Achieving Equity in Hypertension: A Review of Current Efforts by the American Heart Association

Abstract

The purpose of this article is to summarize disparities in blood pressure (BP) by race in the US, discuss evidence-based strategies to increase equity in BP, review recent American Heart Association (AHA) BP equity initiatives, and highlight missed opportunities for achieving equity in hypertension. Over 122 million American adults have hypertension, with the highest prevalence among Black Americans. Racial disparities in hypertension and BP control in the US are estimated to be the single largest contributor to the excess risk for cardiovascular disease (CVD) among Black versus White adults. Worsening disparities in CVD and life expectancy during the COVID-19 pandemic warrant an evaluation of the strategies and opportunities to increase equity in BP in the US. Racial disparities in hypertension are largely driven by systemic inequities that limit access to quality education, economic opportunities, neighborhoods, and health care. To address these root causes, recent studies have evaluated evidence-based strategies, including community health workers, digital health interventions, team-based care, and mobile health care to enhance access to health education, screenings, and BP care in Black communities. In 2021, the AHA made a $100 million pledge and 10 commitments to support health equity. This commitment included implementing multifaceted interventions with a focus on hypertension as a seminal risk factor contributing to disparities in CVD mortality and morbidity. The AHA is one organizational example of advocacy for equity in BP. Achieving equity nationwide will require sustained collaboration among individual stakeholders, and public, private, and community organizations to address barriers across multiple socio-ecological levels.

Hypertension is a major modifiable risk factor for cardiovascular disease (CVD) and mortality.¹ Disparities in hypertension prevalence and blood pressure (BP) control by race/ethnicity have persisted for decades and contribute to disparities in CVD and cardiovascular deaths in the US.^2,3 The disproportionately higher prevalence of elevated BP among Black compared to White adults not only exacerbates health care costs through increased utilization of medical services but also contributes to elevated morbidity rates and shortened life expectancy.^4,5 Worsening BP control rates, despite the existence of effective medications and evidence-based guidelines, indicate there are major barriers to adopting science into practice, particularly for those at the highest risk for worsening BP control.⁶ The purpose of this article is to summarize disparities in BP by race in the US, discuss evidence-based strategies to increase equity in BP, review recent American Heart Association (AHA) BP equity initiatives as an example of efforts to improve inequities, and highlight opportunities for change.

Disparities in Hypertension

Epidemiology of disparities in BP in the US

Approximately half of all adult Americans (i.e. over 122 million adults in 2017–2020) have hypertension, defined as systolic BP (SBP) ≥130 or diastolic BP (DBP) ≥80 mm Hg, with the highest prevalence rates among Black Americans.⁷ On average, Black Americans develop hypertension at younger ages,⁸ with the prevalence of high BP, defined as SBP ≥120 mm Hg or DBP ≥80 mm Hg, being two times higher (20% versus 10%) among Black versus White adolescents 13–17 years of age.⁹ Higher BP in adolescence increases the risk of hypertension and CVD in adulthood, setting the foundation for insidious racial disparities in CVD and mortality to perpetuate across the life course.^10–12

Although substantial improvements in BP control have occurred since the 1960s,¹³ BP control rates remain inadequate. Less than half (48.2%) of US adults with hypertension had controlled BP in 2017–2020, with control rates being markedly lower among Black adults (37.4%).¹⁴ Racial disparities in BP control in the US are estimated to be the single largest contributor to the excess risk for CVD among Black versus White adults.¹⁵ It has been estimated that approximately 8,000 CVD events could be averted annually by achieving equity in SBP between Black and White Americans.³ Yet, BP control rates are stagnant or worsening among all race/ethnic groups.^2,14 Substantial declines in BP control, particularly among Black Americans, during the decade preceding the COVID-19 pandemic and disruptions in care and hypertension management during the pandemic further emphasize the need for immediate action to equitably improve BP control in the US.^2,14

