We screened 260 unique articles, identified 22 eligible articles, and completed a narrative synthesis.

RESULTS

Most studies measured race or ethnicity-based discrimination. All studies made minor revisions to the measure, and most reported high reliabilities. Discrimination in health care, using this measure, was associated with adverse health outcomes.

DISCUSSION AND PRACTICE IMPLICATIONS

Study results indicate that the measure is easy to use and adapt. Researchers should consider using the Discrimination in Health Care Measure when designing studies that will examine individuals' discriminatory experiences when receiving health care.

Sacubitril/valsartan use patterns among older adults with heart failure in clinical practice: a population-based cohort study of >25 000 Medicare beneficiaries

AIMS

Sacubitril/valsartan is strongly supported in guidelines for the management of heart failure, but suboptimal adherence and treatment non-persistence may limit the population-level benefit that this therapy might otherwise offer.

METHODS AND RESULTS

We identified a cohort of Medicare beneficiaries (2014-2017) initiating sacubitril/valsartan after ≥6 months of continuous enrolment. We assessed adherence as the proportion of days covered (PDC) and proportion of patients non-persistent (having no prescription available) at 180 days after initiation. We fit a multivariable negative binomial model with a count of adherent days to evaluate independent factors associated with of sacubitril/valsartan adherence. Among 27 063 new sacubitril/valsartan users, most (n = 17 663, 65%) were prescribed low-dose at 24 mg/26 mg and most (n = 19 984, 74%) were switched from prior angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEi/ARB) rather than being RASi treatment naïve. Median 180-day PDC was 86% (25th-75th percentiles 58-98%). Black patients, those with high comorbid disease burden (≥8 comorbidities), and patients with recent hospitalization within 30 days had fewer adherent days, while those treated with preceding ACEi/ARB had more adherent days. Thirty-four percent of patients did not have an active sacubitril/valsartan prescription at day 180. Among these, few had preceding dose down-titrations (6% among patients on 49 mg/51 mg and 9% among patients on 97 mg/103 mg) and 68% did not have a subsequent ACEi/ARB prescription. Among patients who remained persistent, dose up-titrations occurred in 29% of patients who started on 24 mg/26 mg and 27% of patients on 49 mg/51 mg.

CONCLUSIONS

Overall adherence to sacubitril/valsartan among Medicare beneficiaries is acceptable, but is lower in Black patients, those with higher comorbidities or those who started therapy after recent hospitalization. While broad implementation of guideline-directed medical therapy is a key priority, additional focused efforts to improve adherence early after hospitalization and among at-risk patients are needed in parallel.

Association of Differences in Treatment Intensification, Missed Visits, and Scheduled Follow-up Interval With Racial or Ethnic Disparities in Blood Pressure Control

Importance

Black patients with hypertension often have the lowest rates of blood pressure (BP) control in clinical settings. It is unknown to what extent variation in health care processes explains this disparity.

Objective

To assess whether and to what extent treatment intensification, scheduled follow-up interval, and missed visits are associated with racial and ethnic disparities in BP control.

Design, Setting, and Participants

In this cohort study, nested logistic regression models were used to estimate the likelihood of BP control (defined as a systolic BP [SBP] level <140 mm Hg) by race and ethnicity, and a structural equation model was used to assess the association of treatment intensification, scheduled follow-up interval, and missed visits with racial and ethnic disparities in BP control. The study included 16 114 adults aged 20 years or older with hypertension and elevated BP (defined as an SBP level ≥140 mm Hg) during at least 1 clinic visit between January 1, 2015, and November 15, 2017. A total of 11 safety-net clinics within the San Francisco Health Network participated in the study. Data were analyzed from November 2019 to October 2020.

Main Outcomes and Measures

Blood pressure control was assessed using the patient's most recent BP measurement as of November 15, 2017. Treatment intensification was calculated using the standard-based method, scored on a scale from -1.0 to 1.0, with -1.0 being the least amount of intensification and 1.0 being the most. Scheduled follow-up interval was defined as the mean number of days to the next scheduled visit after an elevated BP measurement. Missed visits measured the number of patients who did not show up for visits during the 4 weeks after an elevated BP measurement.

Results

Among 16 114 adults with hypertension, the mean (SD) age was 58.6 (12.1) years, and 8098 patients (50.3%) were female. A total of 4658 patients (28.9%) were Asian, 3743 (23.2%) were Black, 3694 (22.9%) were Latinx, 2906 (18.0%) were White, and 1113 (6.9%) were of other races or ethnicities (including American Indian or Alaska Native [77 patients (0.4%)], Native Hawaiian or Pacific Islander [217 patients (1.3%)], and unknown [819 patients (5.1%)]). Compared with patients from all racial and ethnic groups, Black patients had lower treatment intensification scores (mean [SD], -0.33 [0.26] vs -0.29 [0.25]; β = -0.03, P < .001) and missed more visits (mean [SD], 0.8 [1.5] visits vs 0.4 [1.1] visits; β = 0.35; P < .001). In contrast, Asian patients had higher treatment intensification scores (mean [SD], -0.26 [0.23]; β = 0.02; P < .001) and fewer missed visits (mean [SD], 0.2 [0.7] visits; β = -0.20; P < .001). Black patients were less likely (odds ratio [OR], 0.82; 95% CI, 0.75-0.89; P < .001) and Asian patients were more likely (OR, 1.13; 95% CI, 1.02-1.25; P < .001) to achieve BP control than patients from all racial or ethnic groups. Treatment intensification and missed visits accounted for 21% and 14%, respectively, of the total difference in BP control among Black patients and 26% and 13% of the difference among Asian patients.

Conclusions and Relevance

This study's findings suggest that racial and ethnic inequities in treatment intensification may be associated with more than 20% of observed racial or ethnic disparities in BP control, and racial and ethnic differences in visit attendance may also play a role. Ensuring more equitable provision of treatment intensification could be a beneficial health care strategy to reduce racial and ethnic disparities in BP control.

