Evaluating the Effectiveness of African School of Hypertension for Non-Physician Health Workers, a Qualitative Study: QuASH Hypertension Study.

Background: The implementation of task sharing and shifting (TSTS) policy as a way of addressing the shortage of physicians and reducing the burden of hypertension in Africa birthed the idea of the African School of Hypertension (ASH). The ASH is saddled with the responsibility of training non-physician health workers across Africa continent in the management of uncomplicated hypertension. Aim: To get feedback from some faculty members and students who participated in the first ASH programme. Methods: This was a cross-sectional exploratory qualitative study conducted among eight students and eight faculty members. Feedback from the program was obtained by conducting in-depth interviews centred on description of course content; expectations and knowledge acquired from ASH; level of interaction between students and faculty members; challenges faced during the ASH; level of implementation of acquired training; and suggestions to improve subsequent ASH programs. Results: The course content of the ASH was described as simple, appropriate and adequate while interaction between students and faculty members were highly cordial and engaging. New knowledge about hypertension management was acquired by the students with different levels of implementation post-graduation. Some identified challenges with the ASH program were poor internet connectivity during lectures, non-uniformity of TSTS policies and hypertension management guidelines across Africa, technical problems with hypertension management app and low participation from other African countries apart from Nigeria. Some recommendations to improve ASH program were development of a uniform hypertension management guideline for Africans, wider publicity of the ASH, interpretation of lectures into French and Portuguese languages and improvement of internet connectivity. Conclusion: The ASH programme has largely achieved its objectives with the very encouraging feedback received from both faculty members and the students. Steps should be taken to address the identified challenges and implement the suggested recommendations in subsequent ASH program to sustain this success.

Applications and outcomes of implementing telemedicine for hypertension management in COVID-19 pandemic: A systematic review.

INTRODUCTION: COVID-19 presented a significant challenge for patients with hypertension in terms of access to care. However, telemedicine offered the healthcare system opportunities that had previously been underutilized. Therefore, this study aims to systematically review the applications and outcomes of telemedicine for hypertension management during the COVID-19 pandemic. METHOD: A structured search was conducted in accordance with PRISMA guidelines across multiple databases, including PubMed, Cochrane, Web of Science, and Scopus. The search was limited to studies published from December 2019 until May 2023, resulting in a total of 3727 studies. After quality appraisal using the CASP checklists version 2018, 29 articles were included in the final review. Data analysis was performed using thematic analysis. RESULTS: Most of the studies reviewed had used the proprietary platforms (N = 14) and 11 studies had used public platforms such as social messengers or email. Also 9 studies relied on phone calls (N = 9) to record and transmit the clinical data. Some studies had applied two different approaches (proprietary/public platforms and phone). six articles (20.7%) focused only on hypertension control, while 23 articles (79.3%) examined hypertension as a comorbidity with other diseases. Also, the study identified 88 unique concepts, 15 initial themes, and six final themes for outcomes of using telemedicine for hypertension management during the COVID-19 pandemic. These themes include BP control, BP measurement and recording, medication management, mental health, care continuity and use and acceptance. CONCLUSION: Telemedicine provides patients with hypertension with the opportunity to engage in medical consultations in a more convenient and comfortable manner, with the same validity as in-person visits. Telemedicine facilitates the creation of a connected network to support patients with high BP at any time and in any location. Limitations and issues may arise due to patients and healthcare staff's unfamiliarity with telemedicine. These issues can be resolved through the ongoing use and continuous feedback.

Advancing cardiovascular neuromodulation: Aortic baroreceptor afferents act as targets for blood pressure control in hypertension.

Aortic baroreceptor afferents act as targets for blood pressure control in hypertension.

The effect of educational intervention based on the PRECEDE-PROCEED model on self-care behaviors and quality of life of hypertensive patients.

