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• W2921520234 abstract "The marked decrease in US cardiovascular disease (CVD) mortality over the last several decades is a remarkable success story, reflecting the reductions in uncontrolled hypertension and hypercholesterolemia, as much as technical advances and various interventions. However, between 2011 and 2014, this impressive fall in cardiovascular deaths decelerated substantially.1 In addition, death attributed to heart failure and other heart diseases has switched from a downward to upward trend,2 stressing the urgent need to address the complex challenges of heart failure, for which hypertension is the most prevalent risk in the general population. Hypertension, globally the most prevalent and potent CVD risk factor, is disproportionately uncontrolled in US minorities, including not only Blacks, but also Hispanics and Asian Americans. Although reasons for this disturbing lag in CVD progress are unclear and probably multifactorial, the obesity epidemic and co-morbid hypertension are troubling, accompanied by persistent and unacceptable racial/ethnic, socioeconomic, and geographic disparities in CVD and risk factors. Based on the current hypertension definition of the 2017 High Blood Pressure Guideline, approximately 103 million individuals, representing 46% of US adults, including almost 60% Black men and women, have hypertension,3-5 considerably contributing to major health conditions including atherosclerosis, heart failure, chronic and end-stage kidney disease, as well as CVD and all-cause mortality.3, 6, 7 Additionally, according to data from NHANES 2011 to 2016, hypertension control using the newer goal of less than 130/80 mm Hg is far from optimal, with only 22% men and 25% women controlled.8 The social determinants of health are major forces behind the persistent disparities in CVD and hypertension control.9, 10 Accordingly, discrepancies in access to health care have been described in multiple prior studies. One report,11 involving over 150 000 participants, noted that 19% had no health insurance, and 24% could not visit a provider because of cost, more commonly seen among Hispanics and those with lower household income. Also, with the continuing significant decline in private primary care providers in solo or small group practices, community health centers will become an increasingly common and an essential source or care, especially for racial/ethnic minorities, and persons with lower socioeconomic status. Health Resources and Services Administration (HRSA)-funded health centers represent a main source of outpatient care for over 27 million patients, 62% of whom are racial/ethnic minorities12 and enable “non-clinical” services including health education, interpretation, and case management, all crucial to improve outcomes, particularly for the most vulnerable patients.13 While needed in the care of underserved populations, these facilities themselves are not a solution if patients cannot afford basic care, essential laboratory testing, multiple medications (even if generic), and appropriate specialty referrals. The present study in JCH by Sripipatana, A. et al adds to our search for potential pathways to curtail the high burden of uncontrolled hypertension and CVD morbidity and mortality, shouldered especially by minorities and persons with lower socioeconomic status, including the uninsured. The authors used data from the 2014 Health Center Patient Survey, with multilevel logistic regression models, to predict hypertension management counseling, patient adherence with counseling and medication regimens, management plan receipt, high blood pressure at last clinical visit, and confidence in hypertension self-management. While the impact of these factors needs to be better understood, perhaps future analysis of these subjects will put even more emphasis on detailing unique characteristics of those patients with hypertension-related emergency department (ED) visits or hospitalizations in the past year. Healthcare utilization data consistently demonstrate that a small portion of patients are the heaviest users of hospital services, signaling a failure in our healthcare system. Importantly, the authors attempted to control for characteristics including age, sex, education, nativity, health behaviors, healthcare access, and comorbidities. All too often, health outcome studies have not done so and spuriously ascribe disparities in blood pressure control and CVD outcomes to some ill-defined and unproven genetic factors. Admirable findings of the present study include significantly higher odds of diet counseling (African Americans, OR: 1.87; Asian Americans, OR: 3.02; AIAN, OR: 2.01) and for reduced sodium intake (African Americans, OR: 2.42) and adherence to exercise counseling (African Americans, OR: 3.52; Asian Americans, OR: 2.93) However, it is unclear how these subjective findings translate into actual patient lifestyle modifications and future CVD burden. Nonadherence significantly impacts the high level of hypertension-related CVD and unacceptable disparities. Further analysis from data Sripipatana, A. et al may hopefully offer a more detailed and in-depth understanding of those individuals with lower