Summary
Objective
The objective of the study was to identify potential explanatory factors for racial differences in blood pressure (BP) control.
Design
The design of the study was a cross-sectional study
Patients/Participants
The study included 608 patients with hypertension who were either African American (50%) or white (50%) and who received primary care in Durham, NC.
Measurements and Main Results
Baseline data were obtained from the Take Control of Your Blood pressure study and included clinical, demographic, and psychosocial variables potentially related to clinic BP measures. African Americans were more likely than whites to have inadequate baseline clinic BP control as defined as greater than or equal to 140/90 mmHg (49% versus 34%; unadjusted odds ratio [OR] 1.8; 95% confidence interval [CI] 1.3–2.5). Among factors that may explain this disparity, being older, reporting hypertension medication nonadherence, reporting a hypertension diagnosis for more than 5 years, reporting high levels of stress, being worried about hypertension, and reporting an increased number of medication side effects were related to inadequate BP control. In adjusted analyses, African Americans continue to have poor BP control relative to whites; the magnitude of the association was reduced (OR = 1.5; 95% CI 1.0–2.1). Medication nonadherence, worries about hypertension, and older age (>70) continued to be related to poor BP control.
Conclusions
In this sample of hypertensive patients, there were a number of factors associated with poor BP control that partially explained the observed racial disparity in hypertension control including age, medication nonadherence, and worry about BP. Medication nonadherence is of particular interest because it is a potentially modifiable factor that might be used to reduce the racial disparity in BP control.
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References
Chobanian AV , Bakris GL, Black H, et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 Report. JAMA. 2003;289(19):2560–71.
Vasan RS, Beiser A, Seshadri S, et al. Residual lifetime risk for developing hypertension in middle-aged women and men: the Framingham Heart Study. JAMA. 2002;287(8):1003–10.
Stamler J, Stamler, Neaton J. Blood pressure, systolic and diastolic, and cardiovascular risks: U.S. population data. Arch Intern Med. 1993;153:598–615.
Perry H, Roccella EJ. Conference report on stroke mortality in the southeastern United States. Hypertens. 1998;31:1206–15.
Kannel W. Blood pressure as a cardiovascular risk factor, prevention and treatment. JAMA. 1996;275:1571–6.
Wong MD, Shapiro MF, Boscardin WJ, Ettner SL. Contribution of major diseases to disparities in mortality. N Engl J Med. 2002;347(20):1585–92.
Hertz RP, Unger AN, Cornell JA, Saunders E. Racial disparities in hypertension prevalence, awareness, and management. Arch Intern Med. 2005;165(18):2098–104.
Bosworth HB, Oddone EZ. A model of psychosocial and cultural antecedents of blood pressure control. J Natl Med Assoc. 2002;94(4):236–48.
Kotchen JM, Shakoor-Abdullah B, Walker WE, Chelius TH, Hoffmann RG, Kotchen TA. Hypertension control and access to medical care in the inner city. Am J Public Health. 1998;881(11):696–9.
Berlowitz DR, Ash AS, Hickey EC, et al. Inadequate management of blood pressure in a hypertensive population. N Engl J Med. 1998;339(27):1957–63.
Weinick RM, Zuvekas SH, Cohen JW. Racial and ethnic differences in access to and use of health care services, 1977 to 1996. Med Care Res Rev. 2000;57(Suppl 1):36–54.
Bosworth HB, Olsen MK, Dudley T, et al. The Take Control of Your Blood pressure (TCYB) study: study design and methodology. Contemp Clin Trials. 2007;28(1):33–47.
Bosworth HB, Bastian LA, Kuchibhatla MN, et al. Depressive symptoms, menopausal status, and climacteric symptoms in women at midlife. Psychosom Med. 2001;63(4):603–8.
Parker R, Baker DW, Williams MV, Nurss JR. The test of functional health literacy in adults: a new instrument for measuring patients’ literacy skills. J Gen Intern Med. 1995;10:537–41.
Davis T, Long SW, Jackson RH, et al. Rapid estimate of adult literacy in medicine: a shortened screening instrument. Family Med. 1993;25:391–5.
