Variations in physicians' advice for managing hypertension in women: A study using NHANES III
Introduction
Hypertension affects one in three adults (Fields et al., 2004). As a major risk factor for stroke and congestive heart failure, controlling hypertension is a priority (Thom et al., 2006). Hypertension control rates, however, are significantly less than the Healthy People 2010 goal of blood pressure control in at least 50% of hypertensive Americans (Hajjar and Kotchen, 2003, Lenfant, 2002). Lifestyle modification can improve control rates; dietary changes, physical activity, and weight loss, reduces blood pressure, prevents or delays its development, and augments the efficacy of prescribed medications (Chobanian et al., 2003).
Physicians can play an important role in helping patients engage in healthy behaviors. Patients advised by physicians to modify behavior are more confident and motivated and may be more successful (Bull and Jamrozik, 1998, Galuska et al., 1999, Huang et al., 2004, Kreuter et al., 2000, Ossip-Klein et al., 2000). Physicians, however, do not routinely advise their patients to make behavior changes (Burt et al., 1995, Kravitz et al., 1993, Yusuf et al., 1996). Among patients with uncontrolled hypertension, in only 47% of office visits did physicians recommend lifestyle changes (Oliveria et al., 2002). Among women with persistent elevated blood pressure, only 37% had physicians recommend or implement therapy or a lifestyle change to better manage their hypertension (Asch et al., 2001).
Little is known about the factors that influence physician advice-giving to hypertensive patients. In one study, exercise and nutrition counseling varied by age, race/ethnicity, number of cardiovascular comorbidities, and type of comorbidity (Mellen et al., 2004). In the general population, physician advice-giving varies by the patient's age, race, gender, education, insurance status, income, health status, health behaviors, and geographical location (Damush et al., 1999, Doescher and Saver, 2000, Honda, 2004, Ossip-Klein et al., 2000, Sciamanna et al., 2000). For example, physicians were more likely to discuss diet and exercise with high income patients whereas smoking was more likely to be discussed with low income patients (Taira et al., 1997).
The variability in physician advice-giving as a function of extraneous factors suggests disparities in quality of care. Although the Institutes of Medicine report indicated racial/ethnic disparities in the receipt of quality care in cardiovascular disease (Smedley et al., 2003), the extent to which physician advice-giving patterns contribute to disparities in cardiovascular health is relatively unknown. In light of racial disparities in cardiovascular health, including higher hypertension-related morbidity and mortality in Blacks (Thom et al., 2006), the extent to which Blacks receive appropriate guidance to manage hypertension should be examined.
In this novel study, we examine the pattern of physician advice-giving and patient adherence among female White and Black hypertensive patients, across a number of lifestyle behaviors, and independently of the factors often associated with race such as education, geographic region of residence, and income. Recent trends indicating a greater increase in hypertension prevalence in women than men (Hajjar and Kotchen, 2003), greater use of the health care system by women (Bertakis et al., 2000, Mellen et al., 2004), and less improvement in hypertension control rates in women (Hertz et al., 2005) make this an important study population.
Section snippets
Study population
The National Health and Nutrition Examination Survey (NHANES) III was a survey conducted from 1988 to 1994 by the National Center for Health Statistics to collect information about the health status of the United States population. This survey was comprised of multiple sections including adult and youth questionnaires and a medical examination. The adult data set containing 20,050 subjects and the exam data set containing 31,311 subjects were gathered from civilian non-institutionalized
Statistical analysis
Statistical analysis was conducted using SAS (1999) and SUDAAN (2001) versions 8.0. SUDAAN has the ability to properly model the complex, stratified, multistage survey design and sample weights of NHANES III. The sampling weights incorporated the differential probabilities of selection and included adjustment for noncompliance and nonresponse (US Department of Health and Human Services, 1996). We compared demographics, select health behaviors and indicators of health status, blood pressure,
Results
The study sample of 2066 hypertensive women was predominately White (84.4%), from the South (36%), and above poverty level (83.2%). Table 1 compares the characteristics of Black and White women. As seen in Table 2, physician advice for specific behaviors for blood pressure control varied across the overall sample and physicians were more likely to advise Black women to lose/control weight, cut salt intake, exercise more, and take prescribed medication. Regarding patient adherence in response to
Discussion
Our study suggests missed opportunities to enhance the management of hypertension. Consistent with previous research (Anis et al., 2004, Edege, 2003), the frequency of physician advice depended on the type of advice. Barriers to counseling include physician concerns: doubt about patients adhering to recommendations; perception that patients are unwilling to change; and concerns about the efficacy of advising and counseling (Henry et al., 1987, Kushner, 1995, Orleans et al., 1985, Valente et
Conclusion
Blacks have poorer hypertension-related outcomes. Our study suggests, however, that physicians are more likely to dispense guideline adherent advice to Black women who in turn are more likely to adhere to recommendations. Eliminating racial/ethnic health disparities may require consideration of a broader range of factors.
Acknowledgment
We would like to thank Diane Williams at the University of Alabama at Birmingham for her assistance in preparing the document.
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