Health Care Disparities: A Focus on Hypertension

Health Care Health Care Disparities: A Disparities: A

Focus on Focus on HypertensionHypertensionBrian K. Irons, PharmD, BCPS,

BC-ADMDivision Head – Primary Care

Associate ProfessorSchool of Pharmacy

ObjectivesObjectives

Review Types and Causes of Review Types and Causes of Healthcare Disparities Healthcare Disparities

Assess Disparities in HTN Assess Disparities in HTN Awareness / Control / Treatment Awareness / Control / Treatment

Examine Ways to Minimize Examine Ways to Minimize Disparities Disparities General MeasuresGeneral Measures Role of AcademiaRole of Academia Focus on HTNFocus on HTN

Disparities in HealthcareDisparities in Healthcare

Health Health Disparities Disparities / Inequities/ Inequities

Race / Ethnicity


Race / Ethnicity

Gender


Race / Ethnicity

Gender

Sexual Orientation


Race / Ethnicity

Gender

Sexual Orientation

SocioeconomicGroup


Race / Ethnicity

Gender

Age

Sexual Orientation

SocioeconomicGroup


Race / Ethnicity

Gender

Age

Sexual Orientation

SocioeconomicGroup

Rural vsUrban

Major Types of Major Types of DisparitiesDisparities

AccessAccess to Care (Disparities to Care (Disparities in Health Care)in Health Care)

QualityQuality of Care of Care (Disparities in Health)(Disparities in Health)

Causes of Disparities in Access Causes of Disparities in Access to Careto Care

Insurance coverageInsurance coverageRegular source of careRegular source of careDelay in seeking careDelay in seeking careDecrease in needed careDecrease in needed care

Financial resourcesFinancial resources Legal barriersLegal barriers Structural barriersStructural barriers

Quality /Access to Care: Quality /Access to Care: Insured vs UninsuredInsured vs Uninsured

Reduced Access to careReduced Access to carePoorer medical outcomesPoorer medical outcomes Increased morbiditiesIncreased morbiditiesEarlier mortalityEarlier mortality

Biggest impact on timeliness Biggest impact on timeliness and quality of health careand quality of health care

American College of Physicians 2004 Institute of Medicine 2001 2002

Population Base and Population Base and UninsuredUninsured

Annals Intern Med 2004;141:226

% of Population White

Latino

Afr-Amer

Asian - PI

AmerIndian

% Uninsured


Insurance coverageInsurance coverage Financial resourcesFinancial resources Legal barriersLegal barriers Structural barriersStructural barriers

TransportationTransportation SchedulingScheduling Employment issuesEmployment issues


Fragmentation of health care Fragmentation of health care “system”“system”

Provider scarcityProvider scarcity Language barriersLanguage barriers Health literacyHealth literacy Healthcare beliefsHealthcare beliefs AgeAge

Social Determinants in Social Determinants in Disparities based on Disparities based on

Race/EthnicityRace/Ethnicity

Socioeconomic Status




Inadequate Housing




Inadequate Housing

Proximity to Environmental Hazards



Education Level


Inadequate Housing

Proximity to Environmental Hazards

Causes of Disparities in Causes of Disparities in Quality of CareQuality of Care

Provider – Patient Provider – Patient CommunicationCommunication

Provider Discrimination / BiasesProvider Discrimination / Biases Poor Preventative CarePoor Preventative Care

Decreased patient satisfactionDecreased patient satisfactionDecreased adherenceDecreased adherenceWorse outcomesWorse outcomes

Awareness / Treatment / Awareness / Treatment / ControlControl

of Hypertension of Hypertension

Differences between Differences between Races/Ethnicities and AgeRaces/Ethnicities and Age

