Equitable Care for Hypertension: Blood Pressure and Patient-Reported Outcomes of the RICH LIFE Cluster Randomized Trial.

BACKGROUND: Disparities in hypertension control are well documented but underaddressed. METHODS: RICH LIFE (Reducing Inequities in Care of Hypertension: Lifestyle Improvement for Everyone) was a 2-arm, cluster randomized trial comparing the effect on blood pressure (BP) control (systolic BP ≤140 mm Hg, diastolic BP ≤90 mm Hg), patient activation, and disparities in BP control of 2 multilevel interventions, standard of care plus (SCP) and collaborative care/stepped care (CC/SC). SCP included BP measurement standardization, audit and feedback, and equity-leadership training. CC/SC added roles to address social or medical needs. Primary outcomes were BP control and patient activation at 12 months. Generalized estimating equations and mixed-effects regression models with fixed effects of time, intervention, and their interaction compared change in outcomes at 12 months from baseline. RESULTS: A total of 1820 adults with uncontrolled BP and ≥1 other risk factors enrolled in the study. Their mean age was 60.3 years, and baseline BP was 152.3/85.5 mm Hg; 59.4% were women; 57.4% were Black, 33.2% were White, and 9.4% were Hispanic; 74% had hyperlipidemia; and 45.1% had type 2 diabetes. CC/SC did not improve BP control rates more than SCP. Both groups achieved statistically and clinically significant BP control rates at 12 months (CC/SC: 57.3% [95% CI, 52.7%-62.0%]; SCP: 56.7% [95% CI, 51.9%-61.5%]). Pairwise comparisons between racial and ethnic groups showed overall no significant differences in BP control at 12 months. Patients with coronary heart disease showed greater achievement of BP control in CC/SC than in SCP (64.0% [95% CI, 54.1%-73.9%] versus 50.8% [95% CI, 42.6%-59.0%]; P=0.04), as did patients in rural areas (67.3% [95% CI, 49.8%-84.8%] versus 47.8% [95% CI, 32.4%-63.2%]; P=0.01). Individuals in both arms experienced statistically and clinically significant reductions in mean systolic BP (CC/SC: -13.8 mm Hg [95% CI, -15.2 to -12.5]; SCP: -14.6 mm Hg [95% CI, -15.9 to -13.2]) and diastolic BP (CC/SC: -6.9 mm Hg [95% CI, -7.8 to -6.1]; SCP: -5.5 mm Hg [95% CI, -6.4 to -4.6]) over time. The difference in diastolic BP reduction between CC/SC and SCP over time was statistically significant (-1.4 mm Hg [95% CI, -2.6 to -0.2). Patient activation did not differ between arms. CC/SC showed greater improvements in patient ratings of chronic illness care (Patient Assessment of Chronic Illness Care score) over 12 months (0.12 [95% CI, 0.02-0.22]). CONCLUSIONS: Adding a collaborative care team to enhanced standard of care did not improve BP control but did improve patient ratings of chronic illness care.

The RICH LIFE Project: A cluster randomized pragmatic trial comparing the effectiveness of health system only vs. health system Plus a collaborative/stepped care intervention to reduce hypertension disparities.

Disparities in the control of hypertension and other cardiovascular disease risk factors are well-documented in the United States, even among patients seen regularly in the healthcare system. Few existing approaches explicitly address disparities in hypertension care and control. This paper describes the RICH LIFE Project (Reducing Inequities in Care of Hypertension: Lifestyle Improvement for Everyone) design. METHODS: RICH LIFE is a two-arm, cluster-randomized trial, comparing the effectiveness of enhanced standard of care, "Standard of Care Plus" (SCP), to a multi-level intervention, "Collaborative Care/Stepped Care" (CC/SC), for improving blood pressure (BP) control and patient activation and reducing disparities in BP control among 1890 adults with uncontrolled hypertension and at least one other cardiovascular disease risk factor treated at 30 primary care practices in Maryland and Pennsylvania. Fifteen practices randomized to the SCP arm receive standardized BP measurement training; race/ethnicity-specific audit and feedback of BP control rates; and quarterly webinars in management practices, quality improvement and disparities reduction. Fifteen practices in the CC/SC arm receive the SCP interventions plus implementation of the collaborative care model with stepped-care components (community health worker referrals and virtual specialist-panel consults). The primary clinical outcome is BP control (<140/90 mm Hg) at 12 months. The primary patient-reported outcome is change from baseline in self-reported patient activation at 12 months. DISCUSSION: This study will provide knowledge about the feasibility of leveraging existing resources in routine primary care and potential benefits of adding supportive community-facing roles to improve hypertension care and reduce disparities. TRIAL REGISTRATION: Clinicaltrials.govNCT02674464.