Widening gap between clinical practice guidelines and BP control among adults

Innovative, emerging hypertension interventions are in the pipeline, including renal denervation, aldosterone synthase inhibitors, dual endothelin antagonists, non-steroid mineralocorticoid receptor antagonists, and RNA interference agents for angiotensinogen.¹⁶ However, successful treatments for hypertension have been known for over 60 years, with randomized controlled trials demonstrating that lifestyle modifications and antihypertensive medications are effective in controlling BP and reducing hypertension-related CVD.^17–19 These latter interventions are included as Class I indications for BP control in the 2017 American College of Cardiology (ACC)/AHA and 2023 European Society of Hypertension BP guidelines. The worsening BP control, despite the existence of effective medications and evidence-based guidelines, indicates that there have been major barriers to adopting science into practice, particularly for those at the highest risk for worsening BP control.⁶

The roles of structural racism and social determinants of health in disparities

Addressing racial inequities in BP across the life course requires identification, understanding, and acknowledgment of their origins. Historical practices like slavery and discriminatory policies have perpetuated generational poverty and limited opportunities for Black Americans, influencing health outcomes.²⁰ Social determinants of health (SDOH), including education and wealth disparities, further exacerbate these inequities.^21–24 Structural racism and adverse SDOH limit the ability to achieve healthy behaviors like guideline-recommended physical activity and nutritious diets, particularly in low-income communities and areas lacking resources.^22,25–29 Limited access to quality healthcare, compounded by socioeconomic factors and healthcare biases, contributes to increased hypertension prevalence and poorer BP control among communities of color.³⁰ Addressing the nexus between structural racism and SDOH is crucial for achieving equity in hypertension and promoting the well-being of all individuals. Implementing approaches that address barriers at multiple socio-ecological framework levels and prioritize equal access to resources and opportunities will likely lead to improved BP control.

The socio-ecological framework includes interrelationships at the individual, organizational, community, and policy levels, and this model is useful for characterizing the barriers to BP control. Key approaches described by the 2023 Scientific Statement from the AHA and American Medical Association (AMA) on Implementation Strategies to Improve BP Control in the United States that address multiple levels of the socio-ecological framework include anti-racism efforts, accurate BP measurement and increased use of self-measured BP (SMBP) monitoring, team-based care, lifestyle modification strategies, standardized treatment protocols using team-based care, improving medication acceptance and adherence, continuous quality improvement, financial strategies that sustain the implementation of effective treatment strategies, and large-scale dissemination and implementation (Table 1).⁶

Table 1.

Implementation strategies for improving blood pressure (BP) control and the socio-ecological framework level that each approach targets

	Socio-ecological framework level
Strategy	Individual	Organization	Community	Policy
Anti-racism efforts	X	X	X	X
Accurate BP measurement and increasing adoption of self-measured BP monitoring	X	X		X
Team-based care		X	X	X
Lifestyle modification strategies	X	X	X	X
Antihypertensive medication treatment protocols	X	X
Improving acceptance and adherence to antihypertensive medications	X	X		X
Continuous quality improvement	X	X		X
Financial	X	X	X	X
Large-scale implementation and dissemination	X	X	X	X

Examples of BP interventions at safety-net clinics and other low-resourced settings

Safety-net clinics and small, low-resourced clinics that provide care for marginalized populations offer an opportune location to implement successful BP interventions that address multilevel barriers to BP control. Although large integrated health systems such as Kaiser Permanente pioneered health system quality improvement (QI) interventions to improve BP control, multiple investigators have since adopted interventions tailored to work in smaller clinics and diverse populations subject to disparities in hypertension.

Bring it Down San Francisco was a BP control intervention, adapted from Kaiser Permanente Northern California (KPNC), implemented in a network of 12 safety-net clinics in San Francisco that led to improvements in BP control of 68% to 74% achieved within 9 months and maintained at 15 months in a racially diverse population of 15,917 low-income patients with hypertension – 15% White, 20% Black, 29% Asian, 31% Hispanic, and 5% other.³¹ The intervention included four key components – a standardized BP measurement protocol, adoption of an evidence-based medication treatment algorithm that emphasized rapid treatment escalation and use of single-pill combination drugs, team-based care with nurse- or pharmacist-led visits for BP management, and quality performance monitoring. Intervention components were tailored to fit the context of the clinics within the network (e.g. consensus on medication choices based on clinician practice patterns, nurse or pharmacist role in BP management based on workforce composition). The study conducted a postintervention time series analysis from May 2015 to August 2016 to assess the effect of the intervention on BP control (<140/90 mmHg) for 15 months across the Health Network clinics. Secondary outcomes were changes in use of guideline-recommended medication prescribing. Rates of BP control increased (69%–74%; P<0.01). Statistically significant improvements in BP control rates occurred in all racial and ethnic groups (blacks, 60%–66%; whites, 69%–75%; Latinos, 67%–72%; Asians, 78%–82%) and the rate of improvement in BP control was greater in blacks as compared with whites (0.35% versus 0.10% per month; P=0.03) when adjusted for age and sex. Use of fixed-dose combination medications increased from 10% to 13% (P<0.01), and the percentage of angiotensin-converting enzyme inhibitor prescriptions dispensed in combination with a thiazide diuretic increased from 36% to 40% (P<0.01).

