Introduction
This study investigates the disparities in blood pressure control in elderly Hispanic patients and non-Hispanic white patients using the PICO(T) framework. PICO(T) is a mnemonic for patient, in this case, the Hispanic elderly with hypertension. I is for intervention, in this case, it is the homebound, C is for comparison, O is for outcome, and T is for time. The following PICO (T) question has been formulated to guide the study.
PICOT question
As reported by providers, are Hispanic elderly patients (P) who are homebound (I) compliant with blood pressure medication adherence (O) as compared to elderly homebound patients (P) who are of American background (C) for two months (T)?
Description of Practice Problem
The United States healthcare system has continued to experience significant criticism for healthcare disparities between the dominant white and non-dominant marginalized races. Existing statistical evidence from research indicates significant variations in knowledge, attitude, self-care, and self-management of hypertension as reported in Aggarwal et al. (2021). Even though there is a higher prevalence of hypertension in Hispanic adults compared to their white counterparts, Aggarwal et al. (2021) found a low level of awareness among the Hispanic adults compared to white Americans at 71% versus 79.1%. The differences in awareness and prevalence rates can be used to inform public efforts and interventions aimed at reducing the inequality gap between the elderly Hispanic and white patients when addressing medication adherence and self-care.
The cost of BP control on individuals, families, and the healthcare system cannot be underscored. According to Aggarwal et al. (2021), the United States spends >$51.2 billion annually. Hypertension is also the leading cause of mortality in marginalized groups, and it deprives the country of an energetic workforce. The prevalence of HTN in the Hispanic population affects individuals and families, especially when breadwinners succumb to the disease. Scholars have started emphasizing the need for blood pressure (BP) control in minority races and ethnic groups, as evidence points out that a significant population in marginalized groups has poor BP awareness, control, and response to treatment (Lora et al., 2020).
A growing body of literature has often found variations in response to treatment, awareness, and health outcomes when samples of marginalized groups are compared with the dominant white race in the United States. The advantage of identifying the weakness where BP control fails is that it enables policymakers and other stakeholders to channel resources towards the problem to yield a positive impact. The present study surveys key gaps in compliance with BP control, with an intention to discover the drivers for disparities observed in the population of non-white Hispanics and their white American counterparts living in the United States. It is anticipated that knowledge obtained from this literature survey will inform the policy-making process regarding the burden of HTN and BP control in racial and ethnic minorities.
Statistical Relevance of the Article
According to research, high blood pressure can cause cardiovascular diseases, stroke, renal failure, and even death for some patients. Statistically, Lora et al. (2020) found a direct correlation between the prevalence, awareness, and response to treatment of hypertension in patients diagnosed with chronic kidney disease (CKD). Blood pressure medication adherence helps keep the heart, nervous system, and kidneys healthy if people take it and maintain their blood pressure under control (Lauder et al., 2020).
Disparities in awareness, knowledge, and self-care about blood pressure affect the quality of life and healthcare outcomes in Hispanic and non-Hispanic White Americans. Studies from Hardy et al. (2021) confirm that at least 25 percent of seniors 65 and older with Medicare Part D prescription drug coverage do not take their blood pressure medication as prescribed. This implies they may skip dosages or discontinue use entirely, leading to adverse health outcomes in the Hispanic population. Healthcare systems, which include clinicians, pharmacies, hospitals, community health workers, and insurance companies, can collaborate with patients to make medication administration more convenient (Hedima et al., 2021). The approach should identify barriers to low uptake, such as literacy levels and attitudes, and systematic barriers such as racism in mainstream healthcare systems that could predict low uptake of services.
Annotated Bibliography
Lora, C. M., Ricardo, A. C., Chen, J., Franceschini, N., Kramer, H. J., Melamed, M. L.,… & Lash, J. P. (2020). Prevalence, awareness, and treatment of hypertension in Hispanics/Latinos with CKD in the Hispanic Community Health Study/Study of Latinos. Kidney Medicine, 2(3), 332-340.
