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Addressing Multi - level Influences on Hypertension DisparitiesCheryl Himmelfarb, RN, PhD, FAAN, FAHA, FPCNA
Vice Dean for Research and Sarah E. Allison Endowed Professor
Disclosures: None
1. Identify and discuss multiple levels influencing disparities in hypertension control among racial and ethnic groups.
2. Review effective strategies for reducing racial and ethnic disparities, including the Reducing Inequities in Care of Hypertension: Lifestyle Improvement for Everyone (RICHLIFE) Project.
Object ives
Virani S. et al. Circulation . 2021;143:e254–e743. DOI: 10.1161/CIR.0000000000000950
US Trends
Hypertension and Cardiovascular Disease Risk
CVD risk increases in a log - linear fashion from SBP levels 115 -180 mm Hg and from DBP levels 75 -105 mm Hg. 1
20 mm Hg higher SBP and 10 mm Hg higher DBP doubles risk of death from CVD, stroke, or other vascular disease.
Among >1 million adult patients higher SBP and DBP increased risk of CVD incidence and angina, MI, HF, stroke, PAD, and abdominal aortic aneurysm 2
1. Lewington S et al. 2002. Lancet2. Rapsomaniki E et al. 2014. Lancet
Ischemic Heart Disease Mortality
Stroke Mortality
Age -adjusted Prevalence of Hypertension: Adults ≥ 20 years, NHANES 2015 -2018
U.S. adults with hypertension
47.3%(121.5 million)
Males51.7%
Females42.8%
White Males51%
Black Males 58.3%
Asian Males 51.0%
Hispanic Males 50.6%
White Females 40.5%
Black Females 57.6%
Asian Females 42.1%
Hispanic Females 40.8%
Virani SS et al. 2021. Circulation
Hypertension Prevalence among US Adults Varies by GeographyPrevalence of Hypertension Awareness, 2019, US Adults Ages 20 and older
Behavioral Risk Factor Surveillance System (BRFSS)
Virani, SS et al. 2021 Circulation.
Awareness, treatment, and control ofhigh blood pressure by race/ethnicity
and sex in the US, NHANES , 2015 –2018
Uncontrolled hypertens ion ma y be w orsening in the US
53.8%43.7%
Hypertension control: <140/90 mm Hg
Muntner P., et al. 2020. JAMA.
Uncontrolled hypertens ion ma y be w orsening in the US
Muntner P et al. 2020. JAMA
25%19%
Hypertens ion control: <130/80 mm Hg
About 1 in 5 adults have
controlled BP
W hy a re BP Control Ra tes Poor?Environment / Society Poor social support Food deserts Inadequate community
resources
Patients Low health literacy Unhealthy lifestyles Non-adherence to
medications
Health SystemQuality orientationStaffingTeam functioningPractice resourcesOutreach focus
Clinicians / StaffClinical inertiaCompeting prioritiesTechnical skillsCommunication skillsCultural competence
Frieden TR. A framework for public health action: The Health Impact Pyramid. Am J Public Health. 2010;100(4):590 -5.
