LeRoi S. Hicks

Control of Hypertension in Adults With Chronic Kidney Disease in the United States

Although improved control of hypertension is known to attenuate progression of chronic kidney disease (CKD), little is known about the adequacy of hypertension treatment in adults with CKD in the United States. Using data from the Fourth National Health and Nutrition Survey, we assessed adherence to national hypertension guideline targets for patients with CKD (blood pressure <130/80 mm Hg), we assessed control of systolic (<130 mm Hg) and diastolic (<80 mm Hg) blood pressure, and we evaluated determinants of adequate blood pressure control. Presence of CKD was defined as glomerular filtration rate <60 mL/min per 1.73 m2 or presence of albuminuria (albumin:creatinine ratio >30 &mgr;g/mg). Multivariable logistic regression with appropriate weights was used to determine predictors of inadequate hypertension control and related outcomes. Among 3213 participants with CKD, 37% had blood pressure <130/80 mm Hg (95% confidence interval [CI], 34.5% to 41.8%). Of those with inadequate blood pressure control, 59% (95% CI, 54% to 64%) had systolic >130 mm Hg, with diastolic ≤80 mm Hg, whereas only 7% (95% CI, 3.9 to 9.8%) had a diastolic pressure >80 mm Hg, with systolic blood pressure ≤130 mm Hg. Non-Hispanic black race (odds ratio [OR], 2.4; 95% CI, 1.5 to 3.9), age >75 years (OR, 4.7; 95% CI, 2.7 to 8.2), and albuminuria (OR, 2.4; 95% CI, 1.4 to 4.1) were independently associated with inadequate blood pressure control. We conclude that control of hypertension is poor in participants with CKD and that lack of control is primarily attributable to systolic hypertension. Future guidelines and antihypertensive therapies for patients with CKD should target isolated systolic hypertension.

Health Behaviors and Racial Disparity in Blood Pressure Control in the National Health and Nutrition Examination Survey

Minorities have a higher prevalence of hypertension, a major risk factor for cardiovascular disease, which contributes to racial/ethnic disparities in morbidity and mortality in the United States. Many modifiable health behaviors have been associated with improved blood pressure control, but it is unclear how racial/ethnic differences in these behaviors are related to the observed disparities in blood pressure control. Cross-sectional analyses were conducted among 21 489 US adults aged >20 years participating in the National Health and Nutrition Examination Survey from 2001 to 2006. Secondary analyses were conducted among those with a self-reported diagnosis of hypertension. Blood pressure control was defined as systolic values <140 mm Hg and diastolic values <90 mm Hg (or <130 mm Hg and <80 mm Hg among diabetics, respectively). In primary analyses, non-Hispanic blacks had 90% higher odds of poorly controlled blood pressure compared with non-Hispanic whites after adjustment for sociodemographic and clinical characteristics (P<0.001). In secondary analyses among hypertensive subjects, non-Hispanic blacks and Mexican Americans had 40% higher odds of uncontrolled blood pressure compared with non-Hispanic whites after adjustment for sociodemographic and clinical characteristics (P<0.001). For both analyses, the racial/ethnic differences in blood pressure control persisted even after further adjustment for modifiable health behaviors, which included medication adherence in secondary analyses (P<0.001 for both analyses). Although population-level adoption of healthy behaviors may contribute to reduction of the societal burden of cardiovascular disease in general, these findings suggest that racial/ethnic differences in some health behaviors do not explain the disparities in hypertension prevalence and control.

