In Ohio, there are significant disparities in hypertension control in African American (AA)/Black and Hispanic populations compared to White populations. There are also geographic disparities in smoking rates and hypertension control, especially between rural and urban populations and in those with greater and lower socioeconomic status. In this heart healthy quality improvement project, we plan to recruit sufficient clinics serving rural, low income and AA/Black patients to ensure disparities in cardiovascular health outcomes can be evaluated and addressed.
The electronic health record (EHR) data will assist us in understanding what disparities exist both across and within primary care practices at baseline for development of appropriate specific, measurable, achievable, realistic and time-framed (SMART) aims around disparities. In particular, for this 1-year quality improvement project, we promote the following evidence-based opportunities mentioned in several recent guidelines for clinics to consider as they work to reduce disparities in cardiovascular health outcomes focused on hypertension and smoking. The links below will take you to the appropriate resources within the toolkit
Strategies Available in the Toolkit to Address Disparities
- Identifying and addressing social determinants of health and racism which are impacting ability for patients to engage in care
- Standardized office procedures for consistently identifying and addressing hypertension and smoking in appropriate patients to reduce the potential for implicit bias. The following toolkit section links have resources around standardizing office procedures: Accurate Assessment and Measurement, Appropriate and Timely Treatment, Effective Outreach, Healthy Equitable Environment for Care, Screened and Well Managed Behavioral Health.
- Treatment algorithms prioritizing low cost once daily medications to enhance adherence
- Consistently identifying and addressing medication adherence and visit adherence (e.g., 90-day prescriptions, multiple follow-up modalities such as staff-led visits, Community Health Worker, and telehealth)
- Adequate doses of thiazide-type diuretics (i.e. HCTZ 25-50 and chlorthalidone 12.5-25 mg or indapamide 1.25-2.5 mg) or long-acting calcium channel blockers (e.g., amlodipine) as first line BP therapy before the use of renin-angiotensin system inhibitors in African American patients*
- Outreach to patients using tailored approaches, focused on those with care gaps
- Home BP monitor coverage and monitoring to address transportation barriers/access
- Communication skill-building to build trusting relationships between providers and patients, including cultural competency, health literacy, and implicit bias
*Race is a social construct and does not reflect biology. While we do not know the underlying etiology of difference in treatment effectiveness, it is important to ensure Black patients are provided the most effective anti-hypertensive first line treatment based on strong clinical trial evidence. Therefore, prioritizing use of antihypertensive medication that is more effective in Black patients is still important for better blood pressure control.9,10
References
- Vital Signs. Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/vitalsigns/million-hearts/infographic.html#map. Accessed 05-20-2020.
- Behavioral Risk Factor Surveillance System. Centers for Disease Control and Prevention (CDC). Available at: https://www.cdc.gov/brfss/index.html. Accessed 05-18-2020.
- Better Health Partnership Adult Community Health Report 24. Available at: http://www.betterhealthpartnership.org/data_center/adult_report_24/adult24_dashboard.asp. Accessed 05-18-2020.
- Samanic M, Barbour K, Liu Y, et al. Prevalence of Self-Reported Hypertension and Antihypertensive Medication Use by County and Rural-Urban Classification—United States, 2017. MMWR Morbidity and Mortality Weekly Report 2020;69:533-9.
- Doogan NJ, Roberts ME, Wewers ME, et al. A growing geographic disparity: Rural and urban cigarette smoking trends in the United States. Prev Med 2017;104:79-85.
- Tobacco Use by Geographic Region. Centers for Disease Control and Prevention (CDC). Office on Smoking and Health. National Center for Chronic Disease Prevention and Health Promotion. Available at: https://www.cdc.gov/tobacco/disparities/geographic/index.htm. Accessed 05-20-2020.
- Whelton PK, Carey RM, Aronow W, et al. Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology 2017;71:1269-324.
- Smoking cessation: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2020.
- Wright JT Jr, Dunn JK, Cutler JA, et al. Outcomes in hypertensive black and nonblack patients treated with chlorthalidone, amlodipine, and lisinopril. JAMA. 2005;293(13):1595-1608. doi:10.1001/jama.293.13.1595
- Still CH, Rodriguez CJ, Wright JT Jr, et al. Clinical Outcomes by Race and Ethnicity in the Systolic Blood Pressure Intervention Trial (SPRINT): A Randomized Clinical Trial. Am J Hypertens. 2017;31(1):97-107. doi:10.1093/ajh/hpx138
- Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines [published correction appears in Hypertension. 2018 Jun;71(6):e140-e144]. Hypertension. 2018;71(6):e13-e115. doi:10.1161/HYP.0000000000000065