The Hea lth Impa ct Pyra mid
Popula t ion Hea lth Fra mew ork
Source: 2017 County Health Rankings: Maryland
Worlds Apart Though the Distance is 5 Miles
Source: Baltimore City Neighborhood Health Profile Reports 2017 (http://health.baltimorecity.gov/neighborhoods/neighborhood -health -profile -reports). Accessed 6/14/2021
Roland Park• 83.9 year life expectancy• Death rate from Heart Disease: 13.6 per 10,000• Death rate from Stroke: 5.1 per 10,000• Median Household Income: $104,482• <HS Diploma: 7% • Unemployment Rate: 2.3%• Hardship Index: 16• % of Land Covered by Food Desert: 0%• % of Land Covered by Green Space: 63.6%
Clifton -Berea• 66.9 year life expectancy• Death rate from Heart Disease: 27.7 per 10,000• Death rate from Stroke: 6.9 per 10,000• Median Household Income: $ 25,738• < HS Diploma only: 63.3% • Unemployment Rate: 17.4%• Hardship Index: 61• % of Land Covered by Food Desert: 47.9%• % of Land Covered by Green Space: 11.8%
Multilevel Influences on Hypertension Disparities
Individual Patient
Local CommunityIncome inequalityPoverty levelsRacial segregationInterpersonal discriminationCrime ratesFood availability
Provider/Clinical TeamKnowledge of guidelinesAwareness of disparitiesBP measurement skillsPatient -centered communication skillsCultural competencyTrustworthiness
Individual Patient LevelBiological effectiveness of medicationsAdherence to medications/lifestyleMental health and substance abuse Reactions to discriminationHealth literacyEnglish proficiencyHealth insurance coverage
National Health PolicyMedicare reimbursementHealth care reformNational initiatives
State Health PolicyHealth care exchangesMedicaid expansionHospital performance data policiesState plans and programs
Organization/Practice SettingOrganization structure and resourcesClinical decision supportElectronic medical recordsPatient education/care coordinationTeam functioning
Family/Social SupportFamily dynamicsFamily historyFinancial strainSocial networks/peer support
Mueller M, Purnell TS, Mensah GA, Cooper LA. Reducing Racial and Ethnic Disparities in Hypertension Prevention and Control: W hat Will It Take to Translate Research into Practice and Policy? Am J Hypertens . 2015;28(6):699 -716.
Best Pra ct ice Stra teg ies
Have the potentia l to improve the delivery a nd qua lity of ca re in clinica l se ttings . Effective s tra tegies in this doma in ca n lea d to ea rlier detection, improved disea se ma na gement, a nd even prevention of the onset of CVD.
Hea lthca re Sys t em In te rven t ions
Connect community progra ms w ith hea lth sys tems to improve chronic disea se prevention, ca re , a nd ma na gement. Effective links ca n reduce ba rriers to ca re a nd increa se pa tient a dherence to clinicia n recommenda tions .
Com m unity-Clin ica l Links
Centers for Disea se Control a nd Prevention. Bes t Pra ctices for Ca rdiova scula r Disea se Prevention Progra ms: A Guide to Effective Hea lth Ca re Sys tem Interventions a nd Community Progra ms Linked to Clinica l Services . Atla nta , GA: Centers for Disea se Control a nd Prevention, US Dept of Hea lth a nd Huma n Services ; 2017.
Examples of Promising Interventions to Address Hypertension DisparitiesIndividual Level
Dietary Approaches to Stop Hypertension (DASH)Patient self -management strategies, e.g., problem -solving skills, SMBP
Family, Peer, & Social NetworkPeer support interventionsBarber shop/beauty parlor interventions
Provider/Team LevelsNurse and pharmacist -delivered care managementProvider audit and feedback and communication skills training
Organizational LevelElectronic medical records with decision supportTele-monitoringVirtual visits
Community LevelCommunity health worker outreach, education and support
Policy LevelEarly childhood education Urban planning and community developmentHousingIncome enhancements and supplementsEmployment
Centers for Disease Control and Prevention. Best Practices for Cardiovascular Disease Prevention Programs: A Guide to Effecti ve Health Care System Interventions and Community Programs Linked to Clinical Services. Atlanta, GA: Centers for Disease Control and Prevention, US Dept of Health and Human Services; 2017.
