Durand Grant, a 41-year-old African American South Carolinian with diabetes.
Fighting Fatalism: Addressing Racial Disparities in Health by Aggressively Treating Hypertension (CME-eligible article)
Upon completion of this article, readers should be able to:
- Recognize that uncontrolled hypertension in African Americans leads to an increased prevalence and severity of stroke and diabetes compared with non-Hispanic whites and that the disparities are most stark in those aged 35-64 years
- Discuss how aggressively treating to blood pressure targets set by national guidelines (Joint National Committee7/ International Society on Hypertension in Blacks) can reduce the rates of stroke and the severity of diabetes in African Americans
Disclosure Statement: In accordance with the ACCME Essentials and Standards, anyone involved in planning or presenting this educational activity is required to disclose any relevant financial relationships with commercial interests in the healthcare industry. Authors who incorporate information about off-label or investigational use of drugs or devices will be asked to disclose that information at the beginning of the article.
Daniel T. Lackland, DrPH, Leonard E. Egede, M.D., Bruce Ovbiagele, M.D., Brent Egan, M.D., and Kimberly McGhee have no relevant financial relationships to disclose. (More CME information, including information on where to take the CME test, are available at the end of the article.)
Being born black and poor, even in the buckle of the stroke belt, should not dictate one’s destiny nor one’s chances of having a long and healthy life. And yet studies by Daniel Lackland, DrPH, Professor of Neurosciences and Epidemiology at MUSC, and others show that being born and raised in the Southeast increases the risk of stroke and other chronic diseases in African Americans even if they later move to other areas of the country.¹
Dr. Leonard E. Egede
Primary care physicians in South Carolina are only too well acquainted with the downward spiral in health that can occur in their African American patients with chronic diseases. Hypertension and type 2 diabetes, which are more aggressive and appear earlier in African Americans than in their non-Hispanic white counterparts, typically manifest first and about the same time, as they have similar risk factors. Both hypertension and diabetes greatly increase the risk of stroke, amputation, and kidney failure, the last of which leaves patients dependent on dialysis and in need of a kidney transplant. Diabetes-related damage to the heart and eyes are also more likely in African Americans.
Faced with such a grim clinical trajectory, physicians and patients alike may begin to despair. Clinicians doubt whether any action of theirs could change the situation dramatically for the better. Patients become fatalistic, assuming because a grandfather lost a foot to diabetes that they are destined to as well.
Such fatalism can lead to undertreatment by physicians, known as clinical inertia,² and to lack of adherence to medical regimens by patients who see a poor outcome as inevitable.
Contributing to this fatalism are socioeconomic factors that seem to present insurmountable barriers to change: poverty that limits access to healthy food, good medical care, and necessary medication; lack of transportation to medical centers that, for rural residents, can be at a great distance; and at times unsafe neighborhoods that do not lend themselves to walking or other physical activity. Those who have no or inadequate insurance coverage also have worse health outcomes: for example, death due to stroke is 24% to 56% more likely in uninsured patients.³
While it is important for clinicians to acknowledge the racial disparities in health care and the barriers to overcoming them, they must guard against becoming paralyzed by their sheer enormity.
Change is possible, as evidenced by South Carolina’s climb in the rankings for cardiovascular health from dead last in the United States in 1995 to 34th currently, the most rapid improvement seen in any stroke belt state.
Indeed, a number of factors are converging to make this a critical time to address the excessive burden of chronic disease borne by African Americans in South Carolina and beyond. With the implementation of health care reform, more younger African Americans who do not currently have health insurance should receive coverage, helping to jumpstart preventive efforts earlier, such as lifestyle modification and, when needed, better control of chronic diseases like hypertension and diabetes. Intervening earlier, before chronic disease becomes entrenched, should improve the long-term outcomes of these patients and make decline into progressive disability less likely, at once saving lives and reducing the economic burden on the state. The availability of good and inexpensive generic drugs (ie, $4 copay) to control blood pressure as well as glucose and cholesterol levels means that combination regimens can be prescribed that are both effective and affordable. Telehealth programs (see October 2012 issue of Progressnotes) are beginning to mitigate the geographic barriers to health care by bringing care to the patient.
