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Original Investigation |

Ethnic Differences in Blood Pressure Control Among Men at Veterans Affairs Clinics and Other Health Care Sites FREE

Shakaib U. Rehman, MD; Florence N. Hutchison, MD; Katharine Hendrix, PhD; Eni C. Okonofua, MD, MSCR; Brent M. Egan, MD
[+] Author Affiliations

Author Affiliations: Departments of Medicine, Ralph H. Johnson VA Medical Center and Medical University of South Carolina, Charleston.


Arch Intern Med. 2005;165(9):1041-1047. doi:10.1001/archinte.165.9.1041.
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Background  Differential access to health care may contribute to lower blood pressure (BP) control rates to under 140/90 mm Hg in African American compared with white hypertensive patients, especially men (26.5% vs 36.5% of all hypertensive patients in the National Health and Nutrition Examination Survey 1999-2000). The Department of Veterans Affairs (VA) system, which provides access to health care and medications across ethnic and economic boundaries, may reduce disparities in BP control.

Methods  To test this hypothesis, BP treatment and control groups were compared between African American (VA, n = 4379; non-VA, n = 2754) and white (VA, n = 7987; non-VA, n = 4980) hypertensive men.

Results  In both groups, whites were older than African Americans (P<.05), had lower BP (P<.001), and had BP controlled to below 140/90 mm Hg more often on their last visit (P<.01). Blood pressure control to below 140/90 mm Hg was comparable among white hypertensive men at VA (55.6%) and non-VA (54.2%) settings (P = .12). In contrast, BP control was higher among African American hypertensive men at VA (49.4%) compared with non-VA (44.0%) settings (P<.01), even after controlling for age, numerous comorbid conditions, and rural-urban classification. African American hypertensive men received a comparable number of prescriptions for BP medications at VA sites (P = .18) and more prescriptions at non-VA sites than did whites (P<.001). African Americans had more visits in the previous year at VA sites (P<.001) and fewer visits at non-VA sites (P<.001) compared with whites.

Conclusions  The ethnic disparity in BP control between African Americans and whites was approximately 40% less at VA than at non-VA health care sites (6.2% vs 10.2%; P<.01). Ensuring access to health care could constitute one constructive component of a national initiative to reduce ethnic disparities in BP control and cardiovascular risk.

Figures in this Article

In the National Health and Nutrition Examination Survey (NHANES) 1999-2000, African Americans had a higher prevalence of hypertension compared with whites.1 Hypertension is a major contributor to excess cardiovascular and renal morbidity and mortality in African Americans than in whites.2,3 Disparities in cardiovascular risk factor control and outcomes are striking for African American men.411 The NHANES 1999-2000 indicated that blood pressure (BP) control to below 140/90 mm Hg was achieved in only 26.5% of African American men and 36.5% of white men with hypertension. In contrast, hypertension control rates were comparable in African American and white women at 29.4% vs 30.5% of all hypertensive women.1

The explanation for the persisting ethnic differences in hypertension control and in cardiovascular and renal outcomes is not fully known but may include biological, cultural, social, health care provider, and health care system factors, such as insurance and access to care and medications. Other reports indicate that greater access to care and medications does not ensure better hypertension control.12,13 These observations raise the possibility that other factors may predominate.14 An accurate assessment of variables contributing to health disparities is essential in allocating resources to support effective solutions.

In the present study, primary care practice data were examined to assess the treatment and control of hypertension in African American and white hypertensive patients at Department of Veterans Affairs (VA) and non-VA health care sites. The analysis focused on men because ethnic differences in hypertension control are more evident in men.1 Moreover, men comprised approximately 97% of patients in the VA Hospital and Clinic system.

Access to health care services and formulary medications in the VA system is without inherent ethnic or economic bias. Thus, ethnic differences in BP control at the VA are likely to reflect factors other than access to care and medications. Moreover, by comparing ethnic differences in hypertension control among patients at VA and non-VA sites, the impact of universal access to care and medications on ethnic disparities in BP control can be estimated.