Risks of Uncontrolled Risks of Uncontrolled HTNHTN

Increased BP

Arrhythmias

Stroke

MyocardialInfarction

Retinopathy

Nephropathy

Cognition

Heart Failure

NCHS Data Brief January 2008



Trends in HTN- GenderTrends in HTN- Gender

0

5

10

15

20

25

30

35

Per

cent

of P

opul

atio

n

1988-1994 1999-2002 2003-2006

MenWomen

DHHS – CDC – NCHS 2009Elevated BP or Taking BP Med

Trends in HTNTrends in HTNRace/Ethnicity - MenRace/Ethnicity - Men

0

5

10

15

20

25

30

35

40

45

Per

cent

of P

opul

atio

n

1988-1994 1999-2002 2003-2006

WhiteAfr-AmerMex-Amer


Trends in HTNTrends in HTNRace/Ethnicity - WomenRace/Ethnicity - Women

0

5

10

15

20

25

30

35

40

45

Per

cent

of P

opul

atio

n

1988-1994 1999-2002 2003-2006

WhiteAfr-AmerMex-Amer


Trends in HTNTrends in HTNIncomeIncome

0

5

10

15

20

25

30

35

Per

cent

of P

opul

atio

n

1988-1994 1999-2002 2003-2006

< 100%100-199%200+ %


Poverty Level

BP Differences: Medicare BP Differences: Medicare EligibilityEligibility

Annals of Intern Med 2009;150:505

Prevalence of HTN – Dyslipidemia Prevalence of HTN – Dyslipidemia – DM– DM

2005-2006 NHANES2005-2006 NHANES

28.9 29.8

13.4 12.812.7

2.8 2.53.8

26.128.6

16.4

4.6

0

10

20

30

40

50

60

Total White Afr-Amer Mex-Amer

Perc

ent 3 Conditions

2 Conditions1 Conditon

CDC NHCS Data Brief #36 April 2010

Hypertension And AgeHypertension And Age

HTN and AgeHTN and Age

13.4

35.9

55.8

69.6

23.2

36.2

53.764.7 64.1

6.2

76.4

16.5

0102030405060708090

20-34 35-44 45-54 55-64 65-74 75+

Per

cen

t o

f P

op

ula

tio

n

Men Women

Lloyd-Jones D, et al. Circulation. 2009.119; e21-e181.

Changes in SBP/DBP with AgeChanges in SBP/DBP with Age

NEJM 2007;357:789

BP-Age and Mortality from Heart BP-Age and Mortality from Heart DiseaseDisease

Chobanian AV, et al. JNC 7. Hypertension. 2003; 42:1206 1252.

80-89 yrs 70-79 yrs 60-69 yrs 50-59 yrs 40-49 yrs

Fatal CAD Risk and AgeFatal CAD Risk and Age

For the same Systolic BPFor the same Systolic BP Patient 80-89 years of age versus Patient 80-89 years of age versus

40-49 years40-49 years 16x risk for fatal CAD16x risk for fatal CAD

Circulation 2007;115

Minimizing DisparitiesMinimizing Disparities

Minimize Disparities: Minimize Disparities: Race/EthnicityRace/Ethnicity

Increase government offices of minority Increase government offices of minority healthhealth

Expanded accessExpanded access Raise awareness (Providers and Patients)Raise awareness (Providers and Patients)

Health Disparities RoundtableHealth Disparities Roundtable Federal Collaboration on Health Disparities Federal Collaboration on Health Disparities

ResearchResearch Disparity Reducing Advances ProjectDisparity Reducing Advances Project CMS’s Health Disparities ProgramCMS’s Health Disparities Program Healthy People 2010 and 2020Healthy People 2010 and 2020

Minimizing Disparities in Minimizing Disparities in HTN Management : AgeHTN Management : Age

Don’t assume benefits will be limited Don’t assume benefits will be limited just because a patient is olderjust because a patient is older

Don’t treat all older patients the Don’t treat all older patients the samesame Functional / Cognitive StatusFunctional / Cognitive Status Living ArrangementsLiving Arrangements Co-morbiditiesCo-morbidities

Who is ‘Older’?

