Medication adherence and resistant hypertension.

Non-adherence has been a major concern in the treatment of hypertension and is particularly important in understanding and intervening in patients who appear to have resistant hypertension. Relatively few studies have examined the role of non-adherence in resistant hypertension. This review will address issues related to measurement of adherence, adherence interventions and rates of non-adherence in general hypertensive populations and in patients classified as having resistant hypertension.

Physical activity does not mitigate G-protein-related genetic risk for obesity in individuals of African descent.

The G-protein beta3 subunit 825 TT genotype has been associated with obesity and hypertension. We examined the interaction between the G-protein TT genotype, physical activity and body mass index (BMI) in a cross-sectional study of African immigrants and African Americans. The genotype frequencies were 6.3% CC, 37.7% CT, and 56% TT. After adjusting for potential confounders, BMI was found to be significantly higher in the sedentary than in the physically active participants (p=0.045). There was no statistically significant effect for genotype (p=0.215) or the interaction between genotype and the level of physical activity (p=0.219). However, the individuals with the CC or CT genotype who were physically active had substantially lower BMIs (M+/-SE) (i.e., 25.74+/-2.02) than any of the other groups: sedentary CC + CT (30.58+/-1.03), sedentary TT (30.65+/-1.00) or active TT (29.43+/-1.65). Because of the low statistical power of this study, further research is needed to confirm these findings and to explore potential gene-environment/lifestyle interactions.

Tooth and periodontal disease: a review for the primary-care physician.

Dental diseases are widespread and are often underrecognized and treated. Caries and periodontal disease are common dental conditions that cause the majority of tooth loss. Although these conditions are preventable, many persons do not receive regular dental care and have acute problems when seen by their physician. Dental diseases frequently affect patients with multiple systemic disorders, including autoimmune disorders, diabetes, and human immunodeficiency virus (HIV) infection. The presence of dental disease may trigger inflammatory responses and have systemic consequences. Since dental disease affects almost all individuals, physicians should be able to recognize common conditions such as caries, periodontal disease, pulpitis, and dental abscess. In addition to initiating treatment and appropriate dental referrals, physicians should be familiar with the management of antibiotics and medications in the perioperative period. Another important role for physicians is to help reduce the societal and economic impact of these diseases through patient education and prevention.

Characteristics of patients with uncontrolled hypertension in the United States.

BACKGROUND: Treatment of hypertension is one of the most common clinical responsibilities of U.S. physicians, yet only one fourth of patients with hypertension have their blood pressure adequately controlled. METHODS: We analyzed data from the third National Health and Nutrition Examination Survey to assess the role of access to and use of health care in the control of hypertension. We assessed demographic characteristics, clinical data, health insurance status, and awareness and treatment of hypertension in subjects with hypertension (defined as a blood pressure of at least 140/90 mm Hg or the use of antihypertensive medication) and subjects without hypertension. RESULTS: The study sample consisted of 16,095 adults who were at least 25 years old and for whom blood-pressure values were known. We estimated that 27 percent of the population had hypertension, but only 23 percent of those with hypertension were taking medications that controlled their condition. Among subjects with untreated or uncontrolled hypertension, the pattern was an elevation in the systolic blood pressure with a diastolic pressure of less than 90 mm Hg. The great majority had health insurance. Independent predictors of a lack of awareness of hypertension were an age of at least 65 years, male sex, non-Hispanic black race, and not having visited a physician within the preceding 12 months. The same variables, except for non-Hispanic black race, were independently associated with poor control of hypertension among those who were aware of their condition. An age of at least 65 years accounted for the greatest proportion of the attributable risk of the lack of awareness of hypertension and the lack of control of hypertension among those who were aware of their condition. CONCLUSIONS: Most cases of uncontrolled hypertension in the United States consist of isolated, mild systolic hypertension in older adults, most of whom have access to health care and relatively frequent contact with physicians.

