Self-reported hypertension treatment practices among primary care physicians: blood pressure thresholds, drug choices, and the role of guidelines and evidence-based medicine.

BACKGROUND: Primary care physician treatment practices affect the rate of hypertension control to the goal of 140/90 mm Hg. Awareness of and agreement with national hypertension management guidelines, and grounding in evidence-based medicine principles, may be important determinants of practice. METHODS: A 26-item mail questionnaire was sent to a national sample of 1200 primary care physicians. The questionnaire elicited (1) the blood pressure (BP) criteria physicians use to initiate and intensify hypertension treatment, (2) first-line drug treatment choices, (3) familiarity with the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC) hypertension treatment guidelines, and (4) familiarity with research methods used to develop evidence-based medicine guidelines. The analysis focused on (1) determining the percentage of physicians who reported treatment practices consistent with JNC recommendations and (2) the relation between familiarity with JNC guidelines, evidence-based medicine methods, and reported treatment practices. RESULTS: The overall response rate was 34%, with no important differences in demographic or professional training variables between respondents and nonrespondents. For middle-aged patients with uncomplicated hypertension, 33% of physicians would not start drug therapy unless the diastolic BP was greater than 95 mm Hg, and 43% would not start unless the systolic BP was greater than 160 mm Hg. In patients without complications who were receiving drug treatment, 25% of physicians would not intensify therapy for a persistent diastolic BP of 94 mm Hg, and 33% would not intensify therapy for a systolic BP of 158 mm Hg. Physicians were generally less aggressive in older patients. Angiotensin-converting enzyme inhibitors were the most common first-line drug choice. Forty-one percent of physicians had not heard of or were not familiar with the JNC guidelines. In multiple logistic regression models, familiarity with the JNC guidelines was associated with lower treatment thresholds, and increased familiarity with research methods was associated with greater use of diuretics or beta-blockers as first-line agents. CONCLUSIONS: Many physicians have higher BP thresholds for the diagnosis and treatment of hypertension than the 140/90 mm Hg criterion recommended by the JNC. Therefore, further improvements in population hypertension control will require physician behavior change. Physician practice is associated with awareness of practice guidelines and familiarity with evidence-based medicine methods, but the precise nature and extent of this relation requires further study.

New profiles of diabetic ketoacidosis: type 1 vs type 2 diabetes and the effect of ethnicity.

BACKGROUND: Diabetic ketoacidosis (DKA) has been reported to occur in type 2 diabetes, but the frequency and distinguishing features of this syndrome remain to be defined. We determined the "diabetic types," ethnic distributions, and phenotypes of patients with DKA in an urban hospital. METHODS: We reviewed the hospital admissions and followed the clinical course of adults who developed DKA. We classified patients as "type 1," "type 2," or "new onset" based on their treatment history. New-onset patients were reassessed 2 1/2 years or more after the episode of DKA and classified as "type 1" or "type 2" based on insulin requirements. We compared the groups for ethnic distributions and clinical features. RESULTS: Of 141 patients, 55 (39%) who presented with DKA had type 2 diabetes, while 75 (53%) had type 1 diabetes and 11 (8%) could not be "typed." Hispanics mainly had type 2 and whites predominantly had type 1, while African Americans had a slight preponderance of type 1 diabetes (P=.001). Type 1 patients were mainly lean, while the body mass indexes (BMIs) (calculated as the weight in kilograms divided by the square of height in meters) of type 2 patients were bimodally distributed (33% with BMI<25 and 51% with BMI>30; P<.001). Age of onset of diabetes was predominantly younger than 40 years in the type 1 group but was more broadly distributed in the type 2 group (P<.001). Ninety-three percent of the new-onset patients who were reassessed had type 2 diabetes. Half of the type 2 patients had no identifiable stress factor associated with the episode of DKA. CONCLUSIONS: A high proportion of DKA in nonwhite adults occurs in persons with type 2 diabetes, especially in those with previously undiagnosed diabetes. The frequency and clinical heterogeneity of this syndrome in a multiethnic population have significant implications for the diagnosis, classification, and management of adults with diabetes.

Medication adherence and resistant hypertension.