Summary
Lora et al. (2020) carried out a cross-sectional cohort study to investigate the impact of awareness, attitude, and rates of prevalence of hypertension in Hispanic Americans in comparison to non-Hispanic white Americans. The researchers used the National Health and Nutrition Examination Survey. The study found that Hispanics living in the United States have lower BP control compared to their white counterparts. According to this source, the Hispanic population has less control over their blood pressure than the American population. Very little is documented regarding whether this racial disparity persists in later life or the variables that lead to it.
Statistical Component Found
Statistically, Lora et al. (2020) confirmed the difference in BP control between the Hispanic and non-Hispanic whites at 30.6% for the Hispanic and % and 48.6% for non-Hispanic whites. The study also reported statistical differences in awareness and prevalence rates, where the prevalence was 78.1% for Hispanics, compared to 70% for non-Hispanic whites. In older people, these authors claim that the incidence of hypertension goes to more than 60 percent, and it is greater in middle-aged and more aging Hispanic populations than in Americans. Despite large-scale clinical research demonstrating that controlling high blood pressure decreases the risk of catastrophic cardiovascular disease outcomes, a considerable proportion of hypertensive Hispanic individuals do not achieve blood pressure management. At the same time, a significant population of elderly patients does not have healthcare insurance coverage (Lora et al., 2020).
Furthermore, the Hispanic population has worse blood pressure management than other racial/ethnic groupings. Disparities in access to healthcare services have contributed to these racial disparities. BP control is affected by various factors such as knowledge, attitude, and systematic barriers such as discrimination within the healthcare system. Scholars have also cited the issue of insurance coverage as a barrier, where the population of insured white Americans is higher than that of insured Hispanic Americans, as observed in the study by Lora et al. (2020).
Strengths and Weaknesses
This presents significant insights that can be used to inform policy changes in addressing the gaps that exist between Hispanic and non-Hispanic elderly people living in the United States. The authors also collected a large representative sample encompassing Hispanic people living in the United States. Because of these features, the study by Lora et al. (2020) can be replicated or applied to the larger population in the United States.
However, weaknesses associated with self-reported data and using a single measurement could have created room for bias. The authors of this study used a cross-sectional survey of Chicago’s Hispanic and American populations. The samples were based on self-reported high blood pressure awareness and management findings.
Potential Importance and Usefulness to the Research Project
The study by Lora et al. (2020) has revealed some of the areas that can be addressed when intervening to close the gap in poor health outcomes between the Hispanic and non-Hispanic whites in the US. Considering that older white persons have more access to healthcare services and medication compared to older Hispanics, the factors contributing to blood pressure management discrepancies differ between the two races. SES, specific educational attainment and income variations, has been demonstrated to account for additional racial inequities in health and health care. Both education and income had minimal influence on racial disparities in blood pressure management in their sample, indicating that socioeconomic variables explain very little of the racial disparities in blood pressure control seen in older persons.
Other factors must be considered to explain reported disparities in blood pressure management by race. Lora et al. (2020) discovered that Hispanics had higher rates of medication noncompliance, prevalence rates in hypertension, and poor health outcomes than whites and offered these characteristics as a potential reason for racial variations in blood pressure management. Variations in medication compliance might also have a role. The authors also explained the role of healthcare insurance coverage as a predictive factor for variation in compliance and health outcomes.
Still, C. H., Rodriguez, C. J., Wright Jr, J. T., Craven, T. E., Bress, A. P., Chertow, G. M.,… & SPRINT Writing Group. (2018). Clinical outcomes by race and ethnicity in the Systolic Blood Pressure Intervention Trial (SPRINT): A randomized clinical trial. American Journal of Hypertension, 31(1), 97-107.
Summary
According to Still et al. (2018), race and ethnic disparities in cardiovascular disease (CVD) continue to be a serious public health problem in the United States. Among the most significant modifiable cardiovascular disease risk factors contributing to coronary heart disease, dementia, end-stage kidney problems, and overall mortality is high blood pressure. In this source, non-Hispanic Black (NHB) and Hispanic people had higher rates of uncontrolled high blood pressure than non-Hispanic Whites (NHWs), and NHBs are already at higher risk of high blood pressure-related CVD morbidity and death.