This study was reviewed and approved by the Office of Research Protection and Integrity at the Medical University of South Carolina and the Research and Development Committee at the Ralph H. Johnson VA Medical Center, Charleston. Men receiving care for hypertension during the years 2001 through 2003 at the VA Medical Center and affiliated VA community-based outpatient clinics as well as from non-VA sites were included. Data from non-VA facilities were derived from the Hypertension Initiative.15

MEDICAL RECORD ABSTRACTION

A computerized patient record system was searched for eligible patients for the VA. The data from non-VA sites were obtained from either electronic medical records or from data cards completed at the time of clinic visits for hypertensive patients.15 The conduct of this study was compliant with the Health Insurance Portability and Accountability Act.

Information obtained from the medical record included patient demographics, dates of medical visits, BP, and antihypertensive medications at each visit from January 2001 through December 2003.

DIAGNOSIS OF HYPERTENSION

The principal criterion for determining the presence of hypertension was based on the diagnostic problem list for each patient. The patient was also designated as hypertensive if a systolic BP (SBP) above 140 mm Hg and/or a diastolic BP (DBP) above 90 mm Hg were recorded on 3 or more consecutive visits in the past year or if the patient was prescribed antihypertensive medications without another diagnostic indication evident.

ANTIHYPERTENSIVE MEDICATIONS

The major categories of antihypertensive medications were α1-receptor blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, β-receptor and α,β-receptor blockers, dihydropyridine calcium channel blocker, nondihydropyridine calcium channel blocker, diuretics, and other (vasodilators, central sympatholytics, and ganglionic blockers).

HYPERTENSION CONTROL

The BP recorded on the most recent clinical visit during the study period was used to determine hypertension control. Blood pressure was defined as controlled when the most recent clinic readings for both SBP and DBP were below 140/90 mm Hg. Blood pressure was defined as partially controlled when the higher of the SBP and/or DBP was 140 to 149/90 to 94 mm Hg at the most recent visit. Blood pressure was designated as uncontrolled when the SBP and/or DBP was above 150/95 mm Hg at the last clinic encounter.

RURAL/URBAN CODE ASSIGNMENT CLASSIFICATION SYSTEM

Patients were classified according to the Rural/Urban Code Assignment (RUCA) classification system developed by the University of Washington’s Rural Health Research Center. This classification addresses limitations in accurately assigning an urban or rural designation to geographic locations.16

STATISTICAL ANALYSIS

Data are reported as mean ± SD for descriptive purposes and as mean ± SEM when mean values for African Americans and whites are compared. When appropriate, data are reported as percentages. Ethnic differences in hypertension treatment and control between African American and white men were examined using χ2 tests. Data in these 2 ethnic groups were further analyzed controlling for age and sex using the Cochran-Mantel-Haenszel method. Multivariable logistic regression was used to compare differences in BP control rates between VA and non-VA patients adjusting for covariates (eg, age, ethnicity, body mass index [BMI], RUCA code, and comorbid diagnoses including diabetes, lipid disorders, cardiovascular disease, chronic heart failure, and renal disease). Because ethnicity was a determinant of differences in BP control between VA and non-VA sites, the multivariable logistic regression analysis was performed separately for whites and African Americans. Statistical Analysis Software version 9.01 (SAS Institute Inc, Cary, NC) was used for all data analysis. P values <.05 were accepted as statistically significant.

VA DATA

The average BP for all VA patients was 138.3/77.2 mm Hg ± 0.2/0.1 mm Hg, and 53% of hypertensive patients achieved the goal BP of below 140/90 mm Hg (Table 1). Among hypertensive men, whites were older than African American (Table 2). Compared with African Americans, whites had lower BP (Table 2) and were more likely to have BP controlled at the last visit (Figure 1A). Approximately 20% of white and African American hypertensive men had BP within 10/5 mm Hg of goal (ie, <150/95 mm Hg but ≥140/90 mm Hg [Table 1 and Figure 2A]).

Place holder to copy figure label and caption
Figure 1.

A, Blood pressure (BP) control to below 140/90 mm Hg is depicted for whites compared with African Americans at Veterans Affairs (VA) and non-VA sites; B, blood pressure control to below 140/90 mm Hg is contrasted within whites and African Americans at VA and non-VA sites; C, the difference in BP control to below 140/90 mm Hg between whites and African Americans (W−AA) at VA and non-VA sites.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

See legend to Figure 1; for Figure 2 the blood pressure (BP) level for analysis is below 150/95 mm Hg.

