Barbershop Blood-Pressure Intervention Benefits for Black Males Sustained

Community-Based Hypertension Intervention has Lasting Benefits Trial Follow-Up Shows 

by Kate Kneisel, Contributing Writer, MedPage Today 

The success of a barbershop intervention to tackle uncontrolled blood pressure (BP) among African-American men persisted at 12 months, mirroring 6-month findings of the randomized trial.

Mean systolic pressure was 28.6 mm Hg below baseline at 12 months in the intervention group compared with the 7.2 mm Hg reduction in the control group (P<0.0001), with end levels of 123.8 vs 147.4 mm Hg, reported Ciantel Blyler, PharmD, of Cedars-Sinai Medical Center in Los Angeles, and colleagues online in Circulation.

Mean diastolic BP reduction was 14.5 mm Hg greater in the intervention group (P<0.0001). Substantially more intervention participants got below 130/80 mm Hg (68.0% vs 11.0%, P=0.0177).

The BP reductions at 12 months "are statistically indistinguishable from our previously reported 6-month data, despite less interactions with the pharmacists in the second 6 months of the trial (7 ± 2 visits vs 4 ± 2)," the group wrote. 

"The observed 90% cohort retention, few treatment-related adverse events, improved patient satisfaction and self-rated health strongly suggest sustainability of our hypertension detection and treatment model."

John Bisognano, MD, of the University of Rochester, New York, told MedPage Today, "The results were phenomenal, and likely represent one of the greatest innovations in healthcare delivery for hypertension in the past 30 years."

"So much of our hypertension management is focused on lifestyle modification and drug selection and follow-up," said Bisognano, who was not involved in the study. "While this approach has been successful over the past half-century, treatment and control rates have largely stalled, and this approach has been particularly ineffective in non-Hispanic black men who continue to have high rates of suboptimally treated hypertension."

Khadijah Breathett, MD, of the University of Arizona in Tucson, commented, "This landmark study heralds the need to engage community members where they live. Health equity will require moving beyond the confines of the ivory tower of medicine." Breathett was not involved in the study.

The trial included 319 African-American men, ages 35-79, with baseline systolic BP over 140 mm Hg at two screenings. They were cluster randomized to 52 barbershops in the Los Angeles area, which had been randomly assigned to study arm. Mean systolic BP at baseline was similar between intervention and control groups (152.4 mm Hg and 154.6 mm Hg, respectively). A higher percentage of the intervention group reported high cholesterol.

The 6-month extension of the study kept the same randomization and protocols. The intervention provided BP management to patrons in their barbershops was not only more convenient, but also helped address distrust and avoidance of the medical profession by using trusted barbers who they had visited on average every 2 weeks for over a decade to deliver health messages, the researchers noted. 

Men randomized to the active arm saw pharmacists certified by the American Society of Hypertension, who under an agreement with participants' primary care providers, monitored their BP, as well as plasma electrolytes and creatinine; provided lifestyle recommendations; and prescribed a combination antihypertensive drug regimen following a generally fixed set of medication adjustments. 

The long-acting thiazide-type diuretic indapamide was the preferred third-line drug, followed by an aldosterone antagonist if needed. Only 50% of regimens required three or more drugs. 

The control group received instruction about BP and lifestyle modification. Barbers were trained to encourage participants in each group accordingly. The researchers attributed the success of the intervention to use of more intensive therapy and combination regimens, more first-line BP drugs, and more long-acting drugs. 

Study limitations included the fact that assignment through cluster randomization could not be blinded but was independently assessed, and the use of financial incentives in both the intervention and control groups ($25 vouchers monthly for haircuts or pharmacist visits, respectively), which reportedly had a small but not insignificant effect on medication adherence. 

Also, use of a BP goal of under 130/80 mm Hg was lower than the 140/90 target used at the time by most community physicians. "Our results indicate that our new model of [hypertension] care can succeed in reaching high-risk hypertensive populations and markedly improve control rates with simple treatment algorithms, frequent follow-up and persistence in adjusting therapy when blood pressure remains above goal," the group noted. 

"Perhaps the most critical first step towards widespread dissemination of our model is the expansion of collaborative practice between pharmacists and physicians, or the elimination of the requirement altogether (as in Canada and the U.K.)." 

First author Ronald Victor, MD, also of Cedars-Sinai, passed away shortly before submission of the paper. "This innovative work represents a great and lasting innovation from a beloved figure in the hypertension community - a prolific researcher both in the clinical and basic science realms, a teacher and a scholar, whose legacy includes revolutionizing how hypertension treatment rates can be tremendously increased by focused community interventions," Bisognano said.