From Pages to Practice

By Michael Mi, MD

Published April 4, 2018

The following testimonial was just one of many peer-experience stories that were posted in black-owned barbershops across Los Angeles County to motivate participation by patrons in a landmark clinical trial published in this week’s NEJM.

"My doctor advised diet and exercise for my high blood pressure. I biked 5 days a week & lost 15 pounds. But my pressure crept up. Diet and exercise aren't enough for me. Eric introduced me to the pharmacist working with him. He's my barber 15 years so I trust him. Kathy prescribed medicine and my doctor is on board. I'm glad because I want to enjoy life at 70."

The study sought to address a key health disparity among non-Hispanic black men — uncontrolled blood pressure and high rates of hypertension-related death — by providing healthcare in a familiar setting. The barbershop was a natural choice because of its cultural and social importance as a safe space where black men can talk freely with trusted peers. 

The investigators enrolled 319 black men with baseline systolic blood pressure (SBP) ≥140 mm Hg from 52 barbershops. The barbershops were cluster-randomized to one of two strategies: Barbers recommended that their patrons meet with a specialty-trained pharmacist in the barbershop for hypertension management (intervention arm, 28 shops) or barbers suggested lifestyle modification and follow-up with the patron’s doctor (control arm, 24 shops). As a testament to the role that barbershops play in this population, most participants in the intervention arm had monthly blood pressure measurements taken during the 6-month trial, and only 5% were lost to follow-up. 

At 6 months, the mean reduction in SBP from baseline (the primary outcome) was significantly greater in the intervention arm than in the control arm (mean reduction, 27.0 mm Hg vs. 9.3 mm Hg; P<0.001). Significantly more patrons in the intervention arm also had blood pressures <140/90 mm Hg (89.4% vs. 32.2%; P<0.001). Although the intervention was not associated with a change in the number of doctor visits, it did increase the use of antihypertensive medications (from 55% to 100% vs. 53% to 63% in the control arm).

Dr. Ronald Victor, the lead investigator, has tested healthcare outreach in the community before. In a previous cluster-randomized clinical trial, he and his colleagues found that routine blood pressure checks in barbershops had minimal effect on hypertension control. What might explain the difference between the two studies? Likely, the addition of pharmacists in the current study bridged the gap between recognition of hypertension and its treatment. Participants in the intervention arm received an average of seven in-person visits and four follow-up telephone calls with a pharmacist. With this amount of healthcare contact, it’s no surprise that the participants benefited from the intervention. More research is needed to determine the cost and effectiveness of this strategy in a larger population, but the results represent an important step towards addressing health disparities in a prevalent condition that is associated with major morbidity.

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Mike is a 2017-2018 NEJM Editorial Fellow and a hospitalist at Beth Israel Deaconess Medical Center. He graduated from Harvard Medical School and completed his internal medicine training at BIDMC.