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

Across race, ethnicity, and language: An intervention to improve advance care planning documentation unmasks health disparities

BACKGROUND

Racial and ethnic minority groups are less likely to have advance directives and living wills, despite the importance of advanced care planning (ACP) in end-of-life care. We aimed to understand the impact of an intervention to improve ACP documentation across race, ethnicity, and language on hospitalized patients at our institution.

METHODS

We launched an intervention to improve the rates of ACP documentation for hospitalized patients aged >75 or with advanced illness defined by the International Classification of Diseases 10th Revision codes. We analyzed ACP completion rates, preintervention, and intervention, and used interrupted time-series analyses to measure the differential impact of the intervention across race, ethnicity, and language.

KEY RESULTS

A total of 10,220 patients met the inclusion criteria. Overall rates of ACP documentation improved from 13.9% to 43.7% in the intervention period, with a 2.47% monthly increase in ACP documentation compared to baseline (p < .001). During the intervention period, the rate of ACP documentation increased by 2.72% per month for non-Hispanic White patients (p < .001), by 1.84% per month for Latinx patients (p < .001), and by 1.9% per month for Black patients (p < .001). Differences in the intervention trends between non-Hispanic White and Latinx patients (p = .04) and Black patients (p = .04) were significant.

CONCLUSIONS

An intervention designed to improve ACP documentation in hospitalized patients widened a disparity across race and ethnicity with Latinx and Black patients having lower rates of improvement. Our findings reinforce the need to measure the impact of quality improvement interventions on existing health disparities and to implement specific strategies to prevent worsening disparities.

Sex Disparities in Management and Outcomes Among Patients With Acute Coronary Syndrome

Importance

Sex disparities in the management and outcomes of acute coronary syndrome (ACS) have received increasing attention.

Objective

To evaluate the association of a quality improvement program with sex disparities among patients with ACS.

Design, Setting, and Participants

The National Chest Pain Centers Program (NCPCP) is an ongoing nationwide program for the improvement of quality of care in patients with ACS in China, with CPC accreditation as a core intervention. In this longitudinal analysis of annual (January 1, 2016, to December 31, 2020) cross-sectional data of 1 095 899 patients with ACS, the association of the NCPCP with sex-related disparities in the care of these patients was evaluated using generalized linear mixed models and interaction analysis. The robustness of the results was assessed by sensitivity analyses with inverse probability of treatment weighting. Data were analyzed from September 1, 2021, to June 30, 2022.

Exposure

Hospital participation in the NCPCP.

Main Outcomes and Measures

Differences in treatment and outcomes between men and women with ACS. Prehospital indicators included time from onset to first medical contact (onset-FMC), time from onset to calling an emergency medical service (onset-EMS), and length of hospital stay without receiving a percutaneous coronary intervention (non-PCI). In-hospital quality indicators included non-PCI, use of statin at arrival, discharge with statin, discharge with dual antiplatelet therapy, direct PCI for ST-segment elevation myocardial infarction (STEMI), PCI for higher-risk non-ST-segment elevation ACS, time from door to catheterization activation, and time from door to balloon. Patient outcome indicators included in-hospital mortality and in-hospital new-onset heart failure.

Results

Data for 1 095 899 patients with ACS (346 638 women [31.6%] and 749 261 men [68.4%]; mean [SD] age, 63.9 [12.4] years) from 989 hospitals were collected. Women had longer times for onset-FMC and onset-EMS; lower rates of PCI, statin use at arrival, and discharge with medication; longer in-hospital delays; and higher rates of in-hospital heart failure and mortality. The NCPCP was associated with less onset-FMC time, more direct PCI rate for STEMI, lower rate of in-hospital heart failure, more drug use, and fewer in-hospital delays for both men and women with ACS. Sex-related differences in the onset-FMC time (β = -0.03 [95% CI, -0.04 to -0.01), rate of direct PCI for STEMI (odds ratio, 1.11 [95% CI, 1.06-1.17]), time from hospital door to balloon (β = -1.38 [95% CI, -2.74 to -0.001]), and rate of in-hospital heart failure (odds ratio, 0.90 [95% CI, 0.86-0.94]) were significantly less after accreditation.

Conclusions and Relevance

In this longitudinal cross-sectional study of patients with ACS from hospitals participating in the NCPCP in China, sex-related disparities in management and outcomes were smaller in some aspects by regionalization between prehospital emergency and in-hospital treatment systems and standardized treatment procedures. The NCPCP should emphasize sex disparities to cardiologists; highlight compliance with clinical guidelines, particularly for female patients; and include the reduction of sex disparities as a performance appraisal indicator.

