In the U.S., blacks have a higher prevalence of hypertension (HTN) and a higher Incidence of ischemic Stroke compared to whites. Less than 50% of adults with hypertension have controlled BP. Racial disparities exist with regard to the proportions of those who are treated and treated successfully, especially between black and white. In Kaiser Permanente Northern California (KPNC), a setting where all members have similar access to healthcare, black patients with ischemic stroke and HTN still had poorer BP control at 6 months post-stroke when compared to other races despite equal healthcare utilization, antihypertensive prescription and adherence. It has been suggested that greater difficulty in controlling BP and lifestyle differences may account for this difference. The goal of this pragmatic study is to improve HTN control rate in blacks and to reduce racial disparity in HTN control. To accomplish this, we propose to perform a cluster randomized controlled trial at the primary care provider (PCP) level and including 191 PCPs within KPNC East Bay Service Area with more than 45,000 patients in the HTN registry of which approximately 15,000 are black. We will randomize all PCP patient panels to a three-arm trial to receiving either 1) usual care;or 2) culturally tailored diet and lifestyle coaching;or 3) an intensified BP management protocol with pharmacotherapy. The "Shake, Rattle and Roll" trial is named for: 1) "shake" the salt habit;2) "rattle" the intensity of current BP management;and 3) design the interventions with the goal of being able to adapt and "roll" them out to community clinics outside of a managed care system. Primary research question: whether a primary prevention intervention of either diet and lifestyle coaching or an intensive pharmacotherapy protocol is more effective than usual care in improving rates of HTN control in blacks and thereby reducing disparities between black and white. Primary aim: By implementing either intervention, we will reduce the disparity in hypertension control rates between blacks and whites by 4% at 1 year post-study enrollment. Hypothesis: Among blacks with HTN, a diet/lifestyle coaching intervention or an intensified BP management protocol will result in an increase in HTN control rate compared to usual care. Primary outcome: the proportion of patients with sustained BP control at 1 year post-study enrollment.
By targeting African Americans with uncontrolled HTN, we are targeting the highest risk group for cardiovascular disease and stroke. By including young adult African Americans in our interventions, we are reaching out to improve HTN control rates in an often-overlooked population which carries the biggest disparities between black and white and therefore potentially will provide us with the greatest impact in reducing disparities.
|Fontil, Valy; Pletcher, Mark J; Khanna, Raman et al. (2014) Physician underutilization of effective medications for resistant hypertension at office visits in the United States: NAMCS 2006-2010. J Gen Intern Med 29:468-76|