The KPNC model was similarly adopted in an ongoing study that has enrolled more than 20,378 adults with elevated BP in Nigeria. The intervention centered around team-based care led by community health workers to implement a national treatment protocol emphasizing single-pill combination drugs, health coaching, and home BP monitoring. Late-breaking, preliminary results show hypertension treatment rates improved from 76% to 97%, while hypertension control improved from 23% to 56%.³² Prescriptions for single-pill combination treatments increased from 43% to 90%.

Quality Improvement Interventions

The AMA developed the MAP BP initiative as a QI model for BP control, emphasizing the need to Measure accurately (with standardized clinic and home measurements), Act rapidly (through frequent visits and treatment intensification), and Partner with patients to facilitate SMBP monitoring and encourage lifestyle modifications.³³ A single-site pre-post pilot study of this program was conducted in 714 adult patients (age 18 to 85) with hypertension who made at least one visit at a Family Medicine primary care clinic during the 12-month study intervention period.³³ Between baseline and the last study visit, BP control (140/<90 mm Hg) increased from 61.2% to 89.9% (P < .0001) among the 716 enrolled patients. In a subsequent, large pragmatic randomized comparative effectiveness trial, investigators implemented the MAP BP quality improvement program designed to improve clinic‐level BP control simultaneously in 24 safety net clinics with 2 different methods—Full Support (FS) and Self‐Guided (SG) (randomly assigned)—and compared their effectiveness against each other and a nonrandomized concurrent Usual Care control using standard EHR‐derived BP control metrics for each clinic. In contrast to Usual Care, clinics in both intervention groups achieved substantial gains in some BP‐related quality metrics, most notably in documentation of confirmatory repeated BP measurement.³⁴ However, only small increases in BP control were observed in the intervention arms (56.7% to 59.1% for FS, 62.0% to 63.1% for SG) and they were not statistically significant.³⁴ This finding highlights the crucial need to tailor BP QI interventions to the local clinic context to achieve equity in blood pressure and to have those interventions driven and implemented local stakeholders.

Digital Technology Initiatives

Multiple studies have reported success in leveraging digital health technology to improve BP in US populations experiencing health disparities.³⁵ A recent systematic review and meta-analysis of 28 studies, representing 8,257 adult participants (mean age 57.4 years), investigated digital health interventions for hypertension management that emphasized social determinants of health and health disparities or included components that were culturally and linguistically tailored to populations with health disparities.³⁵ Most of the digital health interventions studied were multicomponent incorporating remote BP monitoring (18 [64.3%]), community health workers or skilled nurses (13 [46.4%]), and/or cultural tailoring (21 [75.0%]). The analysis found statistically significant and clinically relevant reductions in SBP at 6 months (−4.24 mm Hg) and at 12 months (−4.30 mm Hg).

The AHA’s Commitment to Health Equity: An Example of Organizational Advocacy

AHA’s 2024 Impact Goal

In January 2020, the AHA published its Impact Goal for the subsequent decade, which aimed to equitably increase healthy life expectancy from 66 to 68 years of age for Americans and from 64 to 67 years globally by 2030.³⁶ Following the announcement of this goal, life expectancy decreased globally in 2020,³⁷ driven mainly by excess deaths due to the COVID-19 pandemic. Inequitable decreases in life expectancy and increases in CVD deaths among Black and Hispanic compared to White Americans made the ambitious 2030 goal of an equitable 2-year increase in US healthy life expectancy increasingly challenging.^7,38,39