Background: To prevent the harmful consequences of hypertension and enhance the quality of life of hypertensive patients, the use of educational models is highly suggested. Therefore, the present study was designed to determine the effect of education based on the PRECEDE-PROCEED on self-care behaviors and the quality of life of hypertensive patients in Kazeroon city, Iran, in 2023. Methods: A total of 120 hypertensive individuals who were referred to Kazeroon city health centers participated in the current quasi-experimental study. The participants were divided into two experimental and control groups using a random sampling technique (60 participants in each group). The self-care behaviors questionnaire, the quality of life questionnaire, and a questionnaire based on the PRECEDE-PROCEED model were used as the data acquisition techniques. Both groups completed the questionnaires before and 2 months after the intervention. The educational program included a six-session, 50-60 min training program using three different teaching methods (speaking, Q&A, group discussion, and peer training) in health facilities. The data were examined using paired t, independent t, and chi-square statistical tests after being entered into the SPSS 24 statistical program. Results: Following the intervention, the experimental group showed significantly higher values in quality of life, knowledge, attitude, enabling and reinforcing factors, and self-care behaviors compared to the control group (p < 0.001 for all comparisons). The experimental group also exhibited a significant reduction in systolic blood pressure measures compared to the control group (p < 0.001). Conclusion: In the present study, education based on the PRECEDE-PROCEED model and focusing on blood pressure self-care behavior in patients with hypertension led to a decrease in their systolic blood pressure measures and improved their quality of life.

[Diagnosis and management of patients with pheochromocytoma/paraganglioma: Consensus of experts of the Russian Medical Society for Arterial Hypertension and the Multidisciplinary Group for the Diagnosis and Treatment of Neuroendocrine Tumors].

The understanding of the nature of catecholamine-secreting tumors has changed significantly in recent years, affecting terminology and classification. Phaeochromocytoma/paraganglioma (PCC/PG) is a rare neuroendocrine tumor from chromaffin tissue that produces and secretes catecholamines. The incidence of PCC/PG is relatively low, with 2-8 cases per 1 million population per year; among patients with arterial hypertension, their prevalence is 0.2-0.6%. However, delayed diagnosis of PCC/PG is associated with a high risk of cardiovascular complications and a high mortality rate. The consensus presents the clinical manifestations of the disease with an emphasis on the course of arterial hypertension as the most common symptom in PCC/PG; modern ideas about the features of diagnosis, aspects of preoperative preparation, treatment, and follow-up of patients with PCC/PG are considered.

Identifying personalized barriers for hypertension self-management from TASKS framework.

OBJECTIVE: Effective management of hypertension requires not only medical intervention but also significant patient self-management. The challenge, however, lies in the diversity of patients' personal barriers to managing their condition. The objective of this research is to identify and categorize personalized barriers to hypertension self-management using the TASKS framework (Task, Affect, Skills, Knowledge, Stress). This study aims to enhance patient-centered strategies by aligning support with each patient's specific needs, recognizing the diversity in their unique circumstances, beliefs, emotional states, knowledge levels, and access to resources. This research is based on observations from a single study focused on eight patients, which may have been a part of a larger project. RESULTS: The analysis of transcripts from eight patients and the Global Hypertension Practice Guidelines revealed 69 personalized barriers. These barriers were distributed as follows: emotional barriers (49%), knowledge barriers (24%), logical barriers (17%), and resource barriers (10%). The findings highlight the significant impact of emotional and knowledge-related challenges on hypertension self-management, including difficulties in home blood pressure monitoring and the use of monitoring tools. This study emphasizes the need for tailored interventions to address these prevalent barriers and improve hypertension management outcomes.

[Effects of acupuncture on endothelial active factors and related autonomic neurotransmitters in spontaneous hypertension rats].

