Health Care Disparities:
A Focus on Hypertension
Brian K. Irons, PharmD, BCPS, BC-ADM
Division Head – Primary Care
Associate Professor
School of Pharmacy
Objectives
Review Types and Causes of Healthcare
Disparities
 Assess Disparities in HTN Awareness /
Control / Treatment
 Examine Ways to Minimize Disparities

 General
Measures
 Role of Academia
 Focus on HTN
Disparities in Healthcare
Race / Ethnicity
Health Disparities
/ Inequities
Gender
Race / Ethnicity
Health Disparities
/ Inequities
Gender
Race / Ethnicity
Health Disparities
/ Inequities
Sexual
Orientation
Gender
Race / Ethnicity
Sexual
Orientation
Health Disparities
/ Inequities
Socioeconomic
Group
Gender
Race / Ethnicity
Sexual
Orientation
Health Disparities
/ Inequities
Age
Socioeconomic
Group
Gender
Race / Ethnicity
Rural vs
Urban
Sexual
Orientation
Health Disparities
/ Inequities
Age
Socioeconomic
Group
Major Types of Disparities
 Access
to Care (Disparities in
Health Care)
 Quality of Care (Disparities in
Health)
Causes of Disparities in Access to Care
Insurance coverage
 Regular source of care
 Delay in seeking care
 Decrease in needed care
 Financial resources
 Legal barriers
 Structural barriers

Quality /Access to Care:
Insured vs Uninsured

Reduced Access to care
 Poorer medical outcomes
 Increased morbidities
 Earlier mortality
 Biggest
impact on timeliness and
quality of health care
American College of Physicians 2004
Institute of Medicine 2001 2002
Population Base and Uninsured
% of Population
White
% Uninsured
Latino
Afr-Amer
Asian - PI
Amer
Indian
Annals Intern Med 2004;141:226
Causes of Disparities in Access to Care
Insurance coverage
 Financial resources
 Legal barriers
 Structural barriers

 Transportation
 Scheduling
 Employment
issues
Causes of Disparities in Access to Care
 Fragmentation
of health care “system”
 Provider scarcity
 Language barriers
 Health literacy
 Healthcare beliefs
 Age
Social Determinants in
Disparities based on Race/Ethnicity
Socioeconomic Status
Social Determinants in
Disparities based on Race/Ethnicity
Socioeconomic Status
Inadequate Housing
Social Determinants in
Disparities based on Race/Ethnicity
Socioeconomic Status
Inadequate Housing
Proximity to
Environmental Hazards
Social Determinants in
Disparities based on Race/Ethnicity
Socioeconomic Status
Education Level
Inadequate Housing
Proximity to
Environmental Hazards
Causes of Disparities in
Quality of Care
 Provider
– Patient Communication
 Provider Discrimination / Biases
 Poor Preventative Care
 Decreased
patient satisfaction
 Decreased adherence
 Worse outcomes
Awareness / Treatment / Control
of Hypertension
Differences between
Races/Ethnicities and Age
Risks of Uncontrolled HTN
Stroke
Arrhythmias
Cognition
Myocardial
Infarction
Increased BP
Retinopathy
Nephropathy
Heart Failure
NCHS Data Brief January 2008
NCHS Data Brief January 2008
NCHS Data Brief January 2008
Trends in HTN- Gender
35
Percent of Population
30
25
20
Men
Women
15
10
5
0
1988-1994
Elevated BP or Taking BP Med
1999-2002
2003-2006
DHHS – CDC – NCHS 2009
Trends in HTN
Race/Ethnicity - Men
45
Percent of Population
40
35
30
25
White
Afr-Amer
Mex-Amer
20
15
10
5
0
1988-1994
Elevated BP or Taking BP Med
1999-2002
2003-2006
DHHS – CDC – NCHS 2009
Trends in HTN
Race/Ethnicity - Women
45
Percent of Population
40
35
30
25
White
Afr-Amer
Mex-Amer
20
15
10
5
0
1988-1994
Elevated BP or Taking BP Med
1999-2002
2003-2006
DHHS – CDC – NCHS 2009
Trends in HTN
Income
35
Percent of Population
30
25
Poverty Level
< 100%
100-199%
200+ %
20
15
10
5
0
1988-1994
Elevated BP or Taking BP Med
1999-2002
2003-2006
DHHS – CDC – NCHS 2009
BP Differences: Medicare Eligibility
Annals of Intern Med 2009;150:505
Prevalence of HTN – Dyslipidemia – DM
2005-2006 NHANES
60
50
Percent
40
4.6
2.8
2.5
13.4
12.8
16.4
28.9
29.8
28.6
26.1
Total
White
Afr-Amer
Mex-Amer
3.8
12.7
30
3 Conditions
2 Conditions
1 Conditon
20
10
0
CDC NHCS Data Brief #36 April 2010
Hypertension And Age
Percent of Population
HTN and Age
90
80
70
60
50
40
30
20
10
0
64.7
69.6
76.4
64.1
53.7 55.8
36.2 35.9
23.2
13.4
16.5
6.2
20-34
35-44
45-54
Men
55-64
65-74
75+
Women
Lloyd-Jones D, et al. Circulation. 2009.119; e21-e181.
Changes in SBP/DBP with Age
NEJM 2007;357:789
BP-Age and Mortality from Heart Disease
80-89 yrs 70-79 yrs 60-69 yrs 50-59 yrs 40-49 yrs
Chobanian AV, et al. JNC 7. Hypertension. 2003; 42:1206 1252.
Fatal CAD Risk and Age

