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 • Assess Disparities in HTN Awareness / Control / Treatment • Examine Ways to Minimize Disparities • General Measures • Role of Academia • Focus on HTN

3. Disparities in Healthcare

4. Health Disparities / Inequities Race / Ethnicity

5. Health Disparities / Inequities Gender Race / Ethnicity

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

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

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

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

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

11. 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

12. 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

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

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

15. Causes of Disparities in Access to Care • Fragmentation of health care “system” • Provider scarcity • Language barriers • Health literacy • Healthcare beliefs • 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 Socioeconomic Status Education Level Inadequate Housing Proximity to Environmental Hazards

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

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

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

23. NCHS Data Brief January 2008

24. NCHS Data Brief January 2008

25. NCHS Data Brief January 2008

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

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

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

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

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

31. Prevalence of HTN – Dyslipidemia – DM2005-2006 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 80-89 yrs70-79 yrs 60-69 yrs 50-59 yrs 40-49 yrs Chobanian AV, et al. JNC 7. Hypertension. 2003; 42:1206 1252.

36. 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

37. Minimizing Disparities

38. 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

39. 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

40. 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 Who is ‘Older’?

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 • Thiazide Diuretic • Dihydropyridine CCB • Approach and Goals similar to Essential HTN • < 140/90 mm Hg

43. 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 Lancet 1999;353:793

44. 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

45. 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

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

47. 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?

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

49. 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

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