Graphic Jump Location
Table Graphic Jump LocationTable 1. Comparison of Subject Characteristics at VA and Non-VA Health Care Sites*
Table Graphic Jump LocationTable 2. Descriptive Variables by Ethnic Groups

African American and white men undergoing treatment received a similar number of prescriptions for antihypertensive medications at the VA sites (1.76 ± 0.02 vs 1.73 ± 0.01; P = .18). Compared with whites, African Americans received more diuretics and calcium channel blockers; comparable angiotensin-converting enzyme inhibitors, α-blockers (not shown), α,β-blockers (not shown), and angiotensin receptor blockers; and fewer β-blockers (Table 3). African Americans had more clinic visits compared with whites in the previous year (4.53 ± 0.05 vs 4.12 ± 0.03; P<.001).

Table Graphic Jump LocationTable 3. Classes of Antihypertensive Medication “Prescribed” by Ethnic Group*
NON-VA DATA

Overall the average BP for all non-VA patients was 136.4/80.4 ± 0.2/0.1 mm Hg, and 51% of hypertensive patients achieved the goal BP of below 140/90 mm Hg (Table 1). Compared with African American hypertensive men, white hypertensive men were older, had lower BP (Table 2), and had BP controlled to below 140/90 mm Hg more often on their last visit (Figure 1A). Twenty-two percent of white and African American hypertensive men had BP within 10/5 mm Hg of goal (ie, <150/95 mm Hg but ≥140/90 [Table 1 and Figure 2A]).

Compared with whites, African Americans undergoing treatment received on average more prescriptions for diuretics, calcium channel blockers, angiotensin-converting enzyme inhibitors, α-blockers, α,β-blockers, and angiotensin receptor blockers, and they received fewer β-blockers (Table 2) and more total antihypertensive prescriptions (2.36 ± 0.03 vs 2.08 ± 0.02; P<.001). African Americans had fewer clinic visits than whites in the previous year (2.80 ± 0.02 vs 3.67 ± 0.02; P<.001).

COMPARISON OF VA AND NON-VA DATA

Hypertensive patients at the VA were, on average, approximately 6 years older and had higher SBP and lower DBP compared with non-VA patients in both ethnic groups (Table 1). Despite the older age of VA patients, BP control to below 140/90 mm Hg was similar in white (P = .12) and higher in African American hypertensive patients (P<.005) seen at VA than at non-VA sites (Figure 1B). In whites, the BP goal of below 140/90 mm Hg was achieved in 55.6% of the VA and 54.2% of the non-VA group (P = .12). However, among African American men, BP control to below 140/90 mm Hg was obtained more often in the VA than in the non-VA patients (49.4% vs 44.0%; P<.005) as shown in Figure 1B. In both VA and non-VA settings, the lower rate of BP control in African Americans compared with whites did not reflect a less intensive therapeutic effort defined by the mean number of antihypertensive medications recorded in the medical record. The frequency of visits was greater for African American than for white men in the VA group but lower for African American than for white men at non-VA sites. The ethnic difference in the percentage of white and African American hypertensive men with BP controlled to below 140/90 mm Hg was smaller in VA clinics than in non-VA clinics but remained significant (Figure 1C).

VARIABLES AFFECTING BP CONTROL AT VA AND NON-VA SITES

Because multivariable logistic regression analysis indicated that ethnicity and age were significant determinants of differences in BP control between VA and non-VA sites, the multivariable logistic regression analysis was repeated separately for African Americans and whites. The results of multivariable logistic regression analysis for African Americans showed that BP control remained significantly lower for those seen at non-VA compared with VA sites (odds ratio, 0.839; 95% confidence interval, 0.742-0.949) after controlling for age, BMI, the presence of comorbid disorders of lipid and glucose metabolism, cardiovascular disease, heart failure, nephropathy, and RUCA code (Table 4). In other words, African American hypertensive men seen outside the VA were 16.1% (95% confidence interval, 5.1%-25.8%) less likely to have their BP controlled to below 140/90 mm Hg. The same analysis for whites did not reveal a significant difference in control rates between VA and non-VA sites (data not shown). The presence of cardiovascular disease and heart failure resulted in significantly higher BP control rates, whereas older age, higher BMI, and history of nephropathy were associated with lower BP control rates.

