1. Health Care Disparities: A Focus on Hypertension Brian K. Irons, PharmD, BCPS, BC-ADM Division Head – Primary Care Associate Professor School of Pharmacy

2. Objectives Review Types and Causes of Healthcare Disparities Review Types and Causes of Healthcare Disparities Assess Disparities in HTN Awareness / Control / Treatment Assess Disparities in HTN Awareness / Control / Treatment Examine Ways to Minimize Disparities Examine Ways to Minimize Disparities General Measures General Measures Role of Academia Role of Academia Focus on HTN Focus on HTN

3. Disparities in Healthcare

4. Health Disparities / Inequities Race / Ethnicity

5. Health Disparities / Inequities Race / Ethnicity Gender

6. Health Disparities / Inequities Race / Ethnicity Gender Sexual Orientation

7. Health Disparities / Inequities Race / Ethnicity Gender Sexual Orientation Socioeconomic Group

8. Health Disparities / Inequities Race / Ethnicity Gender Age Sexual Orientation Socioeconomic Group

9. Health Disparities / Inequities Race / Ethnicity Gender Age Sexual Orientation Socioeconomic Group Rural vs Urban

10. Major Types of Disparities Access to Care (Disparities in Health Care) Access to Care (Disparities in Health Care) Quality of Care (Disparities in Health) Quality of Care (Disparities in Health)

11. Causes of Disparities in Access to Care Insurance coverage Insurance coverage Regular source of care Regular source of care Delay in seeking care Delay in seeking care Decrease in needed care Decrease in needed care Financial resources Financial resources Legal barriers Legal barriers Structural barriers Structural barriers

12. Quality /Access to Care: Insured vs Uninsured Reduced Access to care Reduced Access to care Poorer medical outcomes Poorer medical outcomes Increased morbidities Increased morbidities Earlier mortality Earlier mortality Biggest impact on timeliness and quality of health care Biggest impact on timeliness and quality of health care American College of Physicians 2004 Institute of Medicine 2001 2002

13. Population Base and Uninsured Annals Intern Med 2004;141:226

14. Causes of Disparities in Access to Care Insurance coverage Insurance coverage Financial resources Financial resources Legal barriers Legal barriers Structural barriers Structural barriers Transportation Transportation Scheduling Scheduling Employment issues Employment issues

15. Causes of Disparities in Access to Care Fragmentation of health care “system” Fragmentation of health care “system” Provider scarcity Provider scarcity Language barriers Language barriers Health literacy Health literacy Healthcare beliefs Healthcare beliefs Age Age

16. Social Determinants in Disparities based on Race/Ethnicity Socioeconomic Status

17. Social Determinants in Disparities based on Race/Ethnicity Socioeconomic Status Inadequate Housing

18. Social Determinants in Disparities based on Race/Ethnicity Socioeconomic Status Inadequate Housing Proximity to Environmental Hazards

19. Social Determinants in Disparities based on Race/Ethnicity Education Level Socioeconomic Status Inadequate Housing Proximity to Environmental Hazards

20. Causes of Disparities in Quality of Care Provider – Patient Communication Provider – Patient Communication Provider Discrimination / Biases Provider Discrimination / Biases Poor Preventative Care Poor Preventative Care Decreased patient satisfaction Decreased patient satisfaction Decreased adherence Decreased adherence Worse outcomes Worse outcomes

21. Awareness / Treatment / Control of Hypertension Differences between Races/Ethnicities and Age

22. Risks of Uncontrolled HTN Increased BP Arrhythmias Stroke Myocardial Infarction Retinopathy Nephropathy Cognition Heart Failure