Furthermore, it was reported that NHBs have higher CVD age-adjusted mortality rates than the general US population. Still et al. (2018) also reported that the age-adjusted death rates for individuals aged 25 and older due to high blood pressure are 127.2 vs. 135.9 per 100,000 inhabitants for Hispanics vs. NHWs, respectively, despite significant variation in CVD risk in Hispanics depending on their country of origin. Such discrepancies are predicted to cost the US healthcare system $49 billion yearly (Still et al., 2018). As a result, blood pressure management measures to prevent CVD mortality and morbidity among minority racial and ethnic groups are critical at both the individual and population levels.
Statistical Component Found
Racial and treatment groups in each race/ethnicity strata derived descriptive statistics of categorical variables. A 1-way Way analysis of variance with bilateral contrasts was used for continuous data, while categorical variables were compared using independent chi-square tests (Still et al., 2018). To adjust for within-subject connection, the mean and SE of follow-up SBP were calculated by race/ethnicity and treatment group by applying mixed linear regression models with uncontrolled variance-covariance (Still et al., 2018). The impact of the treatment arm task on time to the first event within the race/ethnicity stratum was investigated using an intention-to-treat strategy with invariable Cox proportional-hazards regression models for the treatment arm task with 2-sided tests at the 5 percent level of statistical significance and extreme inequality by the treatment center.
The likelihood-ratio tests and Hommel’s approach to correct for multiple comparison tests were used to analyze two-way correlations between treatment impact and race/ethnicity groups. Since the report’s subgroup classifications differ from the predeļ¬ned race segment of Blacks vs. non-Blacks, outcome statistics for the prespecified race subcategories were supplied in the Appendices section. SAS version 9.4 software was used for all analyses (Still et al., 2018). After a suggestion by the trial’s independent DSMB, the National Heart, Lung, and Blood Institute (NHLBI) Director discontinued the SPRINT BP intervention on August 20, 2015, after a mean follow-up of 3.26 years; each participant’s follow-up was censored at the date of the last assessment for a study event before August 21, 2015. This paper is based on a frozen dataset on September 16, 2016, and covers outcome occurrences from baseline to the trial intervention’s conclusion on August 21, 2015.
Strengths and Weaknesses
SPRINT’s merits include its substantial sample size, diversified patient population, and effectiveness in executing the proper procedure and meeting the SBP objectives. It also included the difference in SBP between the two interventional categories throughout the trial, especially in Americans and Hispanics. SPRINT was not designed to particularly assess the therapeutic efficacy of the lower SBP objective in these subgroups. Nonetheless, their analysis confirms the advantages of aggressive BP reduction on the primary outcome endpoint, consistent across various race groups. The baseline features and cardiovascular risk profile of the American and Hispanic communities in SPRINT were not substantially greater than those of NHWs in SPRINT, which is not representative of that seen in the total population.
However, SPRINT’s evaluation of ethnic background and race was based on self-identification, which has limits. The American NBC and Hispanics are admixed groups, and the US definition of race as just White or Black is considered confusing, which could have resulted in significant misclassification when attempting to differentiate between them. Lastly, the tiny Hispanic sample size prevented direct comparison, rendering the Hispanic analysis weak and potentially unstable.
Potential Importance and Usefulness of the Research Project
The potential importance of SPRINT findings is significant to the research project. Given the prevalence of high blood pressure and unmanaged hypertension within NHBs and Hispanic populations, intense SBP reduction is likely to have higher consequences for public health in these groups. Importantly, obtaining lower SBP objectives in NHB will necessitate additional antihypertensive medication. Still et al.’s (2018) findings point out important noteworthy conclusions. The authors show that most people over 50 with a significantly greater cardiovascular risk level benefit from treatment with an SBP goal of 120 mm Hg, regardless of race or ethnicity.
Hardy, S. T., Chen, L., Cherrington, A. L., Moise, N., Jaeger, B. C., Foti, K.,… & Muntner, P. (2021). Racial and ethnic differences in blood pressure among US adults, 1999ā2018. Hypertension, 78(6), 1730-1741.