Genetic bottlenecks, perceived racism, and hypertension risk among African Americans and first-generation African immigrants.

The complexity of factors influencing the development of hypertension (HTN) in African Americans has given rise to theories suggesting that genetic changes occurred due to selection pressures/genetic bottleneck effects (ie, constriction of existing genetic variability) over the course of the slave trade. Ninety-nine US-born and 86 African-born health professionals were compared in a cross-sectional survey examining genetic and psychosocial predictors of HTN. We examined the distributions of three genetic loci (G-protein, AGT-235, and ACE I/D) that have been associated with increased HTN risk. There were no significant differences between US-born African Americans and African-born immigrants in the studied genetic loci or biological variables (eg, plasma renin and angiotensin converting enzyme activity), except that the AGT-235 homozygous T genotype was somewhat more frequent among African-born participants than US-born African Americans. Only age, body mass index, and birthplace consistently demonstrated associations with HTN status. Thus, there was no evidence of a genetic bottleneck in the loci studied, ie, that US-born African Americans have different genotype distributions that increase their risk for HTN. In fact, some of the genotypic distributions evidenced lower frequencies of HTN-related alleles among US-born African Americans, providing evidence of European admixture. The consistent finding that birthplace (ie, US vs Africa) was associated with HTN, even though it was not always significant, suggests potential and unmeasured cultural, lifestyle, and environmental differences between African immigrants and US-born African Americans that are protective against HTN.

Quantifying the problem of abuse and neglect in adults--analysis of a statewide database.

BACKGROUND: Mistreatment of adults, including abuse, neglect, and exploitation, affects more than 1.8 million older Americans. Presently, there is a lack of precise estimates of the magnitude of the problem and the variability in risk for different types of mistreatment depending on such factors as age and gender. OBJECTIVES: To describe the universe of case reports received during one year in a centralized computer database maintained by the Texas Department of Protective and Regulatory Services--Adult Protective Services Division (TDPRS-APS). DESIGN: Descriptive. SETTING: Texas. PARTICIPANTS: Mistreated or neglected older people. MEASUREMENTS: The distribution of abuse types reported and population prevalence estimates of each abuse type by age and sex. RESULTS: There were over 62,000 allegations of adult mistreatment and neglect filed in Texas in 1997. Neglect accounted for 80% of the allegations. The incidence of being reported to the TDPRS-APS increased sharply after age 65. The prevalence was 1,310 individuals/100,000 > or = 65 years of age for all abuse types. CONCLUSIONS: The TDPRS database is an excellent tool for characterizing and tracking cases of reported elder mistreatment. Achieving a clearer understanding of this ever-increasing public health problem can aid in the development of better interventions and prevention strategies.

Lower hypertension prevalence in first-generation African immigrants compared to US-born African Americans.

Both genetic and environmental factors have been hypothesized to explain the higher prevalence of hypertension in US African Americans compared to populations still residing in western Africa. Studies of first-generation immigrants can help to identify risk factors for increased chronic disease expression in the developed world. Since we could identify no prior studies of hypertension in African immigrants to the United States, we conducted a cross-sectional survey of African-born and US-born African-American health professionals to compare the two groups for the prevalence of hypertension (blood pressure > or = 140/90 mm Hg or use of antihypertensive medication) and risk factors for hypertension (body mass index, lifestyle factors, and psychosocial variables hypothesized to relate to hypertension). Subjects were registered pharmacists and nurses recruited by mail. For the 182 individuals who completed study measurements (95 US-born and 87 African-born), the unadjusted odds ratio for hypertension associated with birthplace was 2.16 (95% CI = 1.12, 3.98). After adjustment for body mass index and age, the OR for birthplace was 1.92 (95% CI = 0.92, 4.00). No lifestyle or psychosocial variables were associated with hypertension prevalence. We conclude that there is a lower prevalence of hypertension in first-generation African immigrants that cannot be readily explained by the environmental effects measured in this study. Larger scale studies with African immigrants could advance understanding of the causes of the increased hypertension prevalence in US-born African Americans.

