Addressing Racial/Ethnic Disparities in Hypertensive Health Center Patients

Addressing Racial/Ethnic Disparities in Hypertensive Health Center Patients Academy Health June 11, 2011 Quyen Ngo Metzger, MD, MPH Data Branch Chief, Office of Quality and Data U.S. Department of Health and Human Services Health Resources and Services Administration Bureau of Primary Health Care

Primary Health Care Mission Improve the health of the Nation s underserved communities and vulnerable populations by assuring access to comprehensive, culturally competent, quality primary health care services

Health Center Program Overview Calendar Year 2009 8,000 Health Center Sites 18.8 Million Patients 92% At or Below 200% Poverty 38% Uninsured 63% Racial/Ethnic Minorities Over 1 Million Homeless Individuals 865,000 Migrant/Seasonal Farm Workers 165,000 Residents of Public Housing Source: Uniform Data System, 2009

Health Center Program National Presence

Background Ethnic minorities are more likely to have hypertension and suffer from increased morbidity and mortality compared to non Hispanic Whites. Health Centers offer a health care delivery model in a primary care setting that promotes cost effectiveness, appropriate chronic care management and equitable treatment.

Objectives Identify and compare racial/ethnic differences in: Receipt of hypertension care in federally supported Health Centers Adherence to hypertension control recommendations Controlled hypertension Hypertension related emergency room use and hospitalization

Methods Data source: 2009 Health Center Patient Survey (n= 4,562) Analysis: For patients with diagnosed chronic hypertension 1 (n=1,464), logistic regression models were estimated to predict: Receipt of lifestyle counseling to control hypertension (diet, sodium intake, exercise, and alcohol consumption) Patient adherence to hypertension control lifestyle counseling Patients with controlled hypertension Hypertension related emergency room visits or hospitalizations over the preceding 2 years 1 Patient was told on 2 or more separate clinical visits s/he had hypertension

Methods Statistical models controlled for: Age Sex Education Nativity Body Mass Index Current smoking status Health insurance status Usual source of care Unmet health care needs in past year Presence or history of chronic health condition(s) Limitations to physical ability Self assessed health

Patient Characteristics Chronic Hypertensive 1 Health Center Patients (n=1,464) Percent (%) Race/ethnicity Hispanic and Latino 32.0 NH White 27.5 NH Black 31.8 NH American Indian and Alaska Native (AIAN) 5.5 NH Native Hawaiian and Pacific Islander (NHPI) 1.0 NH Asian 0.5 NH other 1.7 Age: Mean (SD) 51 years (+ 11.66) Female 62.3 U.S. born 77.1 Educational attainment High school graduate 50.7 Body Mass Index (BMI) 2 Overweight/Obese (25.0 or higher) 78.1 Current smoker (cigarettes) 35.8 1 Patient was told on 2 or more separate clinical visits s/he had hypertension 2 127 patients declined to provide BMI information Source: Primary Health Care Patient Survey 2009

Health Care Access Chronic Hypertensive Health Center Patients (n=1,464) Percent (%) Currently insured 63.6 Has a usual source of care 86.9 Medical needs were met in the past 12 months 1 75.3 Travel time to the health center 2 30 minutes or less 88.5 1 Among patients that doctor believed needed any medical care, tests, or treatment (n=985) 2 Travel time includes walking, driving, public transportation, Health Center provided transportation Source: Primary Health Care Patient Survey 2009

Results Receipt of Hypertension Control Lifestyle Counseling by Race/Ethnicity Diet change (n=1,170) Reduce sodium (n=1,170) Exercise (n=1,170) Reduce alcohol (n=1,168) Covariates OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) Race/Ethnicity (NH White) Reference Reference Reference Reference Hispanic/Latino 1.64* (1.03, 2.61) 2.01* (1.17, 3.43) 1.62 (0.93, 2.82) 2.15* (1.44, 3.22) NH Black 1.91* (1.34, 2.71) 2.97* (1.95, 4.53) 1.89* (1.25, 2.85) 2.35* (1.72, 3.21) NH AIAN 1.70 (0.89, 3.25) 1.55 (0.77, 3.14) 3.51* (1.38, 8.90) 1.50 (0.87, 2.60) NH NHPI 5.43 (0.65, 45.04) 4.54 (0.55, 37.66) 1.45 (0.43, 4.93) NH Asian 2.41 (0.41, 14.24) 0.68 (0.11, 4.16) 0.21 (0.02, 1.80) NH other 0.81 (0.32, 2.04) 0.78 (0.30, 2.07) 0.74 (0.27, 2.05) 0.85 (0.35, 2.11) Covariates include: age, sex, education, nativity, BMI, current smoker, health insurance, usual source of care, hypercholesterolemia, diabetes, history of stroke *p<0.05 Source: Primary Health Care Patient Survey 2009

