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
Health Health Disparities Disparities / Inequities/ Inequities
Race / Ethnicity
Gender
Health Health Disparities Disparities / Inequities/ Inequities
Race / Ethnicity
Gender
Sexual Orientation
Health Health Disparities Disparities / Inequities/ Inequities
Race / Ethnicity
Gender
Sexual Orientation
SocioeconomicGroup
Health Health Disparities Disparities / Inequities/ Inequities
Race / Ethnicity
Gender
Age
Sexual Orientation
SocioeconomicGroup
Health Health Disparities Disparities / Inequities/ Inequities
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
Causes of Disparities in Access Causes of Disparities in Access to Careto Care
Insurance coverageInsurance coverage Financial resourcesFinancial resources Legal barriersLegal barriers Structural barriersStructural barriers
TransportationTransportation SchedulingScheduling Employment issuesEmployment issues
Causes of Disparities in Access Causes of Disparities in Access to Careto Care
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
Social Determinants in Social Determinants in Disparities based on Disparities based on
Race/EthnicityRace/Ethnicity
Socioeconomic Status
Inadequate Housing
Social Determinants in Social Determinants in Disparities based on Disparities based on
Race/EthnicityRace/Ethnicity
Socioeconomic Status
Inadequate Housing
Proximity to Environmental Hazards
Social Determinants in Social Determinants in Disparities based on Disparities based on
Race/EthnicityRace/Ethnicity
Education Level
Socioeconomic Status
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
NCHS Data Brief January 2008
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
DHHS – CDC – NCHS 2009Elevated BP or Taking BP Med
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
DHHS – CDC – NCHS 2009Elevated BP or Taking BP Med
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+ %
DHHS – CDC – NCHS 2009Elevated BP or Taking BP Med
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
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 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
Materson BJ, et al. N Engl J Med. 1993;328:914-921.
-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
Materson BJ, et al. N Engl J Med. 1993;328:914-921.
-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
Minimize Disparities: Race / Minimize Disparities: Race / Ethnicity Ethnicity
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
Minimize Disparities: Race / Minimize Disparities: Race / Ethnicity Ethnicity
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 ????????????
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