Summary
In the United States, the incidence of hypertension is greater among Black Hispanics than among their American counterparts, but it is lower among Asian and Hispanic individuals (Hardy et al., 2021). Non-Hispanic Black and Asian people with hypertension using antihypertensive medication are much less prone to having regulated blood pressure than non-Hispanic White adults. This is based on the evidence from the 2015 to 2018 National Health and Nutrition Examination Survey. Disparities in the incidence of hypertension and blood pressure management are thought to be the most critical contribution to the higher risk of cardiovascular disease in Black adults vs. White individuals.
Statistical Component Found
In this source, the researcher identified some statistical components that will be discussed below. To begin, white Americans and Hispanic individuals who did not use blood pressure medication were a little more likely to be 18 to 44 years old, obese, have a household income of approximately $20,000, and be uninsured than their non-Hispanic counterparts. Hispanic individuals were more likely than non-Hispanic White adults to be uninsured among adults using antihypertensive medication from both 1999 to 2000 and from 2017 to 2018 (Hardy et al., 2021). From 1999 to 2000, non-Hispanic Black individuals using blood pressure medication were also significantly more likely to be obese but have diabetes than non-Hispanic White adults (Hardy et al., 2021). This historical data is linked to literacy levels that vary between White and non-White Hispanics dwelling in the United States.
Strengths and Weaknesses
Various drawbacks to this study are pretty straightforward. Hardy et al. (2021) used BP measures from a single appointment. However, the 2017 American Heart Association blood pressure guideline suggests average BP values from two or more visits. It confirms office hypertension with an out-of-office BP measure, which NHANES does not provide.
Data for non-Hispanic patients were not available from 2011 to 2012. Hence, the analysis of trends for this group was limited to 8 years, from 2011 to 2018. From 1999 to 2000 to 2017 to 2018, the NHANES response rate decreased (Hardy et al., 2021). On the other hand, weighting correction minimized any possible bias from the different response rates between subgroups.
Potential Importance and Usefulness to the Research Project
Racial and ethnic disparities in blood pressure values in the United States extend below the high blood pressure threshold. There is a graded rise in cardiovascular risk with greater systolic blood pressure (SBP) starting at levels over 100 mm Hg. This thus stresses the need to attain BP equality even below high blood pressure levels to reduce race and ethnic differences in Cardiovascular (Hardy et al., 2021). Determining if BP variations by ethnic group and race have diminished over time may indicate the need for more public health efforts to address cardiovascular disease risk disparities.
The current study sought to assess changes in SBP and diastolic BP levels by racial background among US individuals not taking and taking blood pressure medication between 1999 and 2000 and 2017 and 2018. Furthermore, Hardy et al. (2021) analyzed differences in SBP and DBP between race and ethnicity groups from 2015 to 2018 1999 2002. Their main goal was to see if racial and ethnic gaps had shrunk over the last two decades. Data from 10 US NHANES 2-year cycles were studied to achieve these objectives.
Aggarwal, R., Chiu, N., Wadhera, R. K., Moran, A. E., Raber, I., Shen, C.,… & Kazi, D. S. (2021). Racial/ethnic disparities in hypertension prevalence, awareness, treatment, and control in the United States, 2013 to 2018. Hypertension, 78(6), 1719-1726.
Summary
The primary purpose of this study was to evaluate the measures of prevalence, awareness, treatment, and control of the rates of hypertension (HTN) in different groups of the Hispanic population in the United States. These include the rate of Hypertension consciousness, treatment, and oversight among Hispanics; and HTN-related discrepancies, including disproportionate consequences on Hispanic elderly, women, and adults. The authors used the National Health and Nutrition Examination Survey (NHANES) to measure self-reported demographic data. Differences in outcomes were determined using White Americans as a point of reference.
