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Tables
- Table 1.
Characteristics of the Sample by Number of Cardiovascular Comorbidities (N=8,876)
Characteristic 0 Comorbidities (n=6,329) 1 Comorbidity (n=2,056) ≥2 Comorbidities (n=491) Total (N=8,876) BMI = body mass index; SES = socioeconomic status. aBased on the Index of Multiple Deprivation 2004; the higher the score, the greater the neighborhood’s level of deprivation. Sex, % male 40.6 50.7 60.5 44.1 Age, mean, years White 64.6 70.7 76.0 66.6 Black 58.1 64.9 70.7 60.4 South Asian 59.2 63.7 68.6 61.7 Ethnicity, % White 71.5 23.4 5.2 – Black 71.2 23.6 5.2 – South Asian 58.7 28.7 12.6 – BMI, mean, kg/m2 White 27.6 28.7 29.2 27.9 Black 29.6 29.6 29.1 29.6 South Asian 27.5 27.7 26.8 27.5 Smokers, % White 23.6 21.6 18.3 22.8 Black 12.3 9.5 10.6 11.6 South Asian 8.7 6.3 8.1 7.9 Neighborhood SES score, meana 23.1 23.3 23.9 23.2 Measure and Group 0 Comorbidities 1 Comorbidity ≥2 Comorbidities BP=blood pressure. Systolic BP, mean (SE), mm Hg White 140.7 (0.3) 138.0 (0.6) 133.3 (1.5) Black 141.8 (0.4) 140.2 (0.7) 142.2 (1.6) South Asian 139.1 (1.0) 136.4 (1.5) 140.3 (2.8) Diastolic BP, mean (SE), mm Hg White 81.5 (0.2) 77.2 (0.3) 72.5 (0.7) Black 84.4 (0.3) 79.3 (0.5) 76.4 (1.0) South Asian 80.9 (0.6) 78.8 (1.0) 74.0 (1.7) BP <140/90 mm Hg, % White 42.5 52.6 56.7 Black 42.0 47.4 46.3 South Asian 44.8 57.0 54.8 - Table 3.
Disparities in Blood Pressure Control by Ethnicity and Number of Cardiovascular Comorbidities
Measure Mean Difference or Odds Ratio (95% CI) CI = confidence interval; ref = reference group; BP = blood pressure. Note: Values are adjusted for age, sex, neighborhood socioeconomic status score, treatment (number of antihypertensive medications prescribed), and practice-level clustering. a P value for interaction <.001. b P <.001. c P value for interaction = .27. d P <.01. e P value for interaction = .33. Mean difference in systolic BP, mm Hga Ethnic group and number of comorbidities White, 0 0.00 (ref) White, 1 −3.77b White, ≥2 −9.44b Black, 0 1.48b Black, 1 −1.18 Black, ≥2 −0.58 South Asian, 0 −1.07 South Asian, 1 −5.13b South Asian, ≥2 −1.79 Mean difference in diastolic BP, mm Hgc Ethnic group White 1.00 (ref) Black 1.11b South Asian −1.48d Number of comorbidities 0 1.00 (ref) 1 −2.89b ≥2 −5.73b BP <140/90 mm Hge Ethnic group White 1.00 (ref) Black 0.86 (0.74–0.99) South Asian 1.04 (0.85–1.27) Number of comorbidities 0 1.00 (ref) 1 1.55 (1.37–1.77) ≥2 1.79 (1.45–2.22) Antihypertensive Medication Characteristic ≥3 Medications ACE Inhibitor β-Blocker Calcium Antagonist Diuretic ACE=angiotensin-converting enzyme; ref=reference group. Note: Values are odds ratios adjusted for age, sex, neighborhood socioeconomic status score, and practice-level clustering. a Odds for each additional year of age. Agea 1.01 (1.01–1.02) 1.00 (0.99–1.01) 1.00 (0.99–1.01) 1.02 (1.01–1.03) 1.02 (1.02–1.03) Ethnic group White 1.00 (ref) 1.00 (ref) 1.00 (ref) 1.00 (ref) 1.00 (ref) Black 1.60 (1.29–1.99) 0.72 (0.61–0.83) 0.84 (0.72–0.97) 2.83 (2.28–3.51) 1.27 (1.13–1.43) South Asian 0.66 (0.46–0.96) 0.63 (0.47–0.84) 0.99 (0.80–1.21) 1.33 (0.99–1.77) 0.84 (0.66–1.06) Number of comorbidities 0 1.00 (ref) 1.00 (ref) 1.00 (ref) 1.00 (ref) 1.00 (ref) 1 2.31 (1.87–2.85) 2.55 (2.19–2.96) 1.46 (1.21–1.75) 1.28 (1.11–1.48) 1.03 (0.93–1.15) ≥2 4.99 (2.45–6.54) 3.25 (2.59–4.06) 2.33 (1.89–2.87) 1.51 (1.24–1.83) 2.03 (1.72–2.40) - Table 5.