23. NCHS Data Brief January 2008

26. Trends in HTN- Gender DHHS – CDC – NCHS 2009 Elevated BP or Taking BP Med

27. Trends in HTN Race/Ethnicity - Men DHHS – CDC – NCHS 2009 Elevated BP or Taking BP Med

28. Trends in HTN Race/Ethnicity - Women DHHS – CDC – NCHS 2009 Elevated BP or Taking BP Med

29. Trends in HTN Income DHHS – CDC – NCHS 2009 Elevated BP or Taking BP Med Poverty Level

30. BP Differences: Medicare Eligibility Annals of Intern Med 2009;150:505

31. Prevalence of HTN – Dyslipidemia – DM 2005-2006 NHANES CDC NHCS Data Brief #36 April 2010

32. Hypertension And Age

33. HTN and Age Lloyd-Jones D, et al. Circulation. 2009.119; e21-e181.

34. Changes in SBP/DBP with Age NEJM 2007;357:789

35. BP-Age and Mortality from Heart Disease 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

36. Fatal CAD Risk and Age For the same Systolic BP For the same Systolic BP Patient 80-89 years of age versus 40-49 years Patient 80-89 years of age versus 40-49 years 16x risk for fatal CAD 16x risk for fatal CAD Circulation 2007;115

37. Minimizing Disparities

38. Minimize Disparities: Race/Ethnicity Increase government offices of minority health Increase government offices of minority health Expanded access Expanded access Raise awareness (Providers and Patients) Raise awareness (Providers and Patients) Health Disparities Roundtable Health Disparities Roundtable Federal Collaboration on Health Disparities Research Federal Collaboration on Health Disparities Research Disparity Reducing Advances Project Disparity Reducing Advances Project CMS’s Health Disparities Program CMS’s Health Disparities Program Healthy People 2010 and 2020 Healthy People 2010 and 2020

39. Minimizing Disparities in HTN Management : Age Don’t assume benefits will be limited just because a patient is older Don’t assume benefits will be limited just because a patient is older Don’t treat all older patients the same Don’t treat all older patients the same Functional / Cognitive Status Functional / Cognitive Status Living Arrangements Living Arrangements Co-morbidities Co-morbidities

40. 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

41. Benefits to Treating Isolated Systolic HTN 15,693 patients, mean age 70, initial BP 174/83, 3.8 yr follow-up Lancet 2000;355:865

42. Recommended HTN Treatments for Isolated Systolic HTN SHEP / Syst-Eur Trials SHEP / Syst-Eur Trials Thiazide Diuretic Thiazide Diuretic Dihydropyridine CCB Dihydropyridine CCB Approach and Goals similar to Essential HTN Approach and Goals similar to Essential HTN < 140/90 mm Hg < 140/90 mm Hg

43. Treating HTN in the Very Old Most trials excluded or simply didn’t recruit many very elderly patients (> 80) Most trials excluded or simply didn’t recruit many very elderly patients (> 80) Meta-analysis in 1999 for those >80 Meta-analysis in 1999 for those >80 Lancet 1999;353:793

44. Treating HTN in the Very Old Retrospective Study in VA Patients > 80 years old Retrospective Study in VA Patients > 80 years old 85% taking antihypertensives 85% taking antihypertensives Shorter duration survival for those with SBP <140 mm Hg Shorter duration survival for those with SBP <140 mm Hg “Clinicians should use caution in their approach to BP lowering in this age group” “Clinicians should use caution in their approach to BP lowering in this age group” JAGS 2007;55:383

45. Hypertension in the Very Elderly Trial (HYVET) 3845 patients 80+ years of age (mean 83.6 years) 3845 patients 80+ years of age (mean 83.6 years) Baseline BP: 173/91 Baseline BP: 173/91 Indapamide vs placebo (perindopril added prn) Indapamide vs placebo (perindopril added prn) Target BP: < 150/80 Target BP: < 150/80 1.8 years of follow-up 1.8 years of follow-up Primary outcome: Stroke (fatal and non) Primary outcome: Stroke (fatal and non) Secondary outcomes: all cause mortality / CV mortality / CAD mortality / stroke mortality Secondary outcomes: all cause mortality / CV mortality / CAD mortality / stroke mortality NEJM 2008;358:1887

46. Hypertension in the Very Elderly Trial (HYVET) NS NEJM 2008;358:1887 Exp 143/78 vs placebo 158/84

47. What is BP Goal in the Very Elderly? No specific guideline… yet No specific guideline… yet < 150/80 ? < 150/80 ? Reduces mortality, fatal stroke, HF Reduces mortality, fatal stroke, HF Does it cause cognitive problems, increase fall risk? Does it cause cognitive problems, increase fall risk? What about very elderly patients with existing CAD What about very elderly patients with existing CAD Can we risk < 130/80? Can we risk < 130/80?

