At Black Barbershops, BP Reductions Still in Style at 1 Year

Patrice Wendling

December 18, 2018

A barbershop-based intervention aimed at reducing hypertension in high-risk black men passed a major sustainability milestone, demonstrating continued blood pressure (BP) reductions at 1 year despite fewer pharmacist visits.

At 12 months, mean systolic BP fell by 28.6 mm Hg (to 123.8 mm Hg) in the intervention group and by 7.2 mm Hg (to 147.4 mm Hg) in the control group (P < .0001), according to results published online December 17 in Circulation.

"The first 6 months proved the program could work; the second 6 months showed we could continue to achieve that significant reduction," Ciantel Blyler, PharmD, Cedars-Sinai Smidt Heart Institute, Los Angeles, coauthor of the LA Barbershop (LABP) Extension study and a participating pharmacist, told | Medscape Cardiology.

At 6 months, systolic BP fell an average of 27 mm Hg among black men whose local barber measured BP and promoted monthly follow-up with specialty trained pharmacists who monitored BP and prescribed medications in collaboration with primary care providers.

Mean systolic BP reduction was 9.3 mm Hg among black men in the control group where local barbers promoted only lifestyle change and follow-up with primary care providers, according to the architect of the study, Ronald G. Victor, MD, who died just months after presenting the initial findings.

Although described at the time as a "home run" and a "coup," questions were raised about the program's sustainability and portability beyond the 52 participating black-owned Los Angeles County barbershops. It was noted that about 20% of participants did not have a regular provider and that the program requires a high level of coordination by pharmacists, whose ability to act independently varies among states.

To address some of these concerns, the protocol was extended for an additional 6 months to 319 men with complete data at the end of the initial 6 months. Mean baseline systolic BPs were 152.4 mm Hg and 154.6 mm Hg for the intervention and control groups, respectively.

"There was no change at all to the protocol," Blyler said. "The big difference was that we saw most people get to goal in the initial 6-month phase and because people were sort of on 'cruise control,' so to speak, on their medications, and their labs were stable, we saw them less frequently in the second half of the study."

This was partly by design to reduce the burden on pharmacists of having to travel, which in a sprawling city like Los Angeles often meant spending 2 to 3 hours a day in the car to cover the 450-square-mile territory, she said.

At 6 months, 63.6% of men receiving the active intervention and 11.6% of men receiving the control intervention achieved the most recent BP target of less than 130/80 mm Hg.

After 12 months, a BP below 130/80 mm Hg was achieved by 68% and 11%, respectively (P = .0177). Pharmacist visits fell from an average of seven per patient in the first 6 months to four in the second 6 months.

"You don't see patients typically following up with their provider every 2 weeks, 3 weeks, even 5 weeks, and people were willing to do that," Blyler said. "I think it all had to do with the fact that we were coming out of our comfort zones, coming out of the clinic, and meeting them where they are comfortable."

"All the success we had is because of that and, of course, the fact we had barbers willing to endorse the program and make us trustworthy individuals," she said. "Their endorsement, Dr Victor used to always say, was so critical to our success."

In an accompanying editorial, Keith Ferdinand, MD, and Rachel M. Graham, BA, both from Tulane University, New Orleans, said the "LABP Extension clearly demonstrated the effectiveness of a community-partnered team" and "impressively, there was no statistical difference between the 12-month results and previously reported 6-month efficacy data, and no serious adverse events related to the treatment."

Despite these "obvious benefits," they suggest reproducibility of the program "may be limited due to its complexity, high costs, and restrictions on nationwide dissemination due to the limited availability of the California-approved Collaborative Practice Agreement (CPA), giving the pharmacists prescriptive authority."

The editorialists highlight other ongoing initiatives, such as Target BP and Million Hearts, and suggest "improved, standardized treatment approaches in conventional practice settings may be an even more cost-effective solution to reduce uncontrolled hypertension in black men."

For example, a Kaiser Permanente program that takes an approach similar to the barbershop program, using evidence-based guidelines with initial single-pill combination pharmacotherapy, recently reported improving BP control rates — from 76.6% to 81.4% in black participants and from 82.9% to 84.2% in white participants — and cutting the racial gap in BP control by 50%.

The historic distrust many blacks have for the medical profession could pose an obstacle for in-office programs, noted Blyler. Her group is considering using telemedicine and video conferencing as a means of follow-up, particularly in the patients who get to target BP quite quickly. Cost-analyses of the LABP program are also ongoing, she said.

The study was funded by the National Institutes of Health (NIH) National Heart, Lung, and Blood Institute; the NIH National Center for Advancing Translational Sciences; the UCLA Clinical and Translational Science Institute; the California Endowment, the Lincy Foundation; the Harriet and Steven Nichols Foundation; the Burns and Allen Chair in Cardiology Research at the Smidt Heart Institute; and Cedars-Sinai Medical Center.

Coauthor Florian Rader, MD, reports consulting for Recor Medical. The other authors report no conflicts.

Ferdinand reports serving on the LA Barbershop Data and Monitoring Board. Graham has no disclosures.

Circulation. Published online December 17, 2018. Abstract, Editorial

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