Number of Antihypertensive Medications Prescribed by Number of Cardiovascular Comorbidities and Ethnicity
Medications Prescribed White, %a Black, %a South Asian, %a Note: Assessed only among patients with poorly controlled blood pressure (>140/90 mm Hg). a Values are expressed as percentage of patients (numerator/denominator). 0 Comorbidity 0 Medications 20.8 (345/1,658) 16.0 (157/979) 22.5 (36/160) 1 Medication 41.9 (695/1,658) 37.9 (371/979) 42.5 (68/160) 2 Medications 28.0 (464/1,658) 32.1 (314/979) 30.0 (48/160) ≥3 Medications 9.3 (154/1,658) 14.0 (137/979) 5.0 (8/160) 1 Comorbidity 0 Medications 6.3 (28/447) 7.8 (23/294) 16.4 (10/61) 1 Medication 34.7 (155/447) 26.9 (79/294) 39.3 (24/61) 2 Medications 37.8 (169/447) 38.1 (112/294) 31.2 (19/61) ≥3 Medications 21.3 (95/447) 27.2 (80/294) 13.1 (8/61) ≥2 Comorbidities 0 Medications 4.4 (4/90) 1.5 (1/66) 0.0 (0/28) 1 Medication 18.9 (17/90 19.7 (13/66) 21.4 (6/28) 2 Medications 45.6 (41/90) 37.9 (25/66) 50.0 (14/28) ≥3 Medications 31.1 (28/90) 40.9 (27/66) 28.6 (8/28) - Table 6.
Type of Antihypertensive Medication Prescribed by Number of Cardiovascular Comorbidities and Ethnicity
Antihypertensive Medication White, %a Black, %a South Asian, %a ACE = angiotensin-converting enzyme. Note: Assessed among all patients. a Values are expressed as percentage of patients (numerator/denominator). 0 Comorbidities ACE inhibitor 29.8 (859/2,881) 21.6 (365/1,687) 20.7 (60/290 β-Blocker 23.1 (665/2,881) 18.9 (318/1,687) 22.8 (66/290) Calcium antagonist 30.8 (888/2,881) 52.9 (892/1,687) 35.2 (102/290) Diuretic 42.1 (1,214/2,881) 46.8 (789/1,687) 34.5 (100/290) 1 Comorbidity ACE inhibitor 51.8 (488/942) 46.0 (257/559) 40.1 (57/142) β-Blocker 30.4 (286/942) 27.2 (152/559) 28.9 (41/142) Calcium antagonist 41.4 (390/942) 61.4 (343/559) 35.9 (51/142) Diuretic 46.5 (438/942) 47.6 (266/559) 40.1 (57/142 ≥2 Comorbidities ACE inhibitor 59.1 (123/208) 52.9 (65/123) 46.8 (29/62) β-Blocker 39.4 (82/208) 40.7 (50/123) 40.3 (25/62) Calcium antagonist 42.8 (89/208) 68.3 (84/123) 61.3 (38/62) Diuretic 65.4 (136/208) 67.5 (83/123) 50.0 (31/62)
Additional Files
The Article in Brief
Ethnic Disparities in Blood Pressure Management in Patients With Hypertension After the Introduction of Pay for Performance
Christopher Millett , and colleagues
Background The United Kingdom (UK) has implemented a major quality improvement effort, which includes a goal of reducing inequalities in the management of chronic diseases. This study examines differences in the management of high blood pressure by patient ethnicity in the United Kingdom.
What This Study Found Black patients with high blood pressure are less likely to reach an established treatment target for blood pressure control than white or South Asian patients. South Asian patients with high blood pressure have more cardiovascular conditions than white or black patients. The presence of two or more other cardiovascular conditions was associated with better blood pressure control in white but not in black or South Asian patients. South Asian patients with poorly controlled blood pressure were prescribed fewer antihypertensive medications than black or white patients.
Implications
- Ethnic inequalities in the management of high blood pressure have continued in the United Kingdom despite major investment in quality improvement programs, including pay for performance.
- These disparities are particularly marked in patients with additional cardiovascular conditions.
- In universal quality improvement programs, such as pay for performance, additional efforts are required to improve the quality of care for high-risk individuals.
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