OBJECTIVE: To observe the effects of acupuncture at "antihypertensive acupoint prescription" on endothelial active factors and related autonomic neurotransmitters in spontaneous hypertension rats, and explore the vascular regulation and central regulation mechanisms of acupuncture for anti-hypertension. METHODS: Thirty SPF grade male spontaneous hypertension rats were randomly divided into a model group (15 rats) and an acupuncture group (15 rats). Besides, 15 Wistar Kyoto rats were collected as a blank control group (normal group). In the acupuncture group, acupuncture was delivered at the "antihypertensive acupoint prescription" (bilateral "Renying" [ST 9], "Quchi" [LI 11], "Zusanli" [ST 36], "Taichong" [LR 3] and "Neiguan" [PC 6]), with needles retained for 30 min, once daily. The duration of intervention was 28 days. Every week, using the the irritation scale, the sign of sympathetic irritation was evaluated dynamically. The arterial blood pressure of the rats tail was determined, using non-invasive blood pressure measurement system. ELISA was adopted to detect the levels of calcitonin gene-related peptide (CGRP), nitric oxide (NO), endothelin-1 (ET-1), neuropeptide Y (NPY) in the serum. DAB chromogenic in situ hybridization (CISH) was provided to detect the mRNA expression of endothelial nitric oxide synthase (eNOS) in the internal carotid artery and the arcuate nucleus (ARC), and that of CGRP in the paraventricular nucleus posterior (PVP) and the ventrolateral medulla (VLM). Liquid chromatography-mass spectrometry (LC-MS) was used to detect the levels of epinephrine (E) and norepinephrine (NE) in the paraventricular nucleus anterior (PVA). RESULTS: Compared with the normal group, the irritation scores, systolic blood pressure and diastolic blood pressure were increased at each time point in the model group (P<0.05). When compared with the model group, the irritation scores after the intervention for 3 and 4 weeks, and systolic and diastolic blood pressure after intervention for 2, 3 and 4 weeks were reduced in the acupuncture group (P<0.05). In comparison with the normal group, the serum CGRP and NO levels of the rats were decreased (P<0.05), and the serum ET-1 and NPY levels, as well as E and EN levels in PVA were increased (P<0.05) in the model group. The levels of serum CGRP and NO were elevated (P<0.05), and the serum ET-1 and NPY levels, as well as E and EN levels of PVA were reduced (P<0.05) in the acupuncture group when compared with those of the model group. In the model group, the media of internal carotid artery exhibited thickening and remodeling, while the neuron volume in ARC was small. In the acupuncture group, every layer of internal carotid artery was acceptably arranged, and the parvicellular neuron of ARC was moderate in volume. For the in situ hybridization of eNOS mRNA for the rats of each group, the smooth muscle cells were predominantly expressed in each layer of the internal carotid artery, whereas the expression of parvicellular neurons was dominated in ARC. In the model group, the large and small neurosecretory cells were distributed sparsely in the nerves of PVP; in the acupuncture group, the cells of these two species were distributed regularly; and there were few species of glial cell in the VLM of either the model group or the acupuncture group. In each group, for the in situ hybridization of CGRP mRNA, the small neurosecretory cells were expressed predominately in the PVP, while, the expression of glial cell nuclei and the cell cytoplasm was dominated in the VLM. Compared with the normal group, the mRNA expression of eNOS in the internal carotid artery and ARC and that of CGRP mRNA in the PVP and VLM was decreased in the model group (P<0.05). In the acupuncture group, when compared with the model group, the mRNA expression of eNOS in the internal carotid artery and ARC and that of CGRP in the PVP and VLM was increased in the acupuncture group (P<0.05). CONCLUSION: Acupuncture at "antihypertensive acupoint prescription" can upregulate the level of vascular relaxing factors, downregulate the level of contracting factors, enhance the response of relaxing factors in targeting blood vessels and regulating the center. The mechanism may be related to the modulation of the sympathetic-adrenergic autonomic neurotransmitters in the paraventricular nucleus in spontaneous hypertension rats.

Current status and future prospects of Chinese mobile apps for hypertension management.

OBJECTIVE: This study aimed to evaluate the current situation of Chinese mobile apps for hypertension management and explore patients' real requirements for app use, providing a theoretical basis for the future improvement of hypertension apps. METHODS: We reviewed hypertension management apps from mobile app platforms, and summarized their functional characteristics. In addition, we conducted an online survey among 1000 hypertensive patients, collected valid responses, and analyzed the feedback data. RESULTS: Forty hypertension management apps were analyzed, with 72.5% offering no more than six functions, indicating limited coverage of advanced and comprehensive functionalities. Among the 934 valid survey responses, patients emphasized four main functions in apps for hypertension management: long-term dynamic blood pressure monitoring, scientific lifestyle management, strict medication management and systematic health knowledge delivering. CONCLUSION: The existing hypertension management apps mainly serve as "Digital Health" tools with unclear clinical efficacy. The future development of these apps lies in how they transition to "Digital Therapeutics" solutions to better meet patients' needs and provide clear clinical advantages.

COVID-19 pandemic impact on hypertension management in North East London: an observational cohort study using electronic health records.

