Trust, access confer success in community-based hypertension management
Hypertension is a well-established, powerful risk factor for CVD and stroke, especially in black individuals, but the challenge lies in identifying and deploying the most efficient strategy to prevent and control BP.
According to the CDC, 1 in 3 U.S. adults has hypertension, defined as 140 mm Hg over 90 mm Hg or above or use of antihypertensive medication, and nearly half of those with hypertension have not achieved control. In addition, an estimated 13 million U.S. adults with hypertension do not know that they have the condition and, thus, are not receiving treatment.
Hypertension among black adults was the topic of a study published in July in the Journal of the American Heart Association. By age 55 years, approximately 75% of black men and women developed hypertension, compared with 55% of white men and 40% of white women, according to an analysis of data from the longitudinal CARDIA study. In this study, incident hypertension was defined as a mean systolic BP greater than 130 mm Hg, a mean diastolic BP greater than 80 mm Hg and use of antihypertensive medication, based on the 2017 American College of Cardiology/American Heart Association BP guideline definition. The finding in this recent study of a higher risk for hypertension among black individuals is consistent with previous cross-sectional and longitudinal studies such as NHANES and MESA.
“Hypertension is the No. 1 Medicare expenditure,” Kim Allan Williams Sr., MD, professor of cardiovascular disease at Rush University Medical Center in Chicago, past president of the American College of Cardiology and a Cardiology Today Editorial Board Member, said in an interview. “If you look at it from the point of view of patriotism — that is, what can we do in the United States to improve the health of Americans — getting rid of systemic hypertension would go a long way.”
Targeting hypertension in the community
One area of focus has been finding new ways to treat black individuals with uncontrolled hypertension.
A study presented at the ACC Scientific Session in March and simultaneously published in The New England Journal of Medicine looked at BP reduction in the nontraditional health care setting of black-owned barbershops. The NHLBI-funded, cluster-randomized study enrolled 319 black male patrons at 52 barbershops in the Los Angeles region who had systolic BP of 140 mm Hg or greater. Half of the participants were randomly assigned to a pharmacist-led intervention, in which barbers encouraged the patrons with uncontrolled hypertension to meet with specialty trained pharmacists, with monthly meetings at the barbershops to check BP, prescribe medication under a collaborative practice agreement with the patrons’ physicians and monitor electrolytes. The other half were randomly assigned to an active-control group, in which barbers encouraged doctor appointments and lifestyle modification.
At 6 months, those assigned the pharmacist-led intervention with health promotion at barbershops had a mean decrease in systolic BP of 27 mm Hg compared with 9.3 mm Hg in the active-control group. Overall, 63.6% of the intervention group achieved a BP less than 130/80 mm Hg compared with 11.7% of the active-control group. Retention was high in the intervention group, at 95%.
“We think it was the entire package that led to this large reduction in blood pressure,” Ronald G. Victor, MD, associate director of the Smidt Heart Institute at Cedars-Sinai, told Cardiology Today. Victor and colleagues conducted the cluster-randomized study in black barbershops. “One of the main factors is having doctorate-level pharmacists who got extra training in hypertension management to take over on blood pressure management. They were much more accessible than a traditional doctor visit and they made this program optimally convenient for the men by bringing the treatment directly to men in their barbershops so they didn’t have to go to a doctor’s office. They also used a finger-stick amount of blood with a point-of-care device to check blood chemistry in the barbershops so the men didn’t have to travel to a clinical laboratory. The protocol that we used to treat blood pressure was simple, but it was powerful.”
Speaking on the findings at the ACC Scientific Session, Victor said the community outreach study was undertaken because black men have less physician interaction than black women and white individuals, as well as lower rates of treatment and hypertension control.
“In general, it has been difficult to show that control of hypertension in community settings ... has led to an actual increase in blood pressure control,” Keith C. Ferdinand, MD, professor at Tulane University School of Medicine in New Orleans and a Cardiology Today Editorial Board Member, said in an interview. “Nevertheless, the recent study by Ron Victor and colleagues from Cedars-Sinai using community barbershops in the Los Angeles area for the first time perhaps demonstrates robust blood pressure lowering in the community setting.”
This particular study also showed that managing hypertension is a continuous function that goes beyond the physician’s office.
“It is what happens when we engage with the patient, but it’s also what happens when the patient is monitoring blood pressure at home and when a patient is experiencing life in their community,” Clyde W. Yancy, MD, MSc, vice dean for diversity and inclusion, chief of cardiology in the department of medicine, Magerstadt Professor and professor of medicine and medical social sciences at Northwestern University Feinberg School of Medicine, and past president of the American Heart Association, said in an interview. “If we miss the opportunity to have home blood pressures to understand the engagement in the community and only rely on office blood pressures, we have an unfortunate risk of having a therapeutic misadventure, either missing masked hypertension ... or white coat hypertension.”
Promise, challenges of community intervention
While the aforementioned barbershop study represents a huge step in managing hypertension in black communities, the concept of community intervention began years ago. During the past 40 years, programs focusing on CV outreach have been implemented, although research confirming the efficacy of community intervention has been limited.