Results Adherence to Hypertension Control Lifestyle Counseling by Race/Ethnicity Diet change (n=865) Reduce sodium (n=974) Exercise (n=985) Reduce alcohol (n=616) Covariates OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) Race/Ethnicity (NH White) Reference Reference Reference Reference Hispanic/Latino 1.24 (0.56, 2.75) 1.09 (0.47, 2.51) 1.25 (0.64, 2.43) 0.44 (0.17, 1.13) NH Black 1.77 (0.96, 3.28) 1.94 (0.99, 3.82) 1.05 (0.64, 1.71) 1.48 (0.61, 3.59) NH AIAN 1.42 (0.45, 4.49) 1.86 (0.49, 7.04) 1.32 (0.52, 3.33) 1.26 (0.25, 6.32) NH NHPI 1.31 (0.15, 11.18) 0.31 (0.03, 3.58) NH Asian NH other 1.94 (0.21, 18.37) 0.53 (0.14, 2.10) 0.42 (0.06, 2.81) Covariates include: age, sex, education, nativity, BMI, current smoker, health insurance, usual source of care, doctor patient communication, hypercholesterolemia, diabetes, history of stroke, self assessed health compared to last year *p<0.05 Source: Primary Health Care Patient Survey 2009

Results Controlled Hypertension 1 by Race/Ethnicity (n=1,298) OR (95% CI) Race/Ethnicity (NH White) Reference Hispanic/Latino 1.17 (0.79, 1.74) NH Black 0.81 (0.59, 1.10) NH AIAN 1.02 (0.59, 1.78) NH NHPI 1.45 (0.42, 5.07) NH Asian 0.89 (0.20, 4.03) NH other 1.11 (0.46, 2.72) 1 Hypertensive patients told they had normal or borderline blood pressure at last clinical visit Covariates include: age, sex, education, nativity, current smoker, health insurance, usual source of care, met health care needs, hypercholesterolemia, diabetes, history of stroke *p<0.05 Source: Primary Health Care Patient Survey 2009

Results Emergency Room Use or Hospitalization Due to Hypertension in Past 2 Years by Race/Ethnicity (n=1,427) OR (95% CI) Race/Ethnicity (NH White) Reference Hispanic/Latino 1.44 (0.87, 2.40) NH Black 1.54* (1.03, 2.29) NH AIAN 2.09* (1.09, 4.02) NH NHPI 0.85 (0.10, 6.98) NH Asian 3.24 (0.57, 18.54) NH other 2.10 (0.76, 5.82) Covariates include: age, sex, education, nativity, current smoker, health insurance, usual source of care, unmet health care needs, hypercholesterolemia, diabetes, history of stroke *p<0.05 Source: Primary Health Care Patient Survey 2009

Summary of Results There were no racial/ethnic disparities in: Receipt of hypertension control lifestyle counseling Adherence to hypertension control lifestyle counseling Controlled hypertension NH African Americans and NH Native Americans (AIAN) were more likely than NH whites to have a hypertension related emergency department visit or hospitalization in the preceding 2 years.

Limitations Patient Survey data are cross sectional. Association does not equate to causation. Self report acquiescence bias recall bias Race/ethnic comparisons are limited to Hispanic/Latinos, African Americans, and Whites. Sample sizes of other race/ethnic groups are small. Patient survey is conducted in English and Spanish.

Implications Health Centers are succeeding in providing equitable care across population groups. Health care access plays an important role in the control of chronic conditions like hypertension. More research is needed to better understand health services use in ethnic minority groups.

Thank You

Quyen Ngo Metzger MD, MPH Branch Chief, Office of Quality and Data U.S. Department of Health and Human Services Health Resources and Services Administration Bureau of Primary Health Care 5600 Fishers Lane Rm. 15 05 Rockville, MD 20857 Telephone: 301.594.0818 Email: QNgo Metzger@hrsa.gov