1. Utilization Of Lipid-lowering Therapy In Hypertensive Patients In The United States Simon S.K. Tang, MPH* Sean Candrilli, MS** Lizheng Shi, PhD* *Department of Health Systems Management Tulane University School of Public Health & Tropical Medicine; **RTI Health Solutions Oral Presentation at 2008 AcademyHealth Annual Research Meeting

2. Background Hypertension is the leading risk factor for Cardiovascular Disease (CVD) 1 Majority of patients with hypertension have multiple additional CV factors including dyslipidemia 2 and are not optimally managed to goals 3 Lipid-lowering therapy is effective in reducing CV risk in patients with hypertension: –ASCOT-LLA demonstrated that multiple-risk-factor hypertensive patients without CAD who received atorvastatin 10mg led to 36% reduction of major CV events vs. placebo 4 –CARDS demonstrated that patients with diabetes (with high proportion of hypertension – 84%) who received atorvastatin mg led to 37% reduction of major CV events 5 1 American Heart Association. Heart disease and stroke statistics – 2006 update. Circulation 2006 113:e85–e151 (available at: http://circ.ahajournals.org)http://circ.ahajournals.org 2 Kannel WB. J Hum Hypertens 2000;14:83-90. 3 Wong ND, Lopez V, Tang S, et al. Am J Cardiol 2006;98:204-8. 4 Sever PS, Dahlöf B, Poulter NR et al. Lancet 2003;361:1149-58. 5 Colhoun HM, et al. Lancet 2004;364685-96

3. Objectives To understand factors associated with use of lipid-lowering therapy within various hypertenisve populations: –Overall HTN –HTN with Dyslipidemia (DYS) –Treated HTN without CAD (ASCOT-LLA) –HTN with Diabetes –HTN with CHD To evaluate the extent of lipid-lowering therapy use in various hypertensive populations in the United States

4. Methods Design & Population: –Cross-sectional Survey Analysis –Adult sample aged  20 years from the National Health and Nutrition Examination Survey (NHANES) 1999-2004 with data on blood pressure and lipids (Overall n=5,403; 52% female) (HTN n=1,928; 52% female) –HTN defined as: BP >140/90 mm Hg (or >130/80 mm Hg if DM) Or on antihypertensive medication Analysis: –SPSS 15.0 software used for descriptive & SUDAAN for multivariate analyses –Chi-square statistics used to compare between groups –Multivariate Logistic Regression Analysis was conducted to assess odds of taking lipid-lowering therapy adjusting for covariates such as: age, gender, ethnicity, CV risk factors & comorbidities, insurance, education

5. Baseline Charactertistics Demographic, Disease & Socioeconomic groups Mean (SD)* or Proportion of subgroup (%) Hypertension1928 (100%) Mean Age*62.7 years (14.91)* Male48% Non-white minorities46% Dyslipidemia66% CHD13% Diabetes12% Smoker/ Obese15%/ 40% No health insurance11% Less than high school education13%

6. Results - Gender Proportion (%) of Patients with Hypertension reported taking lipid-lowering therapy N = 1928 1279 939 224259

7. Results – Stroke & Life-style CV risk factors Proportion (%) of Patients with Hypertension reported taking lipid-lowering therapy N = 1928 1279 939 224259

8. Results – Socio-Cultural Factors Proportion (%) of Patients with Hypertension reported taking lipid-lowering therapy N = 1928 1279 939 224259 *Chi-square statistics – all within-group comparisons different at p<0.0001

9. Summary of Descriptive Results Only 23% of Overall HTN patients received LLT –Primary Prevention: 27% (HTN-ASCOT) –Mixed: 34% (HTN-DYS) –High-Risk/ Secondary Prevention: 38% (HTN-DM), 45% (HTN-CHD) No major disparities seen between Male & Female LLT treatment is suboptimal in HTN patients with Stroke or other life-style-related CHD risk factors Significant disparities seen among: –Ethnic groups: Greater of proportion of Non-hispanic whites received LLT than other non-white minorities –Insured vs. uninsured –High School or Above education vs. below Disparities gap widen as CV risk increased