48. Risks of BP Meds in the Elderly Prone to ADRs Prone to ADRs Lots of comorbidities / contraindications to look out for Lots of comorbidities / contraindications to look out for Cognitive impairment Cognitive impairment Compliance Compliance Costs Costs

49. Risks of BP Meds in the Elderly Orthostatic hypotension Orthostatic hypotension Sensitive to volume depletion / sympathetic inhibition Sensitive to volume depletion / sympathetic inhibition Increased risk for falls Increased risk for falls Definition: Definition: Sitting to standing drop in BP (usually increase in heart rate) Sitting to standing drop in BP (usually increase in heart rate) >20 mm difference in SBP / >10 mm dif in DBP >20 mm difference in SBP / >10 mm dif in DBP

50. Strategies for HTN Medication use in Elderly Start low and go slow Start low and go slow COMMUNICATE COMMUNICATE Once daily regimens if compliance issues Once daily regimens if compliance issues Avoid central acting agonists and alpha- blockers Avoid central acting agonists and alpha- blockers Caution with beta-blockers without a compelling co-morbidity Caution with beta-blockers without a compelling co-morbidity

51. Optimize use of medications that may have pharmacodynamic benefits in certain populations Optimize use of medications that may have pharmacodynamic benefits in certain populations Minimizing Disparities in HTN Management : Race / Ethnicity

52. African-Americans with HTN and Medication Adherence Beliefs Positive Factors Negative Factors Family Friends Neighbors God Financial Resources Neighborhood Violence Distrust of Healthcare Professionals J Cardiovasc Nursing 2010; 25:199

53. 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 Materson BJ, et al. N Engl J Med. 1993;328:914-921. Change in DBP (mm Hg) from Baseline *P ≤ 0.05 vs. placebo †P ≤ 0.05 vs. white men of all ages ‡P ≤ 0.05 vs. placebo and atenolol AtenololDiltiazemPlacebo White men, <60 yr Black men, <60 yr White men, ≥60 yr Black men, ≥60 yr * * ‡ * *†*† * ** DBP = diastolic blood pressure

54. 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 Materson BJ, et al. N Engl J Med. 1993;328:914-921. Change in DBP (mm Hg) from Baseline *P ≤ 0.05 vs. placebo only †P ≤ 0.05 vs. captopril or placebo ‡P ≤ 0.05 vs. HCTZ or placebo HCTZCaptoprilClonidinePrazosinPlacebo White men, <60 yr Black men, <60 yr White men, ≥60 yr Black men, ≥60 yr * * * * * ** * * * † ‡ † DBP = diastolic blood pressure; HCTZ = hydrochlorothiazide

55. 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 Materson BJ, et al. N Engl J Med. 1993;328:914-921. Change in SBP (mm Hg) from Baseline *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 AtenololCaptoprilPrazosinPlacebo White men, <60 yr Black men, <60 yr White men, ≥60 yr Black men, ≥60 yr * * * * *§ * * SBP = systolic blood pressure † ‡

56. 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 Materson BJ, et al. N Engl J Med. 1993;328:914-921. Change in SBP (mm Hg) from Baseline *P ≤ 0.05 vs. placebo only HCTZClonidineDiltiazemPlacebo HCTZ = hydrochlorothiazide; SBP = systolic blood pressure White men, <60 yr Black men, <60 yr White men, ≥60 yr Black men, ≥60 yr * ** * * * * * * * * *

