Reducing ethnic and racial disparities by improving undertreatment, control, and engagement in blood pressure management with health information technology (REDUCE-BP) hybrid effectiveness-implementation pragmatic trial: Rationale and design

Psychosocial factors and associations with preventive cardiovascular screening among U.S adults: Findings from the National Health Interview Survey, 2023

OBJECTIVE

Structural and COVID-related factors have been linked with the decline in preventive health screenings among adults. However, associations between psychosocial factors and undergoing preventive cardiovascular screening are not fully known. The current study examined associations between psychosocial factors and preventive cardiovascular screening among U.S. adults.

METHODS

We used data from the 2023 National Health Interview Survey (N = 23,428). Data were collected from January to December from adults living in U.S. Preventive cardiovascular (CV) screening (i.e., blood pressure, cholesterol, or blood sugar level) was defined as no screening, and undergoing screening for any CV risk within the past year. Psychosocial factors were defined as discrimination, life satisfaction, and depression. Multivariable logistic regression models examined the associations between psychosocial factors and preventive cardiovascular screening, adjusted for sociodemographic characteristics.

RESULTS

Adults with diagnosis of depression (OR: 1.93, 95 % CI: 1.65-2.25) had higher odds of undergoing screening for any CV risk. Adults who experienced discrimination had lower odds of undergoing screening for cholesterol (OR: 0.77, 95 % CI: 0.71-0.84) and blood sugar level specifically (OR: 0.78, 95 % CI: 0.72-0.85), while life dissatisfaction was associated with lower odds of screening for blood pressure (OR: 0.76, 95 % CI: 0.58-0.99) and blood sugar level specifically (OR: 0.80, 95 % CI: 0.65-0.97).

CONCLUSIONS

Discrimination and life dissatisfaction were associated with decreased odds of undergoing specific preventive cardiovascular screening, and depression is associated with increased odds of undergoing any preventive cardiovascular screening. Equitable health care policies focused on addressing psychosocial factors are needed to increase preventive cardiovascular screening among U.S. adults.

Global Evidence on the Sustainability of Telemedicine in Outpatient and Primary Care During the First 2 Years of the COVID-19 Pandemic: Scoping Review Using the Nonadoption, Abandonment, Scale-Up, Spread, and Sustainability (NASSS) Framework

BACKGROUND

The rapid implementation of telemedicine during the early stages of the COVID-19 pandemic raises questions about the sustainability of this intervention at the global level.

OBJECTIVE

This research examines the patient experience, health inequalities, and clinician-patient relationship in telemedicine during the COVID-19 pandemic's first 2 years, aiming to identify sustainability factors.

METHODS

This study was based on a prepublished protocol using the Joanna Briggs Institute (JBI) methodology for scoping reviews. We included academic and gray literature published between March 2020 and March 2022 according to these criteria: (1) population (any group); (2) concepts (patient experience, clinician-patient relationship, health inequalities); (3) context (telemedicine in primary and outpatient care); (4) excluding studies pertaining to surgery, oncology, and (inpatient) psychiatry. We searched Ovid Medline/PubMed (January 1, 2022), Web of Science (March 19, 2022), Google/Google Scholar (February and March 2022), and others. The risk of bias was not assessed as per guidance. We used an analysis table for the studies and color-coded tabular mapping against a health care technology adoption framework to identify sustainability (using double-blind extraction).

RESULTS

Of the 134 studies that met our criteria, 49.3% (66/134) reported no specific population group. Regarding the concepts, 41.8% (56/134) combined 2 of the concepts studied. The context analysis identified that 56.0% (75/134) of the studies referred to, according to the definition in the United Kingdom, an outpatient (ambulatory care) setting, and 34.3% (46/134) referred to primary care. The patient experience analysis reflected positive satisfaction and sustained access during lockdowns. The clinician-patient relationship impacts were nuanced, affecting interaction and encounter quality. When mapping to the nonadoption, abandonment, scale-up, spread, and sustainability (NASSS) framework, 81.3% (109/134) of the studies referenced the innovation's sustainability. Although positive overall, there were some concerns about sustainability based on quality, eHealth literacy, and access to health care for vulnerable migrants and the uninsured.

CONCLUSIONS

We identified confusion between the concepts of patient experience and patient satisfaction; therefore, future research could focus on established frameworks to qualify the patient experience across the whole pathway and not just the remote encounter. As expected, our research found mainly descriptive analyses, so there is a need for more robust evidence methods identifying impacts of changes in treatment pathways. This study illustrates modern methods to decolonize academic research by using gray literature extracts in other languages. We acknowledge that the use of Google to identify gray literature at the global level and in other languages has implications on reproducibility. We did not consider synchronous text-based communication.

TRIAL REGISTRATION

Open Science Framework 4z5ut; https://osf.io/4z5ut/.