Care Management to Reduce Disparities and Control Hypertension in Primary Care: A Cost-effectiveness Analysis.

BACKGROUND: Project ReD CHiP (reducing disparities and controlling hypertension in primary care) care management was a clinic-based intervention that aimed to improve blood pressure control through improved care coordination and provide self-management support to patients from racially and socioeconomically. OBJECTIVE: To evaluate the cost-effectiveness of ReD CHiP care management versus standard care to treat hypertension in diverse communities. RESEARCH DESIGN: Microsimulation model from a health care sector perspective over 15 years. We used the published literature to inform our model including the ReD CHiP trial and the age-specific and race-specific cardiovascular disease risk equations. Deterministic and probabilistic sensitivity analyses were conducted to assess the uncertainty. SUBJECTS: Primary prevention in a racially diverse setting. MEASURES: Costs per quality-adjusted life years (QALYs) to produce an incremental cost-effectiveness ratio (ICER). RESULTS: ReD CHiP had an increase of $2114 and 0.04 QALYs. The ICER was $52,850/QALY. Predominately African American (ICER: $48,250/QALY) and elderly populations (ie, age 65+) derived value from ReD CHiP (ICER: $39,525/QALY). The value of ReD CHiP varied with changes in the reduction in systolic blood pressure (5 mm Hg reduction, ICER: $133,300/QALY; 15 mm Hg reduction, ICER: $18,767/QALY). Probabilistic sensitivity analysis indicated that ReD CHiP CM was cost-effective in over 90% of simulations, based on a willingness-to-pay of $100,000/QALY. CONCLUSIONS: ReD CHiP care management is cost-effective to prevent negative consequences of hypertension. African American and elderly patients have more favorable ICERs, recommending targeted interventions to improve health equity among vulnerable patient populations.

Promoting sustainability in quality improvement: an evaluation of a web-based continuing education program in blood pressure measurement.

BACKGROUND: The accuracy of blood pressure measurement is variable in office-based settings. Even when staff training programs are effective, knowledge and skills decay over time, supporting the need for ongoing staff training. We evaluated whether a web-based continuing education program in blood pressure measurement reinforced knowledge and skills among clinical staff and promoted sustainability of an existing quality improvement program. METHODS: Medical assistants and nurses at six primary care clinics within a health system enrolled in a 30-min online educational program designed to refresh their knowledge of blood pressure measurement. A 20-question pre- and post-intervention survey addressed learners' knowledge and attitudes. Direct observation of blood pressure measurement technique before and after the intervention was performed. Differences in responses to pre- and post-module knowledge and attitudes questions and in observation data were analyzed using chi-square tests and simple logistic regression. RESULTS: All 88 clinical staff members participated in the program and completed the evaluation survey. Participants answered 80.6% of questions correctly before the module and 93.4% afterwards (p < 0.01). Scores improved significantly among staff from all job types. Licensed practical nurses and staff who had been in their current job at least a year were more likely to answer questions correctly than registered nurses and those in their current job less than a year. Attitudes toward correct blood pressure measurement were high at baseline and did not improve significantly. Prior to the intervention, staff adhered to 9 of 18 elements of the recommended technique during at least 90% of observations. Following the program, staff was more likely to explain the protocol, provide a rest period, measure an average blood pressure, and record the average blood pressure, but less likely to measure blood pressure with the arm at heart level and use the right arm. CONCLUSIONS: We designed, implemented, and evaluated a web-based educational program to improve knowledge, skills, and attitudes in blood pressure measurement and use of an automated device among nurses and medical assistants in ambulatory care. The program reinforced knowledge related to recommended blood pressure measurement technique. TRIAL REGISTRATION: Retrospectively registered with ClincalTrials.gov on March 22, 2012; registration number NCT01566864 .