Ethnic differences in nocturnal blood pressure decline in treated hypertensives.

Lack of a nocturnal decline in blood pressure (BP) has been associated with more severe end organ damage in hypertensives, and blacks appear less likely than whites to have a > 10% drop in nighttime BP ("dipping"). Little information is available about the relationship between treatment regimens, ethnic group classification, and dipping in treated hypertensive patient populations. We obtained 24-h ambulatory BP readings in 438 adult white (n = 103), black (n = 200) and Hispanic (n = 135) treated hypertensives. Tycos monitors were connected in patients' homes before their usual morning medication dose time. Research assistants administered a quality-of-life questionnaire, recorded patients' drug regimen, and observed the patients take their morning dose. Monitors were programmed to record BP every 30 min. Dippers were defined as persons who had a drop of > or = 10% decline in average daytime (08:00 to 22:00) compared to nighttime (00:00 to 04:00) BP. Logistic regression modeling was used to assess the relationship between demographic and treatment variables and probability of dipping. Twenty-four-hour average BP was similar in all three ethnic groups. However, the absence of a systolic dip was significantly more common in black and Hispanic men than in white men (OR black v white = 11.54, 95% CI = 3.92 to 34.01; OR Hispanic v white = 7.32, 95% CI = 2.47 to 21.68). There were no ethnic group differences in probability of systolic dipping among women. Absence of a diastolic dip was approximately twice as common in blacks and Hispanics than in whites, with no marked gender-by-ethnic-group interaction in the magnitude of the association. Of the 10 most commonly prescribed antihypertensives, no single drug was positively associated with nocturnal BP decline. Later versus earlier morning dose time, but not once-a-day dosing, was associated with absence of dipping. Treated black and Hispanic hypertensives are less likely to "dip" than non-Hispanic whites. No particular drug was positively associated with dipping.

Self-reported hypertension treatment practices among primary care physicians: blood pressure thresholds, drug choices, and the role of guidelines and evidence-based medicine.

BACKGROUND: Primary care physician treatment practices affect the rate of hypertension control to the goal of 140/90 mm Hg. Awareness of and agreement with national hypertension management guidelines, and grounding in evidence-based medicine principles, may be important determinants of practice. METHODS: A 26-item mail questionnaire was sent to a national sample of 1200 primary care physicians. The questionnaire elicited (1) the blood pressure (BP) criteria physicians use to initiate and intensify hypertension treatment, (2) first-line drug treatment choices, (3) familiarity with the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC) hypertension treatment guidelines, and (4) familiarity with research methods used to develop evidence-based medicine guidelines. The analysis focused on (1) determining the percentage of physicians who reported treatment practices consistent with JNC recommendations and (2) the relation between familiarity with JNC guidelines, evidence-based medicine methods, and reported treatment practices. RESULTS: The overall response rate was 34%, with no important differences in demographic or professional training variables between respondents and nonrespondents. For middle-aged patients with uncomplicated hypertension, 33% of physicians would not start drug therapy unless the diastolic BP was greater than 95 mm Hg, and 43% would not start unless the systolic BP was greater than 160 mm Hg. In patients without complications who were receiving drug treatment, 25% of physicians would not intensify therapy for a persistent diastolic BP of 94 mm Hg, and 33% would not intensify therapy for a systolic BP of 158 mm Hg. Physicians were generally less aggressive in older patients. Angiotensin-converting enzyme inhibitors were the most common first-line drug choice. Forty-one percent of physicians had not heard of or were not familiar with the JNC guidelines. In multiple logistic regression models, familiarity with the JNC guidelines was associated with lower treatment thresholds, and increased familiarity with research methods was associated with greater use of diuretics or beta-blockers as first-line agents. CONCLUSIONS: Many physicians have higher BP thresholds for the diagnosis and treatment of hypertension than the 140/90 mm Hg criterion recommended by the JNC. Therefore, further improvements in population hypertension control will require physician behavior change. Physician practice is associated with awareness of practice guidelines and familiarity with evidence-based medicine methods, but the precise nature and extent of this relation requires further study.

