Response to "Racial Disparities in Hypertension Control: Not the Provider but Still a Problem"

To the Editor: The letter by Miller and colleagues1 titled “Racial Disparities in Hypertension Control: Not the Provider but Still a Problem” correctly notes that our study2 did not focus on the appropriateness of the type of prescribed antihypertensive medication based on the presence of cardiovascular comorbidities, as recommended by the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7). In Miller and colleagues' study of 319 hypertensive patients with ≤1 cardiovascular comorbidity and public insurance, the majority were prescribed antihypertensive medications consistent with JNC 7 guidelines. Further, guideline-consistent treatment was similar for black patients and patients from other ethnic groups. Thus, their data are complementary to our finding of similar or even greater attention to guideline-consistent management of hypertension in black compared with white patients. However, the results of Miller's study differ from ours in that ~75% of patients in both ethnic groups received guideline-concordant care, whereas for our outcome—management of uncontrolled hypertension—only roughly 30% of patients received guideline-concordant intensification of antihypertensive therapy. Because most patients in Miller's study had no cardiovascular comorbidities, diuretic therapy would represent guideline-consistent care, and this presents a relatively low bar to meet as a quality-of-care measure. It may be useful for Miller to examine more challenging aspects of the JNC 7 guidelines such as the recommendation to initiate two drug therapy for patients with systolic levels >20mmHg above goal or diastolic levels >10mmHg above goal3 where disparities in care across racial groups may be more likely to occur. In addition, others have reported that, among diabetics with albuminuria, black patients are less likely to receive angiotensin-converting enzyme/angiotensin receptor blocker therapy than whites.4 It would be interesting to see whether Miller and colleagues observe similar guideline-concordant care by race among these more clinically complex patients.