Understanding racial disparities in treatment intensification for hypertension management

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.