Reaching for Health Equity and Social Justice in Baltimore: The Evolution of an Academic-Community Partnership and Conceptual Framework to Address Hypertension Disparities.

Cardiovascular health disparities persist despite decades of recognition and the availability of evidence-based clinical and public health interventions. Racial and ethnic minorities and adults in urban and low-income communities are high-risk groups for uncontrolled hypertension (HTN), a major contributor to cardiovascular health disparities, in part due to inequitable social structures and economic systems that negatively impact daily environments and risk behaviors. This commentary presents the Johns Hopkins Center to Eliminate Cardiovascular Health Disparities as a case study for highlighting the evolution of an academic-community partnership to overcome HTN disparities. Key elements of the iterative development process of a Community Advisory Board (CAB) are summarized, and major CAB activities and engagement with the Baltimore community are highlighted. Using a conceptual framework adapted from O'Mara-Eves and colleagues, the authors discuss how different population groups and needs, motivations, types and intensity of community participation, contextual factors, and actions have shaped the Center's approach to stakeholder engagement in research and community outreach efforts to achieve health equity.

Assessing Factors Influencing Commitment to a Disparities Reduction Intervention: Social Justice Attitudes and Organizational Mission.

ABSTRACT: This mixed-methods study aims to understand what the perceptions of leaders and healthcare professionals are regarding causes of disparities, cultural competence, and motivation before launching a disparity reduction project in hypertension care, contrasting perceptions in Federally Qualified Health Centers (FQHCs), and in a non-FQHC system. We interviewed leaders of six participating primary care systems and surveyed providers and staff. FQHC respondents reported more positive cultural competence attitudes and behavior, higher motivation to implement the project, and less concern about barriers to caring for disadvantaged patients than those in the non-FQHC practices; however, egalitarian beliefs were similar among all. Qualitative analysis suggested that the organizational missions of the FQHCs reflect their critical role in serving vulnerable populations. All system leaders were aware of the challenges of provider care to underserved groups, but comprehensive initiatives to address social determinants of health and improve cultural competence were still needed in both system types. The study provides insights into the perceptions and motivations of primary care organizational leaders and providers who are interested in improving chronic care. It also offers an example for care disparity programs to understand commitment and values of the participants for tailoring interventions and setting baseline for progress.

AddREssing Social Determinants TO pRevent hypErtension (The RESTORE Network): Overview of the Health Equity Research Network to Prevent Hypertension.

BACKGROUND: The American Heart Association funded a Health Equity Research Network on the prevention of hypertension, the RESTORE Network, as part of its commitment to achieving health equity in all communities. This article provides an overview of the RESTORE Network. METHODS: The RESTORE Network includes five independent, randomized trials testing approaches to implement non-pharmacological interventions that have been proven to lower blood pressure (BP). The trials are community-based, taking place in churches in rural Alabama, mobile health units in Michigan, barbershops in New York, community health centers in Maryland, and food deserts in Massachusetts. Each trial employs a hybrid effectiveness-implementation research design to test scalable and sustainable strategies that mitigate social determinants of health (SDOH) that contribute to hypertension in Black communities. The primary outcome in each trial is change in systolic BP. The RESTORE Network Coordinating Center has five cores: BP measurement, statistics, intervention, community engagement, and training that support the trials. Standardized protocols, data elements and analysis plans were adopted in each trial to facilitate cross-trial comparisons of the implementation strategies, and application of a standard costing instrument for health economic evaluations, scale up, and policy analysis. Herein, we discuss future RESTORE Network research plans and policy outreach activities designed to advance health equity by preventing hypertension. CONCLUSIONS: The RESTORE Network was designed to promote health equity in the US by testing effective and sustainable implementation strategies focused on addressing SDOH to prevent hypertension among Black adults.

Social Determinants of Health as Potential Influencers of a Collaborative Care Intervention for Patients with Hypertension.