Examining Neighborhood Socioeconomic Status as a Mediator of Racial/Ethnic Disparities in Hypertension Control Across Two San Francisco Health Systems

BACKGROUND

A contextual understanding of hypertension control can inform population health management strategies to mitigate cardiovascular disease events. This retrospective cohort study links neighborhood-level data with patients' health records to describe racial/ethnic differences in uncontrolled hypertension and determine if and to what extent these differences are mediated by neighborhood socioeconomic status (nSES).

METHODS

We conducted a mediation analysis using a sample of patients with hypertension from 2 health care delivery systems in San Francisco over 2 years (n=47 031). We used generalized structural equation modeling, adjusted for age, sex, and health care system, to estimate the contribution of nSES to disparities in uncontrolled hypertension between White patients and Black, Hispanic/Latino, and Asian patients, respectively. Sensitivity analysis removed adjustment for health care system.

RESULTS

Over half the cohort (62%) experienced uncontrolled hypertension during the study period. Racial/ethnic groups showed substantial differences in prevalence of uncontrolled hypertension and distribution of nSES quintiles. Compared with White patients, Black, and Hispanic/Latino patients had higher adjusted odds of uncontrolled hypertension: odds ratio, 1.79 [95% CI, 1.67-1.91] and odds ratio, 1.38 [95% CI, 1.29-1.47], respectively and nSES accounted for 7% of the disparity in both comparisons. Asian patients had slightly lower adjusted odds of uncontrolled hypertension when compared with White patients: odds ratio, 0.95 [95% CI, 0.89-0.99] and the mediating effect of nSES did not change the direction of the relationship. Sensitivity analysis increased the proportion mediated by nSES to 11% between Black and White patients and 13% between Hispanic/Latino and White patients, but did not influence differences between Asian and White patients.

CONCLUSIONS

Among patients with hypertension in this study, nSES mediated a small proportion of racial/ethnic disparities in uncontrolled hypertension. Population health management strategies may be most effective by focusing on additional structural and interpersonal pathways such as racism and discrimination in health care settings.

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.

Depression and hypertension awareness, treatment, and control in a multiethnic population in the Netherlands: HELIUS study

Individuals belonging to ethnic minority groups are more susceptible to depression and comorbid hypertension than European host populations. Yet, data on how depression is related to hypertension in ethnic groups in Europe are lacking. Therefore, we studied the association between significant depressed mood (SDM) and hypertension prevalence, awareness, treatment, and control among ethnic groups. Data from the HELIUS study included 22,165 adults (aged 18-70) from six ethnic backgrounds in the Netherlands. Logistic regression analysis was used to explore the association between SDM and hypertension prevalence, awareness, treatment, and control with adjustment for age, sex, and for sensitivity analysis purposes also for anti-depressants. After adjustment for age and sex, Dutch with SDM had an increased odds of hypertension (OR 95% CI 1.67; 1.08-2.59). Among Turkish, SDM was associated with higher odds of hypertension awareness (2.09; 1.41-3.09), treatment (1.92; 1.27-2.90) and control (1.72; 1.04-2.83). Among Moroccans, SMD was associated with an increased odds of hypertension awareness (1.91; 1.14-3.21) but decreased odds of hypertension control (0.42; 0.20-0.89). Additional adjustment for anti-depressant medications did not change the results. There were no associations between SDM and hypertension, awareness, treatment and control in South-Asian Surinamese, African Surinamese and Ghanaian participants. The results underline significant differences in the association between SDM and hypertension awareness, treatment and control between ethnic groups. Our findings emphasize the necessity to further study ethnicity-related factors that may influence the association between SDM and hypertension to promote hypertension control especially, among Moroccans with SDM.

Intersectional Discrimination and Change in Blood Pressure Control among Older Adults: The Health and Retirement Study

BACKGROUND

Associations between multiple forms of discrimination and blood pressure control in older populations remain unestablished.

METHODS

Participants were 14582 non-institutionalized individuals (59% women) in the Health and Retirement Study aged at least 51 years (76% Non-Hispanic White, 15% Non-Hispanic Black, 9% Hispanic/Latino). Primary exposures included the mean frequency of discrimination in everyday life, intersectional discrimination (defined as marginalization ascribed to more than one reason), and the sum of discrimination over the lifespan. We assessed whether discrimination was associated with change in measured hypertension status (N=14582) and concurrent medication use among reported hypertensives (N=9086) over four years (2008-2014).

RESULTS

There was no association between the frequency of everyday discrimination and change in measured hypertension. Lifetime discrimination was associated with higher odds of hypertension four years later among men (OR: 1.21, 95% CI: 1.08, 1.36) but not women (OR: 0.98, 95% CI: 0.86, 1.13). Only among men, everyday discrimination due at least two reasons was associated with a 1.44 (95% CI: 1.03, 2.01)-fold odds of hypertension than reporting no everyday discrimination; reporting intersectional discrimination was not associated with developing hypertension among women (OR: 0.91, 95% CI: 0.70, 1.20). All three discriminatory measures were inversely related to time-averaged antihypertensive medication use, without apparent gender differences (e.g., OR for everyday discrimination-antihypertensive use associations: 0.85, 95% CI: 0.77, 0.94)).

CONCLUSIONS

Gender differences in marginalization may more acutely elevate hypertensive risk among older men than similarly aged women. Experiences of discrimination appear to decrease the likelihood of antihypertensive medication use among older adults overall.

Exploring Culture, Religiosity and Spirituality Influence on Antihypertensive Medication Adherence Among Specialised Population: A Qualitative Ethnographic Approach

BACKGROUND

Hypertension is one of the major risk factors of stroke and leading risk factors for global death. Inadequate control of blood pressure due to medication non-adherence remains a challenge and identifying the underlying causes will provide useful information to formulate suitable interventions.

PURPOSE

This study aimed to explore the roles of culture, religiosity, and spirituality on adherence to anti-hypertensive medications.