Patient 1 81 yo WM No chronic

medications No diagnosed

chronic conditions

Patient 2 66 yo HF Diagnosed with DM

12 years ago h/o CAD / CHF /

CVA / HTN / Lipids / COPD

On 17 meds Cognitively

impaired

Benefits to Treating Isolated Benefits to Treating Isolated Systolic HTNSystolic HTN

-30

-25

-20

-15

-10

-5

0

Rela

tive R

isk R

educti

on

(%)

Stroke ALL CVEvents

MI Mortality

15,693 patients, mean age 70, initial BP 174/83, 3.8 yr follow-up

Lancet 2000;355:865

Recommended HTN Recommended HTN Treatments for Isolated Treatments for Isolated

Systolic HTNSystolic HTN

SHEP / Syst-Eur TrialsSHEP / Syst-Eur Trials Thiazide DiureticThiazide Diuretic Dihydropyridine CCBDihydropyridine CCB

Approach and Goals similar to Approach and Goals similar to Essential HTNEssential HTN < 140/90 mm Hg< 140/90 mm Hg

-40

-35

-30

-25

-20

-15

-10

-5

0

5

10

15

Rela

tive

Change (

%)

Stroke Death

Treating HTN in the Very Treating HTN in the Very OldOld

Most trials excluded or simply didn’t recruit Most trials excluded or simply didn’t recruit many very elderly patients (> 80)many very elderly patients (> 80)

Meta-analysis in 1999 for those >80Meta-analysis in 1999 for those >80

Lancet 1999;353:793

Treating HTN in the Very Treating HTN in the Very OldOld

Retrospective Study in VA Patients > Retrospective Study in VA Patients > 80 years old 80 years old 85% taking antihypertensives85% taking antihypertensives Shorter duration survival for those with Shorter duration survival for those with

SBP <140 mm HgSBP <140 mm Hg ““Clinicians should use caution in Clinicians should use caution in

their approach to BP lowering in this their approach to BP lowering in this age group”age group”

JAGS 2007;55:383

Hypertension in the Very Hypertension in the Very Elderly Trial (HYVET)Elderly Trial (HYVET)

3845 patients 80+ years of age (mean 3845 patients 80+ years of age (mean 83.6 years)83.6 years)

Baseline BPBaseline BP: 173/91: 173/91 Indapamide vs placebo (perindopril Indapamide vs placebo (perindopril

added prn)added prn) Target BPTarget BP: < 150/80 : < 150/80 1.8 years of follow-up1.8 years of follow-up Primary outcome: Stroke (fatal and Primary outcome: Stroke (fatal and

non)non) Secondary outcomes: all cause Secondary outcomes: all cause

mortality / CV mortality / CAD mortality / CV mortality / CAD mortality / stroke mortalitymortality / stroke mortalityNEJM 2008;358:1887

Hypertension in the Very Hypertension in the Very Elderly Trial (HYVET)Elderly Trial (HYVET)

-70

-60

-50

-40

-30

-20

-10

0

% R

e R

educ

tion

(%

)

Stroke AllMortality

StrokeDeath

HF Any CVEvent

NS

NEJM 2008;358:1887Exp 143/78 vs placebo 158/84

What is BP Goal in the What is BP Goal in the Very Elderly?Very Elderly?

No specific guideline… yetNo specific guideline… yet < 150/80 ?< 150/80 ?

Reduces mortality, fatal stroke, HFReduces mortality, fatal stroke, HF Does it cause cognitive problems, Does it cause cognitive problems,

increase fall risk?increase fall risk? What about very elderly patients What about very elderly patients

with existing CADwith existing CAD Can we risk < 130/80?Can we risk < 130/80?