Reducing Inequities in Care of Hypertension: Lifestyle Improvement for EveryoneLisa Cooper MD, MPH and Jill Marsteller, PhD, MPP Co-PIsFunded by thePatient-Centered Outcomes Research Institute (PCORI)NHLBI Grant #UH3 HL130688
• Principal Investigators: Lisa A. Cooper, MD, MPH, and Jill A. Marsteller, PhD, MPP
• Workgroup Leaders: Carmen Alvarez, PhD, RN, CRNP; Romsai Tony Boonyasai, MD, MPH; Kathryn (Kit) Carson, ScM; Deidra Crews, MD, ScM; Cheryl Dennison-Himmelfarb, PhD, RN; Chidinma Ibe, PhD; Lisa Lubomski, PhD; Edgar (Pete) Miller, III, MD, PhD; Jessica Yeh, PhD
• Other Faculty: Rexford Ahima, MD, PhD; Denis Antoine, MD; Lee Bone, RN, MPH; Jeanne Charleston, PhD, RN; Gail Daumit, MD, MHS; Raquel Greer, MD, MHS; Felicia Hill-Briggs, PhD, Yea-Jen Hsu, PhD; David Levine, MD, ScD, MPH; Chiadi Ndumele, MD, MHS; Tanjala Purnell, PhD, MPH; Debra Roter, DrPH; Nae-Yuh Wang, PhD; Kristina Weeks, MHS
• Center Program Manager: Nancy Edwards Molello, MSB
• Project Managers: Katie Dietz, MPH; and Gideon Avornu, MS
• Project Staff: Deven Brown, MPA; Jia Lee; Modupe Oduwole, MD, MPH; Erika McCannon; Jolene Lambertis; Princess Osazuwa; Camila Montejo-Poll; Lia Escobar Acosta; Margaret Mejia; and Ismael Gonzalez
The Research Team
Our Health System Partners
Our Community Partners
• Design: Cluster randomized trial • Setting: 30 practices in Maryland and Pennsylvania• Participants: 1,822 patients (~60 per site)
o Must have uncontrolled hypertension plus at least one other condition: diabetes, depression, high cholesterol, heart disease, or tobacco smoking
• Interventions: o Standard of care plus (SCP)o Collaborative Care/Stepped Care (CC/Stepped Care)
• Primary outcomes at 12 and 24 months (subgroup analyses: race and ethnicity) o Biomedical: BP control (<140/90 mm Hg) and change in average systolic BP o Patient reported: change in patient activation from baseline
Project Overview
Cooper LA, Marsteller JA, Carson KA, et al. Am Heart J. 2020;226:94-113.
Arm 1: Standard of Care Plus
• Standardized BP Measurement Training
• Hypertension Care and Best Practices Training
• Health System Leaders Learning Network
• Hypertension Dashboard
Arm 2: Collaborative Care/Stepped Care InterventionAll Standard of Care Plus elements as well as:• Dashboard data review facilitated by champions• Clinic champions also receive additional health equity
leadership training through monthly coaching calls• Collaborative care intervention delivered by nurse care
managers• Stepped care component
Stepped CareStepped Care
Element
Types of Clinicians
Available to Provide Services
Description of Role/Issues Addressed
Subspecialist Consultation
Services
Subspecialty trained physicians
Engage specialists in the areas of hypertension, diabetes, psychiatry, preventive cardiology, and smoking cessation to assist primary care team in managing complex cases and educating providers
Community-based Contextualization
Community health workers
Support patients in reaching self-management goals; help patients address social and environmental barriers through outreach and navigation services; engage, activate, and empower patients to participate in their care
RICHLife Participant Characteristics, N=1822Gender, N (%): Female 1082 (59.4)Race/Ethnicity, N (%):African American 1044 (57.3)Hispanic 174 (9.6)White 604 (33.2)
Age, years: Mean (SD), range 60.3 (11.9), 22-99Education, highest degree, N (%):No degree (less than HS diploma) 335 (18.4)High school diploma/GED 863 (47.4)College degree 436 (24.0)Graduate degree 183 (9.9)
Marital status, N (%):Married / Living with Partner 820 (45) Widowed 204 (11.2)Divorced/separated 403 (22.1)Never married 390 (21.4)
Has health Insurance 1782 (97.8)Health insurance type, N (%):*Private health insurance 815 (45.7)Medicare / Medi-Gap / Medicaid 1262 (70.8)Military health care 237 (13.3)Indian health services 1 (0.1)State sponsored / Other gov’t plan 207 (11.6)Single service plan 458 (25.7)Other 73 (4.1)
Main daily activity, N (%):Working full-time / part-time 698 (38.3)Unemployed / Looking for work 118 (6.4 )Student 6 (0.3)Keeping house, raising children 48 (2.6)Not working due to health 361 (19.8)Retired 584 (32.0)
* Type of health insurance was coded as all that applied.