Table Graphic Jump LocationTable 4. Multivariable Logistic Regression Model of Blood Pressure Control (<140/90 mm Hg) for African Americans

Figure 2A-B compares the BP control of below 150/95 mm Hg in VA and non-VA sites between white and African American men. Figure 2C shows the ethnic disparity in BP controlled to below 150/95 mm Hg at VA and non-VA sites.

USING THE DATA FROM RUCA CODES

Matched to the 2000 census information, whites had higher income and education status compared with African Americans in each of the RUCA codes. However, there were no significant differences between African American and white hypertensive men at the VA and their race-matched counterparts seen at non-VA sites in median household income (1999 dollars) and the percentages with a high school education or more. Veterans Affairs patients were more likely to originate from the combination of “small rural” and “isolated small rural” zip codes than were men receiving care at non-VA sites (25.1% [VA] vs 13.7% [non-VA]; P<.05). Therefore, RUCA code was included in the multivariable logistic regression analysis comparing BP control at VA and non-VA sites. By RUCA code classification, urban and large rural areas were more likely to have BP in control compared with isolated rural areas.

Blood pressure control among African American hypertensive men was higher for those seen at VA compared with non-VA health care sites. Moreover, the differences in BP control between white and African American men were less at VA than at non-VA health care locations. Blood pressure was controlled to below 140/90 mm Hg in 49.4% of African Americans at the VA and 44.0% of African Americans at non-VA sites. In contrast, BP control among white men was similar at both sites. These results suggest that site of care has greater impact on health care, specifically BP control, in African Americans than in whites.

The lower BP control rate among African Americans at VA compared with non-VA sites was not explained by differences in age, level of education, median household income, or residency in urban or rural locations. In fact, more VA patients were living in the small rural and isolated areas compared with the non-VA patients. Because health care status and outcomes tend to be poorer for rural than for urban areas,17 the observed difference in RUCA code distribution may highlight relative advantages of the VA system in controlling BP.

The better BP control rate among African Americans receiving care at VA compared with non-VA clinics was also not explained by differences in the number of antihypertensive medications (Table 3). African American and white hypertensive men received a similar number of prescriptions for BP medications at VA sites, whereas African American men received more antihypertensive medications at non-VA sites. It could be postulated that poorer hypertension control rates in African Americans should have elicited an even more intensive therapeutic effort than in whites.

The database did not include information on prescriptions filled. The ratio of prescriptions filled to written may have differed by ethnicity and clinic setting. For example, the higher cost of medications for non-VA patients may have contributed to a lower ratio of prescriptions filled to written, leading to even more prescriptions written in an attempt to control BP. By extension, greater financial limitations of African Americans compared with whites could lead to an even lower ratio of prescriptions filled, which may contribute to more prescriptions being written for African American than for white hypertensive patients outside the VA. The data and considerations noted raise the possibility that better access to medications may have contributed to the smaller ethnic difference in BP control at VA compared with non-VA sites.

Compared with whites, African Americans had a greater number of visits per year in the VA sites but fewer documented visits at non-VA sites, suggesting that a higher visit frequency may contribute to better BP control for African American men seen at VA sites. Better access to health care for African American men at VA compared with non-VA sites, as assessed by the number of visits relative to whites seen at the same locations, may have contributed to a smaller ethnic difference in BP control at the VA. Compared with whites, ethnic minorities are less likely to have health insurance,18 are more likely to have publicly funded health insurance (eg, Medicaid), and even when insured equally, may face additional economic barriers to care, including high copayments and geographic barriers (eg, a relative scarcity of health care providers and health care facilities in minority communities and insufficient transportation). These access-related factors are likely the most significant barriers to equitable care.19

On the other hand, other evidence suggests that disparities of insurance and income account for some but probably not most ethnic disparities in health care utilization.2024 Weinick et al14 have shown that disparities in insurance and income account for approximately 23% to 45% of the ethnic differences in access to care and utilization of health care services. In an attempt to elucidate the confounding variables that could explain these differences, additional analysis were performed. In multivariable logistic regression analysis, controlling for age, BMI, RUCA code, and multiple comorbid conditions, ethnicity was a significant determinant of the difference in BP control at VA compared with non-VA sites (data not shown).

Our findings suggest that the VA system offers advantages in controlling hypertension, especially in African Americans. The VA has a long history of leadership in the treatment of hypertension. The earliest multicenter trials demonstrating the benefit of antihypertensive treatment were conducted in the VA health system.25,26 In response to reports of suboptimal BP control in VA patients,12 the VA developed special programs to improve hypertension control.27,28 It may be instructive to assess the potential impact of these efforts on variables such as visit frequency that could favorably impact BP control,29 particularly among African Americans.