METHODOLOGY

A semi-structured qualitative interview was used to explore promoters and barriers to medication adherence among hypertensive individuals residing in urban and rural areas of Perak State, West Malaysia. Study participants were individuals who are able to comprehend either in Malay or English, above 18 years old and on antihypertensive medications. Interview transcriptions from 23 participants were coded inductively and analyzed thematically. Codes generated were verified by three co-investigators who were not involved in transcribing process. The codes were matched with quotations and categorized using three levels of themes named as organizing, classifying and general themes.

RESULTS

Cultural aspects categorized as societal and communication norms were related to non-adherence. The societal norms related to ignorance, belief in testimony and anything "natural is safe" affected medication adherence negatively. Communication norms manifested as superficiality, indirectness and non-confrontational were also linked to medication non-adherence. Internal and organizational religiosity was linked to increased motivation to take medication. In contrast, religious misconception about healing and treatment contributed towards medication non-adherence. The role of spirituality remains unclear and seemed to be understood as related to religiosity.

CONCLUSION

Culture and religiosity (C/R) are highly regarded in many societies and shaped people's health belief and behaviour. Identifying the elements and mechanism through which C/R impacted adherence would be useful to provide essential information for linking adherence assessment to the interventions that specifically address causes of medication non-adherence.

Association of Genetic West African Ancestry, Blood Pressure Response to Therapy, and Cardiovascular Risk Among Self-Reported Black Individuals in the Systolic Blood Pressure Reduction Intervention Trial (SPRINT)

IMPORTANCE

Self-identified Black race is associated with higher hypertension prevalence and worse blood pressure (BP) control compared with other race/ethnic groups. The contribution of genetic West African ancestry to these racial disparities appears not to have been completely determined.

OBJECTIVE

To determine the association between the proportion of West African ancestry with the response to antihypertensive medication, BP control, kidney function, and risk of adverse cardiovascular (CV) events among self-identified Black individuals in the Systolic Blood Pressure Intervention Trial (SPRINT).

DESIGN, SETTING, AND PARTICIPANTS

This post hoc analysis of the SPRINT trial incorporated data from a multicenter study of self-identified Black participants with available West African ancestry proportion, estimated using 106 biallelic autosomal ancestry informative genetic markers. Recruitment started on October 20, 2010, and ended on August 20, 2015. Data were analyzed from May 2020 to September 2020.

MAIN OUTCOMES AND MEASURES

Trajectories of BP and kidney function parameters on follow-up of the trial were assessed across tertiles of the proportion of West African ancestry using linear mixed-effect modeling after adjustment for potential confounders. Multivariable adjusted Cox models evaluated the association of West African ancestry with the risk of composite CV events (nonfatal myocardial infarction, CV death, and heart failure event).

RESULTS

Among 2466 participants in the current analysis (1122 women [45.5%]; median West African ancestry, 81% [interquartile range, 73%-87%]), there were 120 composite CV events (4.9%) over a mean (SD) of 3.2 (0.9) years of follow-up. At baseline, mean (SD) high-density lipoprotein cholesterol levels were higher (tertile 3: 56.5 [15.0] mg/dL vs tertile 1: 54.2 [14.9] mg/dL; P = .006), smoking prevalence (never smoking: tertile 3: 367 [47.9%] vs tertile 1: 372 [42.2%]; P = .009) and mean (SD) Framingham Risk scores (tertile 3: 16.7 [9.7] vs tertile 1: 18.1 [10.2]; P = .01) were lower, and baseline BP was not different across increasing tertiles of West African ancestry. On follow-up, there was no evidence of differences in longitudinal trajectories of BP, kidney function parameters, or left ventricular mass (Cornell voltage by electrocardiogram) across tertiles of West African ancestry in either intensive or standard treatment arms. In adjusted Cox models, higher West African ancestry was associated with a lower risk of a composite CV event after adjustment for potential confounders (adjusted hazard ratio per 5% higher West African ancestry, 0.92 [95% CI, 0.85-0.99]).

CONCLUSIONS AND RELEVANCE

Among self-reported Black individuals enrolled in SPRINT, the trajectories of BP, kidney function, and left ventricular mass over time were not different across tertiles of the proportion of West African ancestry. A higher proportion of West African ancestry was associated with a modestly lower risk for CV events. These findings suggest that extrinsic and structural societal factors, more than genetic ancestry, may be the major drivers of the well-established racial disparity in cardiovascular health associated with hypertension.

The RICH LIFE Project: A cluster randomized pragmatic trial comparing the effectiveness of health system only vs. health system Plus a collaborative/stepped care intervention to reduce hypertension disparities

Disparities in the control of hypertension and other cardiovascular disease risk factors are well-documented in the United States, even among patients seen regularly in the healthcare system. Few existing approaches explicitly address disparities in hypertension care and control. This paper describes the RICH LIFE Project (Reducing Inequities in Care of Hypertension: Lifestyle Improvement for Everyone) design.

METHODS

RICH LIFE is a two-arm, cluster-randomized trial, comparing the effectiveness of enhanced standard of care, "Standard of Care Plus" (SCP), to a multi-level intervention, "Collaborative Care/Stepped Care" (CC/SC), for improving blood pressure (BP) control and patient activation and reducing disparities in BP control among 1890 adults with uncontrolled hypertension and at least one other cardiovascular disease risk factor treated at 30 primary care practices in Maryland and Pennsylvania. Fifteen practices randomized to the SCP arm receive standardized BP measurement training; race/ethnicity-specific audit and feedback of BP control rates; and quarterly webinars in management practices, quality improvement and disparities reduction. Fifteen practices in the CC/SC arm receive the SCP interventions plus implementation of the collaborative care model with stepped-care components (community health worker referrals and virtual specialist-panel consults). The primary clinical outcome is BP control (<140/90 mm Hg) at 12 months. The primary patient-reported outcome is change from baseline in self-reported patient activation at 12 months.

DISCUSSION

This study will provide knowledge about the feasibility of leveraging existing resources in routine primary care and potential benefits of adding supportive community-facing roles to improve hypertension care and reduce disparities.