Adapting self-measured blood pressure monitoring to reduce health disparities (ASPIRE): a pilot hybrid effectiveness‑implementation study protocol

BACKGROUND

Hypertension is the leading risk factor for cardiovascular disease (CVD). Despite advances in blood pressure management, significant racial and ethnic disparities persist, resulting in higher risks of stroke, heart disease, and mortality among non-White populations. Self-measured blood pressure (SMBP) monitoring, also known as home blood pressure monitoring, has shown promise in improving blood pressure control, especially when combined with feedback from healthcare providers. However, the adoption of SMBP remains low, particularly among racial and ethnic minorities, due to various patient, provider, and system-level barriers.

OBJECTIVES

This study aims to evaluate the feasibility of study methods implementing the ASPIRE (adapting self-measured blood pressure to reduce health disparities) toolkit in a primary care setting. The toolkit is designed to address barriers to SMBP adoption and improve hypertension management among underserved populations to increase SMBP adoption.

METHODS

This pilot hybrid effectiveness-implementation randomized controlled trial (RCT) will be conducted at a primary care clinic in South Side Chicago, serving a diverse patient population. Eligible patients with uncontrolled hypertension will be randomized to either the intervention group, receiving the ASPIRE toolkit and support, or the control group, receiving usual care. The primary outcomes include feasibility measures including recruitment rates, attrition, and availability of data in the electronic health records.

RESULTS

The feasibility of the study methods will be analyzed to inform a larger multi-site RCT informed by progression criteria developed in this protocol. Qualitative interviews with patients and providers will explore the appropriateness and implementation success of the toolkit using the Consolidated Framework for Implementation Research (CFIR).

CONCLUSIONS

This pilot RCT will provide critical insights into the feasibility of study methods to evaluate the implementation success of the ASPIRE toolkit in a real-world primary care setting. By addressing barriers to SMBP adoption, this intervention has the potential to improve hypertension management and reduce health disparities in underserved populations.

TRIAL REGISTRATION

NCT: NCT06175793. Registered 19 December 2023, https://clinicaltrials.gov/study/NCT06175793 .

Decreased racial disparities in sepsis mortality after an order set-driven initiative: An analysis of 8151 patients

BACKGROUND

Sepsis is a leading cause of hospital mortality and there is evidence that outcomes vary by patient demographics including race and gender. Our objectives were to determine whether the introduction of a standardized sepsis order set was associated with (1) changes in overall mortality or early antibiotic administration or (2) changes in outcome disparities based on race or gender.

METHODS

Patients seen in the emergency department and admitted to the hospital with a diagnosis code of sepsis were identified and divided into a preintervention cohort seen during the 18 months prior to the initiation of a new sepsis order set and an intervention cohort seen during the 18 months after a quality initiative driven by introducing the order set. Associations between time period, race, gender, and mortality were assessed using univariate and multivariate logistic regression models. Other outcomes included early antibiotic administration (<3 h from arrival).

RESULTS

Overall mortality was unchanged during the intervention period (7.8% vs. 7.2%) in both univariate (relative risk [RR] 1.08, 95% confidence interval [CI] 0.93-1.26) and multivariate logistic regression (RR 1.11, 95% CI 0.93-1.28) models. Although male gender tended to have higher mortality, there was no statistically significant association between gender and mortality in either cohort. In the multivariable model, Black race was associated with increased risk of death in the preintervention period (RR 1.41, 95% CI 1.02-1.94), but this association was not present in the intervention period. Patients of color also saw significantly more improvement in early antibiotic administration during the intervention period than White patients.

CONCLUSIONS

An order set-driven sepsis initiative was not associated with overall improved mortality but was associated with decreased racial disparities in sepsis mortality and early antibiotics.

Achieving Health Equity in the Care of Patients with Heart Failure

PURPOSE OF REVIEW

To discuss the prevailing racial and ethnic disparities in heart failure (HF) care by identifying barriers to equitable care and proposing solutions for achieving equitable outcomes.

RECENT FINDINGS

Throughout the entire spectrum of HF care, from prevention to implementation of guideline-directed medical therapy and advanced interventions, racial and ethnic disparities exist. Factors such as differential distribution of risk factors, poor access to care, inadequate representation in clinical trials, and discrimination from healthcare clinicians, among others, contribute to these disparities. Recent data suggests that despite improvements, disparities prevail in several aspects of HF care, hindering our progress towards equity in HF care. This review highlights the urgent need to address racial and ethnic disparities in HF care, emphasizing the importance of a multifaceted approach involving policy changes, quality improvement strategies, targeted interventions, and intentional community engagement. Our proposed framework was derived from existing research and emphasizes integrating equity into routine quality improvement efforts, tailoring interventions to specific populations, and advocating for policy transformation. By acknowledging these disparities, implementing evidence-based strategies, and fostering collaborative efforts, the HF community can strive to reduce disparities and achieve equity in HF care.

Racial Disparities in Shared Decision-Making and the Use of mHealth Technology Among Adults With Hypertension in the 2017-2020 Health Information National Trends Survey: Cross-Sectional Study in the United States

BACKGROUND

Mobile health (mHealth) technology has the potential to support shared decision-making (SDM) and improve hypertension control. However, our understanding of the variations in individuals' involvement in SDM and mHealth usage across different racial and ethnic groups in the United States is still limited.

