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High blood pressure control in safety-net clinics is lagging, says Michigan State study

UMMA Community Clinic in South L.A., a federally-qualified health center (FQHC). A new study from Michigan State University concluded that FQHCs need to improve how they control the blood pressure in patients with hypertension.
UMMA Community Clinic in South L.A., a federally-qualified health center (FQHC). A new study from Michigan State University concluded that FQHCs need to improve how they control the blood pressure in patients with hypertension.
Christopher Okula/KPCC

High blood pressure rates are out of control at community health clinics that receive federal funding to serve the underserved, according to a new study.

Dr. Adesuwa Olomu, who led the Michigan State University study, said in a statement the findings highlight "the need to design interventions that focus on these safety-net clinics where minority and low-income populations receive their care." She focused in particular on federally-qualified health centers (FQHCs). 

The study, which appeared in the Journal of Clinical Hypertension, looked at one FQHC in Michigan and concluded that there's "a need to improve" how well FQHCs control high blood pressure rates:

BP [blood pressure] control was achieved in only 38.2% of the total cohort and in 31.1% of patients with diabetes. This is much lower than the levels found in previous studies performed both in the general population and in primary care clinics. Recently, the National Health and Nutrition Examination Survey (NHANES) study has shown that BP control is 50.1% in a nationally representative general population, which indicated progress toward the “Healthy People 2010” national objective of controlling BP in 50% of all individuals with [high blood pressure].

In a phone call, Olomu said that while her findings are illustrative, they shouldn't be generalized across the board. The study itself acknowledged as much:

[O]ur study was conducted at an FQHC in Michigan and our results may not be generalizable to other communities.

High blood pressure in South L.A. and the safety net

Along with diabetes, hypertension is one of South L.A.'s biggest health problems. Dr. Cesar Barba, the interim medical director at UMMA Community Clinic, has called it "the number-one diagnosis we see of chronic disease in our clinic." At T.H.E. Clinic, physician assistant Cynthia Francis estimates that about 1 in 3 of the clinic's patients live with the condition. Both UMMA and T.H.E. are FQHCs.

But according to Louise McCarthy, the president and CEO of the Community Clinic Association of Los Angeles County, the association's member clinics (which include UMMA and T.H.E.) do a "very good job of controlling" high blood pressure among patients who don't have any other serious chronic conditions and who have been receiving regular care.

"We look at hypertension separate from other chronic conditions," she wrote in an email. The Michigan State University study, on the other hand, includes in its data people with diabetes and other chronic conditions.

"It looks like the study is looking at really sick people and finding that their blood pressure is (understandably) not controlled," she wrote.

McCarthy noted that in March 2012, among patients with high blood pressure and no other serious chronic conditions (like HIV, cancer, diabetes or heart disease), community clinics in L.A. County had gotten the blood pressure of 66 percent of them under control. A year later, that had jumped to 79 percent.

What safety net clinics are up against

Nina Vaccaro is the executive director of the Southside Coalition of Community Health Centers, whose eight member clinics are all FQHCs in South L.A. (UMMA and T.H.E. are also among those eight). Vaccaro said the study's findings may have something to do with the stark differences between the safety-net patient population and those who are privately insured.

"We know that community health centers and FQHCs serve a lower-income demographic than private practices that are not community health clinics, free clinics or FQHCs," she said. "So we've got a lot of these social factors at play when dealing with the low-income population."

Meaning that there are a lot of factors "outside the health care provider's scope" in South L.A. that may account for the higher rates of uncontrolled blood pressure: People live in an area where it's hard to find places to exercise or buy affordable healthy food.

It's also not a given that people are able to get to a clinic; maybe they don't have time because they have to work two jobs, or maybe they don't have a reliable method of transportation. And even if they do get to a clinic, it's not a given that those visits will become regular, or that those patients will take any medication they're given as prescribed.

It's hard for a health provider to monitor high blood pressure if patients don't show up or follow  instructions.

Not a matter of quality

What wouldn't be fair, asserted Vaccaro, is to say that this reflects badly on the care FQHCs and other safety-net centers provide. In the past, community health centers serving the safety net have been found to perform as well as, if not better than, non-safety net providers in terms of quality of care.

"We know that [high blood pressure] is a real problem in our community, but I don't know that it's fair to say that because you're an FQHC, you're doing a poor job in terms of quality of care," she said. "You're up against a lot of other factors that maybe places who care for patients with private-payer insurance aren't having to deal with."

Olumu, the lead author of the Michigan State study, agreed with that, and said it wasn't necessarily a matter of quality of care. Rather, she said, it's all of those environmental factors—a lack of access to healthy food and space to exercise, a lack of health literacy or transportation—that prevent patients from getting invested in maintaining their health.

"You need to be engaged in your care," she said. "Most patients are not engaged in their own care."

Her study also found that men were much less likely to have their blood pressure under control, and that the likelihood of people's controlling the condition becomes smaller as they age.

Vaccaro said while there may be big regional differences between Michigan and Southern California, there's still an important takeaway for the Southside.

"At the end of the day, they're probably serving a low-income community [in Michigan] similar to what we're seeing in Los Angeles," she said. "I think there are lessons that we can walk away with in terms of understanding the types of patients that these clinics are seeing and the fact that a lot of these patients have several chronic conditions that these clinics are trying to manage."