While too daunting for any one physician, effectively addressing racial disparities is possible when physicians, both academic and community-based, come together to improve guideline-based care for chronic diseases like hypertension and diabetes, as they did in the Outpatient Quality Improvement Network (OQUIN, discussed in more detail later in this article).
The more widespread adoption of electronic medical records should also lead to the better coordination of care and to the expansion of data-sharing initiatives that will facilitate both clinically relevant feedback to participating physicians and meaningful research into improving population health.
In many ways, South Carolina has an historic opportunity to make serious headway in combating racial disparities in health care.
The Deadly Trio
Hypertension, diabetes and stroke comprise a deadly trio for African Americans.
African Americans are more likely to have hypertension (one in two has hypertension vs. one in three in the general population), and their hypertension is more likely to occur early (with the greatest disparity seen in ages 35-64 years) and to be more aggressive.⁴ It more often leads to serious complications such as heart failure and chronic kidney disease as well as stroke in African Americans.⁴ In 2005, the death rate from hypertension was 51.0 (per 100,000 population) in African American men and 40.9 in African American women compared with 15.1 for white men and women.⁴ In hypertensive African Americans, more than 30% of deaths in men and 20% of deaths in women can be attributed to high blood pressure.⁴ Higher blood pressure also contributes to more severe complications in diabetic patients, increasing the likelihood of loss of eyes or limbs.
African Americans are twice as likely to develop diabetes and more likely to have diabetes-related complications than non-Hispanic whites. For example, they are 2.6 times more likely to develop end-stage renal disease. Because of their greater likelihood of developing serious diabetes-related complications, they are more likely to die of diabetes, with African American women having the highest mortality, followed by African American men.5
Diabetes takes a heavy toll on the health of South Carolinians and depletes the state’s coffers. According to 2010 data for South Carolina, 450,000 residents are affected by diabetes, one in five hospitalized patients has diabetes, and one in ten emergency room visits is diabetes related. The economic burden posed by diabetes for South Carolina in 2010 is estimated at $4.2 billion. Although racial disparities in diabetes prevalence have narrowed, largely due to increased frequency of diabetes among the white population, they have widened for diabetes-related mortality, with African Americans experiencing a substantially higher death rate and more life years lost. Some of the sharpest increases in prevalence in South Carolina have been seen in those aged 18-44.6
High blood pressure and diabetes are the two leading risk factors for stroke. The high prevalence and aggressive nature of hypertension and diabetes in African American patients helps explain why stroke remains the second leading cause of death among them, while it has dropped from the third to the fourth leading cause for Americans as a whole.7
Higher blood pressure damages arteries over time, weakening and distending them and making them more prone to both plaque build-up and rupture, thus increasing the risk of ischemic and hemorrhagic stroke, respectively. The high glucose levels in diabetic patients can lead to extra fatty deposits in the blood vessels, contributing, like high blood pressure, to a blockage causing an ischemic stroke. When determining a patient’s risk level for stroke or heart attack, diabetes counts as a coronary heart disease risk equivalent, ie, it increases the risk of stroke or cardiovascular disease as much as a previous heart attack.4 Diabetes mellitus has recently been shown to more than double the chance of dying of a recurrent stroke (hazard ratio, 2.38), whereas controlling blood pressure cut the risk of a recurrent stroke in half (hazard ratio: 0.45).8
As was recently reported by Time magazine, the cost of stroke is expected to more than double by 2030 as the population ages.9 The source of the Time story was a recently published American Heart Association/American Stroke Association policy statement, the lead author of which was Bruce Ovbiagele, M.D., Chair of Neurology, Department of Neurosciences, at MUSC.³ Such a dramatic increase in stroke-related costs is not unexpected in an aging population, as the risk of stroke doubles with every decade of life after age 55.10 What is surprising, however, is that the highest increase in stroke prevalence (5.1%) is projected to be in those aged 45-64 years.³ Of interest, this is the age group in which racial disparities in stroke outcome are also the most stark. African American men aged 45 years are almost 3 times as likely to have a stroke as their non-Hispanic white counterparts, a disparity that narrows at age 65 years.11
The growing prevalence of stroke and the chronic conditions that predispose to it in this younger population, particularly in the African American population, is particularly worrisome since access to medical care can be difficult for those who are underinsured or uninsured. Unlike the elderly population who can rely on Medicare, many in the younger age group who are unable to afford health insurance are left to fend for themselves. The impact on long-term health caused by chronic diseases that manifest earlier in life are not yet fully appreciated but are likely to lead to more rapid declines in health if not well managed. The expansion of insurance coverage that will accompany health care reform could help with efforts to modify risk factors in this younger age group, particularly blood pressure and diabetes, perhaps helping stave off the progressive debilitation caused by chronic disease.