For the same Systolic BP
 Patient 80-89 years of age versus 40-49 years
 16x risk for fatal CAD
Circulation 2007;115
Minimizing Disparities
Minimize Disparities:
Race/Ethnicity



Increase government offices of minority health
Expanded access
Raise awareness (Providers and Patients)
Health Disparities Roundtable
 Federal Collaboration on Health Disparities
Research
 Disparity Reducing Advances Project
 CMS’s Health Disparities Program
 Healthy People 2010 and 2020

Minimizing Disparities in HTN
Management : Age


Don’t assume benefits will be limited just
because a patient is older
Don’t treat all older patients the same
 Functional / Cognitive Status
 Living Arrangements
 Co-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 Systolic HTN
Relative Risk Reduction
(%)
15,693 patients, mean age 70, initial BP 174/83, 3.8 yr follow-up
0
-5
-10
-15
-20
-25
-30
Stroke
ALL CV
Events
MI
Mortality
Lancet 2000;355:865
Recommended HTN Treatments for
Isolated Systolic HTN


SHEP / Syst-Eur Trials
 Thiazide Diuretic
 Dihydropyridine CCB
Approach and Goals similar to Essential
HTN
 < 140/90 mm Hg
Treating HTN in the Very Old

Most trials excluded or simply didn’t recruit many very elderly
patients (> 80)
Meta-analysis in 1999 for those >80
15
10
Relative Change (%)

5
0
-5
-10
-15
-20
-25
-30
-35
-40
Stroke
Death
Lancet 1999;353:793
Treating HTN in the Very Old

Retrospective Study in VA Patients > 80 years
old
85% taking antihypertensives
 Shorter duration survival for those with SBP <140
mm Hg


“Clinicians should use caution in their approach
to BP lowering in this age group”
JAGS 2007;55:383
Hypertension in the Very Elderly
Trial (HYVET)







3845 patients 80+ years of age (mean 83.6
years)
Baseline BP: 173/91
Indapamide vs placebo (perindopril added prn)
Target BP: < 150/80
1.8 years of follow-up
Primary outcome: Stroke (fatal and non)
Secondary outcomes: all cause mortality / CV
mortality / CAD mortality / stroke mortality
NEJM 2008;358:1887
Hypertension in the Very Elderly
Trial (HYVET)
% Re Reduction (%)
0
-10
-20
NS
-30
-40
-50
-60
-70
Stroke
All
Mortality
Exp 143/78 vs placebo 158/84
Stroke
Death
HF
Any CV
Event
NEJM 2008;358:1887
What is BP Goal in the Very
Elderly?


No specific guideline… yet
< 150/80 ?
Reduces mortality, fatal stroke, HF
 Does it cause cognitive problems, increase fall
risk?


What about very elderly patients with
existing CAD

Can we risk < 130/80?
Risks of BP Meds in the Elderly
Prone to ADRs
 Lots of comorbidities /
contraindications to look out for
 Cognitive impairment
 Compliance
 Costs

Risks of BP Meds in the Elderly


Orthostatic hypotension
 Sensitive to volume depletion / sympathetic
inhibition
 Increased risk for falls
Definition:
 Sitting to standing drop in BP (usually
increase in heart rate)
 >20 mm difference in SBP / >10 mm dif in
DBP
Strategies for HTN Medication
use in Elderly
Start low and go slow
 COMMUNICATE
 Once daily regimens if compliance issues
 Avoid central acting agonists and alphablockers
 Caution with beta-blockers without a
compelling co-morbidity