TRIAL REGISTRATION

Clinicaltrials.govNCT02674464.

Reach out behavioral intervention for hypertension initiated in the emergency department connecting multiple health systems: study protocol for a randomized control trial

Background

Hypertension is the most important modifiable risk factor for cardiovascular disease, the leading cause of mortality in the United States. The Emergency Department represents an underutilized opportunity to impact difficult-to-reach populations. There are 136 million visits to the Emergency Department each year and nearly all have at least one blood pressure measured and recorded. Additionally, an increasing number of African Americans and socioeconomically disadvantaged patients are overrepresented in the Emergency Department patient population. In the age of electronic health records and mobile health, the Emergency Department has the potential to become an integral partner in chronic disease management. The electronic health records in conjunction with mobile health behavior interventions can be leveraged to identify hypertensive patients to impact otherwise unreached populations.

Methods

Reach Out is a factorial trial studying multicomponent, behavioral interventions to reduce blood pressure in the Emergency Department patient population. Potential participants are identified by automated alerts from the electronic health record and, following consent, receive a blood pressure cuff to take home. During the initial screening phase, they are prompted to submit weekly blood pressure readings. Responders with persistent hypertension are then randomized into one of three component arms, consisting of varying intensity levels: (1) healthy behavior text messaging (daily vs. none), (2) blood pressure self-monitoring (daily vs. weekly), and (3) facilitated primary care provider appointment scheduling and transportation (yes vs. no). If participants are randomized to receive facilitated primary care provider appointment scheduling and are not established with a primary care provider, care will be established at a local Federally Qualified Health Center. Participants are followed for 12 months.

Discussion

The Reach Out study is designed to determine which behavioral intervention components or ‘dose’ of components contributes to a reduction in systolic blood pressure after 1 year (Aim 1). The study will also assess the effect of primary care provider appointment assistance on total primary care follow-up visits of hypertensive patients treated in an urban, safety net Emergency Department (Aim 2). Ideally, the Reach Out system will contribute to hypertension management, serving as a model for safety net hospitals and Federally Qualified Health Centers to improve chronic disease management in underserved communities.

Trial registration

This study was registered at clinicaltrials.gov, identifier NCT03422718. The record was first available to the public on January 30, 2018 prior to the enrollment of patients on March 25, 2019.

Is insurance instability associated with hypertension outcomes and does this vary by race/ethnicity?

BACKGROUND

Stable health insurance is often associated with better chronic disease care and outcomes. Racial/ethnic health disparities in outcomes are prevalent and may be associated with insurance instability, particularly in the context of health insurance reform.

METHODS

We examined whether insurance instability was associated with uncontrolled blood pressure (UBP) and whether this association varied by race/ethnicity. We used a retrospective longitudinal observational cohort study of patients diagnosed with hypertension who obtained care within two health systems in Massachusetts. We measured the UBP, insurance instability, and race of 43,785 adult primary care patients, age 21-64 with visits from 1/2005-12/2013.

RESULTS

We found higher rates of UBP for blacks and Hispanics at each time point over the entire 9 years. Insurance instability was associated with greater rates of UBP. Always uninsured black patients fared worst, while white and Hispanic patients with consistent public insurance fared best.

CONCLUSIONS

Stable insurance of any type was associated with better hypertension control than no or unstable insurance.

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.

Beyond Medication Adherence: The Role of Patients' Beliefs and Life Context in Blood Pressure Control

Objective

Despite numerous interventions to address adherence to antihypertensive medications, continued high rates of uncontrolled blood pressure (BP) suggest a need to better understand patient factors beyond adherence associated with BP control. We examined how patients' BP-related beliefs, and aspects of life context affect BP control, beyond medication adherence.

Methods

We conducted a cross-sectional telephone survey of primary care patients with hypertension between 2010 and 2011 (N=103; 93 had complete data on all variables and were included in the regression analyses). We assessed patient sociodemographics (including race/ethnicity), medication adherence, BP-related beliefs, aspects of life context, and used clinical BP assessments.

Results

Regression models including sociodemographics, medication adherence, and either beliefs or context consistently predicted BP control. Adding context after beliefs added no predictive value while adding beliefs after context significantly predicted BP control.

Practical Implications

Results suggest that when clinicians must choose a dimension on which to intervene, focusing on beliefs would be the most fruitful approach to effecting change in BP control.

Practice and predictors of self-care behaviors among ambulatory patients with hypertension in Ethiopia

BACKGROUND

Despite the benefits of evidence-based self-care behaviors in the management of hypertension, hypertensive patients have low rate of adherence to the recommended self-care behaviors. Studies related to self-care behaviors among hypertensive patients are limited in Ethiopia.

OBJECTIVE

To assess the rate of adherence to self-care behaviors and associated factors among hypertensive patients.

METHOD

A cross-sectional study was conducted at the cardiac clinic of Ayder comprehensive specialized hospital among ambulatory hypertensive patients. Self-care behaviors were assessed using an adopted Hypertension Self-Care Activity Level Effects (H-SCALE). Data were collected through patient interview and review of medical records. Binary logistic regression analysis was performed to identify predictors of self-care behaviors.

RESULT

A total of 276 patients were included in the study. The majority of the participants were nonsmokers (89.9%) and alcohol abstainers (68.8%). Less than half of the participants were adherent to the prescribed antihypertensive medications (48.2%) and recommended physical activity level (44.9%). Moreover, only 21.45% and 29% were adherent to weight management and low salt diet recommendations, respectively. Our finding indicated that rural resident (adjusted odds ratio [AOR]: 0.45, 95% confidence interval [CI]: 0.21-0.97), comorbidity (AOR: 0.16, 95% CI: 0.08-0.31), and negative medication belief (AOR: 0.25, 95% CI: 0.14-0.46) were significantly associated with medication adherence. Female sex (AOR: 0.46, 95% CI: 0.23-0.92), old age (AOR: 0.19, 95% CI: 0.06-0.60) and lack of knowledge on self-care behaviors (AOR: 0.13, 95% CI: 0.03-0.57) were significantly associated with adherence to weight management. Female sex (AOR: 1.97, 95% CI: 1.03-3.75) and lack of knowledge on self-care (AOR: 0.07, 95% CI: 0.03-0.16) were significantly associated with adherence to alcohol abstinence. Female sex (AOR: 6.33, 95% CI: 1.80-22.31) and khat chewing (AOR: 0.08, 95% CI: 0.03-0.24) were significantly associated with non-smoking behavior. There was also a significant association between female sex and physical activity (AOR: 0.22, 95% CI: 0.12-0.40).