Non-adherence has been a major concern in the treatment of hypertension and is particularly important in understanding and intervening in patients who appear to have resistant hypertension. Relatively few studies have examined the role of non-adherence in resistant hypertension. This review will address issues related to measurement of adherence, adherence interventions and rates of non-adherence in general hypertensive populations and in patients classified as having resistant hypertension.

The high prevalence of depression and dementia in elder abuse or neglect.

BACKGROUND: The risk factors for mistreatment of older people include age, race, low income, functional or cognitive impairment, a history of violence, and recent stressful events. There is little information in the literature concerning the clinical profile of mistreated older people. OBJECTIVES: To describe the characteristics of abused or neglected patients and to compare the prevalence of depression and dementia in neglected patients with that of patients referred for other reasons. DESIGN: A case control study. SETTING: Baylor College of Medicine Geriatrics Clinic at the Harris County Hospital District (Houston, Texas). PATIENTS: Forty-seven older persons referred for neglect and 97 referred for other reasons. INTERVENTION: Comprehensive geriatric assessment. MEASUREMENTS: Standard geriatric assessment tools. RESULTS: There was a statistically significant higher prevalence of depression (62% vs 12%) and dementia (51% vs 30%) in victims of self-neglect compared to patients referred for other reasons. CONCLUSIONS: This is the first primary data study that highlights a high prevalence of depression as well as dementia in mistreated older people. Geriatric clinicians should rule out elder neglect or abuse in their depressed or demented patients.

Quantifying the problem of abuse and neglect in adults--analysis of a statewide database.

BACKGROUND: Mistreatment of adults, including abuse, neglect, and exploitation, affects more than 1.8 million older Americans. Presently, there is a lack of precise estimates of the magnitude of the problem and the variability in risk for different types of mistreatment depending on such factors as age and gender. OBJECTIVES: To describe the universe of case reports received during one year in a centralized computer database maintained by the Texas Department of Protective and Regulatory Services--Adult Protective Services Division (TDPRS-APS). DESIGN: Descriptive. SETTING: Texas. PARTICIPANTS: Mistreated or neglected older people. MEASUREMENTS: The distribution of abuse types reported and population prevalence estimates of each abuse type by age and sex. RESULTS: There were over 62,000 allegations of adult mistreatment and neglect filed in Texas in 1997. Neglect accounted for 80% of the allegations. The incidence of being reported to the TDPRS-APS increased sharply after age 65. The prevalence was 1,310 individuals/100,000 > or = 65 years of age for all abuse types. CONCLUSIONS: The TDPRS database is an excellent tool for characterizing and tracking cases of reported elder mistreatment. Achieving a clearer understanding of this ever-increasing public health problem can aid in the development of better interventions and prevention strategies.

Ethnic differences in nocturnal blood pressure decline in treated hypertensives.

Lack of a nocturnal decline in blood pressure (BP) has been associated with more severe end organ damage in hypertensives, and blacks appear less likely than whites to have a > 10% drop in nighttime BP ("dipping"). Little information is available about the relationship between treatment regimens, ethnic group classification, and dipping in treated hypertensive patient populations. We obtained 24-h ambulatory BP readings in 438 adult white (n = 103), black (n = 200) and Hispanic (n = 135) treated hypertensives. Tycos monitors were connected in patients' homes before their usual morning medication dose time. Research assistants administered a quality-of-life questionnaire, recorded patients' drug regimen, and observed the patients take their morning dose. Monitors were programmed to record BP every 30 min. Dippers were defined as persons who had a drop of > or = 10% decline in average daytime (08:00 to 22:00) compared to nighttime (00:00 to 04:00) BP. Logistic regression modeling was used to assess the relationship between demographic and treatment variables and probability of dipping. Twenty-four-hour average BP was similar in all three ethnic groups. However, the absence of a systolic dip was significantly more common in black and Hispanic men than in white men (OR black v white = 11.54, 95% CI = 3.92 to 34.01; OR Hispanic v white = 7.32, 95% CI = 2.47 to 21.68). There were no ethnic group differences in probability of systolic dipping among women. Absence of a diastolic dip was approximately twice as common in blacks and Hispanics than in whites, with no marked gender-by-ethnic-group interaction in the magnitude of the association. Of the 10 most commonly prescribed antihypertensives, no single drug was positively associated with nocturnal BP decline. Later versus earlier morning dose time, but not once-a-day dosing, was associated with absence of dipping. Treated black and Hispanic hypertensives are less likely to "dip" than non-Hispanic whites. No particular drug was positively associated with dipping.