Objectives: The use of collaborative care teams, comprising nurse care managers and community health workers, has emerged as a promising strategy to tackle hypertension disparities by addressing patients' social determinants of health. We sought to identify which social determinants of health are associated with a patient's likelihood of engaging with collaborative care team members and with the nurse care manager's likelihood of enlisting community health workers (CHW) to provide additional support to patients. Methods: We conducted a within-group longitudinal analysis of patients assigned to receive a collaborative care intervention in a pragmatic, cluster randomized trial that aims to reduce disparities in hypertension control (N=888). Generalized estimating equations were used to identify which social determinants of health, reported on the study's baseline survey, were associated with the odds of patients engaging with the collaborative care intervention, and of nurses deploying community health workers. Results: Patients who were unable to work and those with higher health literacy were less likely to engage with the collaborative care team than those who were employed full time or had lower health literacy, respectively. Patients had a greater likelihood of being referred to a community health worker by their care manager if they reported higher health literacy, perceived stress, or food insecurity, while those reporting higher numeracy had lower odds of receiving a CHW referral. Implications/Conclusions: A patient's social determinants of health influence the extent of engagement in a collaborative care intervention and nurse care manager appraisals of the need for supplementary support provided by community health workers.

A bundled quality improvement program to standardize clinical blood pressure measurement in primary care.

We evaluated use of a program to improve blood pressure measurement at 6 primary care clinics over a 6-month period. The program consisted of automated devices, clinical training, and support for systems change. Unannounced audits and electronic medical records provided evaluation data. Clinics used devices in 81.0% of encounters and used them as intended in 71.6% of encounters, but implementation fidelity varied. Intervention site systolic and diastolic blood pressure with terminal digit "0" decreased from 32.1% and 33.7% to 11.1% and 11.3%, respectively. Improvement occurred uniformly, regardless of sites' adherence to the measurement protocol. Providers rechecked blood pressure measurements less often post-intervention (from 23.5% to 8.1% of visits overall). Providers at sites with high protocol adherence were less likely to recheck measurements than those at low adherence sites. Comparison sites exhibited no change in terminal digit preference or repeat measurements. This study demonstrates that clinics can apply a pragmatic intervention to improve blood pressure measurement. Additional refinement may improve implementation fidelity.

A multi-level system quality improvement intervention to reduce racial disparities in hypertension care and control: study protocol.

BACKGROUND: Racial disparities in blood pressure control have been well documented in the United States. Research suggests that many factors contribute to this disparity, including barriers to care at patient, clinician, healthcare system, and community levels. To date, few interventions aimed at reducing hypertension disparities have addressed factors at all of these levels. This paper describes the design of Project ReD CHiP (Reducing Disparities and Controlling Hypertension in Primary Care), a multi-level system quality improvement project. By intervening on multiple levels, this project aims to reduce disparities in blood pressure control and improve guideline concordant hypertension care. METHODS: Using a pragmatic trial design, we are implementing three complementary multi-level interventions designed to improve blood pressure measurement, provide patient care management services and offer expanded provider education resources in six primary care clinics in Baltimore, Maryland. We are staggering the introduction of the interventions and will use Statistical Process Control (SPC) charting to determine if there are changes in outcomes at each clinic after implementation of each intervention. The main hypothesis is that each intervention will have an additive effect on improvements in guideline concordant care and reductions in hypertension disparities, but the combination of all three interventions will result in the greatest impact, followed by blood pressure measurement with care management support, blood pressure measurement with provider education, and blood pressure measurement only. This study also examines how organizational functioning and cultural competence affect the success of the interventions. DISCUSSION: As a quality improvement project, Project ReD CHiP employs a novel study design that specifically targets multi-level factors known to contribute to hypertension disparities. To facilitate its implementation and improve its sustainability, we have incorporated stakeholder input and tailored components of the interventions to meet the specific needs of the involved clinics and communities. Results from this study will provide knowledge about how integrated multi-level interventions can improve hypertension care and reduce disparities. TRIAL REGISTRATION: ClinicalTrials.gov NCT01566864.