Racial Gap in Achievement of Hypertension Goals Grows

Charlene Laino

November 14, 2003

Nov. 14, 2003 (Orlando) — At a time when the racial gap in achievement of hypertension goals continues to grow, new research suggests that adherence to treatment regimens may play a major role.

Reporting here this week at the American Heart Association (AHA) Scientific Sessions, Pittsburgh researchers said their prospective study showed that black patients are less likely than white patients to take antihypertensive medications correctly.

The report comes on the heels of a study confirming that blacks are less likely to achieve government goals for the control of hypertension — even though blacks are more likely to be aware of and treated for high blood pressure than whites.

"It's well known that blacks have more hypertension than whites and that high blood pressure is more difficult to control in blacks than whites," said Valentin Fuster, MD, past president of the AHA and professor of medicine and cardiology at the Zena and Michael A. Wiener Cardiovascular Institute at Mount Sinai School of Medicine in New York City.

"The question is why," said Dr. Fuster, who was not involved with either study. "Is it because the treatments are less effective in blacks or because there is less compliance?"

The new study suggests that compliance may be a culprit, said chief investigator Mildred A. Jones, PhD, from the University of Pittsburgh in Pennsylvania.

The study demonstrated significant differences between blacks and whites regarding the amount of antihypertensive medication taken, the number of days the medication was taken, and the interval between doses, she said.

For the study, the researchers recruited 105 patients with hypertension from blood pressure screenings in the community; 56% were black and 44% were white. Nearly three quarters of the patients, about half of whom were married, were female. Mean age was 61.4 years; 50% were employed. Mean blood pressure was 145/83 mm Hg, and participants had suffered from hypertension for an average of 12.0 years.

An electronic event monitor that recorded medication bottle openings and closings was used to assess adherence with prescribed regimens, Dr. Jones said.

During the study, black patients took their medication 88% of the time compared with 96% for white patients. Also, 80% of black patients took their medication on the appropriate days versus 86% of white patients.

In addition, 65% of blacks took their medication at the appropriate time, compared with 82% of whites, Dr. Jones said.

Hierarchical stepwise regression that controlled for sociodemographic factors showed that ethnicity explained 9.5% to 22.3% of the variance in adherence, Dr. Jones said.

The findings come at a time when the racial gap continues to worsen, said Robin P. Hertz, PhD, from Pfizer, Inc., in New York City.

From about 1990 to 2000, the prevalence of hypertension increased from 31% to 36% among blacks and from 26% to 30% among whites, according to a comparison of data from the National Health and Examination Survey (NHANES) III, conducted from 1988 to 1994, and NHANES 1999-2000.

Attainment of Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure VII goals improved among white patients, from 22% in NHANES III to 32% in NHANES 1999-2000, Dr. Hertz reported. But in black patients, it remained unchanged at 24%, she said.

This occurred despite the fact that awareness is higher among blacks, with 74% of blacks aware of their blood pressure readings in the NHANES 1999-2000 survey versus 69% of whites.

Also, blacks continued to have higher treatment rates than whites during the entire study period, she said. In NHANES III, 57% of blacks were being treated for high blood pressure compared with 53% of whites. By NHANES 1999-2000, 62% and 58% of blacks and whites, respectively, were being treated.

"Goal attainment is gloomy, with very dramatic race disparities," Dr. Hertz noted. "If we are going to close the racial gap, we need to be more aware that more treatment does not necessarily translate into goal attainment."

Dr. Jones said her findings suggest the problem cannot be solved without increasing rates of compliance among blacks. To achieve that, she said, "culturally sensitive interventions need to be developed to ensure all patients understand the importance of taking their medications."

But just what is a culturally sensitive intervention?

According to Dr. Fuster, "It's very subtle. If a white physician just comes out and says to a black patient, 'Blacks don't take their drugs correctly,' that would be insensitive," he said.

"Patients need to have confidence in their physicians, something that may be [more easily] achieved if they have a physician of their own color," Dr. Fuster said.

"Sometimes the most sensitive thing you can do is to have a physician of the same background available for questions," he said. If that is not possible, "white physicians just need to be very sensitive to the issue of background.

"It's not something that can be taught," Dr. Fuster said.

AHA Scientific Sessions: Abstract 1769, presented Nov. 10, 2003; abstract 3448, presented Nov. 11, 2003.

Reviewed by Michael W. Smith, MD

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