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Hypertension Management in Health Care for the Homeless Clinics: Results from a Survey
Kraig Kinchen, BS, and James D. Wright, PhD
Introduction With the exception of alcohol abuse, hypertension is the most common chronic physical health problem encountered among homeless persons, afflicting between 14% and 25% of this population.'l The management of hypertension in the homeless is complicated by material and existential conditions. Proper dietary practice is exceedingly difficult to maintain,5 rates of alcohol abuse exceed 50%,4 storage and administration of medicines are difficult, and the cost of medication can be prohibitive. Compliance and maintenance of contact with homeless hypertensives are also difficult, and the asyrnptomatic stages of the disease produce little or no motivation to seek or maintain treatment. In 1984, the Robert Wood Johnson Foundation, sensing the widespread unmet medical needs of the nation's homeless, funded health care for the homeless (HCH) clinics in 19 cities. In 1988, the McKinney Homeless Assistance Act extended the system to an additional 89 cities. We surveyed these 108 HCH clinics to learn how medical practice is adapted to the unique needs of homeless hypertensives, using a questionnaire loosely modeled on two recent surveys of hypertension management in "normal" clinical practice.6'7 One of the clinics served only children and was dropped from the sampling frame; responses were obtained from 65 (60.7%) of the remaining 107 clin-
initiation of drug therapy when diastolic blood pressure (DBP) exceeds 94 mm Hg or at somewhat lower pressures if other risk factors are present; nondrug therapies are recommended for DBP between 90 and 94 mm Hg. HCH physicians largely adhere to the JNC recommendations. For an otherwise asymptomatic 45-year-old homeless white male, nondrug therapy would be initiated at an average DBP of 90.5 mm HG or at an average systolic blood pressure (SBP) of 151 mm Hg. Likewise, drug therapy would usually be initiated at a DBP of 97 mm Hg and at an SBP of 161 mm Hg. In both respects, HCH physicians differ little from clinicians in Maryland and New York City. Therapeutic goals are also very similar in both settings, with DBP :e>s:::R...........
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