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Nearly half of all Americans have high blood pressure, but hypertension disproportionately affects Black Americans, with 56 percent of this population affected. The disparity is especially stark for stage II hypertension, which affects 42.1 percent of Black Americans compared with 28.7 percent of white Americans. “In the United States, at any decade of life, blacks have a higher prevalence of hypertension than that of Hispanic Americans, whites, Native Americans, and other subgroups defined by race and ethnicity,” according to a report of the American College of Cardiology and the American Heart Association in 2018 (see section 10.1).
The greater prevalence of hypertension contributes to Black Americans experiencing higher rates of heart disease, stroke, and kidney disease compared with white Americans.
Research establishes that structural racism has a negative impact on the health of Black Americans. A study of more than 21,000 U.S. adults published in 2021 found that race/ethnicity is a factor that negatively impacts hypertension rates. Two years ago, the American Heart Association declared that structural racism causes premature death from heart disease and stroke in part because structural racism contributes to cardiovascular risk factors, including high blood pressure.
As physicians and providers, we are not trained or equipped to unravel most of the structural legacies of racism in America. We can, however, deconstruct and rebuild clinical practices to better serve Black Americans.
Potential solutions
More focus in the U.S. on preventive care would benefit the health of Black Americans generally and would improve hypertension treatment specifically.
Taking steps to increase access to hypertension treatment would provide more focused help for this population.
To mitigate structural racism’s impact on heart health, the American Heart Association pledged $230 million in January 2021. This included a commitment of $121 million to a nationwide high blood pressure initiative focused on health outcomes among racial and ethnic minority populations. The initiative works through Health Resources and Services Administration-funded health centers to improve hypertension treatment. The association also expanded its existing hypertension programs with federally qualified health centers.
Another way to expand access to high-quality hypertension care is through a hybrid approach that combines in-person visits with in-home care. Elements of this approach include:
- Overcoming the lack of access to cardiovascular disease specialists through telehealth and home remote monitoring to better diagnose and monitor treatment of hypertension for Black Americans.
- Shifting ongoing disease management of hypertension to routine telehealth visits that eliminate barriers to care, such as a lack of transportation or need to take time off work.
- Integrate mail delivery of medicines to improve medication adherence.
Virtual care providers working with primary care physicians on hypertension must focus on eliminating technical barriers to providing telehealth and remote patient monitoring (RPM) of blood pressure. Virtual visits or home-monitoring devices that require a high degree of tech-savvy and high-speed internet may not work for all patients.
Instead, hybrid care teams must center simplicity of use in their care designs. For example, provide patients with home monitoring devices with easy-to-use interfaces and do not require home internet access, such as a blood pressure monitor with a cellular chip inside. These devices seamlessly share blood pressure readings with the care team.
The care team needs support, too. While the data collection and alerts can be automated, the interventions still come from doctors, nurses, and other trained professionals. To make this mix of in-person and in-home care and monitoring work, the primary care practice needs the support of specialist care teams who are able to monitor the data, interpret them and intervene more quickly than overburdened primary care practice teams.
Conclusion
As clinicians, we must focus on what we can control to reduce the disparity in hypertension rates among Black Americans. We must design and implement hybrid approaches to delivering care centered on greater access, more data collection, and ease of use for patients. We also can play a role as advocates for more resources for preventive care and reducing social determinants that increase hypertension rates among Black Americans. We must embrace both of these roles to mitigate the factors that have led to higher rates of hypertension for too many Black Americans.
Jie Shi Yan is a physician-executive.
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