Racial Disparity in Hypertension Control: Tallying the Death Toll

Kevin Fiscella; Kathleen Holt

doi:10.1370/afm.873

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Temporal changes in blood pressure disparities
Kevin Fiscella

Published on: 04 September 2009
Couple of Questions
Brian A Chace

Published on: 02 September 2009
Thoughtful comments
Kevin Fiscella

Published on: 15 January 2009
HTN, Racial Disparity and result
Maureen N. Onuigbo

Published on: 13 January 2009
much needed analysis
Mitchell D Wong

Published on: 14 November 2008
Which needs to occur to Eliminate Hypertension Disparities � Rising Water for all or Focus on Rising the Ship for Some?
Hayden B Bosworth

Published on: 14 November 2008

Published on: (4 September 2009)
Page navigation anchor for Temporal changes in blood pressure disparities
Temporal changes in blood pressure disparities
Kevin Fiscella, Rochester, NY USA
This is an excellent question (and I am happy hear about your own work in disparities at your institution). The Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7) issued in 2003, did not change the definition of hypertension (though it did refine categories of subthreshold hypertension). Its primary message was the importance of control of...
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This is an excellent question (and I am happy hear about your own work in disparities at your institution). The Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7) issued in 2003, did not change the definition of hypertension (though it did refine categories of subthreshold hypertension). Its primary message was the importance of control of systolic blood pressure (SBP), particularly among those 50 years and older (the group in which most deaths occur).
In our paper, we used a physician reported diagnosis of hypertension as en eligibility criteria because we were interested in the impact of elimination of racial disparity in control of SBP among persons diagnosed (and thus presumably eligible for treatment).
It is possible that there has been some diagnostic creep between 1999 -2002 and more recent years in terms of clinician diagnosis of hypertension at lower BP levels because of greater clinician awareness of JNC 7. However, I would expect these effects to be relatively small over this time period given the rate at which guidelines diffuse into practice.
Perhaps the most relevant question is whether racial disparity in SBP control among those diagnosed has substantively changed during the intervening years. A comparison of mean SBP between African Americans and non-Hispanic Whites with diagnosed hypertension in NHANES during the years of the original study (1999-2002) and 2003-2006, showed a reduction in SBP both groups. Whether this improvement represents actual improvement in control of SBP or diagnostic creep is not clear.
However, because the SBP reduction in Whites (3.3 mm Hg) was greater than for Blacks (2.7 mm Hg), racial disparity in control of SBP actually worsened by 0.7 mm Hg, suggesting that our original estimate of the death toll may be slightly conservative relative to more current data.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (2 September 2009)
Page navigation anchor for Couple of Questions
Couple of Questions
Brian A Chace, Oklahoma City, OK, USA
My name is Brian Chace and I am a Physical Therapy student researching articles concerning health disparities among minorities with heart disease. My classmates and I are providing our university with a service learning project regarding this issue. After reviewing your article, I had a few questions...
I was just wondering if your calculations for hypertension included the updated definitions of hypertensiv...
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My name is Brian Chace and I am a Physical Therapy student researching articles concerning health disparities among minorities with heart disease. My classmates and I are providing our university with a service learning project regarding this issue. After reviewing your article, I had a few questions...
I was just wondering if your calculations for hypertension included the updated definitions of hypertensive adjusted in 2003... I saw that a lot of the data was from 99-2002 which would have been before the newly categorized hypertensive states. This leaves me to question the figures stated in your article. The article does seem to be very informative and provides us with some staggering numbers that supports the argument that health disparities among the african american population is still high. However, I do not know how relevant we can hold your research to be since the numbers taken are from the years mentioned. Do you have any recent numbers that may still support these findings?
Thanks for your time! Brian Chace
Competing interests: None declared
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Competing Interests: None declared.
Published on: (15 January 2009)
Page navigation anchor for Thoughtful comments
Thoughtful comments
Kevin Fiscella, Rochester, NY USA
I appreciate each of the comments.
Dr Bosworth raises the critical point that rising waters for all may not necessarily lift all boats equally. Global improvement for some quality indicators, particularly those associated with process indicators such those related to timely blood work (e.g. obtaining lipid panels or a1c in diabetes), have been associated with reductions in racial disparities in these measures...
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I appreciate each of the comments.