The NHLBI funded various community studies in the 1980s on the effectiveness of CVD risk reduction including hypertension. The Minnesota Heart Health Program, Stanford Five-City Project and Pawtucket Heart Health Program all increased the evidence base in this area.
The concept of black barbershops was pioneered by Elijah J. Saunders, MD, and B. Waine Kong, PhD, JD, in Baltimore. Subsequently, a project in New Orleans supported by the NHLBI — the Heart Healthy Community Prevention Project — was led by Daphne Ferdinand, RN, PhD, and Keith C. Ferdinand. Centers were set up in beauty shops, barbershops and churches for patients to receive health education and have their BP measured.
Trust is a major aspect of the success of community-based hypertension management.
“In any relationship in a physician’s office, in the hospital, in the ICU setting even, the first thing that has to be accomplished is that the provider and the patient have to build a bond,” Yancy told Cardiology Today. “What makes that bond cemented is trust. When trust is there, we can do so much more. When there’s doubt, when there’s uncertainty, when there’s ambivalence or fear, we can’t be successful. The important thing about going to the community is that when we find the right set of resources in a community, trust happens.”
Trust played a critical part in the recent black barbershop study published in NEJM.
“I cannot overestimate the importance of the barbers’ endorsement of the program,” Victor said. “The barbers and their customers have a trustful relationship, so by the barbers endorsing the program, it overcomes some of the trust issues that are still unfortunately present among minority populations, especially black men when it comes to either participating in medical research or just following up with routine medical care.”
Convenience is also crucial when targeting hypertension in a community setting; for example, in the recent barbershop study, pharmacists brought therapies to a centralized location. Bringing health care intervention to a place where members of a community spend much of their time may yield greater retention and success. Further, the reduced cost of access to a health care provider in a community setting like a barbershop, compared with a doctor’s office, may aid in its effectiveness.
“When you do [all of these things], you begin to empower people,” Marcus L. Williams, MD, cardiologist at Horizon Cardiology in Fair Lawn, New Jersey, and past president of the Association of Black Cardiologists, told Cardiology Today. “In the barbershop, some of these will become real advocates for people and that sometimes works better than coming to a medical facility or a system outside of the community initially to reach them.”
However, barriers exist in the implementation of community-based hypertension management.
“It’s complicated because you take the science of hypertension and what we know generically about what is involved and how it affects different populations, but then you have to bring that information to context within a community and their race, culture and religion,” Marcus Williams told Cardiology Today. “Many factors can sometimes play a role in how well it is perceived in the community.”
Other issues that come into play include the ability to change adult behaviors, privacy regarding patient health information in a public setting and a lack of rigorous evidence on the effect of community interventions for improving BP control, experts told Cardiology Today.
Some health care professionals, and patients, said they believe that a patient can receive more efficient care if they go to the office rather than a center within the community, experts said.
“It is always easier when patients go to their physicians, from a provider standpoint,” Willie E. Lawrence Jr., MD, chief of cardiology at Research Medical Center at HCA Midwest Health in Kansas City, Missouri, said in an interview. “It’s a more efficient system to be in one place and to have everybody come to you. That’s one of the obstacles. I have conducted blood pressure screenings at food clinics and in situations where you think you have people coming back regularly. These approaches may be more resource-intensive as you try to get the providers to the patients. Yet, while traditional systems may be more efficient for the provider, they have not been effective for the patient. We must develop home- and community-based systems that are both effective and sustainable.”
Benefits of active engagement
With hypertension, which is often asymptomatic, once individuals are treated, health care professionals can monitor them to determine whether antihypertensive therapy is effective.
“We can also assess more appropriately whether or not there is a concern with regard to risk by having more active engagement,” Yancy told Cardiology Today. “What someone tells me in the office over an 18-minute visit might not accurately capture what they’re experiencing day in and day out in the rest of the community.”
This increased rate of control can lead to decreases in the effects of hypertension, experts said.
“This is fundamental to stroke prevention, heart attack, aortic blood vessel diseases, heart failure and even some valvular diseases,” Kim Allan Williams Sr. said in an interview. “There are so many things that can go wrong within the cardiovascular system based on elevated blood pressure.”
Some cardiologists believe that the success related to community-based hypertension management — whether in a barbershop, at a health fair, in churches and so on — is based on increased awareness.
“When we focus on working in the community, it allows us to increase awareness within the community and empower the community to take care of its own health,” Marcus Williams said. “For that reason, it’s important to talk about it and to figure out ways to empower a community so that patients can actually take care of themselves and be knowledgeable and make good decisions to control their blood pressure, which ultimately leads to much better outcomes.”
Researchers continue to investigate strategies to target hypertension and other CVDs in the community. While the recent NEJM study of a barbershop-based hypertension management program showed benefit, further research is needed to validate the findings and also establish the best approaches for community-based interventions.
