More than half of African-American men and women have hypertension, which places them in a high-risk population that requires special attention from physicians. To improve blood-pressure control rates and hypertension among black patients, physicians need to address lifestyle changes, health literacy, medication adherence and family support.
“The United States has great disparities in cardiovascular disease based on race, ethnicity, social class, geography and insurance status,” said Keith C. Ferdinand, MD, an African-American cardiologist and professor of medicine at Tulane University School of Medicine. “These disparities should be and can be eliminated if we ensure adequate access to health care, especially preventive care for all patients regardless of their status.”
Physicians should prioritize BP control as a primary means of decreasing morbidity and mortality in all populations, but especially in African-Americans, who have a higher risk of hypertension-related death and disease, said Dr. Ferdinand.
Here are four steps physicians can take to improve BP control rates and hypertension among their black patients.
When providing African-American patients with lifestyle recommendations, it can often be difficult for them to adhere. For example, if a person lives in a food desert, which is when there is less availability of fresh fruits and vegetables, eating a DASH type diet becomes more difficult. And in many minority areas, fast foods often high in saturated fat and sodium are more readily available.
“Even within large grocery stores in some neighborhoods, low-sodium processed foods are less available than seen in more affluent areas,” said Dr. Ferdinand.
The recommendation of 150 minutes of aerobic activity a week can also be more difficult because exercise opportunities in disadvantaged areas are often limited by the fear of physical attack or crime.
To overcome these lifestyle challenges, patients should be able to recognize high-sodium processed foods that are often cheap and inexpensive, but will greatly affect the efficacy of medications. Physicians should offer solutions based on where patients live and the resources available to them, such as alternatives to various food options.
“Salt sensitivity may be more common among African-Americans, but more importantly, the combination of processed foods high in sodium, obesity and physical inactivity can blunt the benefits of blood-pressure medicines,” said Dr. Ferdinand, an AMA member since 1978.
While physicians are comfortable using technical terms during a doctor’s visit, many patients may nod approvingly, but often do not understand exactly what clinicians are saying. This creates a barrier to care and communication.
The use of technical language might be needed to communicate among providers in the EHR, but it is more important to talk to patients in plain, direct and easy-to-understand language. This helps patients better understand their conditions, said Dr. Ferdinand.
The few extra minutes it might take to complete this step can make a significant impact on the patient’s care.
A primary barrier to control of risk factors is medication nonadherence for treatment of hypertension and cardiometabolic diseases.
“Within our health system itself, provider communication skills and addressing disparities in patients’ health beliefs are very important to adherence—as much as high drug costs and the cost of copayments for patients who are on multiple medicines,” said Dr. Ferdinand.
When physicians order medications they should also recognize a patient’s preference and, even if the medication is generic, have some assessment of the cost. Many health care plans often have a list of formulary generic medications that will be less costly than others.
While it is important to recognize the legal constraints of HIPAA in terms of discussing any patient’s condition with another individual, said Dr. Ferdinand, with the patient’s permission, having the significant other or family member present will go a long way with increasing adherence, understanding cardiovascular risk and the need for lifestyle modification.
“Significant others often can help patients interpret what the provider has been saying in terms of cardiovascular risk,” he added. “That second person becomes a partner in care and becomes an assistant to the provider, not a barrier to care.”
Family members can also be a source of inspiration for patients in lifestyle modifications, such as reducing sodium in prepared foods and avoiding processed foods high in sodium. They can also become a partner in an exercise program and ensure patients take their medicines and gets refills when needed. It is a partnership that physicians can encourage to improve care and adherence.
“Programs such as Target: BP™, which focuses on the appropriate identification and early intervention to control blood pressure, may go a long way to reduce the disparities in the outcomes related to elevated blood pressure by race, ethnicity and social class,” said Dr. Ferdinand.