Study Shows Racial Differences in Outcomes of VA Telephone-Delivered Hypertension Disease Management Program

BACKGROUND:
Hypertension is the leading single modifiable risk factor for cardiovascular disease, stroke, and related events — and it is significantly more common among African American adults (prevalence of 41%) than non-Hispanic whites (prevalence of 28%). This study examined whether there were differences in blood pressure (BP) for African American and non-Hispanic white Veterans who participated in the Hypertension Intervention Nurse Telemedicine Study (HINTS) clinical trial that evaluated three telephone-based interventions through a four-group design: 1) nurse-administered, physician-directed medication management intervention; 2) nurse-administered behavioral management intervention; 3) combined behavioral management and medication management intervention; and 4) usual care. Investigators analyzed data for 284 African American and 289 non-Hispanic white Veterans who participated in HINTS and were assigned to one of the four groups. Mean systolic and diastolic BPs were measured at 6, 12, and 18 months, with data collected from 5/06 through 7/09. All Veterans in this study had a diagnosis of hypertension and received treatment through primary care clinics at the Durham VAMC.

FINDINGS:

• A combination of home BP monitoring, remote medication management, and telephone-tailored behavioral self-management appears to be particularly effective for improving BP among African American Veterans. However, the effect was not seen among non-Hispanic white Veterans.
• Among African Americans, improvement in mean systolic BP was greatest for those receiving the combined intervention: compared to usual care, systolic BP was 6.6 mmHg lower at 12 months and 9.7 mmHg lower at 18 months. These decreases in BP were not seen in non-Hispanic white Veterans.

LIMITATIONS:

• Data were limited to African American and white Veterans seen in one tertiary care VAMC.
• The original HINTS trial was not designed to detect treatment differences in patient subgroups, thus the ability to provide definitive evidence of a differential treatment response by race was limited.
• The comprehensive nature of the self-management intervention makes it difficult to discern which aspects of the intervention were most beneficial.

IMPLICATIONS:

• Results suggest that while there are clear biologic risk factors for uncontrolled hypertension that can be treated with medication, there are behavioral factors such as medication adherence, exercise and diet, which also need to be addressed and which may impact African American and white Veterans differently.

AUTHOR/FUNDING INFORMATION:
This study was funded by HSR&D (IIR 04-426). Dr. Bosworth also was supported by an HSR&D Research Career Scientist Award (RCS 08-027), and Dr. Powers was supported by an HSR&D Career Development Award (CDA 09-212). All authors are part of HSR&D's Center for Health Services Research in Primary Care, Durham, NC.

Jackson G, Oddone E, Olsen M, Powers B, Grubber J, McCant F, and Bosworth H. Racial Differences in the Effect of a Telephone-Delivered Hypertension Disease Management Program. Journal of General Internal Medicine August 3, 2012;Epub ahead of print.