Dr Bosworth raises the critical point that rising waters for all may not necessarily lift all boats equally. Global improvement for some quality indicators, particularly those associated with process indicators such those related to timely blood work (e.g. obtaining lipid panels or a1c in diabetes), have been associated with reductions in racial disparities in these measures over time, whereas improvements in quality measures related to disease control (LDL-C or a1c goal attainment) have not been associated with appreciable reduction in disparity.1 These findings support Dr Bosworth's suggestion for the need to develop patient self-management programs specifically tailored for populations at risk and also for the need to improve patient-provider communication as means for addressing adherence barriers. I heartily agree.
Dr Wong highlights the dilemma of where to start. The National Healthcare Disparities Report produced annually by AHRQ under Congressional mandate contains numerous examples of health care disparities (available through either a searchable database (http://nhdrnet.ahrq.gov/nhdr/jsp/nhdr.jsp) or through a large PDF (http://www.ahrq.gov/qual/qrdr07.htm#nhdr). Researchers, clinicians including those working in quality improvement, and policy makers are challenged to pick one area to focus on. Impact of the disparity on annual deaths represents one metric for comparing different health care disparities. Based on this metric, disparity in blood pressure control represents a major priority.
Dr Onguibo correctly reminds us that context affects African American health through individual and institutional discrimination, poverty and lower education. She suggests that international comparisons might be fruitful. Indeed, hypertension prevalence is low among rural Nigerians, higher among urban Nigerians and Jamaicans, and highest among African Americans.2,3 Racial disparity in hypertension incidence and blood pressure control have been reported to be small in Cuba and Trinidad.4,5 Interestingly, hypertension prevalence and blood pressure are significantly higher in Europe than the US.6 Prevalence among European whites is roughly comparable to blacks living in the US. These findings underscore the role of national and local context in shaping blood pressure prevalence and control. Most importantly, data from two large randomized trials show that racial disparity in blood pressure is addressable.7,8
1. Trivedi AN, Zaslavsky AM, Schneider EC, Ayanian JZ. Trends in the quality of care and racial disparities in Medicare managed care. N Engl J Med 2005;353:692-700.
2. Forrester T, Cooper RS, Weatherall D. Emergence of Western diseases in the tropical world: the experience with chronic cardiovascular diseases. Brit Med Bull 1998;54:463-473.
3. Kaufman JS, Owoaje EE, Rotimi CN, Cooper RS. Blood pressure change in Africa: case study from Nigeria. Hum Biol 1999;71:641-657.
4. Ordunez-Garcia PO, Espinosa-Brito AD, Cooper RS, Kaufman JS, Nieto FJ. Hypertension in Cuba: evidence of a narrow black-white difference. Journal of Hum Hypertens 1998;12:111-116.
5. Miller GJ, Maude GH, Beckles GL. Incidence of hypertension and non -insulin dependent diabetes mellitus and associated risk factors in a rapidly developing Caribbean community: the St James survey, Trinidad. J Epidemiol Comm Health 1996;50:497-504.
6. Wolf-Maier K, Cooper RS, Banegas JR, Giampaoli S, Hense HW, Joffres M et al. Hypertension prevalence and blood pressure levels in 6 European countries, Canada, and the United States. JAMA 2003;289:2363- 2369.
7. Hypertension Detection and Follow-up Program Cooperative Group. Five-year findings of the hypertension detection and follow-up program. II. Mortality by race-sex and age. Hypertension Detection and Follow-up Program Cooperative Group. JAMA 1979;242:2572-2577.
8. Connett JE, Stamler J. Responses of black and white males to the special intervention program of the Multiple Risk Factor Intervention Trial. Am Heart J 1984;108:839-48.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (13 January 2009)
Page navigation anchor for HTN, Racial Disparity and result
HTN, Racial Disparity and result
Maureen N. Onuigbo, Ann Arbor, MI
You have to factor in the kind of life black people live in the US. Life in the US is tougher for black americans because of racial discriminiation, generational effects of slavery and institutional discrimination over the years and the emotional response/adjustment to it. Blacks in the US are also poorer, less educated for the same reasons. These are all factors known to impact health status.
It would be im...
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You have to factor in the kind of life black people live in the US. Life in the US is tougher for black americans because of racial discriminiation, generational effects of slavery and institutional discrimination over the years and the emotional response/adjustment to it. Blacks in the US are also poorer, less educated for the same reasons. These are all factors known to impact health status.
It would be important to look at black populations outside the US. These populations may have other forms of discrimination but it would be different from that faced by blacks in the US. It would not be as deeply entrenched as it is in the US. All the same, blacks in the US should be compared with blacks in other parts of the world before making these general statements about black people and hypertension and response to treatment, etc
Maureen N. Onuigbo, MD., MPH