Statistical Component Found
Data on HTN informs healthcare policymakers to make informed decisions. In the study by Aggarwal et al. (2021), the authors reported that 79.1 % of HTN white patients were aware of their status, and 49.1% had managed to control their BP. This figure varied significantly when compared to the self-reported data from Hispanic individuals, with a prevalence of 31.1%, a low rate of awareness at 31%, treatment at 60.5%, and control of BP at 40%. These variations indicate that the white race is ahead when it comes to management and control of BP compared to the Hispanic race.
Strengths and Weaknesses
The research study provides significant evidence on the prevalence and potential impact of the disparities in HTN and low BP control in Hispanics when compared with the members of the white race. The evidence provided in the article by Aggarwal et al. (2021) answers why high blood pressure exists in specific populations but not others. Despite the strengths presented in this paper, the reliance on survey data renders the study prone to bias. The authors were also unable to account for the impact of non-compliance on non-Hispanic patients because they relied on historical data to present the argument.
Potential Importance and Usefulness of the Research Project
The most updated HTN recommendations are anticipated to highlight growing HTN inequities among Hispanics. These findings show that many treatments and screening discrepancies must always be addressed to lower HTN risk among Hispanics. The evidence in this paper informs the need for addressing disparities while also considering the impact of policy formulation to address the varying needs of marginalized groups. The information presented in this article will be used to boost evidence in the literature review and support other research articles in answering the research question and investigating the PICO(T) question.
Lor, M., Koleck, T. A., Bakken, S., Yoon, S., & Dunn Navarra, A. M. (2019). Association between health literacy and medication adherence among Hispanics with hypertension. Journal of Racial and Ethnic Health Disparities, 6(3), 517-524.
Summary
Poor adherence to recommended blood pressure medication primarily contributes to Hispanics’ poor blood pressure management. This source aimed to examine the relationship between health literacy level and compliance with antihypertensive drugs across Hispanic people who self-reported hypertension while adjusting for possible compliance and health literacy variables. The authors investigated the impact of health literacy on BP control and the prevalence of HTN in a sample of the Hispanic population.
Statistical Component Found
In this study, a cross-sectional study of 1355 Hispanic people, predominantly Dominicans, who self-reported hypertension, was conducted. Adherence to antihypertensive medications and health literacy were assessed using sociodemographic factors, depression, stress, and sleep disruption. Linear regression models were developed for each covariate and compliance. Hierarchical multiple linear regressions incorporated factors reported to be substantially linked with observation in separate regression models at a p-value of 0.20.
Most individuals (88.4%; n = 1026) reported poor compliance with antihypertensive medicines and poor health literacy (84.9%; n = 1151) (Lor et al., 2019). When age, gender, educational status, depression, stress, and sleep disruption were all controlled for, having good health literacy vs poor health literacy was linked with a higher compliance score (b = 0.378, p = 0.043). The whole model explained 13.6 percent of the variance in medication compliance (p-value 0.001), while health literacy’s distinctive contribution to the model was small (R2 change = 0.003) (Lor et al., 2019).
Strengths and Weaknesses
Community members and individuals can have strengths and limits in health literacy, affecting how successfully they interact with health-related services and information. Healthcare services can also have strengths and limitations in how they react to persons with varying levels of health literacy. Lor et al. (2019) used the term ‘health literacy responsiveness’ to represent how health organizations and goods (such as drug labels) make health data and services available to people with varying levels of health literacy. To be ‘health literacy responsive,’ a service must employ practices that assist all individuals regardless of their current level of patient education. Furthermore, they must also recognize the health literacy strengths and limits of the people they intend to serve.
Potential Importance and Usefulness of the Research Project
Tailored therapies that address health literacy are required to enhance the outcomes of Hispanics with hypertension. More research is needed to identify and prioritize aspects of developing customized and successful hypertension adherence programs for Hispanics. Health literacy is a predictive factor for observed disparities in health outcomes between Hispanic and non-Hispanic whites. A significant population of white hypertensive patients understands self-care management, has insurance coverage, and has higher medical compliance compared to non-white Hispanics. Low literacy levels among Hispanics drive the variations in healthcare utilization and response to medical treatments, such as medical compliance.