Racial and ethnic equality in health care:
a national imperative

Background

• Since 2002, Aetna has focused on improving health care equality for racial and ethnic minorities.
• The company is working to understand the needs of all its members, especially the cultural differences among targeted racial and ethnic member populations. We then develop programs and services, based on clinical evidence, that improve health outcomes for these populations.
• Company-wide efforts include making grants, developing cultural competency training and health literacy initiatives and augmenting medical management programs, as appropriate.

Hypertension in African Americans Study

Study rationale

• Compared to white Americans, African Americans have a higher prevalence of hypertension (HTN).^1,2
• African Americans also have higher rates of cardiovascular mortality, stroke, hypertension-related heart disease, congestive heart failure, hypertensive nephropathy, and end-stage renal disease.^1,2
• African Americans have an 80% higher rate of stroke mortality, 50% higher rate of heart disease mortality, and 320% higher rate of hypertension-related end-stage renal disease.³

Study goals

• Study objective was to evaluate the effectiveness of a Culturally Competent Disease Management Program (CCDMP) relative to a Light Support Disease Management Program (LSP) to increase the rate of clinically acceptable blood pressure measurements among Aetna-insured African American members with hypertension.

Collaboration

• Funding provided by sanofi-aventis.
• Workgroup/study design developed by Aetna; Health & Technology Vector, Inc.; and Morehouse School of Medicine.

Study design

• Two-arm cluster randomized controlled study to test effectiveness in attaining and maintaining blood pressure (BP) control among Aetna African American members with hypertension.
• Comparison of two Disease Management (DM) Programs:
  • Culturally Competent Disease Management Program (CCDMP)
    • CCDMP participants received culturally competent mailings and outbound member care calls.
    • CCDMP physicians were offered cultural competency training and provided quarterly reporting to physicians.
    • Educational materials included:
      • 7 Steps to A Healthy Heart for African-Americans by Association of Black Cardiologists.
      • Nutrition Fact Sheet: African-American Health and Dairy Foods by National Dairy Council.
      • Aetna Health Eating Tips pamphlet.
    • Participation incentives $15-$55.
  • Light Support Disease Management Program (LSP)
    • Participation incentives $15-$55.

Evaluation methods

• The primary outcome was blood pressure (BP) compliance of less than 120/80, the goal identified by the Joint National Committee (JNC-7) guidelines for African Americans with hypertension.
• Other outcomes were lower systolic; mean change of BP between initial and final assessment; and contributing BP control behaviors, such as frequency of BP monitoring and usage of two or more anti-hypertension medication classes.

Analysis populations

• Of 6,000 Aetna members invited to participate in the study, 954 (15.9% of eligible members) were recruited; 638 (66.9% of recruited members) recruited members completed the Initial BP Assessment; 485 (76.0% of initially assessed members) either returned the Six-Month BP Mailing or completed the Post BP Assessment.

Impact of the initiative

• The Culturally Competent Disease Management Program (CCDMP) was effective in increasing the percentage of members with clinically acceptable blood pressure.
• Other benefits seen in the study were: increase in BP monitoring and CCDMP members’ medication usage.

Sustainability

The Hypertension in African Americans Study was conducted in response to the serious issue of the
prevalence of hypertension in the African American population. Hypertension in African Americans is a leading cause of mortality, premature disability and human suffering. This study was done to help Aetna gain a better understanding of the problem and improve care for the African American population at higher risk of this condition. Aetna is currently developing recommendations regarding the expansion and augmentation of the Hypertension Disease Management Program for this population.

“Studies show that patients with certain racial and ethnic backgrounds
receive lower-quality health care than other patients. We are working to
understand those disparities and develop solutions to help people get the
most value from their health care.”

Troyen Brennan, M.D., Aetna’s chief medical officer

Acknowledgements

Aetna
Troyen A. Brennan, M.D., M.P.H.
James D. Cross, M.D.
Michele Toscano. M.S.
Joseph D. Basiel, R.N.
Margaret Dee, R.N.
Operations Team: Eileen Curtis, R.N.; Mary
Ann Roman, R.N.; Joan Rago, R.N.; Carrie
Kocher, R.N.; Jennifer Phillips, R.N.
Elizabeth J. Lowy, R.N., B.S.N.
Cheryl N. McMahill-Walraven, M.S.W.
Claire M. Spettell, Ph.D.
Aaron Snyder
Allison Freeman, M.S.
Richard M. Dubiel, M.P.H.
Sheryll Roberson, M.S.

Health & Technology Vector, Inc.
Victor Villagra, M.D.
Maryann McGuire, R.N.

Morehouse School of Medicine
Leslie R. Boone, M.S.
Robert M. Mayberry, M.P.H., Ph.D.
Elizabeth Ofili, MD, M.P.H., F.A.C.C.
Alexander Quarshie, M.D.
Pamela Daniels, M.P.H., M.B.A.

Partially funded by a grant from sanofi-aventis.

Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company and its affiliates (Aetna).

Information is believed to be accurate as of the production date; however, it is subject to
change. ©2008 Aetna Inc.

¹ Hertz RP, Unger AN, Cornell JA, Saunders E. Racial disparities in hypertension prevalence,
awareness, and management. Archives of Internal Medicine 2005;165:2098-2104.
² American Heart Association. Heart Disease and Stroke Statistics—2007 Update. Dallas, TX:
American Heart Association; 2007.
³ Ferdinand, KC: Treating the African American with Hypertension: Does Race Really Matter?,
Southern Medical Journal, 95(5):541-544, May 2000.