To beat hypertension, take the 'clinic' to the people


Eliminating racial disparities in the outcomes of programs to control blood pressure can be accomplished with a few one-on-one coaching sessions delivered by health professionals - but not if the program requires people to get to a clinic, according to results of a new Johns Hopkins Medicine study.
Image: A black person's blood pressure is measured; Copyright: Popov

African Americans are more like to suffer from hypertension than Whites in the American population; © Andriy Popov

The finding, described in the current issue of the Ethnicity & Disease journal, adds to mounting evidence that health and wellness programs work best when medical practitioners go out to people in their communities.

"For people who can come to a clinic-based program, that program may work really well, but it is not enough in and of itself to eliminate the racial disparities we see in efforts to reduce blood pressure and other chronic diseases," says Lisa A. Cooper, M.D.,M.P.H., vice president of Health Care Equity for Johns Hopkins Medicine and professor of medicine at the Johns Hopkins University School of Medicine. "Success requires a broader and more comprehensive strategy."

In a commentary accompanying the study, Cooper, who has studied racial disparities in health outcomes for decades, lays out the scope of the problem. She notes that compared with Whites in the U.S. population, African Americans are 80 percent more likely to die from stroke and 50 percent more likely to die of heart disease. African Americans also suffer from a 320 percent higher rate of end-stage renal disease. Each of these conditions is fueled by uncontrolled hypertension, especially among urban poor populations, where geographic wealth and racial inequities are stark.

For instance, in the Roland Park/Poplar Hill neighborhood of the city, which has a median income greater than 90,000 dollars, the rate of deaths from heart disease is 14.1 out of 10,000 individuals. Just five miles away, in the Madison/East End neighborhood, the median income is just over 30,000 dollars, and the rate of deaths from heart disease jumps to 35.4 out of 10,000 individuals. The difference in outcomes is dramatic. A person living in Madison/East End is expected to live 64.8 years - 18.3 years less than a person in Roland Park/Poplar Hill.

In response to this problem, in 2010, Johns Hopkins Medicine established the Johns Hopkins Center to Eliminate Cardiovascular Health Disparities. As explained in the commentary, that center now serves as a case study on how to create ties between researchers and community members to address racial disparities in hypertension. This latest study is funded through the center.

For the study, Cooper and her team sought to eliminate the so-called "selection bias" that has muddied past studies of racial disparity interventions. Instead of recruiting volunteers, Cooper and her team telephoned 3,964 patients with uncontrolled hypertension - or a blood pressure reading higher than 140/90 millimeters of mercury (mm Hg) - who had visited one of six Baltimore health clinics (four in underserved areas) in the previous year. The team was able to reach just over half of the patients they telephoned.

When team members reached patients, they asked them if they would be interested in joining a program to lower blood pressure. Anyone participating, they explained, would have to visit the clinic nearest them three times over three months to meet with a specially trained pharmacist, dietitian, or both. The program included one 60-minute session and two 30-minute sessions, or approximately 120 minutes of contact time overall.

A total of 629 individuals participated in at least one session in the clinic - some 9 percent of those reached by phone - or 184 individuals along with 445 others who were referred to the program by their physicians. A total of 245 of the patients attending the first session completed all three sessions. Because final blood pressure readings were not available for 10 percent of participants, 229 completers, including 140 women and 89 men, were included in the final analysis, which compared completers with 332 partial completers and 330 nonparticipants. The average age for all those who participated was around the mid-50s. Sixty percent of those who completed all three sessions, or 137 individuals, were African American.

Participants who completed all three sessions experienced the biggest drop in blood pressure, with a 9 mm Hg greater drop in systolic blood pressure than the drop for nonparticipants and a 4 mm Hg greater drop in diastolic blood pressure  than the drop for nonparticipants. African Americans, who started with higher blood pressure readings overall, experienced greater drops in blood pressure, which wiped out the racial disparity. As a group, participants who completed the program attained blood pressure control, with an average reading of 137/78 mm Hg.

The 337 participants who completed one or two sessions also experienced a greater drop in blood pressure than nonparticipants, but to a lesser degree. On average, for partial completers, systolic blood pressure dropped 5 mm Hg more, and diastolic blood pressure dropped 2 mm Hg more than it did in non-participating patients eligible for the program, that is, patients who had visited one of the six participating clinics in the past year and had a blood pressure reading higher than 140/90 mm Hg.; Source: Johns Hopkins Medicine

More about John Hopkins at: