Special Article
Predisposing Factors for Severe, Uncontrolled Hypertension in an Inner-City Minority Population
N Engl J Med 1992; 327:776-781September 10, 1992
- Abstract
- Abstract
Background
Hypertensive emergency and urgent hypertension are the most severe forms of uncontrolled hypertension and are now seen predominantly in poor, minority populations. We studied the characteristics of the medical care received by patients with these conditions in order to identify risk factors for severe, uncontrolled hypertension.
Methods
Using a case–control study design, we interviewed 93 patients with severe, uncontrolled hypertension who presented in the hospital emergency room and 114 control patients with hypertension; both groups were seen at two New York City hospitals from 1989 through 1991. All the patients were black or Hispanic. Multiple logistic-regression models were used to adjust for age, sex, race or ethnic background, education, smoking status, alcohol-related problems, and use of illicit drugs during the previous year.
Results
After additional adjustment for lack of health insurance, severe, uncontrolled hypertension was found to be more common among patients who had no primary care physician (adjusted odds ratio, 3.5; 95 percent confidence interval, 1.6 to 7.7) and among those who did not comply with treatment for their hypertension (adjusted odds ratio, 1.9; 95 percent confidence interval, 1.4 to 2.5). Lack of health insurance was marginally associated with severe, uncontrolled hypertension (adjusted odds ratio, 1.9; 95 percent confidence interval, 0.8 to 4.6) after adjustment for lack of a primary care physician and noncompliance with antihypertensive treatment. Patients without a primary care physician and without health insurance were more likely to have their blood pressure checked and receive prescriptions for blood-pressure medications in emergency rooms than in physicians' offices or clinics.
Conclusions
Characteristics of both the health care system and patients' behavior are associated with severe, uncontrolled hypertension. Improving access to primary care physicians, through health insurance or other means, may be an effective strategy for improving control of hypertension in disadvantaged minority populations. (N Engl J Med 1992;327:776–81.)
Media in This Article
Table 1
Clinical Characteristics of 93 Case Patients with Severe, Uncontrolled Hypertension.Table 2
Selected Characteristics of Case Patients and Controls.Article Activity
- Article
HYPERTENSION is one of the most common medical conditions in the United States, with a prevalence of about 22 percent among adults 18 to 74 years of age, according to the second National Health and Nutrition Examination Survey.1 The results of at least 15 randomized controlled clinical trials of drug treatment for hypertension2 , 3 support the current consensus recommendations for treatment.4 The development of a broad pharmacologic armamentarium and the dissemination of information to both physicians and the general public through the National High Blood Pressure Education Program5 have led to improvements in blood-pressure control6 7 8 and have contributed to reductions in the incidence of stroke and ischemic heart disease.9 10 11 Despite these gains, poorly controlled hypertension remains a major health problem, particularly among minority populations, the poor, those with lower educational levels, and those with limited access to medical care.12 13 14 Increasing the rate of blood-pressure control among patients with hypertension to at least 50 percent is one of the national health promotion and disease prevention objectives for the year 2000.15
Hypertensive emergencies and urgent hypertension are the most extreme forms of poorly controlled hypertension4 , 16 and thus can be used as indicator conditions for poorly controlled hypertension. Hypertensive emergencies, which include malignant hypertension, are evidenced by acute end-organ damage and require blood-pressure reduction within one hour.4 , 16 Urgent hypertension, characterized by a severe or accelerated elevation in blood pressure that should be treated within several hours,4 may often be treated in the emergency room with fast-acting drugs, without hospital admission.17 18 19 20 An earlier retrospective study of patients with hypertensive emergencies found that hypertension had previously been diagnosed in more than 90 percent,21 suggesting that hypertensive emergency is almost entirely preventable and that correctable barriers to its prevention may exist. Specific hypotheses suggested in that study were that the lack of medical insurance, the lack of a primary care physician, noncompliance with an antihypertensive drug regimen, and alcohol abuse or the use of illicit drugs may be predisposing factors for hypertensive emergencies and urgent hypertension. We report here the results of a case–control study conducted to test these hypotheses.
Methods
Setting and Subjects
The study was conducted between October 1989 and June 1991 at the Presbyterian Hospital and Harlem Hospital Center in New York. The case patients presented to or were admitted from the emergency room at one of these two hospitals with malignant hypertension (codes 401.0, 402.00, 402.01, 403.0, 404.0, 405.0, and 405.01 of the International Classification of Diseases, 9th revision [ICD-9]22), hypertensive encephalopathy (ICD-9 code 437.2), hypertensive emergency, or severe, uncontrolled hypertension. The control patients had hypertension as indicated by current drug treatment for hypertension or a history of hypertension; these patients presented to or were admitted from the emergency room at Presbyterian Hospital or Harlem Hospital with acute conditions not known to be related to the hypothesized risk factors for severe, uncontrolled hypertension. Examples of such conditions were gastroenteritis, muscle spasm, allergy, backache, hernia, and otitis media. Patients were excluded from the control group if they had previously been admitted for hypertensive emergency, malignant hypertension, or severe, uncontrolled hypertension. Patients were excluded from both the case and control groups if they were admitted for acute myocardial infarction, acute pulmonary edema, aortic dissection, stroke, or renal failure, if they were under 21 years of age, or if they were pregnant.
Eligible subjects were identified each day from admission logs in the emergency rooms and the medical and surgical services at the two hospitals. Five eligible case patients and six eligible control patients declined to participate in the study. There were no patients whose physicians refused permission for the research assistants to screen and attempt to enroll the patient. Altogether, 94 potential case patients and 116 potential controls were interviewed. We excluded three subjects who were not black or Hispanic from the analysis (one white case patient, one white control patient, and one Native American control patient). One French-speaking Haitian black case patient was not excluded, since the research assistant spoke fluent French. Thus, data on 93 case patients and 114 controls were analyzed. A computerized search of all discharges from the Presbyterian Hospital during the study period, using the ICD-9 codes used to define cases, showed that all eligible case patients had been identified and enrolled.
Data Collection
Data were collected by trained research assistants in structured interviews with patients and with use of chart-abstraction forms. Interview forms were available in Spanish and English; the research assistant at the Presbyterian Hospital, where all the Hispanic patients were seen, was bilingual. All interview data were obtained in the patient's preferred language at the time of the visit to the emergency room or during the hospital admission. This study was approved by the institutional review boards of Columbia–Presbyterian Medical Center and the Harlem Hospital Center, and informed consent was obtained from all patients.
Measurements
The blood pressure on admission was defined as the first blood pressure recorded on the emergency room chart. The Keith—Wagener—Barker grade of hypertensive retinopathy,23 the presence of new microscopic hematuria (three or more red cells per high-power field), the presence of encephalopathy attributed to hypertension (indicated by an altered level of consciousness or clouding of the sensorium), and the presence or absence of exclusionary criteria were ascertained by review of the patients' charts. For control patients, the diagnoses recorded in the emergency room or on admission and the presence or absence of hypertension were ascertained by review of the charts. Information on demographic variables, educational level, employment, marital status, use of health services, cigarette-smoking habits, previous diagnosis and treatment of hypertension, and use or abuse of alcohol and illicit drugs was obtained in the interview.
For the 81 patients who reported consuming any alcohol in the previous year, the number of alcohol-related problems during that period was ascertained with use of 41 questions from the 1988 Health Interview Survey. Complete data were obtained from 78 patients. Acceptable detection rates for these questions have been reported.24 We assumed that patients who reported no alcohol consumption during the previous year had no problems related to alcohol. The interview also included questions on the use of several categories of illicit drugs (marijuana, cocaine, "crack" cocaine, heroin, methadone, and "other drugs") during the previous year.
Adherence to the prescribed regimen of blood-pressure medication was assessed with a five-item compliance scale derived from the four-item scale developed by Morisky et al.25 On the basis of preliminary studies in the population we were studying, we made minor changes in the wording of the four yes—no questions in the scale of Morisky et al. The revised versions read as follows: Do you ever forget to take your high-blood-pressure pills? Are you ever careless in taking your pills? Do you ever miss taking your pills when you are feeling better? Do you ever miss taking any of your pills because you are feeling sick? We also added a fifth question: Do you ever miss taking your high-blood-pressure medication for any reason? This scale was scored by assigning one point to each positive response, so that a higher score indicated a lower level of compliance. Cronbach's coefficient alpha,26 a measure of the internal consistency of the scale, was 0.71 for the 202 patients who provided complete data for all five items. Morisky et al. reported that Cronbach's alpha was 0.61 for their four-item scale.25
Statistical Analysis
Bivariate associations were tested with use of the chi-square statistic for categorical data and the t-test for continuous data. The use of a continuity correction for tables with fewer than five subjects in the smallest cell did not materially affect the odds ratio or the test statistic, and the results are reported without this correction. Multiple logistic-regression models were used to calculate adjusted regression coefficients. In these models, age was coded as a continuous variable, and sex, race or ethnic group (black or Hispanic), educational level (less than high-school graduation vs. high-school graduation or equivalency or more), current smoking, one or more alcohol-related problems, and use of illicit drugs in the past year were coded as dichotomous variables. Odds ratios and confidence intervals were calculated from these adjusted regression coefficients.27 In order to simplify the interpretation of the results, all these control variables were retained in all the multiple logistic-regression models, even though in some models the coefficients were not materially affected by the removal of one or more of the control variables. Adjustment for additional variables, including employment, marital status, and site of data collection (Presbyterian Hospital vs. Harlem Hospital) did not materially affect the odds ratios in any model we examined, and these variables were not included in the final models. Additional multiple logistic-regression analyses were performed to test the independence of the three main independent variables examined — namely, whether the patient had any medical insurance, whether the patient had a primary care physician, and the score for compliance with the antihypertensive drug regimen on the five-point scale — by adjusting each for the other two. Logistic-regression analyses were performed with SAS/PC software.28 Other analyses were performed with SPSS/PC +.29 All reported P values are two-tailed.
Results
At the time of the visit to the emergency room, the 93 case patients had severely elevated blood pressure (mean, 222/141 mm Hg) (Table 1Table 1
Clinical Characteristics of 93 Case Patients with Severe, Uncontrolled Hypertension.), and 30 case patients (32 percent) had clinical evidence of acute end-organ damage manifested by hypertensive encephalopathy, grade III or grade IV retinopathy, or new microscopic hematuria. Ninety-one of the case patients (98 percent) reported that they had previously been given a diagnosis of hypertension and had previously been treated for this condition. Case patients who were admitted to the hospital did not differ from those who were treated in the emergency room and released in terms of mean systolic blood pressure, mean age, or the proportion who were male. The mean diastolic blood pressure was somewhat higher among the case patients who were admitted than among those who were treated and released (144 mm Hg vs. 137 mm Hg), and the case patients who were admitted were more likely to be black, reflecting the higher proportion of patients admitted at Harlem Hospital Center, where the patient population was predominantly black, than at Presbyterian Hospital, where the patient population included more Hispanics.The case and control patients were similar with regard to education and place of interview; case patients were younger and were more likely to be male, black, employed, and married (Table 2Table 2
Selected Characteristics of Case Patients and Controls.). In bivariate analyses, the lack of a primary care physician, the lack of medical insurance, the presence of one or more alcohol-related problems, and illicit drug use were associated with severe, uncontrolled hypertension (Table 3Table 3
Bivariate Odds Ratios for Severe, Uncontrolled Hypertension among Case Patients and Controls, According to Various Characteristics.*). The mean score on the compliance scale was 2.3±1.3 for case patients, as compared with 1.1±1.2 for controls (t = 6.78, 200 df; P<0.001).In multivariate analyses, the lack of a primary care physician, the lack of medical insurance, and noncompliance with the antihypertensive regimen were significantly associated with severe, uncontrolled hypertension after adjustment for age, sex, race or ethnic group, educational level, and current smoking (Table 4Table 4
Adjusted Odds Ratios for Severe, Uncontrolled Hypertension According to Various Risk Factors.*). The occurrence of one or more alcohol-related problems and illicit drug use in the previous year was no longer significant after adjustment for these covariates, although the adjusted odds ratio for one or more alcohol-related problems was of the same order of magnitude as that for noncompliance with the drug regimen.The magnitude of the odds ratios for the lack of a primary care physician, the lack of medical insurance, and noncompliance with the drug regimen remained approximately the same after further adjustment for one or more alcohol-related problems and illicit drug use in the previous year. Additional adjustment of each of these three variables for the other two showed significant independent associations between severe, uncontrolled hypertension and both lack of a primary care physician and noncompliance with the antihypertensive regimen (Table 5Table 5
Adjusted Odds Ratios for Severe, Uncontrolled Hypertension According to Various Risk Factors.*). Lack of medical insurance was marginally associated with severe hypertension. The magnitude of the odds ratios was minimally changed by this additional adjustment.Analyses were also conducted in which patients with Medicaid insurance only (n = 56) were classified as uninsured, to test whether such patients were effectively uninsured because of physicians' reluctance to treat patients covered by Medicaid, but the odds ratios for lack of medical insurance combined with Medicaid coverage, as compared with all other insurance, were smaller than when the original classification scheme was used, indicating that Medicaid patients were best classified as insured. The results of subgroup analyses in which the case patients who were admitted and those who were treated in the emergency room and released were compared separately with the whole control group were consistent with the findings of the main analyses.
The lack of a primary care physician was associated with a greater likelihood that a patient would usually have blood-pressure checks performed in an emergency room (odds ratio, 10.5; 95 percent confidence interval, 3.7 to 29.4), that he or she would not have regular blood-pressure checks (odds ratio, 12.1; 95 percent confidence interval, 6.1 to 24.1), and that he or she would not have had a blood-pressure check within six months of admission or the index visit to the emergency room (odds ratio, 9.1; 95 percent confidence interval, 3.5 to 24.0). No patient who had a primary care physician reported receiving prescriptions for antihypertensive medications in the emergency room, whereas 20 of the 70 patients without a primary care physician (29 percent) did receive such medication there. The lack of medical insurance was associated with not having a primary care physician (odds ratio, 2.7; 95 percent confidence interval, 1.4 to 5.1), not having regular blood-pressure checks (odds ratio, 2.9; 95 percent confidence interval, 1.5 to 5.6), and not having had a blood-pressure check within six months of admission or the index visit to the emergency room (odds ratio, 2.7; 95 percent confidence interval, 1.2 to 6.1).
Discussion
During the 21 months of data collection at two hospitals, all but 1 of the 93 case patients with severe, uncontrolled hypertension, as defined in this study, were either black or Hispanic. At Harlem Hospital Center, this racial and ethnic distribution is explained by the fact that the population served by the hospital is almost entirely black. A different explanation is required for the case patients enrolled at the Presbyterian Hospital, where the population served includes a large number of white and privately insured referral patients. No cases of severe, uncontrolled hypertension were identified among these patients. A similar observation was made in an earlier study of hypertensive emergencies at the Presbyterian Hospital during the 1980s.21 The overcrowding of inner-city emergency rooms30 31 32 has led many physicians to avoid or bypass the emergency room in caring for their privately insured patients. Thus, we could not estimate the magnitude of the effects of race and socioeconomic status as risk factors from our data, which were obtained by enrolling patients either seen in the emergency room and released or admitted from the emergency room. Nonetheless, the racial and ethnic composition of the group of case patients in this study and in our earlier study21 indicates that severe, uncontrolled hypertension occurs more frequently among blacks and Hispanics than among non-Hispanic whites and that severe, uncontrolled hypertension is strongly linked to socioeconomic status.
This study confirms our earlier finding21 that almost all cases of hypertension had previously been diagnosed and treated. Thus, the failure to detect hypertension, to make patients aware that they have hypertension, or to initiate treatment does not seem to have been a major contributor to the occurrence of severe, uncontrolled hypertension in this population.
The lack of a primary care physician was the strongest predictor of severe hypertension. The lack of health care insurance was also a risk factor, suggesting that financial barriers to care contribute to the poor control of hypertension. This finding is consistent with data from the Rand Health Insurance Experiment, which showed that hypertensive patients randomly assigned to free care had lower mean blood pressures than those randomly assigned to health care plans that entailed cost sharing, a difference that was greatest among low-income persons with hypertension.14
Compliance with treatment has been widely recognized as a key issue in achieving blood-pressure control.33 We found that noncompliance with an antihypertensive regimen was strongly associated with severe, uncontrolled hypertension. Several factors have been identified as obstacles to compliance with antihypertensive treatment, including the cost of medications34 , 35 and dosing frequency.36 Another factor contributing to noncompliance and the resulting poorly controlled hypertension may be a lack of knowledge about blood pressure. Data from a 1989 survey indicate that higher educational attainment is associated with knowing one's own blood pressure and with knowing that a "good" blood pressure is 140/90 mm Hg or less.37 That study also found that blacks and Hispanics were less likely than whites to know their own blood pressures or to know what constitutes a "good" blood pressure, even after adjustment for educational attainment.
It is possible that our findings may not pertain to persons with hypertension who live under different circumstances. In particular, rural populations may face different barriers to blood-pressure control than the urban population we studied. However, large numbers of blacks and Hispanics with hypertension live in inner cities in the United States, and our findings are likely to apply to them.
The hypertension-control strategy followed by the U.S. Public Health Service in concert with state and local health agencies focuses on increasing knowledge of high blood pressure and its consequences, encouraging the adoption of behavior conducive to blood-pressure control, and implementing systems to improve surveillance and control.38 Our data support the recognition that a key variable is compliance with antihypertensive treatment. Our findings also emphasize the potential importance of changes in the health care system to address the inadequacy of emergency rooms for the treatment of chronic conditions and to increase access to physicians who provide primary or long-term care for hypertension.39 Our findings also point to the importance of health insurance as a means of providing such access to health care, especially for poor and minority population groups.
Supported by a grant (RO1-HL38260) from the National Heart. Lung, and Blood Institute (to Dr. Shea).
We are indebted to Dr. Deborah Hasin for her assistance in designing the sections of the interview dealing with alcohol and illicit drug abuse, to Dr. Bruce Levin for statistical advice, to Drs. Benjamin Okonta and Haydee Rondon for their assistance in data collection, and to Drs. Nancy M. Bennett, Lee Goldman, Jennifer L. Kelsey, and Katherine G. Nickerson for their comments on the manuscript.
Source Information
From the Department of Medicine, Division of General Medicine. Columbia University College of Physicians and Surgeons (S.S.), the Division of Epidemiology. Columbia University School of Public Health (S.S., D.M.), and the Department of Medicine, Harlem Hospital Center (M.H.E., L.F., C.K.F.), all in New York. Address reprint requests to Dr. Shea at Atchley Pavilion 1310, 161 Fort Washington Ave., New York, NY 10032.
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