Risks of BP Meds in the Risks of BP Meds in the ElderlyElderly

Prone to ADRsProne to ADRs Lots of comorbidities / Lots of comorbidities /

contraindications to look out contraindications to look out forfor

Cognitive impairmentCognitive impairment ComplianceCompliance CostsCosts

Risks of BP Meds in the Risks of BP Meds in the ElderlyElderly

Orthostatic hypotensionOrthostatic hypotension Sensitive to volume depletion / Sensitive to volume depletion /

sympathetic inhibitionsympathetic inhibition Increased risk for fallsIncreased risk for falls

Definition:Definition: Sitting to standing drop in BP Sitting to standing drop in BP

(usually increase in heart rate)(usually increase in heart rate) >20 mm difference in SBP / >10 >20 mm difference in SBP / >10

mm dif in DBPmm dif in DBP

Strategies for HTN Strategies for HTN Medication use in ElderlyMedication use in Elderly

Start low and go slowStart low and go slow COMMUNICATECOMMUNICATE Once daily regimens if compliance Once daily regimens if compliance

issuesissues Avoid central acting agonists and Avoid central acting agonists and

alpha-blockersalpha-blockers Caution with beta-blockers without Caution with beta-blockers without

a compelling co-morbiditya compelling co-morbidity

Optimize use of medications that Optimize use of medications that may have pharmacodynamic benefits may have pharmacodynamic benefits in certain populationsin certain populations

Minimizing Disparities in Minimizing Disparities in HTN Management : Race / HTN Management : Race /

EthnicityEthnicity

African-Americans with African-Americans with HTN and Medication HTN and Medication

Adherence BeliefsAdherence Beliefs

Positive Factors

Negative Factors

FamilyFriends

NeighborsGod

Financial ResourcesNeighborhood ViolenceDistrust of Healthcare Professionals

J Cardiovasc Nursing 2010; 25:199

Age and Ethnicity Affect the Response of DBP toAge and Ethnicity Affect the Response of DBP to -Blockers but Not to Calcium Channel Blockers -Blockers but Not to Calcium Channel Blockers VA Cooperative Study of Responses to Single-Drug VA Cooperative Study of Responses to Single-Drug

TherapyTherapy

Materson BJ, et al. N Engl J Med. 1993;328:914-921.

-25

-20

-15

-10

-5

0

Ch

an

ge in

DB

P (

mm

Hg

)fr

om

Baselin

e

*P ≤ 0.05 vs. placebo†P ≤ 0.05 vs. white men of all ages‡P ≤ 0.05 vs. placebo and atenolol

Atenolol Diltiazem Placebo

White men, <60 yr

Black men, <60 yr

White men, ≥60 yr

Black men, ≥60 yr

**

‡*

*†*

* *

DBP = diastolic blood pressure

Reductions in Diastolic Blood Pressure in Reductions in Diastolic Blood Pressure in Response to Specific Drugs Were Influenced by Response to Specific Drugs Were Influenced by

Age and EthnicityAge and EthnicityVA Cooperative Study of Responses to Single-Drug VA Cooperative Study of Responses to Single-Drug

TherapyTherapy


-25

-20

-15

-10

-5

0

Ch

an

ge in

DB

P (

mm

Hg

)fr

om

Baselin

e

*P ≤ 0.05 vs. placebo only†P ≤ 0.05 vs. captopril or placebo‡P ≤ 0.05 vs. HCTZ or placebo

HCTZ Captopril Clonidine Prazosin Placebo

White men, <60 yr

Black men, <60 yr

White men, ≥60 yr

Black men, ≥60 yr

**

* ** * *

*

*

*†

‡†

DBP = diastolic blood pressure; HCTZ = hydrochlorothiazide

Reductions in SBPReductions in SBP** in Response to Atenolol, in Response to Atenolol, Captopril, and Prazosin Were Influenced by Age Captopril, and Prazosin Were Influenced by Age

and Ethnicityand EthnicityVA Cooperative Study of Responses to Single-Drug VA Cooperative Study of Responses to Single-Drug

TherapyTherapy


-35

-30

-25

-20

-15

-10

-5

0

Ch

an

ge in

SB

P (

mm

Hg

) fr

om

Baselin

e

*P ≤ 0.05 vs. placebo only†P ≤ 0.05 vs. older white men‡P ≤ 0.05 vs. older white men and younger black men§P ≤ 0.05 vs. older white men