Determinants of JNC VI Guideline Adherence, Intensity of Drug Therapy, and Blood Pressure Control by Race and Ethnicity

The relationship between blood pressure control and racial differences in the processes of hypertension care have not been well examined. We reviewed medical records of 15 768 visits to 12 general internal medicine clinics during July 1, 2001 to June 30, 2002 to determine whether visits were adherent to the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) by identifying medications selected for hypertension therapy. We compared JNC adherence, blood pressure control, and intensification of therapy by patient characteristics. Using repeated measures logistic regression, we determined the adjusted odds of obtaining blood pressure control when therapy was intensified the visit before, and tested the interaction of intensification of therapy and patient race/ethnicity in predicting blood pressure control. JNC adherence was more frequent among blacks (83.7%) and Hispanics (83%) than whites (78.4%) (P<0.001). Blood pressure was controlled most often among whites (38.7% versus 34.8% for blacks and 33.3% for Hispanics; P<0.001). Blacks (81.5%) and whites (80.9%) were more likely than Hispanics (70.8%) to have therapy intensified (P=0.02). After adjustment for baseline blood pressure, intensifying therapy was associated with higher odds of subsequent blood pressure control (odds ratio, 1.55; P<0.001). There were no significant interactions between race/ethnicity and intensification in predicting control. We found that therapy intensification is associated with subsequent blood pressure control in all racial/ethnic groups and that Hispanics were least likely to have their therapy intensified. Interventions to reduce disparities in cardiovascular outcomes should consider the need to intensify drug therapy more aggressively among all high-risk populations.

Sources of Health Information Related to Preventive Health Behaviors in a National Study

BACKGROUND Current literature suggests that certain sources of information are used in varying degrees among different socioeconomic and demographic groups; therefore, it is important to determine if specific classes of health information sources are more effective than others in promoting health behaviors. PURPOSE This study aims to determine if interpersonal versus mass media sources of health information are associated with meeting recommendations for health behaviors (nonsmoking, fruit/vegetable intake, and exercise) and cancer screening. METHODS Multivariable logistic regression models were used to examine the relationship of health information sources (mass media sources including print, TV, Internet; and interpersonal sources including friends and family, community organizations, and healthcare providers) with meeting recommendations for healthy behaviors and cancer screening in the 2005 and 2007 Health Information National Trends Surveys (HINTS). Analyses were conducted in 2009. RESULTS In the 2005 HINTS, participants reporting use of print media and community organizations as sources of health information over the past year were mostly likely to meet recommendations for health behaviors. In the 2007 HINTS, utilization of healthcare providers for health information was associated with meeting recommendations for health behaviors, particularly cancer screening. CONCLUSIONS Use of print media and interpersonal sources of health information are most consistently associated with self-reported health behaviors. Additional research should explore the relationship of health information sources to clinical outcomes. Social network interventions to promote adoption of health behaviors should be further developed.

Differences in Specialist Consultations for Cardiovascular Disease by Race, Ethnicity, Gender, Insurance Status, and Site of Primary Care

Background— Consultation with cardiologists may improve the quality of ambulatory care and reduce disparities for patients with heart disease. We assessed the use of cardiology consultations and the associated quality by race/ethnicity, gender, insurance status, and site of care. Methods and Results— In a retrospective cohort, we examined electronic records of 9761 adults with coronary artery disease or congestive heart failure (CHF) receiving primary care at practices affiliated with 2 academic medical centers during 2000 to 2005. During this period, 79.6% of patients with coronary artery disease and 90.3% of patients with CHF had a cardiology consultation. In multivariate analyses, women were less likely to receive a consultation than men for both conditions (coronary artery disease: hazard ratio, 0.89; 95% CI, 0.85 to 0.93; CHF: hazard ratio, 0.93; 95% CI, 0.87 to 0.99). Women also had 15% fewer follow-up consultations than men (P<0.001). Similarly, patients at community health centers were less likely to receive a consultation (coronary artery disease: hazard ratio, 0.79; 95% CI, 0.74 to 0.84; CHF: hazard ratio, 0.77; 95% CI: 0.71 to 0.84) and had 20% fewer follow-up consultations (P<0.001) relative to those at hospital-based practices. Black and Hispanic patients with CHF had 13% fewer follow-up consultations than white patients (P=0.01 and P=0.04, respectively). In adjusted analyses, consultation was associated with better processes of care compared with no consultation (P<0.001), particularly for women (P<0.001 for interaction between consultation and gender). Conclusions— Among ambulatory patients with coronary artery disease or CHF, women and those at community health centers have less access to cardiologists. Consultation is associated with better quality of care and narrows the gender gap in quality.

