The Relationship Between Racial/Ethnic Concordance and Hypertension Control



 

Francesca Adriano, MD1; Raoul J Burchette, MS2; Alyson C Ma, PhD3; Alison Sanchez, PhD3; Mindy Ma, PhD4

Perm J 2021;25:20.304

https://doi.org/10.7812/TPP/20.304
E-pub: 08/06/2021

Introduction: Given the increasing impact of the healthcare cost of hypertension on the economy, understanding the control of high blood pressure is warranted, particularly as it pertains to racial/ethnic disparities in hypertension control.

Objective: To understand the relationship between hypertension control and racial/ethnic concordance, we investigated whether the racial/ethnic concordance between a patient’s race/ethnicity and that of the individual’s provider is a predictor of high blood pressure control.

Methods: Data was collected for 612,524 patients from Kaiser Permanente Southern California who were at least 18 year old and received a diagnosis of hypertension between January 1, 2016 and December 31, 2019. A multiple regression analysis was carried out to assess the correlation between hypertension control and patient-provider concordance.

Results: The independent variables proxying for patient-provider relationship are positive and statistically significant at the 5% level. Out of the 3 types of concordance, language has the highest standardized estimate, followed by gender and race.

Discussion: We found correlations between racial/ethnic patient-provider concordance and hypertension control. Consistent with previous studies, we found that Asian patients experience more time in hypertension control. By contrast, Black and Hispanic patients have less time in hypertension control. Having the same primary care provider for a longer span of time is also positively correlated with length of hypertension control.

Conclusion: Correlation between racial/ethnic concordance, length of time under the primary provider’s care, and length of time spent in hypertension control suggests that the patient-provider relationship remains a critical component of health outcomes.

INTRODUCTION

According to the Centers for Disease Control and Prevention (CDC), approximately 1 out of 2 adults in the US has hypertension (HTN).1 In 2018, the primary or contributing cause of nearly half a million deaths in the US was linked to high blood pressure (BP).2 The annual healthcare cost of HTN is estimated to be about $131 billion, as individuals with high blood pressure spend about $2000 more on healthcare relative to non-hypertensive peers.3 Additionally, there are significant racial/ethnic disparities in blood pressure prevalence and control rates.

Of the more than 100 million adults with HTN, only about a quarter of the individuals have their condition under control.2 The number of patients with inadequate BP control is increasing.4,5 While uncontrolled high blood pressure is common, control of the condition varies across race and ethnic groups.6 In particular, non-Hispanic black adults have the highest incidences of HTN (54%) followed by non-Hispanic white adults (46%). The rates of high blood pressure are lower for non-Hispanic Asian adults (39%) and Hispanic adults (36%).2 For those patients for whom blood pressure medication is recommended, blood pressure control is highest for non-Hispanic white patients (32%), followed by non-Hispanic black patients and Hispanic patients (25%) and non-Hispanic Asian patients (19%).2

Due to the prevalence of HTN in the adult population in the US and the burgeoning impact of the healthcare cost of the disease on the economy, understanding the control of high blood pressure is warranted, particularly as it pertains to racial/ethnic groups. While there are multiple factors that are associated with BP control, the patient-provider relationship is a prevalent factor.7 Our paper contributes to the existing literature on racial/ethnic disparities in HTN control by focusing on the patient-provider relationship.

More specifically, we examine whether racial/ethnic concordance between a patient’s race/ethnicity and that of the individual’s provider is a predictor of high blood pressure control. The motivation stems from previous research which suggests that race/ethnicity concordance increases the likelihood of healthcare utilization for Hispanic, black, and Asian patients relative to white patients.8 By narrowing the social distance between patients and providers, race/ethnicity concordances potentially build greater trust and communication in patient-provider relationships to better control HTN across racial/ethnic groups.