Atenolol Captopril Prazosin Placebo

White men, <60 yr

Black men, <60 yr

White men, ≥60 yr

Black men, ≥60 yr

**

**

*§

*

*§

*SBP = systolic blood pressure

†‡

Reductions in Systolic Blood Pressure in Response Reductions in Systolic Blood Pressure in Response to Specific Drugs Were Influenced by Age and to Specific Drugs Were Influenced by Age and

EthnicityEthnicityVA Cooperative Study of Responses to Single-Drug VA Cooperative Study of Responses to Single-Drug

TherapyTherapy


-35

-30

-25

-20

-15

-10

-5

0

Ch

an

ge in

SB

P (

mm

Hg

) fr

om

Baselin

e

*P ≤ 0.05 vs. placebo only

HCTZ Clonidine Diltiazem Placebo

HCTZ = hydrochlorothiazide; SBP = systolic blood pressure

White men, <60 yr

Black men, <60 yr

White men, ≥60 yr

Black men, ≥60 yr

* * *

**

***

* * *

*

0

25

50

75

100

0

25

50

75

100

Reprinted from Materson BJ, et al. Am J Hypertens. 1995;8:189-192, with permission from Elsevier; Materson BJ, et al. N Engl J Med. 1993;328:914-921.

Su

ccessfu

l Tre

atm

en

t (%

)

Cloni

dine

White Men <60 yr

Rates of Successful Treatment Were Similar for Rates of Successful Treatment Were Similar for Most Single Drugs in White MenMost Single Drugs in White Men

VA Cooperative Study of Responses to Single-Drug VA Cooperative Study of Responses to Single-Drug TherapyTherapy

White Men ≥60 yr

Ateno

lol

Capto

pril

Diltia

zem

Prazo

sin

H

CTZ

Place

bo

*There were no clinically important differences (<15%) between the treatment groups spanned by the arrows. Treatment was considered to be successful if the diastolic blood pressure measured <95 mm Hg after 1 year.

HCTZ = hydrochlorothiazide

Su

ccessfu

l Tre

atm

en

t (%

)Clo

nidi

ne

Ateno

lol

Diltia

zem

Prazo

sin

HCTZ

Capto

pril

Place

bo

*

*

*

0

25

50

75

100

Reprinted from Materson BJ, et al. Am J Hypertens. 1995;8:189-192, with permission from Elsevier; Materson BJ, et al. N Engl J Med. 1993;328:914-921.

CCBsCCBs** and Diuretics Produced More Treatment and Diuretics Produced More Treatment Successes in Black MenSuccesses in Black Men

VA Cooperative Study of Responses to Single-Drug VA Cooperative Study of Responses to Single-Drug TherapyTherapy

0

25

50

75

100

Su

ccessfu

l Tre

atm

en

t (%

)

Cloni

dine

Black Men <60 yr Black Men ≥60 yr

Ateno

lol

Capto

pril

Diltia

zem

Prazo

sin

HCTZ

Place

bo Su

ccessfu

l Tre

atm

en

t (%

)Clo

nidi

ne

Ateno

lol

Diltia

zem

Prazo

sin

HCTZ

Capto

pril

Place

bo

††

††

†

*CCB = calcium channel blockers; HCTZ = hydrochlorothiazide†There were no clinically important differences (<15%) between the treatment groups

spanned by the arrows. Treatment was considered to be successful if the diastolic bloodpressure measured <95 mm Hg after 1 year.