OBJECTIVE: There are established inequities in the monitoring and management of hypertension in England. The COVID-19 pandemic had a major impact on primary care management of long-term conditions such as hypertension. This study investigated the possible disproportionate impact of the pandemic across patient groups. DESIGN: Open cohort of people with diagnosed hypertension. SETTINGS: North East London primary care practices from January 2019 to October 2022. PARTICIPANTS: All 224 329 adults with hypertension registered in 193 primary care practices. OUTCOMES: Monitoring and management of hypertension were assessed using two indicators: (i) blood pressure recorded within 1 year of the index date and (ii) blood pressure control to national clinical practice guidelines. RESULTS: The proportion of patients with a contemporaneous blood pressure recording fell from a 91% pre-pandemic peak to 62% at the end of the pandemic lockdown and improved to 77% by the end of the study. This was paralleled by the proportion of individuals with controlled hypertension which fell from a 73% pre-pandemic peak to 50% at the end of the pandemic lockdown and improved to 60% by the end of the study. However, when excluding patients without a recent blood pressure recording, the proportions of patients with controlled hypertension increased to 81%, 80% and 78% respectively.Throughout the study, in comparison to the White ethnic group, the Black ethnic group was less likely to achieve adequate blood pressure control (ORs 0.81 (95% CI 0.78 to 0.85, p<0.001) to 0.87 (95% CI 0.84 to 0.91, p<0.001)). Conversely, the Asian ethnic group was more likely to have controlled blood pressure (ORs 1.09 (95% CI 1.05 to 1.14, p<0.001) to 1.28 (95% CI 1.23 to 1.32, p<0.001)). Men, younger individuals, more affluent individuals, individuals with unknown or unrecorded ethnicity or those untreated were also less likely to have blood pressure control to target throughout the study. CONCLUSION: The COVID-19 pandemic had a greater impact on blood pressure recording than on blood pressure control. Inequities in blood pressure control persisted during the pandemic and remain outstanding.

India Hypertension Control Initiative: decentralization of hypertension care to health wellness centres in Punjab and Maharashtra, India, 2018-2022.

INTRODUCTION: The India Hypertension Control Initiative (IHCI) emphasizes decentralized patient-centric care to boost hypertension control in public healthcare facilities. We documented the decentralization process, enrolment pattern by facility type, and treatment outcomes in nine districts of Punjab and Maharashtra states, India, from 2018-2022. METHODS: We detailed the shift in hypertension care from higher facilities to Health and Wellness Centres (HWCs) using the World Health Organization (WHO) health system pillar framework. We reviewed hypertension treatment records in 4,045 public facilities from nine districts in the two states, focusing on indicators including registration numbers, the proportion of controlled, uncontrolled blood pressure (BP), and missed visits among those under care. RESULTS: The decentralization process involved training, treatment protocol provision, supervision, and monitoring. Among 394,038 individuals registered with hypertension from 2018-2021, 69% were under care in 2022. Nearly half of those under care (129,720/273,355) received treatment from HWCs in 2022. Care of hypertensive individuals from district hospitals (14%), community health centres (20%), and primary health centres (24%) were decentralized to HWCs. Overall BP control rose from 20% (4,004/20,347) in 2019 to 58% (157,595/273,355) in 2022, while missed visits decreased from 61% (12,394/20,347) in 2019 to 26% (70,894/273,355) in 2022. This trend was consistent in both states. HWCs exhibited the highest BP control and the lowest missed visits throughout the study period compared to other facility types. CONCLUSION: We documented an increase in decentralized access to hypertension treatment and improved treatment outcomes over four years. We recommend operationalizing hypertension care at HWCs to other districts in India to improve BP control.

Evaluation of treatment information quality on hypertension and diabetes on WeChat and TikTok: A cross-sectional content analysis.

Objective: This study aimed to assess the quality of the information in WeChat and TikTok videos related to hypertension and diabetes treatment. Methods: A sample of 120 Chinese videos was collected based on specific inclusion and exclusion criteria. The quality was evaluated using DISCERN, JAMA and the latest edition of Chinese guidelines for hypertension and diabetes prevention and treatment, and two observers independently scored each video using the three assessment tools. Results: Among all 120 videos, only 10 scored above 38 points in DISCERN, with 45 videos rated as "very poor". None of the video met all JAMA criteria simultaneously, and there were gaps in accuracy and completeness compared to the two guidelines. Furthermore, there was no significant correlation between information quality and the number of likes and comments. Conclusion: The current quality of information on the treatment of hypertension and diabetes on WeChat and TikTok was unsatisfactory. Consequently, the government should strengthen oversight of information quality, and social media platforms should actively review health-related content to prevent inaccurate information dissemination. Individuals should enhance their digital and health literacy.