Competing interests: none
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Competing Interests: None declared.
Published on: (14 November 2008)
Page navigation anchor for much needed analysis
much needed analysis
Mitchell D Wong, Los Angeles, CA USA
So many in research and public health are calling for interventions to reduce disparities, but with such widespread differences across the spectrum of diseases, it's a challenge just to know where to start. This study provides much needed information about the impact of hypertension on stroke and heart disease mortality. Measuring the magnitude of the impact of risk factors, diseases and aspects of care on disparit...
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So many in research and public health are calling for interventions to reduce disparities, but with such widespread differences across the spectrum of diseases, it's a challenge just to know where to start. This study provides much needed information about the impact of hypertension on stroke and heart disease mortality. Measuring the magnitude of the impact of risk factors, diseases and aspects of care on disparities in mortality and life expectancy is critically important for guiding future disparities interventions. We need to see more of this type of research. Excellent work!
Competing interests: None declared
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Competing Interests: None declared.
Published on: (14 November 2008)
Page navigation anchor for Which needs to occur to Eliminate Hypertension Disparities � Rising Water for all or Focus on Rising the Ship for Some?
Which needs to occur to Eliminate Hypertension Disparities � Rising Water for all or Focus on Rising the Ship for Some?
Hayden B Bosworth, Durham NC, USA
As previously reported (1), there are three levels/generations of health care disparity research. Significant attention has been focused on describing racial/ethnic disparities (first generation), less attention has been directed towards understanding the mechanisms (second generation), and relatively little attention has been focused on developing and evaluating intervention to reduce, and preferably, eliminate health...
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As previously reported (1), there are three levels/generations of health care disparity research. Significant attention has been focused on describing racial/ethnic disparities (first generation), less attention has been directed towards understanding the mechanisms (second generation), and relatively little attention has been focused on developing and evaluating intervention to reduce, and preferably, eliminate health disparities (third generation). The two recent publications (2, 3) and related editorials (4, 5) provide convincing evidence of the consequences of the racial disparities in hypertension as well as provide further evidence that access to adequate and quality health care will not necessarily lead to the direct elimination of racial and ethnic disparities. In fact, based on recent work that our group has conducted, we found comparable racial disparities in blood pressure control in both a VA as well as a university-affiliated primary care setting (6, 7). We concluded that while access to care is important and indirectly influences treatment adherence, further examination of predictors of treatment adherence for hypertension are warranted. While the waters need to rise for all in order to reduce the impact of hypertension, based upon work recently published in the Annals of Family Medicine, a specific focus is needed to understand the mechanisms for reducing racial/ethnic disparities as well as implementing and disseminating interventions to reduce disparities. While work to reduce disparities will need to occur across multiple health care levels (patient, system, provider, environment) as well upstream society perspective (e.g., improving literacy levels and financial well-being), more immediate outcomes may be found downstream with continuing to develop and refine patient self-management programs emphasizing cultural and historical components as well as improving patient/provider communication. Eventually, it is possible that success in reducing disparities could be translated into raising the water levels for all.
1. Saha S, Freeman M, Toure J, et al. Racial and ethnic disparities in the VA health care system: a systematic review. J Gen Intern Med. May 2008;23(5):654-671.
2. Fiscella K, Holt K. Racial disparity in hypertension control: tallying the death toll. Ann Fam Med. Nov-Dec 2008;6(6):497-502.
3. Millett C, Gray J, Bottle A, Majeed A. Ethnic disparities in blood pressure management in patients with hypertension after the introduction of pay for performance. Ann Fam Med. Nov-Dec 2008;6(6):490-496.
4. Cene CW, Cooper LA. Death toll from uncontrolled blood pressure in ethnic populations: universal access and quality improvement may not be enough. Ann Fam Med. Nov-Dec 2008;6(6):486-489.
5. Satcher D. Examining racial and ethnic disparities in health and hypertension control. Ann Fam Med. Nov-Dec 2008;6(6):483-485.
6. Bosworth HB, Dudley T, Olsen MK, et al. Racial differences in blood pressure control: potential explanatory factors. Am J Med. Jan 2006;119(1):70.
7. Bosworth HB, Powers B, Grubber JM, et al. Racial differences in blood pressure control: potential explanatory factors. J Gen Intern Med. May 2008;23(5):692-698.
Competing interests: None declared
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Competing Interests: None declared.