Another potentially important finding in our study was that about 20% of hypertensive men had a BP below 150/95 mm Hg but 140/90 mm Hg or above in all groups, indicating that they were near the goal of below 140/90 mm Hg (Figure 2). This is consistent with other reports on uncontrolled hypertensive patients30 and suggests that modest improvements in BP control for those near the goal of below 140/90 mm Hg could dramatically improve overall control rates to approximately 75% for white men and 65% to 70% for African American men.

The earlier onset, higher prevalence, and greater severity of hypertension coupled with undiagnosed, untreated, and inadequately treated hypertension result in a substantially greater burden of stroke, heart, and end-stage renal disease and a decreased life expectancy in African Americans than in whites.2,10,3133 Improving hypertension treatment and control has a beneficial impact on cardiovascular outcomes in African Americans and whites, with greater relative benefits in the former.11,34 Although hypertension control rates have improved in the last 3 decades, the rates remain unacceptably low, especially in ethnic minorities.1,3

The analysis was limited to medical practices mainly in South Carolina and may not be representative of health care, especially outside the Southeast. However, hypertension control rates in our study are comparable to values reported for aware and treated hypertensive patients in the NHANES 1999-2000 survey. Data for all patients receiving health care at the VA were obtained from a common electronic medical record system, whereas data for non-VA hypertensive patients were obtained from various electronic systems and paper reporting.15 Thus, data on the number of medications and visits, in particular, may not be directly comparable for VA and non-VA hypertensive patients. Nevertheless, a comparison of relative ethnic differences at VA and non-VA sites on variables including visit frequency and number of antihypertensive medications prescribed should not be significantly affected. Ethnicity data were missing in approximately one fourth of patients at VA and non-VA sites. Prescription (re)fill rates were not assessed for either model of care and may have revealed ethnic differences, especially at the non-VA sites for reasons discussed earlier.

The percentage of African American men with controlled hypertension was greater at VA than at non-VA clinics (49.4% vs 44.0%; P<.001), whereas BP control among white men was not significantly different at the 2 sites. The ethnic difference in BP control at the VA was approximately 40% less than at non-VA sites (6.2% vs 10.2%, P<.001). The ethnic difference in BP control between VA and non-VA sites was not diminished in multivariable logistic regression analysis controlling for age, BMI, cardiovascular and renal diseases, and RUCA classification. In fact, these analyses suggest that the ethnic disparity in BP control between VA and non-VA sites would have been even greater if the confounding variables had been equally distributed. Our data raise the possibility that better access to care, assessed by visit frequency, and possibly better access to medications may contribute to the VA advantage for controlling BP in African Americans. While it will be important to identify and quantify the factors explaining better BP control for African Americans at the VA, these data suggest that ensuring access to health care could constitute a constructive national response to reducing ethnic disparities in BP control and cardiovascular outcomes.

Correspondence: Shakaib U. Rehman, MD, Ralph H. Johnson Veterans Affairs Hospital, 109 Bee St (11C), Charleston, SC 29401 (shakaib.rehman@med.va.gov).

Accepted for Publication: January 5, 2004.

Financial Disclosure: None.

Funding/Support: This work was supported in part by the Department of Veterans Affairs Research Service (Drs Rehman and Hutchison) and grants P01HS1087 (EXCEED) from the Agency for Healthcare, Research, and Quality, Rockville, Md; the Duke Foundation, Charlotte, NC; grants HL04290, HL58794, and P60-MD00267 (EXPORT) from the National Heart, Lung, and Blood Institute, Bethesda, Md; the Department of Health and Human Services (Stroke Belt Elimination Initiative), Washington, DC; and the South Carolina Department of Health and Environmental Control, Columbia.