Effect of minor illness on serum cholesterol level.

To ascertain the impact of minor illness on total plasma cholesterol (TC) and high-density lipoprotein cholesterol (HDL-C), we analyzed data collected on 6,880 persons examined for the Stanford Five-City Project. Overall, 8.4% of the population reported having a minor illness on the day of examination, although there were substantial variations in minor illness rates with season, city, and year of data collection. After adjustment for age, sex, body mass index, season, and city of residence, we found that those who reported minor illness at the time of examination had a lower mean TC than those who were well (195.9 mg/dL versus 201.2 mg/dL, P less than .005). HDL-C was 51.2 mg/dL in persons with minor illness, and 52.3 mg/dL in persons without (P = .13). Dietary recall data covering the 24-hour period before the examination was available on a subset of the patients. No dietary differences appeared between individuals who reported minor illness and those who did not. In a subset of 162 persons with a minor illness who were followed longitudinally for up to six years, TC adjusted for age was 191.8 mg/dL with minor illness and 196.1 mg/dL without, a difference that was not statistically significant. The results of this study imply that minor illness may contribute to some of the biological variability of TC and HDL-C. Although small, a differential rate of minor illness may sometimes significantly affect interpretation of TC epidemiological and intervention studies or the timing of measurements in clinical practice.

The impact of public cholesterol screening on diet, general well-being, and physician referral.

Public cholesterol screenings have become common. To evaluate the public health impact of such events, we conducted a public cholesterol screening and, three months later, invited participants between the ages of 18 and 72 to return for follow-up. More than 77% (N = 143) returned. We collected information on diet and general well-being at baseline and follow-up, and we obtained information on further medical evaluation of the initial cholesterol value at follow-up. Diet improved regardless of baseline cholesterol level (overall diet score 2.10 baseline, 1.75 follow-up, P less than .001). There were no adverse psychosocial ("labeling") effects in persons told of elevated cholesterol levels. About one-third of individuals referred to their physicians for elevated cholesterol values discussed the cholesterol issue with their physicians, as did a similar proportion of those told of a desirable cholesterol level. Total cholesterol decreased from 218.5 to 211.6 mg/dL (P = 0.18, 95% CI for the change, -18.5 to +4.7 mg/dL). Public cholesterol screening did not appear to have any adverse effects and may lead to beneficial changes in diet in persons screened.

Dietary intervention for cholesterol reduction in public clinic patients.

OBJECTIVES: To test the feasibility and effectiveness of a diet intervention (consisting of interactive mailings, computer-generated phone calls, and classes) in hypercholesterolemic low-income public clinic patients. METHODS: Clinic patients with serum cholesterol > 200 mg/dl, referred by their primary care physician were randomized to a 6-month special intervention (SI) or usual care (UC). The intervention included mailings, computer phone calls, and four 1-hour classes. Serum total cholesterol (TC) was measured before and after intervention, and participation was monitored. RESULTS: One hundred sixty-five of the 212 patients referred (77.8%) agreed to participate. A medical records review revealed 123 (74.5%) met eligibility criteria. Eligible subjects had a mean age of 56.7 years, 80.0% were African American, 74.8% were female, 33.6% were married, and 89.4% had a high school or lower education. Subjects were randomized with 80.5% (99) completing follow-up cholesterol measures. SI subjects were encouraged to use all three components, with 84.6% (55 of 65) actively participating in at least one component. Seventy-two percent (47 of 65) returned at least one mailing, 49.1% (28 of 57) of those with touch-tone phones accessed the computer system, and 43.1% (28 of 65) attended classes. The TC in SI decreased from 273.2 mg/dl to 265.0 mg/dl (P = 0.05) and in UC 272.4 mg/dl to 267.6 mg/dl (P = 0.32). The net reduction in SI compared with UC was 3.4 mg/dl (P = 0.58). CONCLUSIONS: (1) Low-income public clinic patients will participate in diet interventions, (2) computer-generated interactive phone calls are feasible in this population, and (3) clinically meaningful decreases in serum cholesterol are difficult to achieve with interventions of practical intensity.