The high prevalence of depression and dementia in elder abuse or neglect.

BACKGROUND: The risk factors for mistreatment of older people include age, race, low income, functional or cognitive impairment, a history of violence, and recent stressful events. There is little information in the literature concerning the clinical profile of mistreated older people. OBJECTIVES: To describe the characteristics of abused or neglected patients and to compare the prevalence of depression and dementia in neglected patients with that of patients referred for other reasons. DESIGN: A case control study. SETTING: Baylor College of Medicine Geriatrics Clinic at the Harris County Hospital District (Houston, Texas). PATIENTS: Forty-seven older persons referred for neglect and 97 referred for other reasons. INTERVENTION: Comprehensive geriatric assessment. MEASUREMENTS: Standard geriatric assessment tools. RESULTS: There was a statistically significant higher prevalence of depression (62% vs 12%) and dementia (51% vs 30%) in victims of self-neglect compared to patients referred for other reasons. CONCLUSIONS: This is the first primary data study that highlights a high prevalence of depression as well as dementia in mistreated older people. Geriatric clinicians should rule out elder neglect or abuse in their depressed or demented patients.

New profiles of diabetic ketoacidosis: type 1 vs type 2 diabetes and the effect of ethnicity.

BACKGROUND: Diabetic ketoacidosis (DKA) has been reported to occur in type 2 diabetes, but the frequency and distinguishing features of this syndrome remain to be defined. We determined the "diabetic types," ethnic distributions, and phenotypes of patients with DKA in an urban hospital. METHODS: We reviewed the hospital admissions and followed the clinical course of adults who developed DKA. We classified patients as "type 1," "type 2," or "new onset" based on their treatment history. New-onset patients were reassessed 2 1/2 years or more after the episode of DKA and classified as "type 1" or "type 2" based on insulin requirements. We compared the groups for ethnic distributions and clinical features. RESULTS: Of 141 patients, 55 (39%) who presented with DKA had type 2 diabetes, while 75 (53%) had type 1 diabetes and 11 (8%) could not be "typed." Hispanics mainly had type 2 and whites predominantly had type 1, while African Americans had a slight preponderance of type 1 diabetes (P=.001). Type 1 patients were mainly lean, while the body mass indexes (BMIs) (calculated as the weight in kilograms divided by the square of height in meters) of type 2 patients were bimodally distributed (33% with BMI<25 and 51% with BMI>30; P<.001). Age of onset of diabetes was predominantly younger than 40 years in the type 1 group but was more broadly distributed in the type 2 group (P<.001). Ninety-three percent of the new-onset patients who were reassessed had type 2 diabetes. Half of the type 2 patients had no identifiable stress factor associated with the episode of DKA. CONCLUSIONS: A high proportion of DKA in nonwhite adults occurs in persons with type 2 diabetes, especially in those with previously undiagnosed diabetes. The frequency and clinical heterogeneity of this syndrome in a multiethnic population have significant implications for the diagnosis, classification, and management of adults with diabetes.

Treating elder neglect: collaboration between a geriatrics assessment team and adult protective services.

Neglect is the most common type of elder maltreatment in the United States. Currently, the only formal intervention available is provided by each state's adult protective service agency (APS). Elder neglect involves a complicated relationship among an indvidual's medical problems, social situation, and ability to function in the environment. Geriatric assessment teams are facile at dealing with such complex cases while APS caseworkers are expert in their ability to identify and confirm neglect. Forming a geriatric team that includes APS caseworkers is a logical and innovative approach to the growing problem of elder neglect.

Dietary intervention for cholesterol reduction in public clinic patients.