Engaging an African American Church-based Community in Developing a Technology-focused Virtual Reality Hypertension Program.

BACKGROUND: African Americans are disproportionately affected by cardiovascular disease and hypertension. To address this, we partnered with local church leaders in developing a virtual reality (VR) hypertension reduction program. OBJECTIVES: A community-based participatory research approach was adopted to develop a hypertension education program using VR, incorporating feedback from the African American church congregation members. METHODS: Using a qualitative approach, a modified Delphi exercise, and member checking, the research team collaborated with congregation members who provided feedback and assisted in the development of the intervention. LESSONS LEARNED: Incorporating feedback from church members significantly impacted the educational platform. Encouraged by the reverend, church members were engaged and participated in the 12-week program designed to reduce blood pressure. Novel approaches like VR may need more time to pilot to achieve desired results, particularly with vulnerable populations. CONCLUSIONS: This participatory research platform highlights the importance of incorporating external stakeholders throughout the research process in order to develop a meaningful health intervention using new technology that is tailored to the church members.

Effect of haemodialysis practice guideline on dialysis indicators and haemodynamic complications among patients undergoing haemodialysis.

To assess the effect of haemodialysis practice guidelines on dialysis indicators and haemodynamic complications, the comparative study was conducted at the dialysis unit of Sheikh Zayed Hospital, Lahore, Pakistan, and comprised patients undergoing haemodialysis who were divided into intervention group A in which updated haemodialysis practice guidelines were used, and control group B in which routine base dialysis was given. Data was collected using a self-structured tool. Data was analysed using McNemar test and Mann-Whitney U-test with p<0.05. Compared to baseline, there was a significant improvement in post-intervention ratio of effective removal of clearance (K) resulting from the treatment characterised by time (t) in the patient with a specific volume of distribution (V), or Kt/V, median & IQR 0.83(0.355) vs 1.21(0.11) and percentage of urea reduction ratio with median & IQR 49(12) vs. 66.5(18.65) (p<0.05). Intradialytic hypotension was found in 17(56.6%) subjects in group B and in 4(13.4%) in group A (p=0.002). Intradialytic hypertension was found in 8(25.6%) patients in group B and 1(3.4%) in group A (p=0.039). It is recommended that dialysis be performed in accordance with the most recent clinical guidelines in order to improve practices and to increase haemodialysis effectiveness.

Socioeconomic and Geographical Inequities in Burden and Treatment seeking Behavior for Hypertension among Women in the Reproductive Age (15-45 years) Group in India: Findings from a Nationally Representative Survey.

BACKGROUND: Socioeconomic disparity changed healthcare seeking and management cascade of hypertension due to inequity in hypertension care cascade pathway. OBJECTIVES: The inequities in burden and treatment-seeking behavior of hypertension among reproductive age group women were studied from National Family Health Survey-4 (NFHS-4) data. MATERIALS AND METHODS: We analyzed the data from NFHS-4 of women of reproductive age group between 15 and 49 years among the selected households contributing to 699,686 women. Socioeconomic inequities were assessed by expenditure quintile. Inequities in burden and treatment-seeking behavior were reported using the concentration curve and concentration index. RESULTS: The prevalence of hypertension in India was 15% (95% confidence interval: 14.9%-15.4%). One-third (32%) of the hypertensive population received treatment and only 28% of the women had controlled blood pressure. Wealth and education-based inequalities were more in high wealth index. The inequity in screening and awareness was in the northern and northeastern regions. CONCLUSION: There was inequity in the overall hypertension care cascade pathway with more inequity in the northern and northeastern region.

Long-term trajectories of weight loss and health outcomes: protocol of the SCOOP-RNPC nationwide observational study.