Due to the impact of the COVID-19 pandemic on the achievement of the 2030 goal, and the recognition role of social injustice in worsening health disparities for disadvantaged populations, the AHA’s National Board set aside the 2030 Impact Goal and developed a new goal in November of 2021 with a shortened timeline, to coincide with the 100th anniversary of the founding of the AHA. The new 2024 Impact Goal affirmed that “Every person deserves the opportunity for a full, healthy life. As champions for health equity, by 2024 the AHA will advance cardiovascular health for all, including identifying and removing barriers to health care access and quality”. ⁴⁰ Additionally, a $100M pledge and 10 commitments to advance health equity and combat structural racism were made by the AHA National Board (Table 2).^40,41 These commitments focus on 3 areas: SDOH, rural health, and structural racism.⁴² Many of these commitments have been fulfilled in the past three years,⁴³ including efforts to advocate for the backed expansion of Medicaid coverage, halting of disproportionate marketing of unhealthy products to minority communities, and partnering with community organizations to increase access to social services.⁴²

Table 2.

American Heart Association’s 10 Commitments to Support Health Equity and Combat Structural Racism and Progress through 2023

AHA Health Equity Commitment	Progress through 2023
1. Invest $100 million in new research programs and grants focused on science-based solutions to health inequities and structural racism.	Funding for new research programs, and grants focused health equity have surpassed the $100 million goal by almost $70 million.
2. Invest in community-led solutions to address health inequity and structural racism. Raise and invest at least $100 million to address the barriers to health equity at the community level.	A total of $253.4 million has been invested in community-led efforts, including Voices for Kids, the Social Impact fund, and the Bernard J. Tyson Impact Fund.
3. Improve access to and the quality of health care for under-resourced populations and those in rural communities, as part of a 50-state focus on Medicaid expansion.	Successfully advocated for the expansion of Medicaid in North Carolina at South Dakota, the extension of Affordable Care Act subsidies, and extended postpartum coverage.
4. Leverage AHA advocacy, science and news media enterprise against companies targeting individuals in disadvantaged communities with unhealthful products including sugary beverages and tobacco products (including e-cigarettes).	Launched a media campaign to bring awareness of tobacco companies’ targeted advertisements to Black and other underrepresented communities that had more than 11 million impressions in early 2023.
5. Launch in partnership with the U.S. Department of Health and Human Services (HHS), a $121 million-dollar nationwide hypertension initiative to address a main source of poor cardiovascular health in Black, Hispanic, and Indigenous communities.	The National Hypertension Control Initiative supported community organizations that provided health education and BP screenings, federally funded community health centers, and a community health worker pilot program.
6. Use AHA’s extensive clinical registry programs to capture data and create new scientific knowledge on the health effects of social determinants of health and health care quality variances among racial and ethnic groups.	The Get with the Guidelines program has expanded to include 2,840 hospitals that cover 80% of the US population.
7. Architect a road map, conceptual framework, and related tools for employers to identify and dismantle practices and policies in the workplace that contribute to structural racism and health inequities.	A CEO roundtable of 50 members helped develop a framework and toolkit, Driving Health Equity in the Workplace, to provide companies with resources to increase organizational equity.
8. Create a digital learning platform for clinicians, health professionals, and scientists with courses on issues of reversing structural racism and improving health equity in the delivery of health care, and professional development of the workforce.	Developed a Professional Education Hub that includes 9 free courses and 13 paid courses featuring health equity courses that address structural racism and social determinants of health. The site has be accessed by 100,000 users.
9. Elevate the focus of AHA scientific journals, including Circulation and Stroke, on disparities, anti-racism, health equity, community engaged/community based participatory research and implementation science.	Established the AHA journal Equity, Diversity, and Inclusion Editorial Board to promote quality health equity publications. AHA journals increased representation of underrepresented groups in invited authors from 6% to 9% and reviewers from 5% to 7%
10. Increase the diversity of the AHA workforce, including leadership. Fill at least one-third of hires with diverse individuals and mitigate bias in the recruitment, development, advancement and retention of diverse colleagues.	New AHA hires in the past year included 46.5% diverse candidates overall and 38% diverse candidates for leadership positions. 87% of AHA staff completed a course and book summary on diversity, equity and inclusion.