OBJECTIVES: To test the feasibility and effectiveness of a diet intervention (consisting of interactive mailings, computer-generated phone calls, and classes) in hypercholesterolemic low-income public clinic patients. METHODS: Clinic patients with serum cholesterol > 200 mg/dl, referred by their primary care physician were randomized to a 6-month special intervention (SI) or usual care (UC). The intervention included mailings, computer phone calls, and four 1-hour classes. Serum total cholesterol (TC) was measured before and after intervention, and participation was monitored. RESULTS: One hundred sixty-five of the 212 patients referred (77.8%) agreed to participate. A medical records review revealed 123 (74.5%) met eligibility criteria. Eligible subjects had a mean age of 56.7 years, 80.0% were African American, 74.8% were female, 33.6% were married, and 89.4% had a high school or lower education. Subjects were randomized with 80.5% (99) completing follow-up cholesterol measures. SI subjects were encouraged to use all three components, with 84.6% (55 of 65) actively participating in at least one component. Seventy-two percent (47 of 65) returned at least one mailing, 49.1% (28 of 57) of those with touch-tone phones accessed the computer system, and 43.1% (28 of 65) attended classes. The TC in SI decreased from 273.2 mg/dl to 265.0 mg/dl (P = 0.05) and in UC 272.4 mg/dl to 267.6 mg/dl (P = 0.32). The net reduction in SI compared with UC was 3.4 mg/dl (P = 0.58). CONCLUSIONS: (1) Low-income public clinic patients will participate in diet interventions, (2) computer-generated interactive phone calls are feasible in this population, and (3) clinically meaningful decreases in serum cholesterol are difficult to achieve with interventions of practical intensity.

Blood pressure measurement and antihypertensive treatment in a low-income African-American population.

OBJECTIVES: The purpose of this study was to describe blood pressure measurement and hypertension treatment in an inner-city African-American community. METHODS: A random-digit dialing telephone survey of adults more than 18 years of age was carried out in 12 predominantly African-American zip code areas in Houston, Texas. RESULTS: More than 90% of subjects reported a blood pressure measurement within the past 2 years, and 87% of known hypertensives reported current medication use. CONCLUSIONS: Further improvements in hypertension control among African Americans in this country are likely to depend primarily on changes in diagnosis and management practices of health care providers and on maintaining primary care access for all socioeconomic groups.

Physician education in hyperlipidemia management: the impact on collaboration.

Collaboration of health care professionals is likely beneficial in modifying patient behavior in the treatment of hyperlipidemia. The purpose of this study was to determine whether limited instruction and demonstration of collaborative management of hyperlipidemia in a continuing medical education (CME) would change physicians' office practices, as determined 1 year later by questionnaire. Collaborative practice was defined as physicians working with other allied health care professionals as a team to increase patients' medication compliance and other behavioral outcomes. A 19-credit hour CME Lipid Disorders Training Program (LDTP) was offered emphasizing the collaborative approach to hyperlipidemia patient management. Physicians (n = 196) were surveyed 1 year after LDTP. The response rate was 52.5%, nonrespondents were similar in locations. About 51% of respondents reported increased collaborative practice; of these respondents, 68% reported saving time, 78% reported improved patient outcomes, 76% improved office efficiency, and 90% increased patient satisfaction. According to self-reporting by these physicians, increased collaboration practices after attending the LDTP course led to improved patient outcomes.

Hypertension awareness and control in an inner-city African-American sample.

