San Francisco, California — In an attempt to reduce the prevalence of hypertension in African-American men, an innovative study turned to the local barber as a gatekeeper for encouraging hypertensive men to visit their healthcare professional to get their blood pressure under control.

As previously reported by heartwire , despite the novel approach for dealing with a known cardiovascular risk factor in the African-American community, results of the Barber-Assisted Reduction in Blood Pressure in Ethnic Residents (BARBER-1) study were a little underwhelming, showing that a barber-based referral system reduced systolic blood pressure by only 2.5 mmHg vs a comparator group.

In a new analysis presented here this week at the American Society of Hypertension (ASH) 2013 Scientific Sessions, researchers now suggest that physician inertia might be the reason why these men failed to get their blood pressure down lower.

"Quite likely, the under treatment of hypertension in primary care limited the ability of the barber-based intervention to lower blood pressure," Dr Florian Rader (Cedars-Sinai Medical Center, Los Angeles, CA), who conducted the post-hoc analysis, told ASH attendees. "Hypertension specialists should be made accessible to all hypertensive black patrons to realize the full promise of the barber-based intervention."

The BARBER-1 study

The BARBER-1 study included 17 black-owned barbershops with clienteles consisting almost entirely of African-American men. Participants were randomized to the intervention barbershops (n=9, mean 75 hypertensive patrons per shop) or comparator shops (n=8, mean 77 hypertensive patrons per shop). Rader and colleagues analyzed the follow-up of patients in the intervention arm (who were seen by hypertension specialists) and those treated by primary-care physicians, as well as follow-up data of patients in the comparator arm.

Overall, the blood pressure reduction among men treated by primary-care physicians was similar to the change in blood pressure among those randomized to the comparator group. In BARBER-1, the comparator arm included men received standard educational pamphlets about hypertension in African Americans, but were not given any other encouragement to get their blood pressure checked.

In contrast, men who were treated by hypertension specialists had a significant 16.6 mmHg reduction in systolic blood pressure vs the comparator arm, suggesting that physician inertia among primary-care physicians might be the reason for the small reductions observed in BARBER-1.

"The blood pressure reduction at 10 months was huge among the patients treated by a hypertension specialist," said Rader. "It was greater than 40 mmHg. However, these patients started with a higher baseline systolic blood pressure, so we would expect a large reduction. On the other hand, the patrons treated by primary-care physicians saw the exact same reduction in systolic blood pressure as those in the comparison group."

After adjusting for baseline blood pressure and other confounding variables, including age, smoking status, and education, a large intervention effect remained in those treated by hypertension specialists. Rader noted that patients treated by hypertension experts were more likely to be treated with ACE inhibitors and calcium channel blockers, and on three or more medications. Medication adherence was no different between the three treatment arms.

The analysis, said Rader, has implications for the design of future trials.

"When we design future interventions, we must not only focus on the diagnosis and referral of black men with uncontrolled hypertension, but must include a physician- and treatment-component as part of the intervention to really have an effect on hypertension."


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