CONCLUSION

The rate of adherence to self-care behaviors particularly weight management, low salt intake, physical exercise, and medication intake was low in our study. Elders, females, khat chewers, rural residents, and patients with negative medication belief, comorbidity, and inadequate knowledge of SCBs were less adherent to self-care behaviors compared to their counterparts. Therefore, health care providers should pay more emphasis to patients at risk of having low self-care behaviors.

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

Cardiovascular risk factors from diagnosis in children with type 1 diabetes mellitus: a longitudinal cohort study

BACKGROUND

For childhood onset type 1 diabetes (T1D), the pathogenesis of atherosclerosis is greatly accelerated and results in early cardiovascular disease (CVD) and increased mortality. However, cardioprotective interventions in this age group are not routinely undertaken.

AIMS

To document prevalence of cardiovascular risk factors from diagnosis of childhood T1D and their relationship with disease duration and ethnicity.

METHODS

Routinely collected clinical records for 565 children with T1D were retrospectively analyzed. Data were collected from diagnosis and at routine check-ups at pediatric diabetes clinics across Barts Health National Health Service Trust. Age at diagnosis was 8.5 years (0.9-19.4). Mean follow-up 4.3 years (0-10.8). 48% were boys and 60% were non-white. Linear longitudinal mixed effects models were used to evaluate relationships between risk factors and diabetes duration.

RESULTS

CVD risk factors were present at first screening; 33.8% of children were overweight or obese, 20.5% were hypertensive (elevated diastolic blood pressure (BP)) and total cholesterol, low-density lipoprotein-cholesterol and high-density lipoprotein-cholesterol were abnormal in 63.5%, 34.2% and 22.0%, respectively. Significant associations between diabetes duration and annual increases of body mass index (0.6 kg/m²), BP (0.1 SD score) and lipids (0.02-0.06 mmol/L) were noted. Annual increases were significantly higher in black children for BP and Bangladeshi children for lipids. Bangladeshi children also had greatest baseline levels.

CONCLUSIONS

CVD risk factors are present in up to 60% of children at diagnosis of T1D and increase in prevalence during the early years of the disease. Commencing screening in younger children and prioritizing appropriate advice and attention to ethnic variation when calculating risk should be considered.

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.

Cultural Issues in Medication Adherence: Disparities and Directions

Adherence to medications is dependent upon a variety of factors, including individual characteristics of the patient, the patient's family and culture, interactions with healthcare providers, and the healthcare system itself. Because of its association with worse outcomes, poor medication adherence is considered a potential contributor to disparities in health outcomes observed for various conditions across racial and ethnic groups. While there are no simple answers, it is clear that patient, provider, cultural, historical, and healthcare system factors all play a role in patterns of medication use. Here, we provide an overview of the interface between culture and medication adherence for chronic conditions; discuss medication adherence in the context of observed health disparities; provide examples of cultural issues in medication adherence at the individual, family, and healthcare system/provider level; review potential interventions to address cultural issues in medication use; and provide recommendations for future work.

Cultural Issues in Medication Adherence: Disparities and Directions

Adherence to medications is dependent upon a variety of factors, including individual characteristics of the patient, the patient's family and culture, interactions with healthcare providers, and the healthcare system itself. Because of its association with worse outcomes, poor medication adherence is considered a potential contributor to disparities in health outcomes observed for various conditions across racial and ethnic groups. While there are no simple answers, it is clear that patient, provider, cultural, historical, and healthcare system factors all play a role in patterns of medication use. Here, we provide an overview of the interface between culture and medication adherence for chronic conditions; discuss medication adherence in the context of observed health disparities; provide examples of cultural issues in medication adherence at the individual, family, and healthcare system/provider level; review potential interventions to address cultural issues in medication use; and provide recommendations for future work.

Racial variation in cardiovascular disease risk factors among European children on renal replacement therapy-results from the European Society for Paediatric Nephrology/European Renal Association - European Dialysis and Transplant Association Registry

Background

Racial differences in overall mortality rates have been found in children on renal replacement therapy (RRT). We used data from the European Society for Paediatric Nephrology/European Renal Association - European Dialysis and Transplant Association Registry to study racial variation in the prevalence of cardiovascular disease (CVD) risk factors among European children on RRT.

Methods

We included patients aged <20 years between 2006-13 who (i) initiated dialysis treatment or (ii) had a renal transplant vintage of ≥1 year. Racial groups were defined as white, black, Asian and other. The CVD risk factors assessed included uncontrolled hypertension, obesity, hyperphosphataemia and anaemia. Differences between racial groups in CVD risk factors were examined using generalized estimating equation (GEE) models while adjusting for potential confounders.

Results

In this study, 1161 patients on dialysis and 1663 patients with a transplant were included. The majority of patients in both groups were white (73.8% and 79.9%, respectively). The crude prevalence of the CVD risk factors was similar across racial groups. However, after adjustment for potential confounders, Asian background was associated with higher risk of uncontrolled hypertension both in the dialysis group [odds ratio (OR): 1.27; 95% confidence interval (CI): 1.01-1.64] and the transplant group (OR: 1.37; 95% CI: 1.11-1.68) compared with white patients. Patients of Asian and other racial background with a renal transplant had a higher risk of anaemia compared with white patients (OR: 1.50; 95% CI: 1.15-1.96 and OR: 1.45; 95% CI: 1.01-2.07, respectively). Finally, the mean number of CVD risk factors among dialysis patients was higher in Asian patients (1.83, 95% CI: 1.64-2.04) compared with white patients (1.52, 95% CI: 1.40-1.65).