Minimizing Disparities in HTN
Management : Race / Ethnicity

Optimize use of medications that may have
pharmacodynamic benefits in certain
populations
African-Americans with HTN and
Medication Adherence Beliefs
Negative Factors
Positive Factors
Financial Resources
Neighborhood Violence
Distrust of Healthcare Professionals
Family
Friends
Neighbors
God
J Cardiovasc Nursing 2010; 25:199
Age and Ethnicity Affect the Response of DBP to
-Blockers but Not to Calcium Channel Blockers
VA Cooperative Study of Responses to Single-Drug Therapy
Atenolol
Change in DBP (mm Hg)
from Baseline
0
Diltiazem
Placebo
-5
-10
*
-15
-20
-25
*
*
*†
*
*
*
‡
White men, <60 yr
Black men, <60 yr
*P ≤ 0.05 vs. placebo
†P ≤ 0.05 vs. white men of all ages
‡P ≤ 0.05 vs. placebo and atenolol
DBP = diastolic blood pressure
Materson BJ, et al. N Engl J Med. 1993;328:914-921.
White men, ≥60 yr
Black men, ≥60 yr
Reductions in Diastolic Blood Pressure in Response to Specific
Drugs Were Influenced by Age and Ethnicity
VA Cooperative Study of Responses to Single-Drug Therapy
Change in DBP (mm Hg)
from Baseline
0
HCTZ
Captopril Clonidine Prazosin
Placebo
-5
-10
-15
*
*†
*
*
*
*
‡
*
†
*
*
*
White men, <60 yr
-20
-25
*P ≤ 0.05 vs. placebo only
†P ≤ 0.05 vs. captopril or placebo
‡P ≤ 0.05 vs. HCTZ or placebo
DBP = diastolic blood pressure; HCTZ = hydrochlorothiazide
Materson BJ, et al. N Engl J Med. 1993;328:914-921.
Black men, <60 yr
White men, ≥60 yr
Black men, ≥60 yr
Reductions in SBP* in Response to Atenolol, Captopril, and
Prazosin Were Influenced by Age and Ethnicity
VA Cooperative Study of Responses to Single-Drug Therapy
Change in SBP (mm Hg)
from Baseline
0
Captopril
Prazosin
Placebo
-5
-10
-15
†
*
*
*
‡
*§
*
-25
-30
*§
*
-20
-35
*SBP
Atenolol
*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
= systolic blood pressure
Materson BJ, et al. N Engl J Med. 1993;328:914-921.
White men, <60 yr
Black men, <60 yr
White men, ≥60 yr
Black men, ≥60 yr
Reductions in Systolic Blood Pressure in Response to Specific
Drugs Were Influenced by Age and Ethnicity
VA Cooperative Study of Responses to Single-Drug Therapy
HCTZ
Change in SBP (mm Hg)
from Baseline
0
Clonidine
Diltiazem
Placebo
-5
-10
-15
-20
*
*
*
*
*
*
*
*
* *
*
*
-25
White men, <60 yr
-30
White men, ≥60 yr
-35
Black men, <60 yr
*P ≤ 0.05 vs. placebo only
Black men, ≥60 yr
HCTZ = hydrochlorothiazide; SBP = systolic blood pressure
Materson BJ, et al. N Engl J Med. 1993;328:914-921.
100
75
50
25
0
White Men <60 yr
*
*
Successful Treatment (%)
Successful Treatment (%)
Rates of Successful Treatment Were Similar for Most Single Drugs
in White Men
VA Cooperative Study of Responses to Single-Drug Therapy
100
White Men ≥60 yr
75
*
50
25
0
*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
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.
100
75
50
25
0
Black Men <60 yr
†
Successful Treatment (%)
Successful Treatment (%)
CCBs* and Diuretics Produced More Treatment Successes in Black
Men
VA Cooperative Study of Responses to Single-Drug Therapy
100
75
50
Black Men ≥60 yr
†
†
†
†
25
0
*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 blood
pressure measured <95 mm Hg after 1 year.
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.
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 Academia
Societal Roles
Deliver primary and specialty services
 Service to the poor or uninsured
 Research
 Education

Academic Medicine 2006;81:788
Minimize Disparities: Race / Ethnicity
Role of Academia

Health Care System
 Collect/Report data by race/ethnicity
 Implement/Evaluate disparities-reduction
programs
 Support language interpretation
 Support use of evidence-based therapeutics
Academic Medicine 2006;81:788
Minimize Disparities: Race / Ethnicity
Role of Academia

Education
 Increased cultural competency (everybody in
the work force not just providers)
 Increase minority representation in the
healthcare workforce
 Increase cross-cultural education
 Impact of disparities on decision making
Academic Medicine 2006;81:788
Minimize Disparities: Race / Ethnicity
Role of Academia

Research
 Identify sources of disparities
 Develop and evaluate interventions
Academic Medicine 2006;81:788
TTUHSC SOM Examples

Admissions: Increase minority enrollment
Recruitment activities
 Scholarship monies
 Recognized in past as a top recruiter of Hispanic
students


Curriculum:
Required Basic Medical Spanish
 Required didactic or experiential training in cultural
competency

TTUHSC SOM Examples

Clinical Services:


Grace Clinic (East): Cardiology Fellows clinic serves
underserved patient populations
Other Outreach:
Student run free clinic (Lubbock Impact)
 BP screenings by SOM students

TTUHSC SON Examples



Larry Combest Community and Wellness Center
Endowed Professor on Rural Health Disparities
Grants
Childhood obesity prevention / Focus on Hispanics
 RN-Family home visitation program for low income
first time mothers

TTUHSC SOP Examples



Admissions Process: Increased enrollment of minorities
Curriculum:
 Only SOP in the country with required advanced
experiential training in both Peds and Geries
 Only 1 of 3 SOPs with required Rural rotation
 Medical Spanish Elective / Cult Competency
Elective
 Reviewing cultural competency within the
curriculum
Service: Numerous faculty clinics in West Texas
providing care to underserved populations
QUESTIONS
??????