Baker DW, Williams MV, Parker RM, Gazmararian JA, Nurss J. Development of a brief test to measure functional health literacy. Patient Educ Couns. 1999;38(1):33–42.
Dewalt DA, Berkman ND, Sheridan S, Lohr KN, Pignone MP. Literacy and health outcomes: a systematic review of the literature. J Gen Intern Med. 2004;19(12):1228–39.
Catz SL, Kelly JA, Bogart LM, Benotsch EG, McAuliffe TL. Patterns, correlates, and barriers to medication adherence among persons prescribed new treatments for HIV disease. Health Psychol. 2000;19(2):124–33.
Morisky DE, Green LW, Levine DM. Concurrent and predictive validity of a self-reported measure of medication adherence. Med Care. 1986;24(1):67–74.
Lowry KP, Dudley TK, Oddone EZ, Bosworth HB. Intentional and unintentional nonadherence to antihypertensive medication. Ann Pharmacother. 2005;39(7–8):1198–203.
Jette A, Cummings KM, Brock BM, Phelps MC, Naessens J. The structure and reliability of health belief indices. Health Serv Res. 1981;16:81–98.
Bosworth HB, Dudley T, Olsen MK, et al. Racial differences in blood pressure control: potential explanatory factors. Am J Med. 2006;119(1):70 e9–15.
Hong TB, Oddone EZ, Dudley TK, Bosworth HB. Subjective and objective evaluations of health among middle-aged and older veterans with hypertension. J Aging Health. 2005;17(5):592–608.
Kaplan SH, Gandek B, Greenfield S, Rogers W, Ware JE. Patient and visit characteristics related to physicians’ participatory decision-making style. Results from the Medical Outcomes Study. Med Care. 1995;33(12):1176–87.
Williams RB, Barefoot JC, Califf RM, et al. Prognostic importance of social and economic resources among medically treated patients with angiographically documented coronary artery disease. JAMA. 1992;267:520–4.
Bosworth HB, Hoff J, Box T et-al. Patient factors related to poor blood pressure control. Poster presented at the 19th Annual Health Service Research and Development Meetings. Washington, DC; 2001.
Rothman K, Greenland S. Modern Epidemiology. 2nd ed. Philadelphia, PA: Lippincott-Raven; 1998.
Schildkraut J, Demark-Wahnefried W, Wenham RM, et al. IGF1(CA)19 Repeat and IGFBP3 -202 A/C Genotypes and the Risk of Prostate Cancer in Black and White Men. Cancer Epidemiol Biomarkers Prev. 2005;14(2):403–8.
Cooper R, Sempos C, Hsieh SC, Kovar MG. Slowdown of the decline of stroke mortality in the United States, 1978–1986. Stroke. 1990;21:1274–9.
Sempos C, Cooper R, Kovar MG, McMillen M. Divergence of the recent trends in coronary mortality for the four major race–sex groups in the United States. Am J Public Health. 1988;78(11):1422–7.
Kramer H, Han C, Post W, et al. Racial/ethnic differences in hypertension and hypertension treatment and control in the multi-ethnic study of atherosclerosis (MESA). Am J Hypertens. 2004;17(10):963–70.
Hajjar I, Kotchen TA. Trends in prevalence, awareness, treatment, and control of hypertension in the United States, 1988–2000. JAMA. 2003;290(2):199–206.
Svetkey LP, George LK, Tyroler HA, Timmons PZ, Burchett BM, Blazer DG. Effects of gender and ethnic group on blood pressure control in the elderly. Am J Hypertens. 1996;9(6):529–35.
McCaul KD, Schroeder DM, Reid PA. Breast cancer worry and screening: some prospective data. Health Psychol. 1996;15(6):430–3.
Psaty B, Koepsell TD, Yanez D, et al. Temporal patterns of antihypertensive medication use among adults, 1989 through 1992. JAMA. 1995;273:1436–8.
Caro JJ, Speckman JL, Salas M, Raggio G, Jackson JD. Effect of initial drug choice on persistence with antihypertensive therapy: the importance of actual practice data. CMAJ. 1999;160(1):41–6.
Bosworth HB, Olsen MK, Gentry P, et al. Nurse administered telephone intervention for blood pressure control: a patient-tailored multifactorial intervention. Patient Educ Couns. 2005;57(1):5–14.