odds of taking antihypertensive medication (AIAN, OR: 0.50) and higher odds of hypertension-related ED visits (African Americans, OR: 3.61; AIAN, OR: 5.31). Beyond simply obtaining descriptors of care, the main challenge of primary care providers, cardiovascular specialists, and public health officials will be to markedly decrease, and eventually eliminate, adverse hypertension outcomes based on race/ethnicity, geography, and socioeconomic status. Accordingly, racial and ethnically tailored efforts might be required to manage hypertension and improve outcomes. In this regard, a unique collaborative initiative to address nonadherence, the Enhanced Adherence Strategic Initiative (EASi),14 was created in 2015 with the ultimate goal of reducing the rates of strokes and heart attacks. In a state-of-the-art review, the EASi authors highlighted at least four areas to target in order to substantially reduce nonadherence: identifying the problem accurately, better understanding best practice for adherence, developing team-based engagement strategies, and alleviating health disparities.15 Additional strategies have been proposed by others to improve medication adherence,16 and national programs have emerged to address uncontrolled hypertension and CVD. For instance, the Department of Health and Human Services Million Hearts Campaign focuses on different evidence-based public health strategies to improve adherence, with one of the priority groups being the African American men with hypertension.17 Similarly, target: BP, a collaboration of the American Heart Association and the American Medical Association also focuses on Black men, among others, and seeks to improve blood pressure control by supporting and highlighting evidence-based hypertension care and customized quality improvement programs.18 Despite certain limitations, the findings by Sripipatana, A. et al from health centers are clearly important. As noted in the 2017 ACC/AHA guideline for management of hypertension,4 evidence-based improvements in blood pressure control can be developed and enhanced in health centers, including linkage to social service providers, health education, and care coordination. These guideline approaches may overcome barriers and avoid more expensive care including ED visits and hospitalizations. All patients should have a clear evidence-based plan of care to meet treatment and self-management goals, emphasizing a team-based care approach with access to health coverage, primary care providers, and cardiovascular specialists, when indicated. Ideally, pathways to better hypertension control include addressing specific challenges, such as the introduction of lifestyle interventions, identification and discussion of treatment goals, detecting and reversing nonadherence, insuring appropriate follow-up, as well as accounting for age, race, ethnicity, sex, and special circumstances when considering antihypertensive treatment. Giving advice on sodium intake and diet changes, as documented by Sripipatana for most African Americans, is admirable. Guidelines and working commissions have traditionally recommended low-sodium diets for decades, but the actual ability of patients to change their dietary habits remains unclear. Counseling, while essential, is adequate not enough on its own, as suggested in the present study by the high blood pressure rates at the last clinical visit (53%), as well as hypertension-related ED visits and hospitalizations (10%). For the foreseeable future, hypertension will remain one of the leading reasons for outpatient visits, and directly tied into the high burden of CVD morbidity and mortality. Importantly, elimination of hypertension is projected to have a larger impact on CVD mortality than the eradication of all other risk factors among females and all except smoking among males.5, 19 As a society, we must embrace better blood pressure control or suffer the persistent and growing financial and personal burdens of related ED visits, longer hospital stays, and greater costs. Overall, the results of Sripipatana, A. et al help illuminate a pathway forward to decrease hypertension-related disease and disparities. Successful programs to reignite the CVD mortality downward trend must include effective control of hypertension, especially as the population ages and co-morbid conditions, such as obesity and diabetes, become an epidemic in scope. Finally, the US society must strive to provide equitable access to care, regardless of patient's ability to pay or racial/ethnic background and commit to the logistic and financial support that is fundamental to ensure appropriate care is widely available to eliminate disparities and achieve health equity. The authors report no specific funding in relation to this commentary. Dr Ferdinand has served as a consultant for Quantum Genomics, Novartis, Janssen, and Boehringer. Dr Maraboto has no conflicts of interest to disclose." @default.
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• W2921520234 date "2019-03-11" @default.
• W2921520234 modified "2023-10-16" @default.
• W2921520234 title "Improved pathways to hypertension control and elimination of disparities: Are we there yet?" @default.
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