Kaiser says it halved the hypertension gap between blacks and whites over a decade — but how?

More African American men and women suffer from hypertension than any other ethnic group in the U.S. — and many of them don’t even know it. Defined as a systolic blood-pressure reading of greater than 120, hypertension presents few or no symptoms. But it kills, all the same. High circulatory tension “was the leading cause of death and disability-adjusted life-years worldwide,” according to the American College of Cardiology. It can lead to strokes and heart disease, blindness and even kidney failure. 

In most people, hypertension can be controlled — sometimes with diet and exercise, other times with medication. But African Americans are significantly less likely than whites to have their hypertension controlled. Data from the 2016 National Health and Nutrition Examination Survey found that only 44 percent of African Americans have controlled hypertension, compared to slightly more than half of whites with the same disease. That means African Americans are up to six times more likely than whites to suffer a fatal stroke, and five times more likely to develop kidney disease. 

That disparity has persisted for decades and proven stubbornly difficult to fix, said Michael H. Kanter, executive vice president of the Permanente Federation, Kaiser Permanente’s policy arm, in Oakland, California. But there are bright spots: A 2014 study of elderly enrollees in Medicare Advantage found the racial gap had been virtually erased in Kaiser health plans in the West, where the bulk of Kaiser enrollees reside. Kaiser Permanente had also, by 2011, eliminated disparities between African Americans and whites in controlling levels of LDL cholesterol and glycated hemoglobin, a diagnostic marker of diabetes. More recent data collected on Kaiser Permanente’s national care network by the Centers for Medicare and Medicaid Services showed that the gap in hypertension control between African Americans and whites decreased by 58% from 2009 to 2017 — from 5.3% to 2.2%. 

So what explains Kaiser’s success in narrowing the gap? Kaiser is known for its integrated health care model, in which hospitals and the health insurance plan are part of a single entity and collaborate on patient care. But in a recent talk at USC’s Gehr Family Center for Health Systems Science, Kanter said that model doesn’t completely explain Kaiser’s success with hypertension: Hypertension control among Kaiser patients went from 54 percent in 2004 to 89 percent in 2014, he said, without any change to Kaiser’s basic structure. “Integration is a step,” he said. “But it’s not the basic lever to pull. We had integration 30 years ago and had different care.”

Instead, Kanter said, medical professionals wanting to close racial disparities in health care might look at how Kaiser Permanente Southern California has addressed inefficiencies in its system over the past 15 years. Recognizing that patients with multiple chronic conditions were getting piecemeal treatment from departments that weren’t communicating, the network’s regional leaders developed a team-based approach to care, in which clinic staff systematically monitor a patient. “When people come into the office, regardless of where they go, certain elements of care they need get addressed,” Kanter explained. “You have a checklist of care elements that get addressed at every visit. It’s systematic, and those care elements don’t vary based on race or ethnicity. I think that leaves less room for unconscious bias” in treatment.

But that’s not the whole answer, Kanter said. Outreach and education matter, too. Sometimes people stop taking medications, for instance, because they don’t understand the progression of the disease, or because their physician didn’t take the time to warn them about the side effects. In those cases, nurses and pharmacists can deliver the necessary education. African Americans — particularly older patients on Medicare — may not keep appointments because they’re uncomfortable with the online portals that have become increasingly common in coordinating patient care. Clinic staff can reassure patients that the portal won’t violate their privacy or walk them through technical obstacles.

“With African Americans, there is a trust issue based on historical things that have been done to them that never should have happened,” Kanter said. To regain that trust, medical professionals have to start “investing in the beginning of the relationship” — to reach out to people where they are, instead of waiting for them to come in for a visit, and to follow up after a visit. The care team assigned to a given patient proactively helps with all of that.

“Sometimes all the outreach and education in the world can’t budge people,” Kanter said. “But that doesn’t mean you tolerate the disparity. We need to work on trust with patients so they understand what we’re doing.”

With hundreds of quality measures and dozens of racial and cultural categories — and, in California, languages — it’s not possible to fix everything — or even to know exactly what worked in a given instance. “We did a ton of stuff,” Kanter said. “It’s hard to know what was causative in reducing racial disparities, because we didn’t have a control group to compare ourselves to.”

But he advises other institutions and health care professionals to carefully document differences in health care outcomes and never stop trying to resolve them. “Don’t let inertia get in the way and wait for somebody else to fix the problem,” he said. “We all need to look at what we can do ourselves.”