Insurance status and hospital care for myocardial infarction, stroke, and pneumonia†

BACKGROUND Despite widely documented variations in health care outcomes by insurance status, few nationally representative studies have examined such disparities in the inpatient setting. OBJECTIVE To determine whether there are insurance-related differences in hospital care for 3 common medical conditions. DESIGN AND SUBJECTS Retrospective database analysis of 154,381 adult discharges (age 18-64 years) with a principal diagnosis of acute myocardial infarction (AMI), stroke, or pneumonia from the 2005 Nationwide Inpatient Sample (NIS). MEASUREMENTS For each diagnosis, we compared in-hospital mortality, length of stay (LOS), and cost per hospitalization for Medicaid and uninsured patients with the privately insured. RESULTS Compared with the privately insured, in-hospital mortality among AMI and stroke patients was significantly higher for the uninsured (adjusted odds ratio [OR] 1.52, 95% confidence interval [CI] [1.24-1.85] for AMI and 1.49 [1.29-1.72] for stroke) and among pneumonia patients was significantly higher for Medicaid recipients (1.21 [1.01-1.45]). Excluding patients who died during hospitalization, LOS was consistently longer for Medicaid recipients for all 3 conditions (adjusted ratio 1.07, 95% CI [1.05-1.09] for AMI, 1.17 [1.14-1.20] for stroke, and 1.04 [1.03-1.06] for pneumonia), although costs were significantly higher for Medicaid recipients for only 2 of the 3 conditions (adjusted ratio 1.06, 95% CI [1.04-1.09] for stroke and 1.05 [1.04-1.07] for pneumonia). CONCLUSIONS In this nationally representative study of working-age Americans hospitalized for 3 common medical conditions, significantly lower in-hospital mortality was noted for privately insured patients compared with the uninsured or Medicaid recipients. Interventions to reduce insurance-related gaps in inpatient quality of care should be investigated.

Disparities in Adherence to Hypertensive Care in Urban Ambulatory Settings

Nationally, a higher proportion of the medically underserved than of the general population suffer from hypertension. Poorer adherence to recommended therapies (including medication regimens, salt intake reduction, and regular visits with provider) has been linked to poorer blood pressure control. To identify whether differences in adherence are associated with racial/ethnic and socioeconomic characteristics, we administered a survey to 141 African American and non-Hispanic White hypertensive patients within two hospital-based clinics in an urban setting in the Northeast U.S. There were no differences in adherence to follow-up appointments or dietary recommendations between racial/ ethnic or income groups. However, there were differences between groups in adherence to medication regimens, with African Americans and lower-income groups significantly more likely to be non-adherent to medication regimens. When treating patients or implementing interventions aimed at improving adherence, special attention should be paid to African Americans and patients from low-income communities.

Determinants of racial/ethnic differences in blood pressure management among hypertensive patients.

BackgroundPrior literature has shown that racial/ethnic minorities with hypertension may receive less aggressive treatment for their high blood pressure. However, to date there are few data available regarding the confounders of racial/ethnic disparities in the intensity of hypertension treatment.MethodsWe reviewed the medical records of 1,205 patients who had a minimum of two hypertension-related outpatient visits to 12 general internal medicine clinics during 7/1/01-6/30/02. Using logistic regression, we determined the odds of having therapy intensified by patient race/ethnicity after adjustment for clinical characteristics.ResultsBlacks (81.9%) and Whites (80.3%) were more likely than Latinos (71.5%) to have therapy intensified (P = 0.03). After adjustment for racial differences in the number of outpatient visits and presence of diabetes, there were no racial differences in rates of intensification.ConclusionWe found that racial/ethnic differences in therapy intensification were largely accounted for by differences in frequency of clinic visits and in the prevalence of diabetes. Given the higher rates of diabetes and hypertension related mortality among Hispanics in the U.S., future interventions to reduce disparities in cardiovascular outcomes should increase physician awareness of the need to intensify drug therapy more agressively in patients without waiting for multiple clinic visits, and should remind providers to treat hypertension more aggressively among diabetic patients.