LITERATURE REVIEW

A number of studies document that incidence rates of HTN are higher for black adults as compared to white adults, even after controlling for covariates such as age, gender, weight, and neighborhood education level.9-11 Additionally, the incident rates of HTN are even higher among Hispanic black patients than Hispanic white patients.12-14 Compared to white patients, black patients are diagnosed with HTN earlier in life and their BP rates are higher on average.15 However, Hispanics in general have a lower prevalence of self-reported HTN than non-Hispanics.14

Using the 2013-2016 data from the National Health and Nutrition Examination Survey and criteria from the American College of Cardiology and American Heart Association, the CDC estimates that 19% (or 21 million) of US adults with HTN received recommendations of lifestyle modifications to control the condition.16 Lifestyle modifications include a reduction in sodium intake, an increase in physical activity, weight loss, and limitation on alcohol consumption.17 The vast majority of adults with HTN (81% or 87 million) were recommended a combination of lifestyle modifications and medication to control for high blood pressure.

Individuals with HTN also tend to have other co-morbidities.18,19 HTN is also interrelated with diabetes as more than two-thirds of adults with diabetes also have HTN.20-22 The 2 diseases share many similar underlying risk factors, including ethnicity and lifestyle determinants.20 Moreover, high blood pressure is common among patients not only with diabetes but also kidney disease.23

Control of HTN is a process which includes: 1) identifying those at risk of the disease, 2) implementing appropriate treatment, and 3) following up to determine whether the high blood pressure is controlled.24 However, there are many barriers to controlling HTN, some of which may be considered as non-modifiable characteristics (eg, region, socio-economic status, age or sex).24 Control of HTN could also be hampered due to poor management by health care providers and clinical inertia, particularly between race/ethnic groups.6,25

By contrast, factors such as patient-provider relationships may enhance HTN awareness, treatment, as well as follow up care. Additionally, BP control is influenced by successful patient self-management. Part of the self-management of chronic disease care is to form a collaborative patient-provider relationship.26 Low quality patient-provider interactions are associated with decreases in self-management behaviors.27 Previous studies establish a connection between the quality of provider-patient relationships and another critical element of BP control, medication adherence.

When patients trust their provider, this can promote adherence to the established care plan and improve both health outcomes and patient satisfaction.28 Black patients in race/ethnic-concordant relationships are more likely to report higher trust in their physician as compared to those in race/ethnic-disconcordant relationships.29 The dimensions of the patient-physician relationship include communication, partnership, power, trust, knowing, and concordance.30,31 The providers’ knowledge of the unique attributes of individual patients is associated with continuity of care and patient adherence.30,32

Concordance consists of shared identities between patients and physicians that are both visible (race/ethnicity, age, gender, education, language) and less visible (beliefs, values, preferences).30 Racial/ethnic concordance influences clinical health outcomes by mitigating factors such as outgroup bias. For example, patient-provider racial concordance helps to reduce black infant mortality rates by half.33 More specifically, race/ethnic-disconcordant relationships may explain differences in communication style and level of care, including durations of visits.30,33,34

Shared racial or ethnic identities between providers and patients is related to patient reports of satisfaction, participatory decision-making, timeliness of treatment, and trust in the health system.35 Black patients consistently experience poorer communication quality, information-giving, patient participation, and participatory decision-making than equivalent white patients. Further, racial concordance is associated with improved communication with providers among multiple communication domains.36 In addition to communication and trust factors, physicians of a social outgroup are more likely to be aware of unique challenges that arise when treating patients of their group.37,38 Umscheid et al (2010) examined the relationship between patient-provider race and intensification of blood pressure treatment for black, white, and Asian groups. Their retrospective cohort study consisted of 16,881 hypertensive adults in 6 academic primary care practices in Philadelphia, Pennsylvania. Their results suggested that racial/ethnic discordance is not consistently associated with inferior or superior medical management of uncontrolled HTN.39

Our paper contributes to the existing literature on the patient-provider relationship and HTN control by focusing on racial/ethnic concordance. We hypothesized that there is a positive association between racial/ethnic concordance and BP control. The reason is that the patients and providers of the same ethnic/racial group may share less visible commonalities such as beliefs, values, and preferences, which leads to increases in perceived trust. Studies show that trusting relationships between patients and providers are positively correlated with medical adherence due to improved communication and shared decision making.40-45 Additionally, by utilizing patient level data from Kaiser Permanente Southern California (KPSC), our paper controls for variations across care management, which allows us to focus on the patient-provider relationship.