Maintenance of cholesterol reduction using automated telephone calls.

A critical problem in the dietary treatment of hypercholesterolemia is the long-term maintenance of cholesterol reduction. A system to maintain contact and provide feedback through a computer-interactive phone system was used with 115 subjects who completed a four-week diet and behavioral cholesterol reduction program. The subjects, mean age 48 years, were 87% non-Hispanic Caucasian and 74.8% were female. They were randomized to a control or maintenance group. The maintenance group received calls twice a month for six months. Total cholesterol (TC) and weight (lb) were obtained before and after a four-week program and after the six-month maintenance period. Neither group of subjects with all cholesterol measurements fully maintained initial cholesterol reductions (mean TC: in maintenance [n = 48) 248, 221, 231 versus control [n = 43] 243, 224, 232 mg/dL). All (n = 59) of the maintenance subjects used the phone system, with 83.3% of a subset evaluating it indicating the phone messages were helpful. Patients (n = 25) with > or = 5 lb weight loss and 10% TC decrease from baseline had a better maintenance of TC reduction in the maintenance versus control group (273,208,231 versus 259,205,246 mg/dL) (P < .05). We conclude that (1) maintenance remains a problem for cholesterol-lowering diet interventions, (2)automated phone calls are capable of maintaining contact and providing patient feedback, and (3) this system may help in the maintenance of TC levels for patients who made greater changes.

Cholesterol-related knowledge, attitudes, and behaviors in a low-income, urban patient population.

To determine knowledge, attitudes, behaviors, and self-reported cholesterol measurement in a low-income, urban patient population, we conducted an interview survey of users and potential users of primary care services in a public health care system for low-income Harris County, Texas, residents. The response rate was 93%, with a final sample of 547 randomly selected subjects 18 years of age and older, who were Hispanic (54%), black (28%), non-Hispanic white (14%), and Asian, Native American, or other (4%). Results indicated that 76% had heard of serum or blood cholesterol, and 30% reported past cholesterol measurement. Knowledge that dietary saturated fat can raise blood cholesterol ranged from 11% in Hispanic men to 51% in non-Hispanic white men and women. A lower percentage of Hispanics correctly answered all knowledge questions, and Hispanics reported higher-fat food choices than blacks and non-Hispanic whites. More than 90% of the respondents expressed interest in more information on diet, 60% reported that they read nutrition labels, and 15% said they have been trying to reduce blood cholesterol levels. A lower percentage of Hispanics reported previous cholesterol measurement than blacks or non-Hispanic whites, a difference that persisted after adjusting for multiple factors associated with cholesterol measurement. Older age (older than 50) and more physician visits in the past year also were associated with past cholesterol measurement. Comparisons with national surveys show that cholesterol knowledge and actual measurement in this low-income sample lag behind those of the national population. Yet, despite gaps in knowledge and cholesterol measurement, respondents showed positive attitudes about and interest in cholesterol-lowering interventions.

Hypertension control in multi-ethnic primary care clinics.

The most recent JNC-V guidelines for hypertension treatment call for control of blood pressure (BP) to < 140/90 mm Hg, with increased emphasis on control of systolic pressure. To determine the extent and determinants of BP control in a large multi-ethnic, low-income clinic population of diagnosed hypertensives immediately prior to issuance of the new guidelines, we reviewed the medical records of 2925 patients sampled from a population of over 14,000 hypertensives following in a network of nine primary care clinics operated by the Harris County Hospital District in Houston, Texas. Variables extracted from the medical record included: systolic (SBP) and diastolic (DBP) blood pressure at the initial clinic visit, average of all BP readings in the 12 months prior to the chart review (the measure of current control), antihypertensives prescribed at the most recent visit, and patient sociodemographic variables. The mean age of the sample was 61.6 +/- 12.8 years, and 67% were female. Average 12-month SBP and DBP were 141 +/- 14.7 and 83.6 +/- 8.5 respectively. Forty-nine per cent of patients had SBP controlled to < 140 mm Hg, 79.5% had DBP controlled to < 90 mm Hg, and 46% of patients achieved the criterion of < 140/90 mm Hg. In logistic regression analysis, age, baseline BP, body mass index and ethnicity, but not gender, were associated with current control. After adjustment for other covariates, Hispanics and Black people were significantly more likely to be in poor control than whites (ORHISP = 2.05, 95%Cl = 1.57-2.70; ORBlack = 1.48, 95%Cl = 1.21-1.81). Twelve per cent of patients were not receiving any antihypertensive medication. Of the remaining, the majority (52%) were on monotherapy. In the monotherapy group, 45% had SBP > or = 140 mm Hg and 16% had DBP > or = 90 mm Hg. We conclude that the achievement of new treatment recommendations will require education of primary care providers in more aggressive titration of antihypertensive medications to control SBP.