Lifestyle modification counseling for hypertensive patients: results from the National Health and Nutrition Examination Survey 1999-2004.

BACKGROUND Lifestyle modification is recommended for all patients with the diagnosis of hypertension. METHODS We examined 3,497 adult hypertensive participants (representing 42 million Americans), from the National Health and Nutrition Examination Survey (NHANES) 1999-2004. We analyzed the rate, demographic, and clinical factors of participants who reported receiving lifestyle counseling and their adherence. RESULTS Of the 3,497 participants with hypertension, 84% reported receiving lifestyle modification counseling. After adjustment for demographic and clinical characteristics, non-Hispanic blacks were more likely to report receiving counseling (odds ratio (OR), 2.5; P < 0.001) when compared to whites. Men (OR, 1.5; P = 0.02) reported receiving counseling more often than women as well as those with Medicare insurance (OR, 1.5; P = 0.02) compared to the privately insured. Participants who were hypercholesterolemic (OR, 1.7; P < 0.001), diabetic (OR, 3.5; P < 0.001), overweight (OR, 1.5; P < 0.001), or obese (OR 3.0; P < 0.001) reported receiving lifestyle counseling more often than those without these conditions. Of those receiving counseling, 88% reported adhering to those recommendations. After adjustment for demographic and clinical characteristics, only non-Hispanic blacks (OR, 2.8; P < 0.001) and those aged >60 (OR, 1.9; P = 0.04) were more likely to report adhering when advised. CONCLUSIONS High cardiovascular risk hypertensive patients had high rates of lifestyle counseling. However, gaps exist in lifestyle counseling for young and low cardiovascular risk hypertensive patients. In addition, differences in rates of adherence exist especially in those with high cardiovascular risk comorbid conditions. Future work is needed to increase adherence to lifestyle counseling for all hypertensive patients.

Hospitalists and the Quality of Care in Hospitals

BACKGROUND Little is known about the link between hospitalists and performance on hospital-level quality indicators. METHODS From October 1, 2005, through September 31, 2006, we linked the Hospital Quality Alliance (HQA) data to the American Hospital Association data on the presence of hospitalists. Main outcome measures included composite measurements of hospital-level quality of care for 3 conditions (acute myocardial infarction [AMI], congestive heart failure [CHF], and pneumonia) and 2 dimensions of care (treatment and diagnosis, as well as counseling and prevention). We fitted a series of logistic regression models to examine the relationship between hospitalists and overall quality of care for each condition, controlling for all other hospital characteristics. RESULTS Of 3619 hospitals reporting HQA data, 1461 (40.4%) had hospitalists. Hospitals with hospitalists tended to be large, private, not-for-profit, teaching institutions located in the southern United States. The mean unadjusted composite scores were higher for hospitals with hospitalists vs those with no hospitalists for all 3 conditions (93% vs 86% for AMI, 82% vs 72% for CHF, and 75% vs 71% for pneumonia) and both dimensions of care (87% vs 77% for treatment and diagnosis and 75% vs 66% for counseling and prevention) (P < .001 for all comparisons). After multivariable adjustment, hospitals with hospitalists continued to perform significantly better than those without hospitalists across all composite scores except for CHF. CONCLUSION Hospitals with hospitalists were associated with better performance on HQA indicators for AMI, pneumonia, and the domains of overall disease treatment and diagnosis, as well as counseling and prevention.