KPSC consists of an ethnically and socioeconomically diverse population spanning from Bakersfield to San Diego with more than 4.7 million members.46 Starting in the early 2000’s, KPSC implemented a system-level approach to managing HTN. This system included: 1) creation of a HTN registry; 2) standardization of blood pressure measurements; 3) creation of an internal treatment algorithm; and 4) the embracement of a multidisciplinary approach of stakeholders, including medical assistants, nurses, and pharmacists.6 As a health maintenance organization, KPSC has defined plans that include no copay for BP measurements. This feature along with email communication with the primary care provider (PCP)a and no copay for telephone appointments, reduce the financial barriers to health utilization.

DATA AND METHODOLOGY

This paper includes patient level data from Kaiser Permanente Southern California (KPSC). The project was reviewed and approved by KPSC IRB on June 12, 2020 (IRB Protocol #12212). The 2 main criteria for inclusion were patients who were at least 18 year old and received a diagnosis of HTN between the study period of January 1, 2016 and December 31, 2019. We excluded pregnant patients, those with more than 1 PCP, those without any visits with their PCP of record, or those who were not identified as black, Hispanic, white, or Asian. Additionally, we only included patients with at least 4 BP measurements over the study period. The study included a total of 612,524 patients (see Table 1). To assess the correlation between patient-provider relationship and HTN control, our analysis consisted of a multiple regression carried out using SAS 9.4.

Table 1. Summary statistics (n = 612,524)

Variable Mean Std Dev Minimum Maximum
Duration of HTN control 0.78 0.26 0.00 1.00
Race concordance 0.36 0.48 0.00 1.00
Language concordance 0.94 0.23 0.00 1.00
Gender concordance 0.65 0.48 0.00 1.00
White 0.41 0.49 0.00 1.00
Asian 0.12 0.33 0.00 1.00
Black 0.13 0.34 0.00 1.00
Hispanic 0.34 0.47 0.00 1.00
Patient age 62.04 13.75 17.99 108.78
PCP age 44.99 7.61 22.93 76.85
PCP span 8.13 4.36 0.00 15.41
Diabetes diagnosis 0.39 0.49 0.00 1.00
Chronic kidney disease 0.20 0.40 0.00 1.00
Antihypertension medications 0.92 0.27 0.00 1.00

Dependent Variable

Within a measurement day, a patient was considered to be in HTN control if any of the blood pressure measurements taken that day could be considered non-hypertensive according to age, diabetic and Chronic Kidney Disease (CKD) status, according to Eighth Report of the Joint National Committee (JNC8) guidelines. The control designation was given for the number of days until the next BP measurement record. The length of HTN control for each patient is measured as a percentage by dividing the number of days the patient was designated as having met the JNC8 guidelines for HTN control by the number of days between the patient’s first and last BP recordings. The average time in control, as given in Table 1, is 78%.

Independent Variables

Our study included 3 independent variables to proxy for patient-provider relationships (race/ethnic concordance, language concordance, and gender concordance). Race/Ethnic Concordance is a binary variable that is equal to 1 if the race/ethnicity of the PCP and patient matched and 0 otherwise. Table 1 shows that about 36% or 220,509 of the patients were in race/ethnic concordant relationships with their PCPs. Language Concordance is another binary variable that equals 1 if the PCP is proficient in the patient’s preferred language. The incidence of language concordance was very high at 94%, which translates to 575,773 patient-provider relationships. The binary variable Gender Concordance equals 1 if the reported gender of both patient and PCP was a match. About 65% of the patients had a PCP of the same identified gender.

Covariates

The covariates include the race/ethnicity indicators of Asian (12%), black (13%), Hispanic (34%), and white (41%). The Patient Age was measured at the first blood pressure measurement in study window. The PCP Age was measured on the same date as the patient’s age. The average patient age in the study was 62 year old, whereas the average PCP age was 45 year old. The PCP Span is a measure of the duration of the patient-provider relationship in years. It is defined as the time of record the patient had the same PCP from the time the PCP was assigned until either the PCP ceased being assigned to the patient or as of December 31, 2019, whichever is less. The average duration of the patient-provider relationship was just over 8 years. The 2 patient comorbidities are diabetes and chronic kidney disease, following the JNC8 guidelines. About 239,000 (or 39%) of the HTN patients also had diabetes. Out of the 612,524 HTN patients in the study, 20% (or approximately 122,505) also had chronic kidney disease. Over 90% of the HTN patients were on at least 1 antihypertension medication (Figures 1, 2, and 3).