Because hypertension makes the complications of diabetes worse and because it is the leading risk factor for stroke, clinicians can have the greatest impact on the long-term health outcomes of their African American patients by aiming for good blood pressure control. Even incremental changes can have huge health payoffs. According to Elijah Saunders, a noted cardiologist, International Society on Hypertension in Blacks (ISHIB) investigator, and national expert on hypertension in African Americans, reduction of 5 mm Hg in blood pressure (from 140/90 mm Hg to 135/85 mm Hg) can reduce the risk of stroke by 40% and of coronary disease by 30%.12
Controlling Blood Pressure To National Targets
Incremental changes in blood pressure can have important health implications, but real progress in narrowing racial disparities will come from aggressively treating blood pressure to national targets.13 Although JNC7 (The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure) recommends that hypertensive patients be treated to a target blood pressure of 140/90 mm Hg,14 the ISHIB guidelines recommend a target blood pressure of 135/85 mm Hg for African Americans with no comorbid disease or organ damage and 130/80 mm Hg for those with diabetes or organ damage.4 Evidence suggests that establishing such guidelines and formulating recommendations for the management of high blood pressure have reduced population blood pressure levels and reduced the risk of stroke.15
In other words, treating to these targets is possible and doing so saves lives.
Currently, good blood pressure control as defined by these targets is achieved in only about 50% of patients overall.16 In hypertensive non-Hispanic blacks, that number drops to only about 30% for men and 36% for women.4
Why aren’t clinicians hitting these targets more reliably?
Some clinicians have come to believe that good control of hypertension in African Americans is virtually impossible to achieve and that rates of resistant hypertension are very high. Because of this belief, they can sometimes be satisfied with some reduction in blood pressure and fail to continue to adjust treatment to meet national guidelines. Such clinical inertia, opting for the status quo in treatment though targets are not met, can mean that patients remain at higher risk of stroke or diabetic complications or are misdiagnosed as having resistant hypertension when in fact their blood pressure could be controlled with the proper combination regimen. According to Dr. Elijah Saunders, it should be possible to achieve good control in 60%-70% of patients seen at community hospitals and in 80%-90% of patients treated at academic medical centers. He estimates that only 5%-10% of patients have truly resistant hypertension.12
Advice to Clinicians for Meeting Blood Pressure Targets in African Americans
Clinicians should be aware that monotherapy is less likely to lower blood pressure in African Americans than whites. Combination regimens will almost always be necessary and, because they use only small amounts of each agent, have the advantage of minimizing side effects (eg, the sexual dysfunction associated with diuretics), thereby improving the likelihood of adherence. If clinicians do not attain control with two categories of medications, they should go to three or four categories of carefully chosen medications to do so. Although such multiple-drug strategies can be complicated for patients and could hurt adherence, the use of single-pill combinations, which combine two different categories of antihypertensive agents in fixed dosages in a single pill, can be used to minimize this problem.17 Although RAS inhibitors like angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) are less likely than calcium channel blockers to achieve blood pressure control as monotherapy, especially in African Americans, they are useful in combination therapy as they have been shown to have organ-protective function, particularly for the kidney.
In addition to minimizing side effects and adopting fixed-dose combination regimens, adherence to antihypertensive therapy can be improved by controlling costs. Patients cannot take medications if they cannot afford to buy them. Stories of African American family members sharing a single prescription to cut costs are not uncommon. According to Leonard E. Egede, M.D., Director of the Center for Health Disparities Research at MUSC, “Physicians need to think very much about the interface between race and poverty and the cost of medications they are prescribing. Think about trying to hold medication costs to a total $50 copay per month for low-income, minority patients. If you do, you will do a big service for your patients and the adherence will go up and people will be more likely to take their medication and more likely to achieve control.” The $50 copay per month is a realistic target because many older but effective blood pressure agents are available as $4 copays.