Design and Rationale of the Home Blood Pressure Telemonitoring Linked with Community Health Workers to Improve Blood Pressure (LINKED-BP) Program

BACKGROUND

Disparities in hypertension outcomes persist among Black and Hispanic adults and persons living in poverty in the United States. The "LINKED-BP Program" is a multi-level intervention linking home blood pressure (BP) monitoring with a mobile health application, support from community health workers (CHWs), and BP measurement training at primary care practices to improve BP. This study is part of the American Heart Association RESTORE (AddREssing Social Determinants TO pRevent hypErtension) Network. This study aims to examine the effect of the LINKED-BP Program on BP reduction and to evaluate the reach, adoption, sustainability, and cost-effectiveness of the intervention.

METHODS

Using a hybrid type I effectiveness-implementation design, 600 adults who have elevated BP or untreated stage 1 hypertension without diabetes, chronic kidney disease, history of cardiovascular disease (stroke or coronary heart disease) and age < 65 years will be recruited from 20 primary care practices including community health centers in the Maryland area. The practices are randomly assigned to the intervention or the enhanced usual care arms. Patients in the LINKED-BP Program receive training on home BP monitoring, BP telemonitoring through the Sphygmo app, and CHW telehealth visits for education and counseling on lifestyle modification over 12 months. The primary clinical outcome is change from baseline in systolic BP at 6 and 12 months.

DISCUSSIONS

The LINKED-BP Program tests a sustainable, scalable approach to prevent hypertension and advance health equity. The findings will inform implementation strategies that address social determinants of health and barriers to hypertension prevention in underserved populations.

CLINICALTRIALS.GOV IDENTIFIER

NCT05180045.

Leveraging Implementation Science for Cardiovascular Health Equity: A Scientific Statement From the American Heart Association

Reducing cardiovascular disease disparities will require a concerted, focused effort to better adopt evidence-based interventions, in particular, those that address social determinants of health, in historically marginalized populations (ie, communities excluded on the basis of social identifiers like race, ethnicity, and social class and subject to inequitable distribution of social, economic, physical, and psychological resources). Implementation science is centered around stakeholder engagement and, by virtue of its reliance on theoretical frameworks, is custom built for addressing research-to-practice gaps. However, little guidance exists for how best to leverage implementation science to promote cardiovascular health equity. This American Heart Association scientific statement was commissioned to define implementation science with a cardiovascular health equity lens and to evaluate implementation research that targets cardiovascular inequities. We provide a 4-step roadmap and checklist with critical equity considerations for selecting/adapting evidence-based practices, assessing barriers and facilitators to implementation, selecting/using/adapting implementation strategies, and evaluating implementation success. Informed by our roadmap, we examine several organizational, community, policy, and multisetting interventions and implementation strategies developed to reduce cardiovascular disparities. We highlight gaps in implementation science research to date aimed at achieving cardiovascular health equity, including lack of stakeholder engagement, rigorous mixed methods, and equity-informed theoretical frameworks. We provide several key suggestions, including the need for improved conceptualization and inclusion of social and structural determinants of health in implementation science, and the use of adaptive, hybrid effectiveness designs. In addition, we call for more rigorous examination of multilevel interventions and implementation strategies with the greatest potential for reducing both primary and secondary cardiovascular disparities.

Prevalence, Treatment, and Control of Hypertension Among US Women of Reproductive Age by Race/Hispanic Origin

BACKGROUND

To explore the prevalence, pharmacologic treatment, and control of hypertension among US nonpregnant women of reproductive age by race/Hispanic origin to identify potential gaps in care.

METHODS

We pooled data from the 2011 to March 2020 (prepandemic) National Health and Nutrition Examination Survey cycles. Our analytic sample included 4,590 nonpregnant women aged 20-44 years who had at least 1 examiner-measured blood pressure (BP) value. We estimated prevalences and 95% confidence intervals (CIs) of hypertension, pharmacologic treatment, and control based on the 2003 Joint Committee on High Blood Pressure (JNC 7) and the 2017 American College of Cardiology and the American Heart Association (ACC/AHA) guidelines. We evaluated differences by race/Hispanic origin using Rao-Scott chi-square tests.

RESULTS

Applying ACC/AHA guidelines, hypertension prevalence ranged from 14.0% (95% CI: 12.0, 15.9) among Hispanic women to 30.9% (95% CI: 27.8, 34.0) among non-Hispanic Black women. Among women with hypertension, non-Hispanic Black women had the highest eligibility for pharmacological treatment (65.5%, 95% CI: 60.4, 70.5); current use was highest among White women (61.8%, 95% CI: 53.8, 69.9). BP control ranged from 5.2% (95% CI: 1.1, 9.3) among women of another or multiple non-Hispanic races to 18.6% (95% CI: 12.1, 25.0) among Hispanic women.

CONCLUSIONS

These findings highlight the importance of monitoring hypertension, pharmacologic treatment, and control by race/Hispanic origin and addressing barriers to equitable hypertension care among women of reproductive age.