Conclusions

We found a higher prevalence of modifiable CVD risk factors in Asian children on RRT. Early identification and management of these risk factors could potentially improve long-term outcomes.

A Systematic Review of Beliefs About Hypertension and its Treatment Among African Americans

PURPOSE OF REVIEW

The prevalence of hypertension and uncontrolled hypertension is higher among African Americans than any other ethnicity in the USA. Certain patient medical beliefs may lead to adverse health behaviors. The aim of this study was to systematically review and narratively synthesize beliefs about hypertension among African Americans.

RECENT FINDINGS

In a narrative review of 22 studies, many participants attributed hypertension to stress and fatty foods. Hypertension was perceived to be an episodic, symptomatic disease. Many patients exhibited a strong faith in the efficacy of medications, but used them as needed to treat perceived intermittent hypertensive episodes or infrequently to avoid addiction and dependence. Home remedies were often reported to be used concurrently to treat the folk disease "high blood" or in place of medications associated with unwanted effects. Nevertheless, participants were invested in treatment of hypertension to prevent long-term complications. Trends over time suggest that beliefs about hypertension among African Americans have change significantly and now reflect the currently accepted biomedical model. African American beliefs about hypertension may frequently differ from those of healthcare professionals. These results suggest that reconciliation of differences between patient and provider expectations for disease management may improve adherence to and acceptance of medical treatments among African Americans with hypertension. Nevertheless, discordant health beliefs are common among all patients and additional work to elucidate beliefs of other patient subgroups such as age and gender is warranted.

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.

Knowledge, attitudes, and beliefs related to hypertension and hyperlipidemia self-management among African-American men living in the southeastern United States

OBJECTIVE

Perceptions of illness affect cardiovascular disease (CVD) self-management. This study explores knowledge, attitudes, and beliefs regarding hypertension and hyperlipidemia management among 34 African-American men with hypertension and/or hyperlipidemia, age 40-65, living in the Southeastern United States.

METHODS

In-person focus groups were conducted using semi-structured interview questions informed by the Health Belief Model (HBM).

RESULTS

Participants had a high level of knowledge about hypertension self-management, but less about cholesterol self-management. Perceived severity of both conditions was acknowledged, though participants perceived hypertension as more severe. Barriers to self-management included medication side effects and unhealthy dietary patterns. Facilitators included social support, positive healthcare experiences, and the value placed on family. Cultural implications highlighted the importance of food in daily life and social settings. Participants expressed how notions of masculinity affected self-management-noting the impact of feelings of vulnerability and perceived lack of control stemming from diagnosis and treatment expectations.

CONCLUSIONS

The findings highlight gaps in knowledge of hyperlipidemia versus hypertension, and the impact of cultural context and perceptions on engagement in self-management behaviors.

PRACTICE IMPLICATIONS

Public health practitioners and healthcare providers serving African-American men should address cultural factors and notions of masculinity which can hinder effective disease management among this population.

A multicomponent quality improvement intervention to improve blood pressure and reduce racial disparities in rural primary care practices

The Southeastern United States has the highest prevalence of hypertension and African Americans have disproportionately worse blood pressure control. The authors sought to evaluate the effect of a multicomponent practice-based quality improvement intervention on lowering mean systolic blood pressure (SBP) at 12 and 24 months compared with baseline among 525 patients, and to assess for a differential effect of the intervention by race (African Americans vs white). At 12 months, both African Americans (-5.0 mm Hg) and whites (-7.8 mm Hg) had a significant decrease in mean SBP compared with baseline, with no significant between-group difference. Similarly, at 24 months, mean SBP decreased in both African Americans (-6.0 mm Hg) and whites (-7.2 mm Hg), with no significant difference between groups. Notably, no significant racial disparity in mean SBP at baseline was shown. The intervention was effective in lowering mean SBP in both African Americans and whites but there was no differential effect of the intervention by race.

HIV Testing and Health Care Utilization Behaviors Among Men in the United States: A Latent Class Analysis

Emphasis has been placed on HIV testing and health care engagement, but little is known about how testing and engagement intersect, especially for men. We used latent class analysis to explore underlying profiles of U.S. men regarding HIV testing and health care utilization using data from the 2014 National Health Interview Survey. Multinomial regression was used to predict class membership in four classes: (a) Low HIV Testing/No Health Care Utilization, (b) Some HIV Testing/Low Health Care Utilization, (c) No HIV Testing/Some Health Care Utilization, and (d) High HIV Testing/High Health Care Utilization. Most men were in the No HIV Testing/Some Health Care Utilization class (46%), with a 0% chance of ever having had an HIV test but an 89% chance of seeing a general practitioner in the previous year. Research should include qualitative measures to capture information on facilitators and barriers to HIV testing for men who see general practitioners.

A Tale of Two Patients: Patient-Centered Approaches to Adherence as a Gateway to Reducing Disparities

The disparate effects of social determinants of health on cardiovascular health status and health care have been extensively documented by epidemiology. Yet, very little attention has been paid to how understanding and addressing social determinants of health might improve the quality of clinical interactions, especially by improving patients' adherence to recommended therapies. We present a case and suggested approach to illustrate how cardiovascular clinicians can use patient-centered approaches to identify and address social determinants of health barriers to adherence and reduce the impact of unconscious clinician biases. We propose that cardiovascular clinicians (1) recognize that patients may have different belief systems about illnesses' cause and treatment, which may influence their actions, and not assume they share one's experiences or explanatory model; (2) Endeavor to understand the individual patient before you; (3) based on that understanding, tailor your approach to that individual. We suggest a previously-developed mnemonic for an approach to RESPECT the patient: First, show Respect; then elicit patients' understandings of their illness by asking about their Explanatory model. Ask about the patient's Social context, share Power in the interaction, show Empathy, ask about Concerns or fears, and work to develop Trust by building the relationship over time. We provide additional clinical resources to support these efforts, including lay descriptions of cardiovascular conditions, challenges to adherence, and suggested strategies to address them.