Hajjar  IKotchen  TA Hypertension trends in the United States, 1988-2000. JAMA 2003;290199- 206
PubMed
Lackland  DTKeil  JEGazes  PCHames  CGTyroler  HA Outcomes of black and white hypertensive individuals after 30 years of follow-up. Clin Exp Hypertens 1995;171091- 1105
PubMed
Douglas  JGBakris  GLEpstein  M  et al.  Management of high blood pressure in African Americans: consensus statement of the Hypertension in African Americans Working Group of the International Society on Hypertension in Blacks. Arch Intern Med 2003;163525- 541
PubMed
Kjellstrand  CM Age, sex, and race inequality in renal transplantation. Arch Intern Med 1988;1481305- 1309
PubMed
Yergan  JFlood  ABLoGerfo  JPDiehr  P Relationship between patient race and intensity of hospital services. Med Care 1987;25592- 603
PubMed
Blendon  RJAiken  LHFreeman  HECorey  CR Access to medical care for black and white Americans: a matter of continuing concern. JAMA 1989;261278- 281
PubMed
Schwartz  EKofie  VYRivo  MTuckson  RV Black/white comparisons of deaths preventable by medical intervention: United States and the District of Columbia 1980-1986. Int J Epidemiol 1990;19591- 598
PubMed
Weissman  JSStern  RFielding  SLEpstein  AM Delayed access to health care: risk factors, reasons, and consequences. Ann Intern Med 1991;114325- 331
PubMed
Pappas  GQueen  SHadden  WFisher  G The increasing disparity in mortality between socioeconomic groups in the United States, 1960 and 1986. N Engl J Med 1993;329103- 109
PubMed
Levine  RSFoster  JEFullilove  RE  et al.  Black-white inequalities in mortality and life expectancy, 1933-1999: implications for healthy people 2010. Public Health Rep 2001;116474- 483
PubMed
Hypertension Detection and Follow-up Program Cooperative Group, Five-year findings of the Hypertension Detection and Follow-up Program, II: mortality by race, sex and age. JAMA 1979;2422572- 2577
PubMed
Berlowitz  DRAsh  ASHickey  EC  et al.  Inadequate management of blood pressure in a hypertensive population. N Engl J Med 1998;3391957- 1963
PubMed
Kotchen  JMShakoor-Abdullah  BWalker  WEChelius  THHoffmann  RGKotchen  TA Hypertension control and access to medical care in the inner city. Am J Public Health 1998;881696- 1699
PubMed
Weinick  RMZuvekas  SHCohen  JW Racial and ethnic differences in access to and use of health care services. Med Care Res Rev 2000;57 ((suppl 1)) 36- 54
PubMed
Hendrix  KLackland  DTEgan  BM Cardiovascular risk factor control and treatment patterns in primary care. Manag Care Interface 2003;1621- 26
PubMed
Washington State Department of Health, Guidelines for using rural-urban classification systems for public health assessment. Available at: http://www.doh.wa.gov/Data/Guidelines/RuralUrban.htm. Accessed October 29, 2004
Ricketts  TC The changing nature of rural health care. Annu Rev Public Health 2000;21639- 657
PubMed
Collins  KSHall  ANeuhaus  C US Minority Health: A Chartbook.  New York, NY Commonwealth Fund1999;
Smedley  BDStith  AYNelson  AR Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.  Washington, DC National Academy of Sciences2003;5- 8417- 459
Bigby  JA The challenge of eliminating disparities in health. J Gen Intern Med 2002;17489- 490
PubMed
Corbie-Smith  GFlagg  EWDoyle  JPO'Brien  MA Influence of usual source of care on differences by race/ethnicity in the receipt of preventive services. J Gen Intern Med 2002;17458- 464
PubMed
Stewart  SHSilverstein  MD Racial and ethnic disparity in blood pressure and cholesterol measurement. J Gen Intern Med 2002;17405- 411
PubMed
Cooper  LAHill  MNPowe  NR Designing and evaluating interventions to eliminate racial and ethnic disparities in health care. J Gen Intern Med 2002;17477- 486
PubMed
Kressin  NRPetersen  LA Racial differences in the use of invasive cardiovascular procedures: review of the literature and prescription for future research. Ann Intern Med 2001;135352- 366
PubMed
Veterans Administration Cooperative Study Group on Antihypertensive Agents, Effects of treatment on morbidity in hypertension: results in patients with diastolic blood pressure averaging 115 through 129 mm Hg. JAMA 1967;2021028- 1034
PubMed
Veterans Administration Cooperative Study Group on Antihypertensive Agents, Effects of treatment on morbidity in hypertension, II: results in patients with diastolic blood pressures averaging 90 through 114 mm Hg. JAMA 1970;2131143- 1152
PubMed
Perry  HMFries  EDFrolich  ED Department of Veterans Affairs hypertension meeting: a proposal for improved care. Hypertension 2000;35853- 857
PubMed
Jha  AKPerlin  JBKizer  KWDudley  RA Effect of the transformation of the Veterans Affairs health care system on the quality of care. N Engl J Med 2003;3482218- 2227
PubMed
Ahluwalia  JSMcNagny  SERask  KJ Correlates of controlled hypertension in indigent, inner-city hypertensive patients. J Gen Intern Med 1997;127- 14
PubMed
Hyman  DJPavlik  VN Characteristics of patients with uncontrolled hypertension in the United States. N Engl J Med 2001;345479- 486
PubMed
Berenson  GSVoors  AWWebber  LSDalferes  ER  JrHarsha  DW Racial differences of parameters associated with blood pressure levels in children: the Bogalusa Heart Study. Metabolism 1979;281218- 1228
PubMed
Harshfield  GATreiber  FA Racial differences in ambulatory blood pressure monitoring-derived 24 h patterns of blood pressure in adolescents. Blood Press Monit 1999;4107- 110
PubMed
Lynch  GFGorelick  PG Stroke in African Americans. Neurol Clin 2000;18273- 290
PubMed
Ooi  WLBudner  NSCohen  H  et al.  Impact of race on treatment response and cardiovascular disease among hypertensives. Hypertension 1989;14227- 234
PubMed

