Background: Disparities in blood pressure (BP) control may be a function of disparities in treatment intensification (TI). Objective: To examine racial differences in TI, understand modifiable factors that may mediate this relationship, and explore the relative effects of TI and race on blood pressure. Design: Prospective cohort study. Participants: Participants were 819 black and white patients with hypertension from an urban, safety-net hospital Main Measures: We sequentially explored the effects of patient race, sociodemographic and clinical characteristics, beliefs about BP/medications, perceptions of provider/discrimination, sodium intake, medication adherence, and provider counseling on TI, performing a series of random effects analyses. To assess the effects of race and TI on BP, we performed linear regressions, using systolic BP (SBP) as the outcome. Key Results: Unadjusted analyses and those including sociodemographic and clinical characteristics revealed that black patients had less TI than whites (-0.31 vs.-0.24, p<0.001), but adjustment for patient beliefs and experiences eliminated the effects of race (β=-0.02, p=0.5). Increased patient concerns about BP medications were related to lower TI, as was more provider counseling (β=-0.06, p=0.02 and β= -0.01, p=0.001, respectively). In the unadjusted analysis, black race was a significant predictor of SBP (134 mm/Hg for blacks vs. 131 mm/Hg for whites, p=0.009), but when both race and TI were included in the model, TI was a significant predictor of SBP (final SBP 2.0 mm/Hg lower for each additional therapy increase per 10 visits, p<0.001), while race was not (Blacks 1.6 mm/Hg higher than whites, p=0.17). Conclusions: Improved patient-provider communication targeted towards addressing patient concerns about medications may have the potential to reduce racial disparities in TI and ultimately, BP control.
Bibliographical noteFunding Information:
Funding sources: This work was supported by the NIH/National Heart, Lung and Blood Institute grant R01 HL072814 (N. Kressin, PI). Dr. Kressin is supported in part by a Research Career Scientist Award from the Department of Veterans Affairs Health Services Research and Development Service. Dr. Rose is funded by a career development award from the Department of Veterans Affairs Health Services Research and Development Service. The views expressed in this article are those of the authors and do not necessarily represent the official views and policies of the Department of Veterans Affairs.
- treatment intensification