“In general, we need to continue to document in a science-based, evidence-based approach that these interventions outside of the physician’s office actually lead to better control of risk factors,” Ferdinand told Cardiology Today. He also called for research in “in other parts of the United States and in other racial/ethnic groups including disadvantaged or poor white communities.”
Community sites beyond barbershops should also be a focus of future research, such as hair salons for women, churches and grocery stores, in addition to the other communities that would benefit from these types of interventions, experts told Cardiology Today.
It is also important to develop ideal strategies to achieve this benefit with a larger number of patients in ways that do not place a great burden on providers.
For example, “it is demanding to have pharmacists go to barbershops on a weekly basis,” Lawrence said. “That is a lot of resources. It is trying to create these systems of care that make use of pharmacists and of community workers. In the end, we need to figure out ways to get patients to come to the providers to close that gap, to figure out how to meet people where they are while at the same time not having to require this system of care to require such intensive demand on pharmacists or whoever their providers might be.”
Cost-effectiveness also should be considered when creating a community-based program for hypertension management, and quantifying the costs of these interventions is critical to establish benefit for patients and providers, experts said.
All of this research combined can come together to help shape policy or create opportunities within local, state or federal government to provide resources to members of their community, experts said. Some of this research will be in the works in the future.
“Now that we have evidence from a randomized controlled trial on efficacy, the key thing is to scale this up and to implement it in the real world,” Victor said. “We are going to do cost-effectiveness analyses of this. What we hope to do is have industry partners as well as governmental agencies like CMS to partner with us on implementation research on a broad scale.”
This type of research on community-based hypertension management is different than other studies that assess the benefits of a drug or device, experts said.
“It is unique in a sense that it is not as clean as a pure bench-lab science project,” Marcus L. Williams told Cardiology Today. “You are incorporating science and health issues and social science to understand social determinants that help create success in implementing whatever intervention it is you want to do.”
Although research is important in this area, implementation is also critical.
“It is less about research and more about clinical application of a great technique in terms of the barbershop program,” Kim Allan Williams Sr. said. “It needs to be globalized. We need to be doing this everywhere.”
Benefit of cardiologists in community settings
While hypertension management in the community setting may commonly be done by pharmacists, nurse practitioners and other health care providers, the cardiologist can also play an important role in the success of this approach.
“Cardiologists are uniquely positioned due to the respect that the general community and primary care providers have in the wisdom of the cardiologist to help guide therapy,” Ferdinand said. “Despite busy personal schedules, the community would be well-served if cardiologists could find time on occasion to volunteer as an on-site representative of the medical field during some of these community interventions and, furthermore, to help educate primary care providers in the community in general about the importance of intensive blood pressure control to decrease heart attacks, strokes, heart failure, peripheral arterial disease and chronic kidney disease.”
Whether in a leadership role or behind the scenes, cardiologists are critical in the implementation of community-based interventions.
“What we really can and should do is to be the coach, be the champion, be the person who helps put these networks together, be the person who helps makes certain that the protocols are right, the titration schemes are correct, that there is someone with whom the community provider can identify when questions arise,” Yancy told Cardiology Today. – by Darlene Dobkowski
- CDC. Undiagnosed hypertension. Available at: www.cdc.gov/features/undiagnosed-hypertension/index.html. Accessed July 3, 2018.
- Ferdinand KC, et al. J Clin Hypertens. 2012;doi:10.1111/j.1751-7176.2012.00622.x.
- Thomas SJ, et al. J Am Heart Assoc. 2018;doi:10.1161/JAHA.117.007988.
- Victor RG, et al. N Engl J Med. 2018;doi:10.1056/NEJMoa1717250.
- For more information:
- Keith C. Ferdinand, MD, can be reached at Tulane University School of Medicine, 1430 Tulane Ave., SL-8548, New Orleans, LA 70112; email: firstname.lastname@example.org.
- Willie E. Lawrence Jr., MD, can be reached at Midwest Heart and Vascular Specialists, 2330 East Meyer Blvd., Suite T 509, Kansas City, MO; email: email@example.com.
- Ronald G. Victor, MD, can be reached at Advanced Health Sciences Pavilion, 127 S. San Vicente Blvd., Third Floor, A3600, Los Angeles, CA 90048; email: firstname.lastname@example.org.
- Kim Allan Williams Sr., MD, can be reached at Rush University Medical Center, 1653 W. Congress Parkway, Chicago, IL 60612; email: email@example.com.
- Marcus L. Williams, MD, can be reached at Horizon Cardiology, 10-14 Saddle River Road, Fair Lawn, NJ 07410; email: firstname.lastname@example.org.
- Clyde W. Yancy, MD, MSc, can be reached at Northwestern University, Feinberg School of Medicine, 676 N. St. Clair, Suite 600, Chicago, IL 60611; email: email@example.com.
Disclosures: Lawrence, Victor, Marcus Williams, Kim Allan Williams Sr. and Yancy report no relevant financial disclosures. Ferdinand reports he was on the data and safety monitoring board for the Los Angeles barbershop study that was funded by the NHLBI.