Figures

Place holder to copy figure label and caption
Figure 1.

A, Blood pressure (BP) control to below 140/90 mm Hg is depicted for whites compared with African Americans at Veterans Affairs (VA) and non-VA sites; B, blood pressure control to below 140/90 mm Hg is contrasted within whites and African Americans at VA and non-VA sites; C, the difference in BP control to below 140/90 mm Hg between whites and African Americans (W−AA) at VA and non-VA sites.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

See legend to Figure 1; for Figure 2 the blood pressure (BP) level for analysis is below 150/95 mm Hg.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Comparison of Subject Characteristics at VA and Non-VA Health Care Sites*
Table Graphic Jump LocationTable 2. Descriptive Variables by Ethnic Groups
Table Graphic Jump LocationTable 3. Classes of Antihypertensive Medication “Prescribed” by Ethnic Group*
Table Graphic Jump LocationTable 4. Multivariable Logistic Regression Model of Blood Pressure Control (<140/90 mm Hg) for African Americans

References

Hajjar  IKotchen  TA Hypertension trends in the United States, 1988-2000. JAMA 2003;290199- 206
PubMed
Lackland  DTKeil  JEGazes  PCHames  CGTyroler  HA Outcomes of black and white hypertensive individuals after 30 years of follow-up. Clin Exp Hypertens 1995;171091- 1105
PubMed
Douglas  JGBakris  GLEpstein  M  et al.  Management of high blood pressure in African Americans: consensus statement of the Hypertension in African Americans Working Group of the International Society on Hypertension in Blacks. Arch Intern Med 2003;163525- 541
PubMed
Kjellstrand  CM Age, sex, and race inequality in renal transplantation. Arch Intern Med 1988;1481305- 1309
PubMed
Yergan  JFlood  ABLoGerfo  JPDiehr  P Relationship between patient race and intensity of hospital services. Med Care 1987;25592- 603
PubMed
Blendon  RJAiken  LHFreeman  HECorey  CR Access to medical care for black and white Americans: a matter of continuing concern. JAMA 1989;261278- 281
PubMed
Schwartz  EKofie  VYRivo  MTuckson  RV Black/white comparisons of deaths preventable by medical intervention: United States and the District of Columbia 1980-1986. Int J Epidemiol 1990;19591- 598
PubMed
Weissman  JSStern  RFielding  SLEpstein  AM Delayed access to health care: risk factors, reasons, and consequences. Ann Intern Med 1991;114325- 331
PubMed
Pappas  GQueen  SHadden  WFisher  G The increasing disparity in mortality between socioeconomic groups in the United States, 1960 and 1986. N Engl J Med 1993;329103- 109
PubMed
Levine  RSFoster  JEFullilove  RE  et al.  Black-white inequalities in mortality and life expectancy, 1933-1999: implications for healthy people 2010. Public Health Rep 2001;116474- 483
PubMed
Hypertension Detection and Follow-up Program Cooperative Group, Five-year findings of the Hypertension Detection and Follow-up Program, II: mortality by race, sex and age. JAMA 1979;2422572- 2577
PubMed
Berlowitz  DRAsh  ASHickey  EC  et al.  Inadequate management of blood pressure in a hypertensive population. N Engl J Med 1998;3391957- 1963
PubMed
Kotchen  JMShakoor-Abdullah  BWalker  WEChelius  THHoffmann  RGKotchen  TA Hypertension control and access to medical care in the inner city. Am J Public Health 1998;881696- 1699
PubMed
