Skip to main content
SpringerLink
Log in

Understanding Racial Disparities in Treatment Intensification for Hypertension Management

  • Original Research
  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript

Abstract

Background

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

Objective

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

Design

Prospective cohort study.

Participants

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

Main Measures

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

Key Results

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

Conclusions

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

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Hertz R, Unger A, Cornell J, Saunders E. Racial disparities in hypertension prevalence, awareness, and management. Arch Intern Med. 2005;165:2098–104.

    Article  PubMed  Google Scholar 

  2. Smedley B, Stith A, Nelson A. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academy Press; 2002.

    Google Scholar 

  3. Cutler JA, Sorlie PD, Wolz M, Thom T, Fields LE, Roccella EJ. Trends in hypertension prevalence, awareness, treatment, and control rates in United States adults between 1988–1994 and 1999–2004. Hypertension. 2008;52:818–27.

    Article  CAS  PubMed  Google Scholar 

  4. Nesbitt SD. Hypertension in black patients: special issues and considerations. Curr Hypertens Rep. 2005;7:244–8.

    Article  PubMed  Google Scholar 

  5. Hajjar I, Kotchen T. Trends in prevalence, awareness, treatment, and control of hypertension in the United States, 1988–2000. J Am Med Assoc. 2003;290:199–206.

    Article  Google Scholar 

  6. Chobanian A, Bakris G, 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. J Am Med Assoc. 2003;289:2560–72.

    Article  CAS  Google Scholar 

  7. Wong M, Shapiro M, Boscardin W, Ettner S. Contributions of major diseases to disparities in mortality. N Engl J Med. 2002;347:1585–92.

    Article  PubMed  Google Scholar 

  8. Phillips LS, Branch WT, Cook CB, et al. Clinical inertia. Ann Intern Med. 2001;135:825–34.

    CAS  PubMed  Google Scholar 

  9. Berlowitz D, Ash AA, Hickey EC, et al. Inadequate management of blood pressure in a hypertensive population. N Engl J Med. 1998;339:1957–63.

    Article  CAS  PubMed  Google Scholar 

  10. Rose AJ, Shimada SL, Rothendler JA, et al. The accuracy of clinician perceptions of "usual" blood pressure control. J Gen Intern Med. 2007.

  11. Selby JV, Uratsu CS, Fireman B, et al. Treatment intensification and risk factor control: toward more clinically relevant quality measures. Med Care. 2009;47:395–402.

    Article  PubMed  Google Scholar 

  12. Okonofua EC, Simpson KN, Jesri A, Rehman SU, Durkalski VL, Egan BM. Therapeutic inertia is an impediment to achieving the Healthy People 2010 blood pressure control goals. Hypertension. 2006;47:345–51.

    Article  CAS  PubMed  Google Scholar 

  13. Hicks LS, Fairchild DG, Horng MS, Orav EJ, Bates DW, Ayanian JZ. Determinants of JNC VI guideline adherence, intensity of drug therapy, and blood pressure control by race and ethnicity. Hypertension. 2004;44:429–34.

    Article  CAS  PubMed  Google Scholar 

  14. Safford MM, Halanych JH, Lewis CE, Levine D, Houser S, Howard G. Understanding racial disparities in hypertension control: intensity of hypertension medication treatment in the REGARDS study. Ethn Dis. 2007;17:421–6.

    PubMed  Google Scholar 

  15. Rose A, Berlowitz D, Manze M, Orner M, Kressin N. Comparing methods of measuring treatment intensification in hypertension care. Circulation Cardiovascular Quality and Outcomes. 2009;2:385–91.

    Article  PubMed  Google Scholar 

  16. Horne R, Weinman J, Hankins M. The beliefs about medicines questionnaire: the development and evaluation of a new method for assessing the cognitive representation of medication. Psychol Health. 1999;14:1–24.

    Article  Google Scholar 

  17. Horne R, Buick D, Fischer M, Leake H, Cooper V, Weinman J. Doubts about the necessity and concerns about adverse effects: identifying the types of beliefs that are associated with non-adherence to HAART. Int J STD AIDS. 2004;15:38–44.

    Article  PubMed  Google Scholar 

  18. Kressin N, Wang F, Long J, et al. Hypertensive patients’ health beliefs, process of care, and medication adherence: is race important? J Gen Intern Med. 2007;22:768–74.