Primary care physicians could also consider becoming a resource for their community by becoming certified by the American Society of Hypertension (ASH) as a hypertension specialist (for more information, see http://www.ash-us.org/HTN-Specialist/Exam-Application-Protocol.aspx). The increase in ASH-certified hypertension specialists achieved by OQUIN is thought to be one of the reasons for South Carolina’s improved ranking for cardiovascular health.18
Growing out of the ASH-supported Hypertension Initiative begun in 1999 to take South Carolina “from a leader in cardiovascular disease to a model of heart and vascular health,” OQUIN, under the leadership of Brent Egan, M.D., Professor of Medicine & Pharmacology at MUSC and Director of the Hypertension Initiative, has forged a strong collaboration between academic and community-based physicians. It has largely achieved its aim of having at least one ASH-certified hypertension specialist in each county in South Carolina, who can help train other physicians on guideline-recommended blood pressure targets and suggest strategies for reaching them. All OQUIN practices share their clinical data with MUSC experts, who provide regular and very granular audit feedback regarding how well they are treating to guideline-recommended targets overall and for each individual patient. A newsletter focusing on state-of-the-art control of hypertension and offering continuing medical education accompanies each audit report. Using such measures, OQUIN has been able to increase hypertension control from 49% to 72% among its participating practices.19 The data sharing at the heart of OQUIN has also allowed much more clinically relevant research. Using these data, OQUIN researchers were able to show that African Americans with prehypertension (120-139 mm Hg) developed hypertension one year earlier than did their non-Hispanic white counterparts, providing a useful target for intervention.20 Because prehypertension is much easier to control than hypertension, Egan and others are questioning whether pharmacological intervention in addition to lifestyle modification at this stage could prevent full-blown hypertension and its consequences, thereby helping reduce racial disparities. Such pharmacological intervention in prehypertensive African American patients is not yet part of any guideline, though all acknowledge the importance of early diagnosis of prehypertension/hypertension for improved outcomes.
With more persistent efforts at controlling blood pressure in African Americans to guideline-set targets by prescribing affordable and effective combination regimens and working with academic medical institutions to continuously improve the quality of care, primary care physicians in South Carolina can play a large role in narrowing racial disparities in health care and making the state a model of cardiovascular health.
Tools for Primary Care Providers in Addressing Social Determinants of Health, a CME series organized by Dr. Daniel T. Lackland in cooperation with the South Carolina AHEC SCHOOLS program, offers much more detailed recommendations by nationally recognized experts on the management of chronic disease in African Americans (for more information, see Box below).
Howard VJ, McClure LA, Glymour MM, et al. Effect of duration and age at
exposure to the Stroke Belt on incident stroke in adulthood.
1 Howard VJ, McClure LA, Glymour MM, et al. Effect of duration and age at exposure to the Stroke Belt on incident stroke in adulthood.Neurology 2013 Apr 30;80(18):1655-1661.
² Oliveras A, Schmieder RE. Clinical situations associated with difficult-to-control hypertension. J Hypertens. 2013 Mar;31 Suppl 1:S3-8.
³ Ovbiagele B, Goldstein LB, Higashida RT, et al; on behalf of the American Heart Association Advocacy Coordinating Committee and Stroke Council. Forecasting the Future of Stroke in the United States: A Policy Statement From the American Heart Association and American Stroke Association. Stroke. 2013 May 22. [Epub ahead of print] Available at http://stroke.ahajournals.org/content/early/2013/05/22/STR.0b013e31829734f2.long
⁴ Flack JM, Sica DA, Bakris G, et al; on behalf of the International Society on Hypertension in Blacks. Management of high blood pressure in blacks. An update of the International Society on Hypertension in Blacks Consensus Statement. Hypertension 2010; 56: 780-800.
⁵ Campbell JA, Walker RJ, Smalls BL, and Egede LE. Glucose control in diabetes: the impact of racial differences on monitoring and outcomes. Endocrine 2012;42:471-482.