10. Adjusted Odds Ratios of Taking LLT: HTN Overall Independent Variables and Lower 95% Upper 95% Effects Odds Ratio Limit OR Limit OR ------------------------------------------------------------------------------------- Intercept 0.10 0.05 0.18 RIDAGEYR 1.02 1.01 1.02 MALE 1.09 0.82 1.46 DXDIABETES 2.43 1.50 3.94 CHF 0.76 0.43 1.34 CHD 3.26 2.32 4.58 STROKE 1.66 0.89 3.08 OBESE 1.03 0.78 1.36 CURRENTSMOKER 0.90 0.51 1.59 LT_HS 0.51 0.25 1.03 NO_INSURANCE 0.62 0.33 1.14 NON_WHITE 0.77 0.58 1.02 -------------------------------------------------------------------------------------

11. Adjusted Odds Ratios of Taking LLT: HTN-ASCOT Independent Variables and Lower 95% Upper 95% Effects Odds Ratio Limit OR Limit OR --------------------------------------------------------------------------------- Intercept 0.16 0.07 0.38 RIDAGEYR 1.01 1.00 1.03 MALE 1.27 0.84 1.92 DXDIABETES 1.73 0.95 3.15 CHF 0.70 0.18 2.71 STROKE 1.61 0.65 3.97 OBESE 0.86 0.61 1.22 CURRENTSMOKER 0.83 0.39 1.78 LT_HS 0.51 0.22 1.19 NO_INSURANCE 0.85 0.42 1.71 NON_WHITE 0.96 0.65 1.42 --------------------------------------------------------------------------------

12. Adjusted Odds Ratios of Taking LLT: HTN with Diabetes Independent Variables and Lower 95% Upper 95% Effects Odds Ratio Limit OR Limit OR ------------------------------------------------------------------------------ Intercept 0.63 0.04 9.14 RIDAGEYR 1.01 0.97 1.04 MALE 0.70 0.30 1.60 CHF 3.71 0.78 17.70 CHD 1.78 0.63 5.02 STROKE 1.09 0.38 3.13 OBESE 0.54 0.24 1.19 CURRENTSMOKER 0.73 0.27 1.94 LT_HS 0.12 0.03 0.44 NO_INSURANCE 0.94 0.19 4.58 NON_WHITE 1.64 0.70 3.84 ------------------------------------------------------------------------------

13. Adjusted Odds Ratios of Taking LLT: HTN with CHD Independent Variables and Lower 95% Upper 95% Effects Odds Ratio Limit OR Limit OR ------------------------------------------------------------------------------------- Intercept 16.34 0.97 276.36 RIDAGEYR 0.96 0.93 1.00 MALE 0.91 0.50 1.69 DXDIABETES 2.35 0.88 6.27 CHF 0.84 0.45 1.56 STROKE 1.32 0.52 3.34 OBESE 0.66 0.31 1.41 CURRENTSMOKER 1.04 0.48 2.25 LT_HS 0.30 0.06 1.53 NO_INSURANCE 0.14 0.02 0.84 NON_WHITE 0.47 0.18 1.18 -------------------------------------------------------------------------------------

14. Summary – Multivariate Results Overall HTN: –Age and CHD/DM comorbidities are significant factors associated with likelihood of receiving LLT HTN ASCOT: –Significant factors include Age HTN with Diabetes –Significant factors include LTHS HTN with CHD –Significant factors include No insurance

15. Limitations Associations can not imply specific causal/directional effects due to cross- sectional design Self-reported nature of data –Disease conditions and medication use Medication dose and treatment patterns are unknown Adherence to medications is unknown Not all factors are accounted for in this analysis

16. Conclusions Lipid-Lowering Therapy are not optimally used in overall & high-risk HTN populations in the US Age, Diabetes and CHD are associated with higher LLT use in overall HTN Less than high school education is associated with underutilization of LLT among HTN patients with Diabetes Lack of insurance is associated with underutilization of LLT among HTN patients with CHD Many variables become non-significant in multivariate analyses Future analyses should leverage longitudinal databases

17. Significance & Policy Implications Improve understanding of opportunities in aggressive LLT management of cardiovascular risk Contribute to development of quality indicators for specific high-risk or vulnerable populations