    Article  PubMed  Google Scholar 

  19. Weinman J, Petrie KJ, Moss-Mossis R, Horne R. The illness perception questionnaire: a new method for assessing the cognitive representation of illness. Psychol Health. 1996;11:431–45.

    Article  Google Scholar 

  20. Johnson RL, Saha S, Arbelaez JJ, Beach MC, Cooper LA. Racial and ethnic differences in patient perceptions of bias and cultural competence in health care. J Gen Intern Med. 2004;19:101–10.

    Article  PubMed  Google Scholar 

  21. Bird ST, Bogart LM. Perceived race-based and socioeconomic status (SES)-based discrimination in interactions with health care providers. Ethn Dis. 2001;11:554–63.

    CAS  PubMed  Google Scholar 

  22. Kim MT, Hill MN, Bone LR, Levine DM. Development and testing of the hill-bone compliance to high blood pressure therapy scale. Prog Cardiovasc Nurs. 2000;15:90–6.

    Article  CAS  PubMed  Google Scholar 

  23. Pbert L, Adams A, Quirk M, Hebert J, Ockene J, Luippold R. The patient exit interview as an assessment of physician-delivered smoking intervention: a validation study. Health Psychol. 1999;18:183–8.

    Article  CAS  PubMed  Google Scholar 

  24. Hyman DJ, Pavlik VN. Characteristics of patients with uncontrolled hypertension in the United States. N Engl J Med. 2001;345:479–86.

    Article  CAS  PubMed  Google Scholar 

  25. Umscheid CA, Gross R, Weiner MG, Hollenbeak CS, Tang SS, Turner BJ. Racial disparities in hypertension control, but not treatment intensification. Am J Hypertens. 2010;23:54–61.

    Article  PubMed  Google Scholar 

  26. Kerr EA, Zikmund-Fisher BJ, Klamerus ML, Subramanian U, Hogan MM, Hofer TP. The role of clinical uncertainty in treatment decisions for diabetic patients with uncontrolled blood pressure. Ann Intern Med. 2008;148:717–27.

    PubMed  Google Scholar 

  27. Ferrari P. Reasons for therapeutic inertia when managing hypertension in clinical practice in non-Western countries. J Hum Hypertens. 2009;23:151–9.

    Article  CAS  PubMed  Google Scholar 

  28. Bokhour B, Long J, Berlowitz D, Kressin N. Assessing patient adherence in medical encounters: How do providers talk with patients about antihypertensive medication taking? J Gen Intern Med. 2006;21:577.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

The authors thank Mark Glickman, PhD for his advice regarding statistical analyses.

Funding sources

This work was supported by the NIH/National Heart, Lung and Blood Institute grant R01 HL072814 (N. Kressin, PI). Dr. Kressin is supported in part by a Research Career Scientist Award from the Department of Veterans Affairs Health Services Research and Development Service. Dr. Rose is funded by a career development award from the Department of Veterans Affairs Health Services Research and Development Service.

The views expressed in this article are those of the authors and do not necessarily represent the official views and policies of the Department of Veterans Affairs.

Conflict of Interest

None disclosed.

Financial Disclosure

No authors have identified any financial conflicts of interest.

Author information

Authors and Affiliations

  1. Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA

    Meredith Manze MPH, Adam J. Rose MD, MSc & Nancy R. Kressin PhD

  2. Health Policy & Management Department, Boston University School of Public Health, Boston, MA, USA

    Meredith Manze MPH & Dan R. Berlowitz MD, MPH

  3. Center for Health Quality, Outcomes, and Economic Research, Bedford VA Medical Center, Bedford, MA, USA

    Adam J. Rose MD, MSc, Michelle B. Orner MPH, Dan R. Berlowitz MD, MPH & Nancy R. Kressin PhD

  4. VA Boston Healthcare System, Boston, MA, USA

    Nancy R. Kressin PhD

Authors
  1. Meredith Manze MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Adam J. Rose MD, MSc
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Michelle B. Orner MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Dan R. Berlowitz MD, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Nancy R. Kressin PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Meredith Manze MPH.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Manze, M., Rose, A.J., Orner, M.B. et al. Understanding Racial Disparities in Treatment Intensification for Hypertension Management. J GEN INTERN MED 25, 819–825 (2010). https://doi.org/10.1007/s11606-010-1342-9

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11606-010-1342-9

KEY WORDS

Search

Navigation