OBJECTIVE

This study aimed to investigate the extent of involvement in SDM and the usage of mHealth technology in health-related activities among US adults with hypertension from diverse racial and ethnic backgrounds and to examine whether the mHealth usage differed by individuals' level of engagement in SDM.

METHODS

This study used cross-sectional data from the 2017 to 2020 Health Information National Trends Survey, which was conducted on US adults with self-reported hypertension, and race and ethnicity data were included. The exposure of interest was race and ethnicity. The outcomes were SDM and mHealth usage. SDM was assessed using an item: "In the past 12 months, how often did your health professional: involve you in decisions about your healthcare as much as you wanted?" mHealth usage was defined as using a smartphone or tablet to engage in (1) making health decisions, (2) discussing health decisions with health providers, (3) tracking health progress, and (4) sharing health information. Weighted multivariable logistic regression models were used to examine the association between race and ethnicity and SDM or mHealth usage adjusted for covariates and stratified by the level of engagement in SDM.

RESULTS

This study included 4893 adults with hypertension, and the mean age was 61 (SD 13) years. The sample was 53% female, 61% (n=3006) non-Hispanic White, 19% (n=907) non-Hispanic Black or African American, 12% (n=605) Hispanic, 4% (n=193) non-Hispanic Asian, and 4% (n=182) non-Hispanic other. Compared to the non-Hispanic White adults, non-Hispanic Black adults were more likely to use mHealth to make health decisions (adjusted odds ratio [aOR] 1.70, 95% CI 1.23-2.34), share health information (aOR 1.46, 95% CI 1.02-2.08), and discuss health decisions with health providers (aOR 1.38, 95% CI 1.02-1.87). Significant associations were observed specifically among those who were always involved in SDM. Asian adults were less likely to be involved in SDM (aOR 0.51, 95% CI 0.26-0.99) and were more likely to use mHealth to track progress on a health-related goal (aOR 2.07, 95% CI 1.28-3.34) than non-Hispanic White adults. Hispanic adults were less likely to use mHealth to share health information (aOR 0.47, 95% CI 0.33-0.67) and discuss health decisions with health providers (aOR 0.65, 95% CI 0.46-0.94) compared to non-Hispanic White adults.

CONCLUSIONS

This study observed racial and ethnic disparities in SDM and mHealth usage among US adults with hypertension. These findings emphasize the significance of comprehending the involvement of SDM and the usage of mHealth technology within racially and ethnically diverse populations.

Clinicians' and Patients' Perspectives on Hypertension Care in a Racially and Ethnically Diverse Population in Primary Care

IMPORTANCE

Hypertension control remains suboptimal, particularly for Black and Hispanic or Latino patients. A need exists to improve hypertension management and design effective strategies to efficiently improve the quality of care in primary care, especially for these at-risk populations. Few studies have specifically explored perspectives on blood pressure management by primary care providers (PCPs) and patients.

OBJECTIVE

To examine clinician and patient perspectives on barriers and facilitators to hypertension control within a racially and ethnically diverse health care system.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study was conducted in a large urban US health care system from October 1, 2020, to March 31, 2021, among patients with a diagnosis of hypertension from a racially and ethnically diverse population, for a range of hypertension medication use hypertension control, as well as practicing PCPs. Analysis was conducted between June 2021 and February 2022 using immersion-crystallization methods.

MAIN OUTCOMES AND MEASURES

Perspectives on managing blood pressure, including medication adherence and lifestyle, considerations for intensification, and experiences and gaps in using health information technology tools for hypertension, were explored using semistructured qualitative interviews. These cycles of review were continued until all data were examined and meaningful patterns were identified.

RESULTS

Interviews were conducted with 30 participants: 15 patients (mean [SD] age, 58.6 [16.2] years; 10 women [67%] and 9 Black patients [60%]) and 15 clinicians (14 PCPs and 1 medical assistant; 8 women [53%]). Eleven patients (73%) had suboptimally controlled blood pressure. Participants reported a wide range of experiences with hypertension care, even within the same clinics and health care system. Five themes relevant to managing hypertension for racially and ethnically diverse patient populations in primary care were identified: (1) difficulty with self-management activities, especially lifestyle modifications; (2) hesitancy intensifying medications by both clinicians and patients; (3) varying the timing and follow-up after changes in medication; (4) variation in blood pressure self-monitoring recommendations and uptake; and (5) limited specific functionality of current health information technology tools.

CONCLUSIONS AND RELEVANCE

In this qualitative study of the views of PCPs and patients on hypertension control, the participants felt that more focus should be placed on lifestyle modifications than medications for hypertension, particularly for patients from racial and ethnic minority groups. Participants also expressed concerns about the existing functionality of health information technology tools to support increasingly asynchronous hypertension care. More intentional ways of supporting treatment intensification, self-care, and follow-up care are needed to improve hypertension management for racially and ethnically diverse populations in primary care.