Hypertension awareness and control in an inner-city African-American sample.

African-Americans in the US are at high risk for hypertension-related morbidity and mortality. The majority of African-Americans live in central city areas, and lower socioeconomic status and health care utilization patterns have been hypothesized to contribute to higher blood pressure (BP) levels and poorer control of treated hypertension in this group. In order to plan an intervention to improve hypertension care for inner city African-Americans in Houston, Texas, we conducted a baseline survey of residents in 12 low-income ZIP code areas with a > 70% African-American population to determine the level of hypertension awareness, treatment and control, and associated sociodemographic, health care utilization, and medication compliance variables. Subjects were recruited to attend a BP measurement and assessment of knowledge, attitudes and behaviors through random digit phone dialing in the target ZIP code areas. Of the 962 subjects examined, 433 (45%) were hypertensive (systolic BP > or = 140 mm Hg or diastolic pressure > or = 90 mm Hg or taking antihypertensive medication). Among all hypertensives, 73% were aware, 64% were on treatment, and 28% were controlled to 140/90 mm Hg. Of hypertensives on treatment, 43% were controlled to 140/90 mm Hg, but 72% were controlled using the criterion of 160/95 mm Hg, and 75% were controlled using a diastolic pressure < 90 mm Hg only. These results are similar to those reported for African-Americans in the most recent US national health survey. Males were less likely to be aware, receiving treatment and controlled than were females. Although lack of awareness was associated with less frequent BP measurement, 77% of those unaware reported a measurement within the past 2 years. The majority of aware hypertensives reported frequent physician contact and high compliance with medication. We conclude that intervention to improve hypertension control in this population should focus on ensuring that health providers diagnose BP and establish treatment goals based on the current standard of 140/90 mm Hg.

Genetic bottlenecks, perceived racism, and hypertension risk among African Americans and first-generation African immigrants.

The complexity of factors influencing the development of hypertension (HTN) in African Americans has given rise to theories suggesting that genetic changes occurred due to selection pressures/genetic bottleneck effects (ie, constriction of existing genetic variability) over the course of the slave trade. Ninety-nine US-born and 86 African-born health professionals were compared in a cross-sectional survey examining genetic and psychosocial predictors of HTN. We examined the distributions of three genetic loci (G-protein, AGT-235, and ACE I/D) that have been associated with increased HTN risk. There were no significant differences between US-born African Americans and African-born immigrants in the studied genetic loci or biological variables (eg, plasma renin and angiotensin converting enzyme activity), except that the AGT-235 homozygous T genotype was somewhat more frequent among African-born participants than US-born African Americans. Only age, body mass index, and birthplace consistently demonstrated associations with HTN status. Thus, there was no evidence of a genetic bottleneck in the loci studied, ie, that US-born African Americans have different genotype distributions that increase their risk for HTN. In fact, some of the genotypic distributions evidenced lower frequencies of HTN-related alleles among US-born African Americans, providing evidence of European admixture. The consistent finding that birthplace (ie, US vs Africa) was associated with HTN, even though it was not always significant, suggests potential and unmeasured cultural, lifestyle, and environmental differences between African immigrants and US-born African Americans that are protective against HTN.

A comparison of participants and nonparticipants in a worksite cholesterol screening.