AHA Health Equity Research Networks - RESTORE

As one aspect of advancing AHA’s $100M commitment toward new research addressing health inequities, the AHA created a novel funding mechanism, the Health Equity Research Network (HERN). These multi-site, multi-project networks, each of which are $20M research awards, have a core focus of addressing health inequities in underserved populations. In addition, each network must have at least one project that incorporates Community-Based Participatory Research (CBPR) in its research design, and the overall activities of each HERN are facilitated by a centralized Coordinating Center.

Since improving hypertension and BP control was identified as a primary avenue for increasing health equity due to the high prevalence of hypertension and uncontrolled BP among Black adults,⁴⁰ prevention of hypertension was chosen as the inaugural HERN topic. Following submission and a two-stage peer review of several excellent proposals, funding was awarded to the RESTORE network. The mission of the RESTORE Network is to advance the AHA’s mission by building a society where every person lives a healthy life free of hypertension and CVD by 1) partnering with Black communities to mitigate the impact of SDOH on BP, 2) develop and evaluation strategies to implement evidence-based lifestyle interventions to lower BP, 3) disseminate findings to policymakers and stakeholders to ensure sustainability, and 4) train the next generation of early career health equity and hypertension scholars (Figure 1). Activated in October of 2021 and coordinated by New York University’s Grossman School of Medicine, RESTORE has 5 research projects, each assessing novel approaches to prevent hypertension in Black Americans.⁴⁴ All studies utilize a community-based approach, and each study is being conducted at a distinct site in the US. Table S1 lists all projects and study sites; additional information about RESTORE can be found at the following link: https://professional.heart.org/en/research-programs/aha-funded-research/health-equity-research-network-on-prevention-of-hypertension. Outcomes from the RESTORE Network will be available following the completion of trials in 2025.

Figure 1:

Advancing the American Heart Association mission through translation and implementation.

Additional AHA Health Equity Research Networks

AHA has funded two additional HERNs as part of its $100M research commitment to address health inequities. P3 (Pregnancy and Postpartum/Preconception) EQUATE (Enhancing Access and Quality to Achieve Equitable Maternal and Infant Health) was activated in July of 2022 to address the substantial disparities seen in maternal and infant health outcomes. RURAL PRO-CARE (Reciprocal Innovations to Improve Cardiovascular care in Rural America) was activated in July of 2023. This network seeks to address health inequities - which have grown substantially in recent decades - in rural populations.

As with RESTORE, each of these HERNs are multi-institution networks that include five community-focused research projects that are being conducted at several sites across the country. Although not an explicit focus of these networks, hypertension plays a critical role in the clinical conditions being addressed in each of these Health Equity Research Networks. Tables S2 and S3 summarize the projects of the P3 EQUATE and RURAL PRO-CARE HERNs; additional information can be found at the following links: https://professional.heart.org/en/research-programs/aha-funded-research/health-equity-research-network-on-disparities-in-maternal-infant-health and https://professional.heart.org/en/research-programs/aha-funded-research/health-equity-research-network-on-rural-health

AHA Strategically Focused Research Networks

The AHA Strategically Focused Research Network (SFRN) mechanism is another large-scale approach to address some of our most intractable health challenges. Started in 2014, SFRNs are $15M, multi-institution research networks focused on a particular topic. An SFRN consists of 3–4 centers, each of which conducts research using basic, clinical, and/or population health approaches. AHA has funded 1–2 SFRNs annually since their inception, for a total of 15 networks. The Hypertension SFRN was the second SFRN funded (2015), further underscoring the critical role of hypertension in cardiovascular mortality and morbidity. Centers based at four institutions – Cincinnati Children’s Hospital, Medical College of Wisconsin, the University of Alabama – Birmingham, and the University of Iowa – comprised the network. At the conclusion of the network, investigators had published more than 130 papers, including over 50 in the AHA journal Hypertension. An overview of the Hypertension SFRN can be found at https://www.ahajournals.org/doi/10.1161/HYPERTENSIONAHA.115.06433.