Racial Disparities in HIV Care Extend to Common Comorbidities: Implications for Implementation of Interventions to Reduce Disparities in HIV Care

BACKGROUND

Prior studies have described racial disparities in the quality of care for persons with HIV infection, but it is unknown if these disparities extend to common comorbid conditions. To inform implementation of interventions to reduce disparities in HIV care, we examined racial variation in a set of quality measures for common comorbid conditions among Veterans in care for HIV in the United States.

METHOD

The cohort included 23,974 Veterans in care for HIV in 2013 (53.4% black; 46.6% white). Measures extracted from electronic health record and administrative data were receipt of combination antiretroviral therapy (cART), HIV viral control (serum RNA < 200 copies/ml among those on cART), hypertension control (blood pressure < 140/90 mm Hg among those with hypertension), diabetes control (hemoglobin A1C < 9% among those with diabetes), lipid monitoring, guideline-concordant antidepressant prescribing, and initiation and engagement in substance use disorder (SUD) treatment. Black persons were less likely than their white counterparts to receive cART (90.2% vs. 93.2%, p<.001), and experience viral control (84.6% vs. 91.3%, p<.001), hypertension control (61.9% vs. 68.3%, p<.001), diabetes control (85.5% vs. 89.5%, p<.001), and lipid monitoring (81.5% vs. 85.2%, p<.001). Initiation and engagement in SUD treatment were similar among blacks and whites. Differences remained after adjusting for age, comorbidity, retention in HIV care, and a measure of neighborhood social disadvantage created from census data.

SIGNIFICANCE

Implementation of interventions to reduce racial disparities in HIV care should comprehensively address and monitor processes and outcomes of care for key comorbidities.

Can stories influence African-American patients' intentions to change hypertension management behaviors? A randomized control trial

OBJECTIVES

Information-only interventions for hypertension management have limited effectiveness, particularly among disadvantaged populations. We assessed the impact of viewing African-American patients' stories of successfully controlling hypertension on intention to change hypertension management behaviors and engagement with educational materials.

METHODS

In a three-site randomized trial, 618 African-American Veterans with uncontrolled hypertension viewed an information-only DVD about hypertension (control) or a DVD adding videos of African-American Veterans telling stories about successful hypertension management (intervention). After viewing, patients were asked about their engagement with the DVD, and their intentions to change behavior. Mean scores were compared with two-sided t-tests.

RESULTS

Results favored the Stories intervention, with significantly higher emotional engagement versus control (4.3 vs. 2.2 p<0.0001). Intervention patients reported significantly greater intentions to become more physically active (4.6 vs. 4.4, p=0.018), use salt substitutes (3.9 vs. 3.4, p=0.006), talk openly with their doctor about hypertension (4.6 vs. 4.5, p=0.049), and remember to take hypertension medication (4.8 vs. 4.6, p=0.04).

CONCLUSION

Patients were more emotionally engaged and reported intentions to change behavior when watching real patient hypertension management success stories.

PRACTICE IMPLICATIONS

Stories may be more influential than information alone, and represent a scalable approach to modifying behavioral intention.

Cost-effectiveness of Wisconsin TEAM model for improving adherence and hypertension control in black patients

OBJECTIVES

To assess the cost-effectiveness of the 6-month Team Education and Adherence Monitoring (TEAM) intervention for black patients with hypertension in community pharmacies using prospectively collected cost data.

DESIGN

Cost-effectiveness analysis of a cluster-randomized trial.

SETTING

Twenty-eight chain pharmacies in 5 Wisconsin cities from December 2006 to February 2009.

PARTICIPANTS

Five hundred seventy-six black patients with uncontrolled hypertension.

INTERVENTION

Pharmacists and pharmacy technicians using novel tools for improving adherence and feedback to patients and physicians as compared to information-only control group.

MAIN OUTCOME MEASURES

Incremental cost analysis of variable costs from the pharmacy perspective captured prospectively at the participant level. Outcomes (effect measures) were 6-month refill adherence, changes in systolic blood pressure (SBP) and diastolic blood pressure (DBP), and proportion of patients achieving blood pressure (BP) control.

RESULTS

Mean cost of intervention personnel time and tools was $104.8 ± $45.2. Incremental variable costs per millimeter of mercury decrease in SBP and DBP were $22.2 ± 16.3 and $66.0 ± 228.4, respectively. The cost of helping 1 more person achieve the BP goal (<140/90 mm Hg) was $665.2 ± 265.2; the cost of helping 1 more person achieve good refill adherence was $463.3 ± 110.7. Prescription drug costs were higher for the TEAM group ($392.8 [SD = 396.3] versus $307.0 [SD = 295.2]; P = 0.02). The startup cost for pharmacy furniture, equipment, and privacy screen was $168 per pharmacy.

CONCLUSION

Our randomized, practice-based intervention demonstrates that community pharmacists can implement a cost-effective intervention to improve hypertension control in blacks. This approach imposes a nominal expense at the pharmacy level that can be integrated into the ongoing pharmacist-patient relationship, and can enhance clinical and behavioral outcomes.

A Brief, Multifaceted, Generic Intervention to Improve Blood Pressure Control and Reduce Disparities Had Little Effect

BACKGROUND

Poor blood pressure (BP) control and racial disparities therein may be a function of clinical inertia and ineffective communication about BP care.

METHODS

We compared two different interventions (electronic medical record reminder for BP care (Reminder only, [RO]), and clinician training on BP care-related communication skills plus the reminder (Reminder + Training, [R+T]) with usual care in three primary care clinics, examining BP outcomes among 8,866 patients, and provider-patient communication and medication adherence among a subsample of 793.