African-Americans in the US are at high risk for hypertension-related morbidity and mortality. The majority of African-Americans live in central city areas, and lower socioeconomic status and health care utilization patterns have been hypothesized to contribute to higher blood pressure (BP) levels and poorer control of treated hypertension in this group. In order to plan an intervention to improve hypertension care for inner city African-Americans in Houston, Texas, we conducted a baseline survey of residents in 12 low-income ZIP code areas with a > 70% African-American population to determine the level of hypertension awareness, treatment and control, and associated sociodemographic, health care utilization, and medication compliance variables. Subjects were recruited to attend a BP measurement and assessment of knowledge, attitudes and behaviors through random digit phone dialing in the target ZIP code areas. Of the 962 subjects examined, 433 (45%) were hypertensive (systolic BP > or = 140 mm Hg or diastolic pressure > or = 90 mm Hg or taking antihypertensive medication). Among all hypertensives, 73% were aware, 64% were on treatment, and 28% were controlled to 140/90 mm Hg. Of hypertensives on treatment, 43% were controlled to 140/90 mm Hg, but 72% were controlled using the criterion of 160/95 mm Hg, and 75% were controlled using a diastolic pressure < 90 mm Hg only. These results are similar to those reported for African-Americans in the most recent US national health survey. Males were less likely to be aware, receiving treatment and controlled than were females. Although lack of awareness was associated with less frequent BP measurement, 77% of those unaware reported a measurement within the past 2 years. The majority of aware hypertensives reported frequent physician contact and high compliance with medication. We conclude that intervention to improve hypertension control in this population should focus on ensuring that health providers diagnose BP and establish treatment goals based on the current standard of 140/90 mm Hg.

Comparing two strategies to modify dietary behavior and serum cholesterol.

AIM: To test the hypothesis that a strategy including cholesterol screening and dietary education is more effective than dietary education alone in changing dietary behavior and serum cholesterol levels. METHODS: Individuals at four worksites were enrolled in a randomized trial with a 'full intervention' condition in which subjects were told their serum cholesterol value and also received a dietary change kit (n = 236), and a 'partial intervention' condition in which subjects received the same dietary change kit, but were not told their serum cholesterol value (n = 284). Individuals (n = 115) in two worksites served as a nonrandomized 'untreated control group'. Subjects were tested for serum cholesterol and completed a questionnaire at baseline, and 3 and 6 months later. RESULTS: Dietary changes occurred in seven of nine categories in individuals subjects to the full and partial interventions but in only one of nine categories in those studied in the control condition. Mean dietary intake differed between the full and partial intervention conditions for only three of nine dietary categories. Cholesterol level dropped in the full, partial and control conditions by 4.9, 3.9 and 9.6%, respectively. CONCLUSIONS: Dietary education has favorable effects on the dietary behaviors of individuals. Being told one's cholesterol level at the outset of this educational intervention has little effect on dietary change.

Smoking, smoking cessation, and understanding of the role of multiple cardiac risk factors among the urban poor.

OBJECTIVE: To determine in a population of low socioeconomic status (SES) patients: (a) rates of current smoking and smoking cessation, (b) persons' understanding of the adverse health impact of multiple cardiovascular disease (CVD) risk factors, and (c) if the diagnosis of other CVD risk factors, specifically hypertension or hypercholesterolemia, was related to smoking cessation. DESIGN: Cross-sectional interview survey. SETTING: Community clinics and eligibility centers of the Harris County Hospital District (HD), which provides primary care to over 166,000 indigent persons in Houston, Texas. SUBJECTS: Randomly selected adults attending an HD setting for eligibility screening or primary care. RESULTS: Over 93% of subjects approached participated (n = 547). Their mean age was 40.7 years, 55% were female, and 39% had > 9 years of education. The ethnic distribution was 54% Hispanic, 28% black, and 14% non-Hispanic white. Current smoking ranged from 10% among Hispanic females to 56% among black males. The percentage of ever smokers who had quit was 24% among black males, 44% among black females, 43% among Hispanic males, and 70% among Hispanic females. The majority recognized the increase in danger from smoking in the presence of hypertension or hypercholesterolemia. Among patients who were smokers when they found out they had hypertension (n = 70), 65% reported it increased their desire to quit. After adjustment for other variables including age and known CVD, predictors of being an ex-smoker were being female (OR 2.1, 95% CI 1.3-3.5), being Hispanic (OR 2.8 95% CI 1.5-5.7), and having hypertension (OR 2.3, 95% CI 1.3-4.2). CONCLUSION: In this low SES population, there was substantial smoking cessation, widespread acknowledgment of the cumulative effect of smoking and other CVD risk factors, and some evidence that smoking cessation increased after the diagnosis of hypertension.