PURPOSE: The purpose of this study is to determine if worksite cholesterol screening reaches only those who are already aware of their cholesterol and interested in lifestyle modification. DESIGN: A voluntary worksite cholesterol screening was conducted followed by a survey of a random sample of nonparticipants. SETTING: A large university worksite was the setting for this study. SUBJECTS: Out of 9,137 university employees, 1,583 attended the voluntary screening, and a random sample of nonparticipants was obtained (n = 154), of which 87% (n = 138) responded. MEASURES: Subjects completed a questionnaire on health behaviors, perceived risk, self-efficacy for diet change, and attention to media messages. A capillary blood cholesterol level was also taken. RESULTS: Nonparticipants were more likely to be male (64% versus 39%) and smokers (17% versus 9%), more likely to exercise, to have had a prior cholesterol measurement (64% versus 49%), and to "know" their cholesterol value (56% versus 26%). The two groups were otherwise similar. Over half (51%) of the participants were receiving their first cholesterol measurement. These subjects were younger, less educated, had less perceived risk, were less attentive to media messages, and more likely to be from a minority group than those individuals who had prior measurements. DISCUSSION: These findings suggest that worksite cholesterol screening does not only reach those already aware of their cholesterols, but also can reach some persons not previously screened or concerned.

Cholesterol treatment practices of primary care physicians.

The active involvement of primary care physicians is necessary in the diagnosis and treatment of elevated blood cholesterol. Empirical evidence suggests that primary care physicians generally initiate dietary and pharmacological treatment at threshold values higher than is currently recommended. To determine current treatment thresholds and establish factors that distinguish physicians who are more likely to initiate therapy at lower cholesterol values, 119 primary care physicians in four northern California communities were surveyed. Data collection included their demographic factors, treatment of hypothetical patients, self-efficacy regarding counseling patients about cholesterol reduction and personal health behaviors, outcome expectations, and cholesterol knowledge and attitudes. Results indicated that 59 percent of respondents would not start dietary treatment on a middle-aged female patient with a cholesterol of 215 milligrams per deciliter (mg per dl). Only 44 percent of respondents indicated that they would initiate pharmacological therapy for a middle-aged man with a cholesterol of 276 mg per dl. Logistic regression models were used to determine characteristics that influenced dietary and pharmacological treatment practices. Younger physicians, those who had had their own cholesterol checked, and those who personally ate a low-fat diet, were more likely to recommend diet therapy to patients with modest elevations of cholesterol. Willingness to use lipid lowering medications at more marked elevations was associated only with increased self-efficacy regarding use of drugs to lower cholesterol. These results indicate that physicians' personal health behaviors and self-efficacy should be addressed in interventions to modify cholesterol-related practice behavior.

Response rates to random digit dialing for recruiting participants to an onsite health study.

OBJECTIVE: To evaluate the response rates when random digit dialing was used as a substitute for geographic area sampling and household interviews to recruit 2100 African Americans for a blood pressure measurement and hypertension-related knowledge and attitudes survey. METHODS: Random digit dialing was used to identify African American adults living in 12 low-income ZIP code areas of Houston, Texas. A brief survey of hypertension awareness and treatment was administered to all respondents. Those who self-identified as African American were invited to a community location for blood pressure measurement and an extended personal interview. An incentive of $10 was offered for the completed clinic visit. A substudy of nonrespondents was carried out to test the effectiveness of a $25 incentive in increasing the response rate. Data from the initial random telephone interview were used to identify differences between those who did and did not attend the measurement session. RESULTS: Ninety-four percent of eligible persons contacted completed the telephone survey, and 65% agreed to visit a central community site for blood pressure measurement. In spite of the financial incentive and multiple attempts to reschedule missed appointments, only 26% of the 65% who agreed to attend completed the scheduled visit. In the substudy of the higher financial incentive, all of those who missed the original appointment agreed to another appointment, and 85% of this subgroup kept it. Not being employed full-time and a history of hypertension were consistently associated with agreement to be measured and keeping an appointment. In spite of the low response rate for scheduled appointments, differences--other than in employment status and a history of hypertension--between responders and nonresponders were small and consistent with what is usually observed in health surveys. CONCLUSIONS: The use of random digit dialing as a substitute for area sampling and household screening resulted in unacceptably low response rates in the study population and should not be undertaken without further research on ways to increase response rates.