⁶ Division of Chronic Disease Epidemiology, the South Carolina Diabetes Prevention and Control Program (DPCP) of the Bureau of Community Health and Chronic Disease Prevention (DHEC), the Office of Public Health Statistics and Information Systems (DHEC), and the Diabetes Initiative of South Carolina. Burden of diabetes in South Carolina 2012. Available at http://clinicaldepartments.musc.edu/medicine/divisions/endocrinology/dsc/2012_Burden_Of_Diabetes_Final_Jan_31_2013.pdf
⁷ Towfighi A, Ovbiagele B, Saver JL. Therapeutic milestone: stroke declines from the second to the third leading organ- and disease-specific cause of death in the United States. Stroke 2010;41:499–503.
⁸ Huhtakangas J, Löppönen P, Tetri S, et al. Predictors for recurrent primary intracerebral hemorrhage: a retrospective population-based study. Stroke 2013 Mar;44(3):585-90. Available at http://dx.doi.org/10.1161/STROKEAHA.112.671230.
⁹ Sifferlin A. Stroke Costs To Double By 2030. Time Magazine, May 29, 2013. Available at http://healthland.time.com/2013/05/29/stroke-costs-to-double-by-2030/
10 American Heart Association/American Stroke Association. Stroke risk factors. Available at http://www.strokeassociation.org/STROKEORG/AboutStroke/UnderstandingRisk/Understanding-Risk_UCM_308539_SubHomePage.jsp. Last updated October 23, 2012. Accessed June 1, 2013.
¹¹ Howard G, Cushman M, Kissela BM, et al; for the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Investigators. Traditional risk factors as the underlying cause of racial disparities in stroke: lessons from the half-full (empty?) glass. Stroke 2011;42:3369-3375.
¹² Saunders E, Saunders S. Considerations of Social Determinants in the Clinical Management of Hypertension and Disease. South Carolina Area Health Education Consortium SCHOOLS telepresentations, available at http://www.scahec.net/schools/programs/2013.04.11.social_determ.html.
¹³ Ferdinand KC, Saunders E. Hypertension-related morbidity and mortality in African Americans–why we need to do better. The Journal of Clinical Hypertension 2006;8(1):21.30. Suppl.
14 Chobanian AV, et al. and the National High Blood Pressure Education Program Coordinating Committee. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 report. JAMA 2003 May 21; 289:2560-72.
15 Lackland DT. Hypertension: Joint National Committee on detection, evaluation, and treatment of high blood pressure guidelines. Curr Opin Neurol 2013 Feb;26(1):8-12.
16 Egan BM, Zhao Y, Axon R. US Trends in Prevalence, Awareness, Treatment, and Control of Hypertension, 1988-2008. JAMA. 2010;303(20):2043-2050. Available at http://dx.doi.org/10.1001/jama.2010.650.
17 Egan BM, Bandyopadhyay D, Shaftman SR , et al. Initial monotherapy and combination therapy and hypertension control the first year. Hypertension 2012; 59: 1124-1131.
18 Egan BM, Laken MA, Wagner CS, et al. Impacting population cardiovascular health through a community-based practice network: update on an ASH-supported collaborative. J Clin Hypertens (Greenwich) 2011;13:543–550.
19 Punzi HA, Back JG, Egan BM. How to start a type 1 hypertension center in practice. American Society of Hypertension 2013 Annual Meeting, San Francisco, CA, May 17, 2013.
20 Selassie A, Wagner CS, Laken ML, et al., Progression is accelerated from prehypertension to hypertension in blacks.Hypertension 2011, 58:579-587: originally published online September 12, 2011.
Date of Release: August 9, 2013 Date of Expiration: August 9, 2015
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Sister telepresentations on social determinants of health will be broadcast by South Carolina AHEC to its member sites (full list of sites available at http://scahec.net/schools): Dr. Ovbiagele on race and stroke on August 27, 2013 from 1:00 to 2:00 pm and Dr. Egede on race and diabetes on September 30, 2013, from 3:00-4:00 pm. Participants can register online at http://scahec.net/schoolsregistration, identify a participating location, and attend the program free at an available SCHOOLS location. Each of these live activities has been approved for AMA PRA Category 1 Credit™. The session will be recorded as enduring material and made available at MUSChealth.com/progressnotescme for those who could not attend the live session.