ALLHAT Outcomes: Black vs ‘Nonblack’

No benefit of chlorthalidone over amlodipine in: Nonfatal MI / Death CHD All-cause mortality Stroke Combined CHD events

Favored thiazide over CCB for heart failure

Same results for age (< 65 or >65 years)

JAMA 2002;288:2981

ALLHAT Outcomes: Black vs ‘Nonblack’

No benefit of chlorthalidone over lisinopril in: Nonfatal MI / Death CHD All-cause mortality

Favored thiazide over ACE-I for: Stroke Combined CHD events Heart failure

JAMA 2002;288:2981

ALLHAT Outcomes: Age (< 65 or > 65)

No benefit of chlorthalidone over lisinopril in: Nonfatal MI / Death CHD All-cause mortality Stroke

Favored thiazide over ACE-I for: Combined CVD events Combined CHD events Heart failure

JAMA 2002;288:2981

Minimize Disparities: Role of Minimize Disparities: Role of AcademiaAcademia

Societal RolesSocietal Roles

Deliver primary and specialty services

Service to the poor or uninsured Research Education

Academic Medicine 2006;81:788

Minimize Disparities: Race / Minimize Disparities: Race / Ethnicity Ethnicity

Role of AcademiaRole of Academia Health Care SystemHealth Care System

Collect/Report data by Collect/Report data by race/ethnicityrace/ethnicity

Implement/Evaluate disparities-Implement/Evaluate disparities-reduction programsreduction programs

Support language interpretationSupport language interpretation Support use of evidence-based Support use of evidence-based

therapeuticstherapeuticsAcademic Medicine 2006;81:788


Role of AcademiaRole of Academia EducationEducation

Increased cultural competency Increased cultural competency (everybody in the work force not (everybody in the work force not just providers)just providers)

Increase minority representation in Increase minority representation in the healthcare workforcethe healthcare workforce

Increase cross-cultural educationIncrease cross-cultural education Impact of disparities on decision Impact of disparities on decision

makingmakingAcademic Medicine 2006;81:788


Role of AcademiaRole of Academia ResearchResearch

Identify sources of disparitiesIdentify sources of disparities Develop and evaluate Develop and evaluate

interventionsinterventions

Academic Medicine 2006;81:788

TTUHSC SOM ExamplesTTUHSC SOM Examples

Admissions: Increase minority Admissions: Increase minority enrollmentenrollment Recruitment activitiesRecruitment activities Scholarship moniesScholarship monies Recognized in past as a top recruiter of Recognized in past as a top recruiter of

Hispanic studentsHispanic students Curriculum:Curriculum:

Required Basic Medical SpanishRequired Basic Medical Spanish Required didactic or experiential Required didactic or experiential

training in cultural competencytraining in cultural competency

TTUHSC SOM ExamplesTTUHSC SOM Examples

Clinical Services:Clinical Services: Grace Clinic (East): Cardiology Fellows Grace Clinic (East): Cardiology Fellows

clinic serves underserved patient clinic serves underserved patient populationspopulations

Other Outreach:Other Outreach: Student run free clinic (Lubbock Student run free clinic (Lubbock

Impact)Impact) BP screenings by SOM studentsBP screenings by SOM students

TTUHSC SON ExamplesTTUHSC SON Examples

Larry Combest Community and Larry Combest Community and Wellness CenterWellness Center

Endowed Professor on Rural Health Endowed Professor on Rural Health DisparitiesDisparities

GrantsGrants Childhood obesity prevention / Focus on Childhood obesity prevention / Focus on

HispanicsHispanics RN-Family home visitation program for RN-Family home visitation program for

low income first time motherslow income first time mothers

TTUHSC SOP ExamplesTTUHSC SOP Examples Admissions Process: Increased enrollment of Admissions Process: Increased enrollment of

minoritiesminorities Curriculum:Curriculum:

Only SOP in the country with required Only SOP in the country with required advanced experiential training in both Peds advanced experiential training in both Peds and Geriesand Geries

Only 1 of 3 SOPs with required Rural rotationOnly 1 of 3 SOPs with required Rural rotation Medical Spanish Elective / Cult Competency Medical Spanish Elective / Cult Competency

ElectiveElective Reviewing cultural competency within the Reviewing cultural competency within the

curriculumcurriculum Service: Numerous faculty clinics in West Texas Service: Numerous faculty clinics in West Texas

providing care to underserved populationsproviding care to underserved populations

QUESTIONS QUESTIONS ????????????

Documents

Health Care Disparities: A Focus on Hypertension