Background. Hypertension clearly contributes to the racial disparities
in health outcomes. The Charleston Heart Study indicated that hypertension
contributed to ~40% of deaths in Blacks compared to ~20% in Whites.
- The prevalence and complications of hypertension are greater and control
rates lower among hypertensive patients of lower socioeconomic status (SES)
which are disproportionately Black.
- For these and other reasons, blacks in
South Carolina continue to die from stroke at double the rate of whites.
- The Hypertension Detection and Follow-Up Program (HDFP) showed that
stepped-care treatment of high blood pressure (BP) reduced stroke and total
mortality more in blacks than in whites.
- Although access to care is a significant issue for low income individuals, especially the uninsured,
control of hypertension to <140/90 mmHg is obtained on >75% of visits in
only ~20% of patients. Therefore, a logical approach to optimizing BP
control rates in the population is to first improve efficiency, i.e., do
a better job with the >50% of hypertensive patients who are already in
the system but the majority of whom are not consistently at the goal BP.
- Once that is accomplished, then improving access will lead to a more
efficient utilization of resources and greater control rates. Reluctance
of providers to increase therapy is a major contributor to inadequate BP control.
- An outpatient hypertension management program at Univ. of Pennsylvania,
which focused on providers, increased BP control rates from 19–53%
within one year.
- Thus, our initial focus and the principal emphasis of this proposal
is on the provider and treatment of hypertension and associated risk
factors.
Hypothesis Raising provider awareness through a either local
Hypertension Expert or feedback on BP control for individual patients will
be more effective than traditional continuing medical education (CME)
in improving BP control rates. Study design.
Using a randomized design, we propose to identify primary care providers in geographically separate
areas serving a large proportion of lower income black patients. Given an
aging population, a disproportionate increase of systolic BP with aging,
and the fact that systolic BP is less often controlled than diastolic BP
and contributes to cardiovascular events and dementia, practices serving a
high proportion of elderly Blacks will be selected. Practices will be
randomly allocated to one of three groups.
- Hypertension Expert-Selected
providers will be trained as the group expert (opinion leader) to
- develop goals and practice guidelines for implementation in their practice
- educate their peers and provide consultations on uncontrolled hypertensive
patients and
- participate in evaluating BP control at their site.
- Feedback on BP control. These providers will receive feedback on treatment
goals and control for individual hypertensive patients in their practice.
- Hypertension Expert plus Feedback. BP control rates at one year will be
assessed by chart review.
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