Response rates to random digit dialing for recruiting participants to an onsite health study.

OBJECTIVE: To evaluate the response rates when random digit dialing was used as a substitute for geographic area sampling and household interviews to recruit 2100 African Americans for a blood pressure measurement and hypertension-related knowledge and attitudes survey. METHODS: Random digit dialing was used to identify African American adults living in 12 low-income ZIP code areas of Houston, Texas. A brief survey of hypertension awareness and treatment was administered to all respondents. Those who self-identified as African American were invited to a community location for blood pressure measurement and an extended personal interview. An incentive of $10 was offered for the completed clinic visit. A substudy of nonrespondents was carried out to test the effectiveness of a $25 incentive in increasing the response rate. Data from the initial random telephone interview were used to identify differences between those who did and did not attend the measurement session. RESULTS: Ninety-four percent of eligible persons contacted completed the telephone survey, and 65% agreed to visit a central community site for blood pressure measurement. In spite of the financial incentive and multiple attempts to reschedule missed appointments, only 26% of the 65% who agreed to attend completed the scheduled visit. In the substudy of the higher financial incentive, all of those who missed the original appointment agreed to another appointment, and 85% of this subgroup kept it. Not being employed full-time and a history of hypertension were consistently associated with agreement to be measured and keeping an appointment. In spite of the low response rate for scheduled appointments, differences--other than in employment status and a history of hypertension--between responders and nonresponders were small and consistent with what is usually observed in health surveys. CONCLUSIONS: The use of random digit dialing as a substitute for area sampling and household screening resulted in unacceptably low response rates in the study population and should not be undertaken without further research on ways to increase response rates.

Hypertension control in multi-ethnic primary care clinics.

The most recent JNC-V guidelines for hypertension treatment call for control of blood pressure (BP) to < 140/90 mm Hg, with increased emphasis on control of systolic pressure. To determine the extent and determinants of BP control in a large multi-ethnic, low-income clinic population of diagnosed hypertensives immediately prior to issuance of the new guidelines, we reviewed the medical records of 2925 patients sampled from a population of over 14,000 hypertensives following in a network of nine primary care clinics operated by the Harris County Hospital District in Houston, Texas. Variables extracted from the medical record included: systolic (SBP) and diastolic (DBP) blood pressure at the initial clinic visit, average of all BP readings in the 12 months prior to the chart review (the measure of current control), antihypertensives prescribed at the most recent visit, and patient sociodemographic variables. The mean age of the sample was 61.6 +/- 12.8 years, and 67% were female. Average 12-month SBP and DBP were 141 +/- 14.7 and 83.6 +/- 8.5 respectively. Forty-nine per cent of patients had SBP controlled to < 140 mm Hg, 79.5% had DBP controlled to < 90 mm Hg, and 46% of patients achieved the criterion of < 140/90 mm Hg. In logistic regression analysis, age, baseline BP, body mass index and ethnicity, but not gender, were associated with current control. After adjustment for other covariates, Hispanics and Black people were significantly more likely to be in poor control than whites (ORHISP = 2.05, 95%Cl = 1.57-2.70; ORBlack = 1.48, 95%Cl = 1.21-1.81). Twelve per cent of patients were not receiving any antihypertensive medication. Of the remaining, the majority (52%) were on monotherapy. In the monotherapy group, 45% had SBP > or = 140 mm Hg and 16% had DBP > or = 90 mm Hg. We conclude that the achievement of new treatment recommendations will require education of primary care providers in more aggressive titration of antihypertensive medications to control SBP.