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Figure 1. Summary statistics (mean and standard deviation) and number of patients by variable.

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Figure 2. Summary statistics (mean and standard deviation) for patient race/ethnicity.

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Figure 3. Summary statistics (mean and standard deviation) and age/years.

RESULTS

Table 2 presents the estimation results. The independent variables proxying for patient-provider relationship are positive and statistically significant at the 5% level. Out of the 3 types of concordance, language has the highest standardized estimate (0.0054, p-value ≤ 0.0001), followed by gender (0.0047, p-value = 0.0002) then race (0.0038, p-value = 0.0038). Race is statistically significant at the 1% level. Relative to white KPSC patients, Asian patients (coef = 0.0056, p-value ≤ 0.0001) experience more time in control of HTN; whereas black (coef = −0.0592, p-value ≤ 0.0001) and Hispanic (coef = −0.0223, p-value ≤ 0.0001) patients have less time in HTN control.

Table 2. Multiple regression results

Variable Estimate Standard Error p-value Standardized estimate
Intercept 0.5450 0.0031 < 0.0001 0.0000
Race concordance 0.0021 0.0007 0.0038 0.0038
Language concordance 0.0061 0.0015 < 0.0001 0.0054
Gender concordance 0.0026 0.0007 0.0002 0.0047
Asian 0.0056 0.0011 < 0.0001 0.0070
Black −0.0592 0.0011 < 0.0001 −0.0761
Hispanic −0.0223 0.0008 < 0.0001 −0.0402
Patient age 0.0044 0.0000 < 0.0001 0.2314
PCP age 0.0003 0.0000 < 0.0001 0.0079
PCP span 0.0024 0.0001 < 0.0001 0.0399
Diabetes diagnosis −0.0141 0.0007 < 0.0001 −0.0261
Chronic kidney disease −0.0527 0.0009 < 0.0001 −0.0808
Antihypertension medications −0.0492 0.0012 < 0.0001 −0.0508
No. of observations 612,524      
Root MSE 0.254      
Adj R-Sq 0.064      

Both patient (coef = 0.0044, p-value ≤ 0.0001) and PCP (coef = 0.0003, p-value ≤ 0.0001) ages were positively associated with time in BP control. Patient age has the highest standardized estimate (0.2314) of all independent variables and covariates. Having the same PCP for a longer span of time (coef = 0.0024, p-value ≤ 0.0001) was also positively correlated with length of HTN control.

Similar to previous studies, comorbidities were negatively associated with duration of HTN control. Chronic kidney disease (coef = −0.0527, p-value ≤ 0.0001) has a slightly more negative association as compared to diabetes (coef = −0.0141, p-value ≤ 0.0001). By contrast, patients taking antihypertensive medications (coef = −0.0492, p-value ≤ 0.0001) have a shorter length of HTN control.

DISCUSSION

Overall, the empirical results indicate that the independent variables and covariates are statistically significant with the expected direction. The one exception is the covariate indicating whether patients are taking antihypertensive medication(s). We expected the association between HTN control and patients taking antihypertensive medication(s) to be positive. Namely, patients taking antihypertensive medication(s) are more likely to be in control of their high blood pressure. However, the estimated coefficient on antihypertensive medication(s) was negative and statistically significant.

Although the estimated coefficients were statistically significant, it is important to note that the estimated coefficients were relatively small. More specifically, the small magnitude of the estimated coefficients does not provide clinical significance to support our hypothesis of a positive association between race/ethnic concordance and HTN control.

One main reason for the lack of clinical significance is due to the high HTN control rates (78% in our study) at Kaiser Permanente. As part of its initiatives to combat HTN, KPSC implemented programs for patients to have easy access to nonphysician providers in order to manage their HTN. This includes having their blood pressure measured by a medical assistant without a copay. These visits improve blood pressure monitoring and review of antihypertensive medications, while enhancing intervention among nurse practitioners, pharmacists, and physicians.

