PS2-33: Understanding Racial Disparities in Physician Advice and Patient Actions to Control Blood Pressure in an MCO

Abstract

Background/Objective: The Chronic Care Model (CCM) links proactive practice teams and activated patients with better chronic care outcomes. We studied the associations of blood pressure (BP) control with 1) physician advice and patient actions on lifestyle behaviors (exercise, diet, salt and alcohol intake) to control BP and 2) medication adherence in a cohort of adults with hypertension (HTN) in a managed care organization (MCO). Our primary analysis focused on the apparent paradox that, in this MCO, African Americans were more likely to report receipt of advice and be taking actions to control BP yet had worse BP control. Methods: Adults 18–74 years of age with HTN were identified from computerized data. Two independent samples of 3,000 adults each (750 per JNC-VII level) were randomly selected for telephone survey in October 2007 and March 2008. The survey included BRFSS items on advice and actions to control BP and self-reported race and education. Medication adherence was measured as proportion of days covered (PDC) with any HTN-related medication in the 12-month period preceding the survey. Mean SBP and DBP were measured from computerized data in the same period. Associations among receipt of advice, taking actions, PDC, and BP control were estimated using multivariate path analysis (controlling for age, gender, and education) for the 1,330 respondents who were African American (751) or white (579). Results: Compared to whites, African Americans had significantly (p<0.05) higher SBP (standardized beta of 0.137). Better medication adherence was associated with lower SBP (0.229); however, African Americans had lower medication adherence (0.074). Patients taking action to control BP were more likely to have received physician advice to take action (0.232); and, African Americans were more likely to receive advice (0.187) and to take action (0.056). Poor SBP was associated with greater likelihood of taking action (0.075). A similar pattern of associations was observed for DBP. Conclusions: Compared to Whites, African Americans in this MCO were less adherent with antihypertensive medications; and, this contributed to worse BP control. Worse BP control, however, increased the likelihood that physicians advised African Americans to take actions to control BP. Consistent with the CCM, physicians appear to be directing their advice on lifestyle actions to the subset of patients most likely to benefit with improved BP control.