57. 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. Successful Treatment (%) Clonidine White Men <60 yr Rates of Successful Treatment Were Similar for Most Single Drugs in White Men VA Cooperative Study of Responses to Single-Drug Therapy White Men ≥60 yr Atenolol Captopril Diltiazem Prazosin HCTZ Placebo *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 Successful Treatment (%) ClonidineAtenolol Diltiazem Prazosin HCTZ Captopril Placebo * * *

58. 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. CCBs * and Diuretics Produced More Treatment Successes in Black Men VA Cooperative Study of Responses to Single-Drug Therapy Successful Treatment (%) Clonidine Black Men <60 yrBlack Men ≥60 yr Atenolol Captopril Diltiazem Prazosin HCTZ Placebo Successful Treatment (%) Clonidine Atenolol Diltiazem Prazosin HCTZ Captopril Placebo † † † † † *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.

59. 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 years) JAMA 2002;288:2981

60. 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

61. ALLHAT Outcomes: Age ( 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

62. 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

63. Minimize Disparities: Race / Ethnicity Role of Academia Health Care System Health Care System Collect/Report data by race/ethnicity Collect/Report data by race/ethnicity Implement/Evaluate disparities-reduction programs Implement/Evaluate disparities-reduction programs Support language interpretation Support language interpretation Support use of evidence-based therapeutics Support use of evidence-based therapeutics Academic Medicine 2006;81:788

64. Minimize Disparities: Race / Ethnicity Role of Academia Education Education Increased cultural competency (everybody in the work force not just providers) Increased cultural competency (everybody in the work force not just providers) Increase minority representation in the healthcare workforce Increase minority representation in the healthcare workforce Increase cross-cultural education Increase cross-cultural education Impact of disparities on decision making Impact of disparities on decision making Academic Medicine 2006;81:788

65. Minimize Disparities: Race / Ethnicity Role of Academia Research Research Identify sources of disparities Identify sources of disparities Develop and evaluate interventions Develop and evaluate interventions Academic Medicine 2006;81:788

66. TTUHSC SOM Examples Admissions: Increase minority enrollment Admissions: Increase minority enrollment Recruitment activities Recruitment activities Scholarship monies Scholarship monies Recognized in past as a top recruiter of Hispanic students Recognized in past as a top recruiter of Hispanic students Curriculum: Curriculum: Required Basic Medical Spanish Required Basic Medical Spanish Required didactic or experiential training in cultural competency Required didactic or experiential training in cultural competency

67. TTUHSC SOM Examples Clinical Services: Clinical Services: Grace Clinic (East): Cardiology Fellows clinic serves underserved patient populations Grace Clinic (East): Cardiology Fellows clinic serves underserved patient populations Other Outreach: Other Outreach: Student run free clinic (Lubbock Impact) Student run free clinic (Lubbock Impact) BP screenings by SOM students BP screenings by SOM students

68. TTUHSC SON Examples Larry Combest Community and Wellness Center Larry Combest Community and Wellness Center Endowed Professor on Rural Health Disparities Endowed Professor on Rural Health Disparities Grants Grants Childhood obesity prevention / Focus on Hispanics Childhood obesity prevention / Focus on Hispanics RN-Family home visitation program for low income first time mothers RN-Family home visitation program for low income first time mothers

69. TTUHSC SOP Examples Admissions Process: Increased enrollment of minorities Admissions Process: Increased enrollment of minorities Curriculum: Curriculum: Only SOP in the country with required advanced experiential training in both Peds and Geries Only SOP in the country with required advanced experiential training in both Peds and Geries Only 1 of 3 SOPs with required Rural rotation Only 1 of 3 SOPs with required Rural rotation Medical Spanish Elective / Cult Competency Elective Medical Spanish Elective / Cult Competency Elective Reviewing cultural competency within the curriculum Reviewing cultural competency within the curriculum Service: Numerous faculty clinics in West Texas providing care to underserved populations Service: Numerous faculty clinics in West Texas providing care to underserved populations

70. QUESTIONS ??????