INTRODUCTION: Behavioural weight loss programmes are generally accepted as being beneficial in reducing cardiometabolic risk and improving patient-reported outcomes. However, prospective data from large real-world cohorts are scarce concerning the mid-term and long-term impact of such interventions. The objective of this large prospective cohort study (n>10 000 participants) is to demonstrate the effectiveness of the standardised Nutritional and Psycho-Behavioural Rehabilitation programme (RNPC Programme) in reducing the percentage of subjects requiring insulin and/or other diabetes drug therapy, antihypertensive drugs, lipid-lowering therapies and continuous positive airway pressure therapy for obstructive sleep apnoea after the end of the intervention. The rate of remission of hypertension, type 2 diabetes and sleep apnoea will also be prospectively assessed. METHODS: This is a prospective multicentre observational study carried out in 92 RNPC centres in France. Participants will follow the standardised RNPC Programme. The prospective dataset will include clinical, anthropometric and biochemical data, comorbidities, medications, body composition, patient-reported outcome questionnaire responses, sleep study data with objective measurements of sleep apnoea severity and surrogate markers of cardiovascular risk (ie, blood pressure and arterial stiffness). About 10 000 overweight or obese participants will be included over 2 years with a follow-up duration of up to 5 years. ETHICS AND DISSEMINATION: Ethical approval for this study has been granted by the Ethics Committee (Comité de protection des personnes Sud-Est I) of Saint-Etienne University Hospital, France (SI number: 23.00174.000237). Results will be submitted for publication in peer-review journals, presented at conferences and inform the design of a future randomised controlled trial in the specific population identified as good responders to the RNPC Programme. TRIAL REGISTRATION NUMBER: NCT05857319.

Evaluating the Effectiveness of a Patient-Centered, Nonphysician Led Self-Monitoring Blood Pressure Program in a Rural Federally Qualified Health Center.

CONTEXT: Uncontrolled hypertension can lead to an increased risk of cardiovascular disease, myocardial infarction, stroke, or death. Self-monitoring blood pressure (SMBP) programs have been associated with blood pressure (BP) reduction, particularly among rural, minority, and low-income individuals. There is limited literature about nonphysician SMBP programs. OBJECTIVES: To evaluate the effectiveness of an SMBP program designed to engage nonphysician team members in hypertension management within a federally qualified health center (FQHC). DESIGN: Self-monitoring blood pressure program activities were implemented using a Plan, Do, Study, Act model. The University of Washington Health Promotion Research Center evaluated processes and patient-level outcomes in a mixed-methods design. Quantitative analysis examined clinical outcomes related to hypertension, and qualitative analysis relied on interviews with clinical staff examining program implementation, adoption, and sustainability. SETTING: Family Health Centers (FHCs), a FQHC located in rural Washington, serving medically underserved populations. PARTICIPANTS: Two hundred five active SMBP patients out of 2600 adult patients (over 18 years old) who had a diagnosis of hypertension within the last 12 months. INTERVENTION: Patients with uncontrolled hypertension were given a BP cuff to log their daily BP. Patients met with community health workers (CHWs) and medical staff to review logs and set self-management goals over 3 to 4 months. MAIN OUTCOME MEASURE: Controlled BP measurements and factors to implementation and sustainment. RESULTS: Facilitators to implementation included expanded telehealth reimbursement during the COVID-19 pandemic, integration of CHWs, and linguistically adapted resources. Barriers included a lack of reimbursement for nonphysician time and BP monitors. Quantitative results demonstrated an effort to reach minoritized populations but did not show an improvement in BP outcomes. CONCLUSIONS: Family Health Center implemented an SMBP program adapted to meet the linguistic and social needs of their patients. The successful integration of CHWs and the need for reimbursement policies to support SMBP programs were key factors for implementation and sustainability.

Engaging Nonphysician Staff in Practice Facilitation-Mediated Quality Improvement to Improve Health Outcomes in Under-Resourced Clinical Practices in New York City.

In New York City (NYC), hypertension and high cholesterol disproportionately affect residents with low household income and people of color. The NYC Health Department employed practice facilitation (PF) to help nonphysician staff assume added roles aligned with team-based care. The objective was to improve blood pressure (BP) and cholesterol management in 132 small primary care practices serving mostly patients of color. We categorized practices into higher or lower levels of integrated PF, defined as physicians and nonphysician staff collectively participating in PF. Higher integrated PF was associated with improvements in BP (rate ratio [RR] = 1.09, P-value < .05) and cholesterol management (RR = 1.12, P-value < .01). Nonphysician staff in higher integrated PF practices reported skills enhancement and improved teamwork. Involving nonphysician staff in PF-mediated quality improvement efforts can be an effective strategy to improve health outcomes in small clinical practices serving communities with a higher burden of chronic disease and disproportionately impacted by poverty and structural racism.