Weinick  RMZuvekas  SHCohen  JW Racial and ethnic differences in access to and use of health care services. Med Care Res Rev 2000;57 ((suppl 1)) 36- 54
PubMed
Hendrix  KLackland  DTEgan  BM Cardiovascular risk factor control and treatment patterns in primary care. Manag Care Interface 2003;1621- 26
PubMed
Washington State Department of Health, Guidelines for using rural-urban classification systems for public health assessment. Available at: http://www.doh.wa.gov/Data/Guidelines/RuralUrban.htm. Accessed October 29, 2004
Ricketts  TC The changing nature of rural health care. Annu Rev Public Health 2000;21639- 657
PubMed
Collins  KSHall  ANeuhaus  C US Minority Health: A Chartbook.  New York, NY Commonwealth Fund1999;
Smedley  BDStith  AYNelson  AR Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.  Washington, DC National Academy of Sciences2003;5- 8417- 459
Bigby  JA The challenge of eliminating disparities in health. J Gen Intern Med 2002;17489- 490
PubMed
Corbie-Smith  GFlagg  EWDoyle  JPO'Brien  MA Influence of usual source of care on differences by race/ethnicity in the receipt of preventive services. J Gen Intern Med 2002;17458- 464
PubMed
Stewart  SHSilverstein  MD Racial and ethnic disparity in blood pressure and cholesterol measurement. J Gen Intern Med 2002;17405- 411
PubMed
Cooper  LAHill  MNPowe  NR Designing and evaluating interventions to eliminate racial and ethnic disparities in health care. J Gen Intern Med 2002;17477- 486
PubMed
Kressin  NRPetersen  LA Racial differences in the use of invasive cardiovascular procedures: review of the literature and prescription for future research. Ann Intern Med 2001;135352- 366
PubMed
Veterans Administration Cooperative Study Group on Antihypertensive Agents, Effects of treatment on morbidity in hypertension: results in patients with diastolic blood pressure averaging 115 through 129 mm Hg. JAMA 1967;2021028- 1034
PubMed
Veterans Administration Cooperative Study Group on Antihypertensive Agents, Effects of treatment on morbidity in hypertension, II: results in patients with diastolic blood pressures averaging 90 through 114 mm Hg. JAMA 1970;2131143- 1152
PubMed
Perry  HMFries  EDFrolich  ED Department of Veterans Affairs hypertension meeting: a proposal for improved care. Hypertension 2000;35853- 857
PubMed
Jha  AKPerlin  JBKizer  KWDudley  RA Effect of the transformation of the Veterans Affairs health care system on the quality of care. N Engl J Med 2003;3482218- 2227
PubMed
Ahluwalia  JSMcNagny  SERask  KJ Correlates of controlled hypertension in indigent, inner-city hypertensive patients. J Gen Intern Med 1997;127- 14
PubMed
Hyman  DJPavlik  VN Characteristics of patients with uncontrolled hypertension in the United States. N Engl J Med 2001;345479- 486
PubMed
Berenson  GSVoors  AWWebber  LSDalferes  ER  JrHarsha  DW Racial differences of parameters associated with blood pressure levels in children: the Bogalusa Heart Study. Metabolism 1979;281218- 1228
PubMed
Harshfield  GATreiber  FA Racial differences in ambulatory blood pressure monitoring-derived 24 h patterns of blood pressure in adolescents. Blood Press Monit 1999;4107- 110
PubMed
Lynch  GFGorelick  PG Stroke in African Americans. Neurol Clin 2000;18273- 290
PubMed
Ooi  WLBudner  NSCohen  H  et al.  Impact of race on treatment response and cardiovascular disease among hypertensives. Hypertension 1989;14227- 234
PubMed

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