Lower hypertension prevalence in first-generation African immigrants compared to US-born African Americans.

Both genetic and environmental factors have been hypothesized to explain the higher prevalence of hypertension in US African Americans compared to populations still residing in western Africa. Studies of first-generation immigrants can help to identify risk factors for increased chronic disease expression in the developed world. Since we could identify no prior studies of hypertension in African immigrants to the United States, we conducted a cross-sectional survey of African-born and US-born African-American health professionals to compare the two groups for the prevalence of hypertension (blood pressure > or = 140/90 mm Hg or use of antihypertensive medication) and risk factors for hypertension (body mass index, lifestyle factors, and psychosocial variables hypothesized to relate to hypertension). Subjects were registered pharmacists and nurses recruited by mail. For the 182 individuals who completed study measurements (95 US-born and 87 African-born), the unadjusted odds ratio for hypertension associated with birthplace was 2.16 (95% CI = 1.12, 3.98). After adjustment for body mass index and age, the OR for birthplace was 1.92 (95% CI = 0.92, 4.00). No lifestyle or psychosocial variables were associated with hypertension prevalence. We conclude that there is a lower prevalence of hypertension in first-generation African immigrants that cannot be readily explained by the environmental effects measured in this study. Larger scale studies with African immigrants could advance understanding of the causes of the increased hypertension prevalence in US-born African Americans.

Do public clinic systems provide health care access for the urban poor? A cross-sectional survey.

The purpose of this study was to describe the health care access provided to a low-income urban population by a system of county run public clinics. We conducted a cross-sectional interview survey of a random sample of subjects applying for or renewing eligibility to use the public system. The setting was a public system consisting of inner-city community health centers and hospital-based clinics delivering primary care. We interviewed 547 adult nonpregnant subjects; mean age was 41 years; 55% were women, 54% were Hispanic and 28% were non-Hispanic Blacks; 78% had household income below $15,000 per year, and 75% had no health insurance. Access to health care was measured in three ways: physician contact during year prior to survey; and answers to two separate questions concerning delaying needed medical care because it cost too much, and delaying care because it would take too long to be seen. Although 80% of subjects had seen a physician at least once, 46% had stayed away sometime during the year due to financial reasons and 24% had stayed away because of waiting time. Surprisingly, 35% reported private sector use. These rates varied significantly with insurance status. Hispanics had significantly less access by all three measures, even after multivariable adjustment for potential confounders such as sex, age, chronic disease and insurance status. We conclude that this study demonstrates financial barriers to access, while showing substantial private sector contact, even by low-income subjects already using the public sector.

Characteristics of patients with uncontrolled hypertension in the United States.

BACKGROUND: Treatment of hypertension is one of the most common clinical responsibilities of U.S. physicians, yet only one fourth of patients with hypertension have their blood pressure adequately controlled. METHODS: We analyzed data from the third National Health and Nutrition Examination Survey to assess the role of access to and use of health care in the control of hypertension. We assessed demographic characteristics, clinical data, health insurance status, and awareness and treatment of hypertension in subjects with hypertension (defined as a blood pressure of at least 140/90 mm Hg or the use of antihypertensive medication) and subjects without hypertension. RESULTS: The study sample consisted of 16,095 adults who were at least 25 years old and for whom blood-pressure values were known. We estimated that 27 percent of the population had hypertension, but only 23 percent of those with hypertension were taking medications that controlled their condition. Among subjects with untreated or uncontrolled hypertension, the pattern was an elevation in the systolic blood pressure with a diastolic pressure of less than 90 mm Hg. The great majority had health insurance. Independent predictors of a lack of awareness of hypertension were an age of at least 65 years, male sex, non-Hispanic black race, and not having visited a physician within the preceding 12 months. The same variables, except for non-Hispanic black race, were independently associated with poor control of hypertension among those who were aware of their condition. An age of at least 65 years accounted for the greatest proportion of the attributable risk of the lack of awareness of hypertension and the lack of control of hypertension among those who were aware of their condition. CONCLUSIONS: Most cases of uncontrolled hypertension in the United States consist of isolated, mild systolic hypertension in older adults, most of whom have access to health care and relatively frequent contact with physicians.