Information about additional SFRNs, several of which have a health equity focus (e.g., Disparities in Cardiovascular Disease and Stroke; Disparities in Cardio-Oncology; the Science of Diversity in Clinical Trials) or are on a topic for which hypertension is a key driver of risk (e.g., Heart Failure; Prevention; Psychosocial Stress) can be found at https://professional.heart.org/en/research-programs/aha-funded-research/strategically-focused-research-networks

Other AHA initiatives

In addition to funding ambitious and cutting-edge research addressing hypertension, AHA is working to address hypertension through additional strategies. One key example is the National Hypertension Control Initiative (NHCI), launched by AHA in 2021 through a $19.5M award from the US Department of Health and Human Services (DHHS) Office of Minority Health (OMH) and $12.5M from the DHHS Health Resources and Service Administration (HRSA). NHCI is using evidence-based approaches to improve BP control in persons with hypertension. The program incorporates a multi-pronged strategy of national scope that includes work at the community and clinic systems levels to improve awareness, timely diagnosis, treatment, and long-term management of BP control.

One example of NHCI’s impact is its work with community health centers on training individuals to accurately take their own blood pressure, with the objective of increasing the percentage of individuals whose blood pressure is controlled. Recent results have shown that community health centers that have worked with NHCI on this approach reported an average increase in blood pressure control of 12% over two years (2020 – 2022), with some communities reporting an improvement of upwards of 20%.⁴⁵

Despite inequities in access to access to and/or familiarity with digital devices, use of advanced technologies generally may be useful in addressing some aspects of health disparities. For instance, projections that are part of AHA’s SFRN on Health Technology and Innovation are focused on use of these tools in addressing health disparities. As one example, one center’s project is focused on using technology to improve outcomes for individuals with rheumatic heart disease, a disease that is prominent in under-resourced countries, while another is focused on use of mobile technologies to reduce disparities in diagnosis of management of heart disease and stroke (https://professional.heart.org/en/research-programs/aha-funded-research/strategic-networks/health-technologies-and-innovation).

Opportunities for achieving equity in hypertension

Although inequities in health and healthcare have been persistent and long-lasting, they are not inevitable. Successful strategies have been demonstrated for improving hypertension disparities through clinic-based interventions where disproportionately affected populations receive care (e.g. safety-net clinics),⁴⁶ place-based interventions (e.g. black barbershops) where individuals can be screened and referred or treated for high blood pressure,⁴⁷ digital health technology to facilitate communication and coaching to address social determinants, and team-based strategies that delegate healthcare tasks to nonphysicians, especially in areas access to care may be limited. The challenge is to determine the right mix of strategies with cost-effective policies and funding mechanisms to sustain them at scale. The AHA provides one example of how funding and advocacy can advance health equity from a concept to action. As we await outcomes from these initiatives, many policy options and strategies can target current gaps at the societal, health system, and individual levels to reduce or eliminate inequities in blood pressure.

Innovative strategies to address SDOH must start with broad social and economic policies at the governmental level – State and Federal in the US – to eliminate poverty, reduce racial wealth gaps, address housing and food insecurity, fortify healthy school-based nutrition, and provide universal access to health insurance and services. Policy interventions to achieve these goals can be achieved. It simply requires resolve and political skill on the part of policymakers.

SDOH must also be addressed at the point of care. Community health workers can be equipped to provide individually tailored coaching including dietary counseling and physical activity contextualized to the client’s social situation, and connect patients to resources that assist with housing, food, and financial support while also being trained to use evidence-based treatment algorithms for treatment of high BP in trusted spaces within patients’ communities like their homes, churches, barbershops, and other community centers (in partnership with community pharmacists and clinics through collaborative practice agreements).^47–52 However, these workers’ roles in helping patients with high BP are limited without access to their medical data and/or ways to communicate with patients’ healthcare providers. Providing these workers with access to digital health technologies for communication and clinical decision-support linked to electronic medical records that doctors and other clinicians use may help solve this problem.

In December 2022, the World Health Organization (WHO) released a manual recommending taxes on sugar-sweetened beverages as a “win-win-win strategy” for public health (and averted healthcare costs), government revenue, and health equity.⁵³ Revenue from tax policies can be used to support other public health policies like increasing broadband internet connectivity in rural and low-income urban neighborhoods, food programs, and Medicaid reimbursement policies that can help support community health workers and community-based organizations provide health-related services like nutrition, mental health counseling, housing services, and physical activity.