KPSC also implemented strategies to overcome clinical inertia by providing performance feedback and encouraging participations in HTN-focused conferences and activities. KPSC monitors the database of HTN patients and reaches out to patients whose last BP was not controlled or who have not had a BP on record within the last 12 months. Kaiser Permanente physicians make medication changes “on the spot” when patients visit the facilities for a free BP check with the medical assistant. Moreover, blood pressure measurements are performed at all visitations and maintained in the electronic health record. Kaiser Permanente provides education programs for patients, including peer group-focused meetings to address similar cultural barriers of which their physicians might not be aware, and in the same language.47

The system-level steps implemented by KPSC may reduce the reliance on concordance in control HTN. Fontil et al (2018) highlight the success of an adaption of Kaiser Permanente’s evidence-based treatment protocols at 12 safety-net clinics in the San Francisco Health Network.48 According to the authors, the evidenced-based system approaches could play a pivotal role in improving HTN control and reducing blood pressure disparities.

Additionally, Kaiser Permanente offers cultural humility training through its Institute for Culturally Competent Care for health professionals.49 Programs focused on cultural humility improve the quality of patient-provider communication, access to high-quality care as well as encouraging patient-centered care, understanding, and trust. 48,50-53 Kaiser Permanente defines “culturally competent care” as care that respects the health beliefs, values, and behaviors of culturally diverse populations and individuals.”52,53 Such understanding helps to build skills for working and interacting with patients to improve the overall health of different racial and ethnic populations.54

Our paper has a number of limitations that could be considered for further research. Inclusion of other comorbidities such as obesity would more accurately control for a patient’s underlying health risks. Given the relationship between socioeconomic factors and health disparities, the addition of covariates capturing income and educational attainment would enhance the estimation. Another factor which may impact BP control is a patient’s marital status. This is would particularly pertinent if both spouses have HTN as medication adherence and lifestyle modifications may be more effective through common regiments and goals. Another consideration for future research is to focus on the 22% of Kaiser Permanente patients without BP control. Additionally, a disaggregate examination of the type and number of antihypertension medications would be fruitful to understanding BP control. Lastly, a survey to determine the prevalence of antihypertension medications, lifestyle modifications, or the combination of both could provide improved BP management.

CONCLUSION

Using data from Kaiser Permanente Southern California (KPSC), our results do not provide strong clinical significance on the positive association between racial/ethnic concordance and hypertension control. Moreover, language concordance between patient and provider has a slightly larger clinical impact on BP control than race/ethnic concordance. The results suggest that a systematic approach to management care, such as the program implemented by KPSC, may provide more effective in BP control than less visible dimensions of patient-provider relationships.

aPCPs are the patients physicians of record.

Disclosure Statement

The authors declare that they have no affiliations with or involvement in any organization or entity with any financial or non-financial interest in the subject matter discussed in this manuscript.

Abbreviations

BP = blood pressure; CDC = Centers for Disease Control and Prevention; CKD = Chronic Kidney Disease; HTN = hypertension; KPSC = Kaiser Permanente Southern California; JNC8 = Eighth Report of the Joint National Committee; PCP = primary care provider

Funding

No funding was provided for this study.

Author Affiliations

1Kaiser Permanente San Diego Family Medicine Residency Program, Kaiser Permanente Southern California, San Diego, CA

2Southern California Permanente Medical Group, Research and Evaluation, Pasadena, CA

3Department of Economics, University of San Diego School of Business, San Diego, CA

4Department of Psychology and Neuroscience, Nova Southeastern University, Ft. Lauderdale, FL

Corresponding Author

Alison Sanchez, PhD (alisonsanchez@sandiego.edu)

Author Contributions

F.A., A.M., A.S., M.M. conceived the original idea and designed the research; R.B. conducted the statistical analysis; A.M., A.S. wrote the manuscript in consultation with F.A., R.B. and M.M.; all authors provided critical feedback.

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Keywords: concordance, discrimination, disparities, hypertension, relationship

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