Inventing a New Model of Hypertension Care for Black Men

here are more than 200,000 deaths in the United States each year from heart disease, stroke, and hypertensive disease that could be avoided by timely and effective preventive medical care.1 The risk of avoidable cardiovascular deaths among black men is 80% higher than that among white men or black women. The combination of a high prevalence of hypertension and poor blood-pressure control is a major contributor to the high rates of cardiovascular death and disease among black men.2 Despite the high priority for finding ways to improve blood-pressure treatment in black men, few unequivocal success stories have been reported.

The trial reported by Victor et al. in this issue of the Journal is a notable exception.3 The trial is remarkable for the magnitude of the intervention effect: a reduction in systolic blood pressure of 27 mm Hg, as compared with 9 mm Hg in the control group, and a more than 5 times greater likelihood of meeting currently recommended blood-pressure goals. This is a much larger effect than has been achieved in most pharmacist- or nurse-delivered collaborative care interventions in less hard-to-reach populations.4,5

The trial builds on a previous trial in 15 black-owned barbershops in Texas.6 In that trial, 483 regular patrons with hypertension in the control shops were given educational pamphlets, whereas 539 patrons in intervention shops were offered blood-pressure checks with haircuts, given sex-specific health messages, and encouraged to seek health care follow-up for elevated blood pressure. Although the results were encouraging, the difference between the two groups was small (−2.5 mm Hg in systolic blood pressure and 9% percentage points in blood-pressure control). In the present trial, patrons in control barbershops received lifestyle advice and were urged to seek medical care in a traditional clinic setting. In intervention shops, medical care was brought to the barbershop; pharmacists working under collaborative practice agreements with physicians provided state-of-the-art hypertension care in a convenient and supportive nonclinical environment that the men already visited every 2 weeks.

The men in the present trial were well educated (94% were high school graduates) but low income (more than half had household incomes ≤300% of the federal poverty level) and had a high level of cardiovascular risk. Although most had a regular medical care provider and insurance, nearly half were taking no antihypertensive medications at enrollment. In addition to locating care in the community, three features of the intervention were likely to have been essential ingredients in the substantial blood-pressure improvement in this challenging population.

First, the pharmacists had direct prescribing authority and used a highly effective antihypertensive protocol that started with evidence-based dual therapy. Most men were treated initially with a dihydropyridine calcium-channel blocker combined with either an angiotensin-converting–enzyme inhibitor or angiotensin-receptor blocker. The next treatment step added a thiazide diuretic, followed by an aldosterone antagonist if a fourth drug was needed. Second, pharmacists had frequent contact with the participants during the 6-month trial period — face-to-face visits occurred about once per month, plus four outbound telephone calls from pharmacists were made and six additional inbound messages or calls from participants were received. Third, treatment was intensified until a target 5 mm Hg lower than the usual goal for out-of-office blood pressure was attained (130/80 mm Hg, as compared with 135/85 mm Hg). At the end of the 6-month trial period, participants in the intervention group were receiving a mean of 2.6 medications, as compared with 1.4 in the control group.

The unique trial setting and population of regular barbershop patrons present the next challenge — scaling up, extending, and disseminating the intervention. The relatively small number of participants recruited from each shop poses logistic obstacles that might be addressed, in part, by incorporating telemonitoring, which has worked well in trials involving predominantly nonblack participants and shown some success in one trial involving exclusively black participants.7-10 Even a favorable economic analysis does not clearly identify who is responsible for paying for the resources required for outreach programs like this. Follow-up of the trial cohort will answer key questions about the durability of the blood-pressure results, transitions of care back to regular health care providers, and how successful the men are in obtaining future medication refills, laboratory testing, and blood-pressure checks.

Despite these caveats, Victor et al. provide persuasive evidence that we can succeed in reaching treatment-resistant hypertensive populations with powerful yet simple treatment algorithms, short follow-up intervals, and persistence in adjusting therapy when blood pressure remains above the goal. Programs that include these elements are likely to improve care when carried out in traditional primary care settings but promise even greater benefit by extending into communities, businesses, and homes. The time is right — our patients are demanding that we invent new models of care.