Quality improvement in safety-net and low-resourced clinics that provide care for low-income and minority populations is another key opportunity for achieving BP equity. 75% of patients with elevated BP visited a healthcare professional at least twice in the prior year, which presents a tremendous opportunity to leverage the healthcare delivery system to address BP inequities. Optimizing the care we provide for these patients - by prescribing medications for high BP, scheduling return visits within four weeks, and employing proven methods to increase medication adherence – would achieve BP control upwards of 78% in the overall US population.⁵⁴ As the examples outlined above prove, Community Health Centers and small clinics can improve BP control for marginalized patients when given access to resources and support. Community Health Centers account for 33% of primary care visits with uncontrolled hypertension and 56% of primary care visits by Black patients with hypertension.⁴⁶ Hence national QI initiatives such as AHA funded Million Hearts, TARGET BP, and other initiatives should refine and expand their efforts to target clinics that predominantly care for marginalized populations with disproportionately high BP. These efforts include reimbursement incentives to improve quality metrics, practice facilitation and other assistance to improve clinics’ capacity to implement QI (Table 3). Clinics should be supported to track racial differences in BP, broaden access to care, implement SMBP and partner with community-based programs to refer for interventions that address SDOH.

Table 3.

Recommendations for healthcare systems to increase equity in blood pressure

Track racial differences in blood pressure control and process metrics*

Broaden and streamline access to frequent encounters forhypertension management  • Nurse or pharmacist-led visits  •Weekend and after-hours visits  • Telemedicine (video >telephone)

SMBP program with seamless workflowintegration  • Easy-to-use devices and easy data communication –e.g.cellular-enabled devices  • Use of clinic personnel† for health coaching (digital literacy and lifestyle)and facilitated workflow (e.g.pre-appointment phone calls)

Partner and integrate with community-based programs.  • Referral system to resources

^*Process metrics: % missed visits, %treatment intensification per visit with elevated BP, medication adherence

^†Nurse, nurse practitioner, pharmacist or community health worker hired by the clinic SMBP: self-measured blood pressure

Digital Health Equity in BP management must be addressed. As with other chronic diseases, hypertension is increasingly managed with the use of technology like home BP measuring devices to enable SMBP, video visits to increase care access and more frequent clinical encounters for treatment, and patient electronic health record portals to facilitate communication between patients and their healthcare providers to address health needs that come up outside of routine medical visits. However, patients from marginalized communities have lower access to devices, lower digital literacy that hampers their ability to use technology applications and inadequate internet connectivity to transfer their data or participate in video visits with their healthcare providers. Hence, inequities in digital health access and usability are another form of injustice that stands to exacerbate existing disparities in BP.

Ensuring digital health equity will require a purposeful approach on the part of healthcare systems, technology developers and vendors and policy makers. Healthcare systems should identify and monitor disparities in the use of SMBP and telemedicine in their patient population and employ QI efforts to improve access in patient groups with known limited digital literacy and access (low socioeconomic status, racial/ethnic minorities limited English proficiency, older adults) to⁵⁵ (1) implement training to each patients how to use SMBP measuring devices and conduct video visits, (2) facilitate prescription of SMBP covered by Medicaid and other insurers, (3) offer video visits to every patient to enable more frequent follow-up visits, and telephone visits as an alternative, (4) ensure all training and patient-facing technology features are available in multiple languages, (5) inform patients about newly free or reduced-cost broadband internet in their area. Digital health technology developers should be required to prove usability and relevance in population groups with known limited health and digital literacy, design for multiple contexts (e.g. private and secure space) with human support (caregiver or family member), codesign with community in reciprocal relationships (safety-net clinics, community organizations), and implement and evaluate in clinical diverse clinical settings (small, large, rural, urban).⁵⁶ Policymakers should enact policies to mandate and increase broadband in all neighborhoods and cover the cost of validated SMBP devices.

Conclusion

The AHA’s $100 million commitment to increasing hypertension and cardiovascular health equity has funded innovative research networks and initiatives addressing the root causes of inequities in BP and implementing evidence-based interventions. Yet, structural, and societal changes that provide equitable opportunities for education, economic resources, and healthcare are grossly inadequate. The decades of structural racism that created inequities in hypertension will take decades of sweeping, structural changes to reverse. Approaches that address barriers at multiple socio-ecological framework levels and dismantle structural racism are needed to sustainably improve equity in BP control on a national scale.