Implementation ChallengesChallenges RICH LIFE Response
CM/CHW engagement with patients Monthly case and panel reviews, in-service trainings, implemented difficult to engage protocol
Confusion over the use of the phrase “Step-up”
Discontinued use of the phrase “step-up” and adopted “CHW referral” and “specialist consultation.”
Establishing clear understanding of the CM and CHW roles within the context of RICH LIFE
In-service trainings, webinars, and individual CM-CHW team meetings to discuss roles and responsibilities in RICH LIFE
Unable to fully document RICH LIFE patient visits into existing EMR templates
Created a separate research database for CMs and CHWs to enter more detailed accounts of their visits with patients
Cumbersome documentation requirements for CMs and CHWs
Regular meetings with CMs and CHWs to review data entry, discuss challenges, and offer support in completing data entry
Shifting care from a traditional medical assessment focus to a patient needs approach
Motivational interviewing (MI) trainings with CMs and CHWs and application of MI to patient case review
Primary Content of CM Follow-Up Visits62.1%
5.6%
25.3%
7.0%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
Medical Condition Social Determinants ofHealth/Barriers to Care
Lifestyle Other
N = 2691
Referrals to Stepped-Care Interventions
28.5%
12.9%
30.1%
71.4%
34.6%38.4%
2.1% 1.9% 2.7% 1.6% 0.0%3.1%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
Overall Health System A Health System B Health System C Health System D Health System EPercent referred to CHW Percent referred to specialist core
42.3%
38.2%
8.7% 8.1%
2.4%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
45.0%
Medical Condition Social Determinants ofHealth/Barriers to Care
Lifestyle COVID-19 Other
Primary Content of CHW Follow-Up Visits
Lifestyle Topics
11.1%
34.5%
16.1%
24.0%
2.4% 11.9%
Medication Adherence DASH DietWeight Loss ExerciseAppointment Adherence Other
Care Manager, N=678 Community Health Worker, N=25
12.0%
24.0%
12.0%8.0%
12.0%
32.0%
Medication Adherence DASH DietWeight Loss ExerciseAppointment Adherence Other
Social Determinants of Health/Barriers to Care Topics
10.7%
8.1%
2.7%
34.9%
4.7%
4.7%0.7%
15.4%
18.1%
Housing Social Support EmploymentPsychosocial Transportation EnvironmentalEducation Economy/Financial Other
Care Manager, N=149 Community Health Worker, N=74
18.9%
5.4%
1.4%2.7%
9.5%
5.4%
21.6%
35.1%
Housing Social Support EmploymentTransportation Environmental EducationEconomy/Financial Other
Discuss ion Stay tuned for outcomes of the RICHLife Project
Hypertens ion control is w orsening in the US
Multi- level influences drive pers is tent hypertens ion dispa rities
Build on popula tion hea lth funda menta ls a nd a ddress SDOH
Employ bes t pra ctices for hea lthca re sys tem interventions a nd to es ta blish robust community-clinica l links
Enga ge pa rtne rs a cros s s ectors
Meet peop le w here they lea rn , p la y, p ra y a nd w ork
Our impa ct on improving hype rtens ion control a nd reducing inequit ie s is dependent on our s ucces s in tra ns la ting evidence -ba s ed recommenda tion in to “p ra ctice” a nd high leve l a dop tion a t the popula tion leve l.