RESULTS

Clinician counseling improved most at R+T. BP improved overall; R+T had a small but significantly greater reduction in diastolic BP (DBP; -1.7 mm Hg). White patients at RO experienced greater overall improvements in BP control. Site and race disparities trends suggested that disparities decreased at R+T, either stayed the same or decreased at Control; and stayed the same or increased at RO.

CONCLUSIONS

More substantial or racial/ethnically tailored interventions are needed.

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.

Impact of Medicare Part D on Racial Disparities in Adherence to Cardiovascular Medications Among the Elderly

Medicare Part D improved medication adherence among the elderly, but to date, its effect on disparities in adherence remains unknown. We estimated Part D impact on racial/ethnic disparities in adherence to cardiovascular medications among seniors, using pooled data from the Medical Expenditure Panel Survey (2002-2010) on 14,221 Medicare recipients (65+ years) and 3,456 near-elderly controls (60-64 years). Study sample included White, Black, or Hispanic respondents who used at least one cardiovascular medication. Twelve-month adherence was measured as having an overall proportion of days covered ≥80%. Adherence disparities were defined according to the Institute of Medicine framework. Using difference-in-differences logistic regression, we found Part D to be associated with a 16-percentage-point decrease in the White-Hispanic disparity in overall adherence among seniors, net of the change among controls. Black-White disparities worsened only among men, by 21 percentage points. Increasing access and improving quality of medication use among disadvantaged seniors should remain a policy priority.

Determinants of adherence to treatment in hypertensive patients of African descent and the role of culturally appropriate education

BACKGROUND

In Western countries, better knowledge about patient-related determinants of treatment adherence (medication and lifestyle) is needed to improve treatment adherence and outcomes among hypertensive ethnic minority patients of African descent.

OBJECTIVE

To identify patient-related determinants of adherence to lifestyle and medication recommendations among hypertensive African Surinamese and Ghanaian patients with suboptimal treatment results (SBP≥140) living in the Netherlands and how culturally appropriate hypertension education (CAHE) influenced those determinants.

METHODS

This study analysed data of 139 patients who participated in the CAHE trial. Univariate logistic regression analysis was used to measure the association between patient-related determinants (medication self-efficacy, beliefs about medication and hypertension, social support, and satisfaction with care) and treatment adherence. We also tested whether CAHE influenced the determinants.

RESULTS

Medication self-efficacy and social support were associated with medication adherence at baseline. At six months, more medication self-efficacy and fewer concerns about medication use were associated with improved medication adherence. Self-efficacy was also associated with adherence to lifestyle recommendations at baseline. CAHE influenced patients' illness perceptions by creating more understanding of hypertension, its chronic character, and more concerns about the associated risks.

CONCLUSION

In this high-risk population, health care providers can support medication adherence by paying attention to patients' medication self-efficacy, the concerns they may have about medication use and patients' perceptions on hypertension. The CAHE intervention improved patients' perception on hypertension.

Race/ethnicity and Americans' experiences with treatment decision making

OBJECTIVE

Despite widespread documentation of racial/ethnic disparities in medical care, population-wide variation in Americans' experiences with care are not well understood. We examined whether race/ethnicity is associated with information received from physicians regarding treatment recommendations.

METHODS

We conducted a secondary analysis of cross-sectional survey data from a nationally representative sample (N=1238). We assessed patients' personal experiences of receiving information about the rationale for treatment recommendations from their physicians.

RESULTS

Overall, respondents of minority race/ethnicity received less information from their doctors about the rationale for treatment recommendations. After adjustment for possible confounders, doctors talked less often with patients of 'other' race/ethnicity about reasons for treatment recommendations. Both Blacks' and Hispanics' doctors less often cited their own experiences, or scientific research as a reason for treatment recommendations.

CONCLUSION

Americans' experiences with information communicated by physicians regarding treatment rationale varies significantly on some dimensions by race/ethnicity, suggesting that differences in key elements of shared decision making are evident in the care of racial/ethnic minorities.

PRACTICE IMPLICATIONS

Physicians should evaluate the extent to which their communication with patients varies by patient race/ethnicity, and make efforts to ensure that they share equally with all patients regarding the rationale for treatment recommendations.

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).

Differential Outcomes by Race and Ethnicity in Patients with Coronary Heart Disease: A Contemporary Review

Coronary heart disease (CHD) is a leading cause of death for people of most ethnicities in the USA. However, several racial and ethnic minority groups are disproportionately burdened by CHD and experience higher mortality rates and rehospitalization rates compared with whites. Contemporary CHD research has been dedicated in part to broadening our understanding of the root causes of racial and ethnic disparities in CHD outcomes. Several factors contribute, including socioeconomic and comorbid conditions. These factors may be amenable to change, and targets for initiatives to reduce disparities and improve CHD outcomes. In this article, we review the recently published research related to the distribution and determinants of racial and ethnic differences in CHD outcomes in the USA.

Brief provider communication skills training fails to impact patient hypertension outcomes

OBJECTIVES

Hypertension remains a prevalent risk factor for cardiovascular disease, and improved medication adherence leads to better blood pressure (BP) control. We sought to improve medication adherence and hypertension outcomes among patients with uncontrolled BP through communication skills training targeting providers.

METHODS

We conducted a randomized controlled trial to assess the effects of a communication skills intervention for primary care doctors compared to usual care controls, on the outcomes of BP (systolic, diastolic), patient self-reported medication adherence, and provider counseling, assessed at baseline and post-intervention. We enrolled 379 patients with uncontrolled BP; 203 (54%) with follow-up data comprised our final sample. We performed random effects least squares regression analyses to examine whether the provider training improved outcomes, using clinics as the unit of randomization.

RESULTS

In neither unadjusted nor multivariate analyses were significant differences in change detected from baseline to follow-up in provider counseling, medication adherence or BP, for the intervention versus control groups.

CONCLUSION

The intervention did not improve the outcomes; it may have been too brief and lacked sufficient practice level changes to impact counseling, adherence or BP.

PRACTICE IMPLICATIONS

Future intervention efforts may require more extensive provider training, along with broader systematic changes, to improve patient outcomes.