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

To the Editor: We read with interest the Umscheid et al. article entitled “Racial Disparities in Hypertension Control, but Not Treatment Intensification,” which looked at the likelihood of hypertension treatment intensification for blacks vs. whites.1 This study found hypertensive blacks more likely to have uncontrolled blood pressure, despite medication intensification based on guidelines from the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7).2 Although the authors collected data on the types of comorbidities, they did not address the appropriateness of medication selection based on comorbidities, as is recommended by the JNC 7 guidelines. We briefly present a small study completed at the San Francisco Department of Public Health (SFDPH) that addressed this missing information. We conducted a cross-sectional review of hypertensive patients with SFDPH County Health Insurance who were seen from January to December 2006. Patients were limited to those with ≤1 comorbidity. Medication selection was classified as to whether they were in agreement or not with the JNC 7 guidelines based on compelling indication. t-tests and χ2 tests with a significance level of ≤0.05 were used. Three-hundred nineteen patients were included in the analysis, of which 148 were blacks and 171 were patients from other ethnic groups. A summary of results is shown in Table 1. Black patients had significantly higher systolic (146 mm Hg vs. 140 mm Hg, P = 0.02) and diastolic blood pressure (82 mm Hg vs. 79 mm Hg, P = 0.01). Blacks also had a lower percent of patients with blood pressure at goal, although this difference was modest and was not statistically significant. However, there was no difference in guideline adherence for medication selection in blacks vs. other ethnic groups (75% vs. 73%, P = 0.70). This result was consistent through multivariate analysis for demographics, types of comorbidities, number of medications, and medication adherence. Demographics and results of African Americans vs. other ethnics in hypertension treatment and control Demographics and results of African Americans vs. other ethnics in hypertension treatment and control Our results were consistent with those of Umscheid et al. Failure to achieve blood pressure control does not appear a consequence of providers' inequities of treatments. In both studies, providers are treating black patients similarly to other ethnic groups, and possibly even following guidelines for medication management more strictly in black patients. It seems that blacks may be unique in their response to therapy.3 Future efforts to find optimal therapy for blacks should focus on finding appropriate combination treatments, or novel therapies targeted for this population. Aggressive therapy that appears to be warranted in this population may be achieved more easily if ideal treatment regimens are better defined. The health-care community should continue to be sensitive to differences in response to treatment of hypertensive black patients to reduce the possibility of health outcome disparities. The findings also underscore the need for lifestyle modifications such as weight loss, restriction of sodium, moderation of alcohol intake, and increase in physical activity. Population-based public health efforts to maintain healthy lifestyles may be the best way to approach this problem because lifestyle modifications are shown to be effective but hard to enforce. As a project for a doctor of pharmacy candidate, the only funding source used in this study was a small administrative grant from the School of Pharmacy Office of Student and Curricular Affairs at the University of California–San Francisco.