By Melinda Young
Recent research revealed a reason why more Black Americans than white Americans die from hypertension. It also provides a care coordination solution to this health inequity.
Hypertension affects nearly half of U.S. adults, and more deaths are attributed to hypertension than any other modifiable risk factor. Overall, 23 deaths per 100,000 population occur from hypertension. But for Black Americans, the rate is more than double at 54.1 deaths per 100,000 men and 37.8 deaths per 100,000 women.1
Investigators compared Black and white patients with hypertension control problems and found racial differences in blood pressure control rates disappeared in patients with two or more health barriers. The findings suggest when health systems and providers focus on case management that addresses patients’ social determinants of health, they can help alleviate disparities and improve care.1
One problem for providers is helping patients control their blood pressure. About half the patients with hypertension report poorly controlled blood pressure. Plus, while death rates for some diseases have declined in recent decades, hypertension-related deaths in the United States have risen by 23%, according to data through 2016.2
When hypertension is well-treated and well-controlled, it can prevent more cardiovascular events than management of other modifiable risk factors.3
The big question for case managers and providers is: How can they help patients achieve better blood pressure control? Using digital technology, researchers can monitor patients and provide care management that was not dependent on transportation or time constraints.1
Two Social Determinants Eliminated
The study intervention eliminated two common social determinants of health for all patients included in the study, and it helped patients overcome other barriers, says Richard Milani, MD, lead study author and chief clinical transformation officer and vice chairman of cardiology at Ochsner Health in New Orleans.
For example, the intervention removed the barrier of variability, which means patients in some settings with certain physicians may receive less effective treatment than other patients in different settings. Or it could mean some patients do not attend their follow-up appointments, or their medication is not adjusted as well as needed.
The patients in the study intervention received guideline-directed care from a team, eliminating variability. The intervention included education, drug management, and lifestyle recommendations, all according to hypertension guidelines.1,4
“All they needed was a smartphone and a $30 smart blood pressure cuff, and it would send us their information,” Milani explains.
Patients were asked to take their blood pressure three or four times a week, and no less than once a week. “It takes a minute or two, and they don’t have to sign in and enter passwords,” Milani says. “They can just hit a button on their smartphone to turn it on.”
Each person was assigned a health coach and clinician — usually a pharmacist — who uses current guidelines. “The health coach helps with lifestyle and social determinant issues, and the pharmacist makes sure they’re on the guidelines,” Milani says.
With digital technology sending data, patients did not need to visit the clinic. Pharmacists called patients to discuss treatment options for controlling their blood pressure. Together, patients and pharmacists created a treatment plan with lifestyle and medication modifications.4
“We built this not as a study, but as a transformation in health delivery for healthcare,” Milani notes. “What we do is manage huge populations and get two- to threefold better control than standard of care, and they don’t have to leave their living room or come into a clinic. We can look at many different issues.”
After transportation and time constraints, the intervention eliminated financial stress for medication, low health literacy, and patient activation. “If you had any of those barriers, it dropped your control rate at one year from 73% to 60%,” Milani explains. “If you had two or more barriers, it dropped to 55% control.”
Milani and colleagues studied a large, diverse population in New Orleans and found a 45% prevalence of health barriers in African American patients. In white patients, it was 31%. They reported no difference in blood pressure control between Black and white patients with two or more barriers present.
“For years and years, there was this thought that hypertension is more prevalent in Blacks than whites,” Milani says. “There was this thought that there may be some genetic predisposition in lack of control in Blacks vs. whites.”
The study results demonstrated the difference is not genetic. “The difference in control rates is more a function of social determinants of health as opposed to genetics,” Milani explains.
To address these barriers, health coaches provided lifestyle advice and helped improve patients’ health literacy and activation. For example, they directed patients to a dedicated hypertension website with educational and lifestyle materials, such as custom videos and downloadable handouts. Health coaches also address patient activation through motivational interviewing, which researchers found to be effective, Milani says.
Each patient received a monthly report progress report that included additional tips. Their doctors also received monthly reports. Pharmacists addressed medication cost barriers by helping patients obtain generics and find cheaper pharmacies.
The difference between this intervention and other ways to improve blood pressure control is this intervention specifically addresses the barriers that are invisible in the world of standard medical care, Milani notes. Most clinicians ask patients about their health and medical history, but they do not ask them about factors such as their ability to afford a medication or whether they fully understand the dosing instructions.
If a patient returns for a checkup and their blood pressure remains high, the physician may prescribe a higher dose or more medication. But if the doctor does not seek answers from the patient, such as whether cost is a factor, then they will not succeed with prescribing even more medication. It is similar to the proverbial glass ceiling metaphor for women in leadership roles: No one can see the ceiling, but it is there all the same.
“The image of a glass ceiling stuck in my mind because these social determinates are things that are not measured,” Milani explains. “If it’s not measured, it’s unknown to us.”
As the nation prepares for more elderly baby boomers, it is essential to use evidence-based solutions to improve patients’ chronic illnesses. “We have this ‘gray tsunami’ that’s taking place — a rapid population growth from the baby boomer perspective,” Milani says. “You have this huge demand for care that’s hitting us and getting worse, and we have a diminished supply of physicians in the workforce.”
Hypertension and diabetes control rates are worsening, so new methods are needed to help patients control these conditions. “The only way to solve it is to re-engineer how care is delivered, and this is a fundamental change in our processes,” Milani says. “Anybody can do this — it just takes the effort.”
REFERENCES
- Milani RV, Price-Haywood EG, Burton JH, et al. Racial differences and social determinants of health in achieving hypertension control. Mayo Clin Proc 2022;97:1462-1471.
- Milani RV, Lavie CJ, Wilt JK, et al. New concepts in hypertension management: A population-based perspective. Prog Cardiovasc Dis 2016;59:289-294.
- Commodore-Mensah Y, Loustalot F, Himmelfarb CD, et al. Proceedings from a National Heart, Lung, and Blood Institute and the Centers for Disease Control and Prevention Workshop to control hypertension. Am J Hypertens 2022;35:232-243.
- Milani RV, Wilt JK, Milani AR, et al. Digital management of hypertension improves systolic blood pressure variability. Am J Med 2019;133:e355-e359.
Recent research revealed a reason why more Black Americans than white Americans die from hypertension. It also provides a care coordination solution to this health inequity.
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