Home Blood Pressure Monitoring Intervention for Self-Management of High Blood Pressure Among Alaska Native People

Background:

Cardiovascular disease (CVD) and stroke have become leading causes of mortality among ANAI people, who experience CVD disparities in incidence, risk factors, and mortality, especially for stroke, compared to the general population. From 1994-2003 stroke mortality in ANAIs was at least 25% higher than for Whites in Alaska. Over the same period, stroke mortality for ANAIs under age 45 increased 400%, but declined in Whites. In addition, the decline in age-adjusted CVD mortality observed in recent decades within the general population does not extend to ANAIs. Controlling hypertension is a pillar of prevention for CVD and stroke.

Although ANAIs were formerly thought to have a very low prevalence of stroke and CVD, more reliable newer data indicate high levels of hypertension and associated mortality. A recent systematic review of 141 publications on hypertension in ANAI people documented a significant increase in recorded prevalence over the past 3 decades, as well as a significantly higher prevalence in ANAI adults than in reference populations, usually White. Aggregated data from the Behavioral Risk Factor Surveillance System (BRFSS) also show a higher prevalence of self-reported hypertension in ANAIs than in non-Hispanic Whites (27% vs. 22%). The National Health Interview Survey found a similar disparity of 35% vs 26% in ANAIs vs. Whites. As in non-Hispanic Whites, 61% of ANAIs with hypertension were taking anti-hypertensive medication. In a previous study, an investigator on the present proposal examined the health records of 524 ANAI elders, finding that 23% had undiagnosed hypertension, and 38% had diagnosed hypertension. Of those with diagnoses, 81% were taking medication, 37% had well-controlled blood pressure (BP), and lifestyle counseling was rare.

Ongoing management of high BP often requires healthcare providers to initiate or intensify therapy in response to uncontrolled high BP. A recent review concluded that the patient/provider relationship, patient/provider communication, and patient-centered decision making were essential to appropriate decisions on medication change. Another study using electronic health record (EHR) data on military veterans found that ~60% of patients with hypertension had poorly controlled systolic BP, yet less than half of clinicians made medication changes after a computer-generated notification.

Improving BP control requires the involvement not only of individuals but of healthcare systems and social environments. Communications must extend care to patients "where patients are" outside the clinic; facilitate BP self-management; and minimize barriers to care AN/AIs face in healthcare access. Across Alaska, 60% of residents are medically underserved, and in 75% of Alaskan communities, regardless of residents' race, comprehensive healthcare services are accessible only by air or water. Even in urban areas, health disparities among AN/AIs persist, and access to care is affected by factors such as lack of transportation.