A new clinical investigation published in the Journal of the American Heart Association confirms that race and ethnicity are significant determinants of engagement in shared decision making (SDM), a communication model between patients and providers that is associated with greater blood pressure reductions.
Data from a large U.S.-based randomized trial shows that higher SDM engagement improves treatment outcomes in individuals with uncontrolled hypertension and that racial disparities exist in SDM levels and corresponding BP control.
The study draws attention to the structural role of education, knowledge, and race in shaping how patients participate in treatment decisions—and the measurable cardiovascular outcomes that follow.
Key Study Highlights
- Black patients reported higher SDM scores than White patients, despite having higher baseline BP levels.
- Greater SDM engagement was strongly associated with larger reductions in systolic BP at 12 months.
- Patients who believed medication was “very important” showed greater SDM engagement.
- Surprisingly, having more than a high school education was linked with lower SDM scores.
- BP reductions were most pronounced in patients with higher SDM interaction over time.
Contents
Background: Disparities in Hypertension Care and Medication Adherence
Hypertension prevalence is disproportionately high among Black and Latino patients, yet adherence to antihypertensive medications remains lower compared to White patients.
These differences are often attributed to socioeconomic inequities and educational gaps, which may be mitigated through shared decision making strategies.
SDM encourages patients to actively participate in choosing their treatment path, increasing adherence and satisfaction with care.
Methodology: Assessing SDM and Blood Pressure Outcomes
The study analyzed 1,426 patients enrolled in the Reducing Inequities in Care of Hypertension: Lifestyle Improvement for Everyone (RICH LIFE) trial, which was conducted across 30 clinical sites in the United States.
Participants had uncontrolled hypertension at baseline, with systolic BP readings averaging 149.9 mmHg in White patients, 151.8 mmHg in Latino patients, and 153.5 mmHg in Black patients.
SDM engagement was measured using the CollaboRATE instrument, a validated patient-reported tool assessing clinician support in decision-making.
Demographics were stratified by race: 59.2% Black, 32.2% White, and 8.6% Latino, with mean ages of 58, 65, and 57 years, respectively.
Findings: Racial and Knowledge-Based Predictors of Engagement
At the 12-month follow-up, Black patients had significantly higher SDM scores than White patients (b = 0.14; P < .001), even after adjusting for clinical variables.
Patient activation—the extent to which individuals are engaged in their own health management—was positively associated with SDM scores (b = 0.09; P = .001).
Patients who believed that blood pressure medication was “very important” had higher SDM scores (b = 0.06; P = .022).
Paradoxically, individuals with education levels above high school reported lower SDM engagement (b = -0.08; P = .045), suggesting complexity in the way education interacts with care expectations.
Blood Pressure Reduction: The Impact of Engagement
Patients who reported higher levels of SDM engagement had significantly greater reductions in systolic BP over time.
At 12 months, greater SDM engagement was associated with a mean systolic BP reduction of 11.41 mmHg (P < .001), with a further improvement linked to the time-by-SDM interaction (b = -0.42; P = .035).
Other covariates influencing BP change included Black race vs. White (b = 3.14), knowledge of what hypertension means (b = 1.71), comorbid diabetes (b = 1.60), and age (b = 0.12).
Limitations and Call for Future Research
The study was limited by its underrepresentation of Latino patients and the absence of Asian, Native American, and multiracial groups, which restricts the generalizability of its findings.
Authors noted that education, hypertension knowledge, patient activation, and cultural engagement may each uniquely affect SDM participation and BP outcomes.
They recommend further research to better understand racial and ethnic SDM disparities in order to develop more responsive, equitable care models.