Charles H, Good CB, Hanusa BH, Chang CC, Whittle J. Racial differences in adherence to cardiac medications. J Natl Med Assoc. 2003;95(1):17–27.
Black D, Brand RJ, Greenlick M, Hughes G, Smith J. For the SHEP Pilot Research Group. Compliance to treatment for hypertension in elderly patients: The SHEP pilot study. J Gerontol. 1987;42:552–7.
Monane M, Bohn RL, Gurwitz JH, Glynn RJ, Levin R, Avorn J. Compliance with antihypertensive therapy among elderly Medicaid enrollees: the roles of age, gender, and race. Am J Pub Health. 1996;86(12):1805–8.
Psaty BM, Manolio TA, Smith NL, et al. Time trends in high blood pressure control and the use of antihypertensive medications in older adults: the cardiovascular health study. Arch Intern Med. 2002;162(20):2325–32.
Hyman DJ, Pavlik VN. Characteristics of patients with uncontrolled hypertension in the United States. N Engl J Med. 2001;345(7):479–86.
Burt V, Whelton P, Roccella EJ, et al. Prevalence of hypertension in the US adult population: results from the third National Health and Nutrition Examination Survey. 1988–1991. Hypertens. 1995;25:305–13.
Schectman JM, Bovbjerg VE, Voss JD. Predictors of medication-refill adherence in an indigent rural population. Med Care. 2002;12:1294–300.
Monane M, Bohn RL, Gurwitz JH, Glynn RJ, Levin R, Avorn J. Compliance with antihypertensive therapy among elderly Medicaid enrollees: the roles of age, gender, and race. Am J Pub Health. 1996;86(12):1805–8.
Brach C, Fraser I. Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model. Med Care Res Rev. 2000;57(Suppl 1):181–217.
Fiscella K, Franks P, Gold MR, Clancy CM. Inequality in quality: addressing socioeconomic, racial, and ethnic disparities in health care. JAMA. 2000;283(19):2579–84.
Franklin SS, Gustin WT, Wong ND, et al. Hemodynamic patterns of age-related changes in blood pressure. The Framingham Heart Study. Circulation. 1997;96(1):308–15.
Messerli FH, Mancia G, Conti CR, et al. Dogma disputed: can aggressively lowering blood pressure in hypertensive patients with coronary artery disease be dangerous? Ann Intern Med. 2006;144(12):884–93.
Ong KL, Cheung BM, Man YB, Lau CP, Lam KS. Prevalence, awareness, treatment, and control of hypertension among United States adults 1999–2004. Hypertens. 2007;49(1):69–75.
Holmes JS, Arispe IE, Moy E. Heart disease and prevention: race and age differences in heart disease prevention, treatment, and mortality. Med Care. 2005;43(3 Suppl):I33–41.
Howard G, Prineas R, Moy C, et al. Racial and geographic differences in awareness, treatment, and control of hypertension: the REasons for Geographic And Racial Differences in Stroke study. Stroke. 2006;37(5):1171–8.
Cho AH, Voils CI, Yancy WS Jr, Oddone EZ, Bosworth HB. Does participatory decision making improve hypertension self-care behaviors and outcomes? J Clin Hypertens (Greenwich). 2007;9(5):330–6.
Acknowledgment
This research is supported by a grant from the National Heart, Lung, and Blood Institute (R01 HL070713), a grant from the Pfizer Health Literacy Communication Initiative Foundation, and an Established-Investigator award from the American Heart Association to the first author. Dr. Powers is supported through the Mentored Clinical Research Scholar Program through Duke and the NIH (KL2 RR024127). Dr. Thorpe was supported by an Office of Academic Affairs VA-funded postdoctoral fellowship.
Conflict of Interest
None disclosed.
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Bosworth, H.B., Powers, B., Grubber, J.M. et al. Racial Differences in Blood Pressure Control: Potential Explanatory Factors. J GEN INTERN MED 23, 692–698 (2008). https://doi.org/10.1007/s11606-008-0547-7
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DOI: https://doi.org/10.1007/s11606-008-0547-7