Inequities in hypertension management: observational cross-sectional study in North East London using electronic health records

Abstract

Background: Hypertension is a key modifiable risk factor for cardiovascular disease - the leading cause of death in the UK. Good blood pressure (BP) control reduces mortality. However, health inequities may lead to variability in hypertension monitoring and control.

Aim: To investigate health inequities related to ethnicity, sex, age, and socioeconomic status in the monitoring, treatment, and control of BP in a large cohort of adult patients with hypertension.

Design and setting: A cross-sectional cohort study of adults with hypertension registered with general practices in North East London on 1 April 2019.

Method: Multivariable logistic regression was used to estimate associations of demographics and treatment intensity for the following hypertension management indicators: a) BP recording in past 12 months; b) BP on age- adjusted target; and c) BP on age-adjusted target and BP recorded in past 12 months.

Results: In total, 156 296 adults were included. The Black ethnicity group was less likely to have controlled BP than the White ethnicity group (odds ratio [OR] 0.87, 95% [confidence interval] CI = 0.84 to 0.91). The Asian ethnicity group was more likely to have controlled BP (OR 1.28, 95% CI = 1.23 to 1.32). Ethnicity differences in control could not be explained by the likelihood of having a recent BP recording, nor by treatment intensity differences. Older adults (aged ≥50 years) were more likely to have controlled hypertension than younger patients.

Conclusion: Individuals of Black ethnicity and younger people are less likely to have controlled hypertension and may warrant targeted interventions. Possible explanations for these findings are presented but further research is needed about reasons for ethnic differences.

Keywords: antihypertensives; blood pressure; cardiovascular diseases; general practice; health inequities; hypertension.

Figure 1.

Study population flowchart. BP = blood pressure. CCG = clinical commissioning group. DBP = diastolic BP. SBP = systolic BP.

Figure 2.

Forest plots of ORs for a) Blood_Pressure_ Recorded; b) Hypertension_Controlled; and c) Blood_ Pressure_Controlled. The squares plot the OR relative to the reference category and the whisker bars are the 95% CI for the OR. Squares to the left of the vertical line (OR = 1.0) indicate categories in which individuals are less likely to have a blood pressure recorded in the 12 months up to and including the index date (a), or controlled blood pressure (b and c). Squares on the right indicate individuals more likely to have a recorded blood pressure (a), or a controlled blood pressure (b and c). Hypertension_Controlled (b) considers the whole cohort whereas Blood_Pressure_Controlled (c) considers only cohort members with a valid blood pressure recorded in the 12 months up to and including the index date. The ORs for treatment intensity for Blood_Pressure_Recorded are not plotted as they are significantly larger than the other ORs and affect graph clarity (1 medication: 7.83, 95% CI = 7.48 to 8.21; ≥2 medications: 9.99, 95% CI = 9.55 to 10.45; both P<0.001). OR = odds ratio. ref = reference.

Figure 2.

Forest plots of ORs for a) Blood_Pressure_ Recorded; b) Hypertension_Controlled; and c) Blood_ Pressure_Controlled. The squares plot the OR relative to the reference category and the whisker bars are the 95% CI for the OR. Squares to the left of the vertical line (OR = 1.0) indicate categories in which individuals are less likely to have a blood pressure recorded in the 12 months up to and including the index date (a), or controlled blood pressure (b and c). Squares on the right indicate individuals more likely to have a recorded blood pressure (a), or a controlled blood pressure (b and c). Hypertension_Controlled (b) considers the whole cohort whereas Blood_Pressure_Controlled (c) considers only cohort members with a valid blood pressure recorded in the 12 months up to and including the index date. The ORs for treatment intensity for Blood_Pressure_Recorded are not plotted as they are significantly larger than the other ORs and affect graph clarity (1 medication: 7.83, 95% CI = 7.48 to 8.21; ≥2 medications: 9.99, 95% CI = 9.55 to 10.45; both P<0.001). OR = odds ratio. ref = reference.

Figure 3.

ORs (Blood_Pressure_Controlled) by ethnicity for patients on 0, 1, and ≥2 antihypertensive medications. OR = odds ratio. ref = reference.