Equitable and Timely Care of Febrile Neonates: A Cross-Sectional Study

OBJECTIVES

In pediatric emergency departments (EDs), racial/ethnic minorities are less likely to receive needed and timely care; however, clinical protocols have the potential to mitigate disparities. Neonatal fever management is protocolized in many EDs, but the timeliness to antibiotic administration is likely variable. We investigated the timeliness of antibiotic administration for febrile neonates and whether timeliness was associated with patients' race/ethnicity.

METHODS

Retrospective cross-sectional study of febrile neonates evaluated in one pediatric ED that uses an evidence-based guideline for the management of neonatal fever between March 2010 and December 2015. Primary outcome was time from ED arrival to antibiotic administration. Analysis of variance tests compared mean time with antibiotic administration across race/ethnicity. Multivariable linear regression investigated racial/ethnic differences in time to antibiotic administration after adjusting for patient demographics, timing of visit, the number of physicians involved, and ED census.

RESULTS

We evaluated 317 febrile neonates. Of the 269 patients with racial/ethnic data (84.9%), 54% were white non-Hispanic, 13% were black non-Hispanic, and 23% were Hispanic. The mean time to antibiotic administration was 204 minutes (range = 51-601 minutes). There was no significant association between patient race/ethnicity and time to first antibiotic administration. Emergency department census was significantly associated with timeliness.

CONCLUSIONS

There was a 10-hour range in the time to antibiotic administration for febrile neonates; however, variability in timeliness did not differ by race or ethnicity. This study demonstrates the need to further examine the role of protocols in mitigating disparities as well as factors that influence timeliness in antibiotic administration to febrile neonates.

Application of an antiracism lens in the field of implementation science (IS): Recommendations for reframing implementation research with a focus on justice and racial equity

Background

Despite the promise of implementation science (IS) to reduce health inequities, critical gaps and opportunities remain in the field to promote health equity. Prioritizing racial equity and antiracism approaches is critical in these efforts, so that IS does not inadvertently exacerbate disparities based on the selection of frameworks, methods, interventions, and strategies that do not reflect consideration of structural racism and its impacts.

Methods

Grounded in extant research on structural racism and antiracism, we discuss the importance of advancing understanding of how structural racism as a system shapes racial health inequities and inequitable implementation of evidence-based interventions among racially and ethnically diverse communities. We outline recommendations for explicitly applying an antiracism lens to address structural racism and its manifests through IS. An anti-racism lens provides a framework to guide efforts to confront, address, and eradicate racism and racial privilege by helping people identify racism as a root cause of health inequities and critically examine how it is embedded in policies, structures, and systems that differentially affect racially and ethnically diverse populations.

Results

We provide guidance for the application of an antiracism lens in the field of IS, focusing on select core elements in implementation research, including: (1) stakeholder engagement; (2) conceptual frameworks and models; (3) development, selection, adaptation of EBIs; (4) evaluation approaches; and (5) implementation strategies. We highlight the need for foundational grounding in antiracism frameworks among implementation scientists to facilitate ongoing self-reflection, accountability, and attention to racial equity, and provide questions to guide such reflection and consideration.

Conclusion

We conclude with a reflection on how this is a critical time for IS to prioritize focus on justice, racial equity, and real-world equitable impact. Moving IS towards making consideration of health equity and an antiracism lens foundational is central to strengthening the field and enhancing its impact.

Plain language abstract

There are important gaps and opportunities that exist in promoting health equity through implementation science. Historically, the commonly used frameworks, measures, interventions, strategies, and approaches in the field have not been explicitly focused on equity, nor do they consider the role of structural racism in shaping health and inequitable delivery of evidence-based practices/programs. This work seeks to build off of the long history of research on structural racism and health, and seeks to provide guidance on how to apply an antiracism lens to select core elements of implementation research. We highlight important opportunities for the field to reflect and consider applying an antiracism approach in: 1) stakeholder/community engagement; 2) use of conceptual frameworks; 3) development, selection and adaptation of evidence-based interventions; 4) evaluation approaches; 5) implementation strategies (e.g., how to deliver evidence-based practices, programs, policies); and 6) how researchers conduct their research, with a focus on racial equity. This is an important time for the field of implementation science to prioritize a foundational focus on justice, equity, and real-world impact through the application of an anti-racism lens in their work.

Socioeconomic Disparities in Functional Status in a National Sample of Patients With Rheumatoid Arthritis

IMPORTANCE

Little is known about the association of poverty with functional status (FS) in patients with rheumatoid arthritis (RA) who use rheumatology care.

OBJECTIVES

To examine the association between socioeconomic status (SES) and FS among patients with RA and to evaluate the association between SES and functional declines over time in patients who received at least some rheumatology care.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used data from the American College of Rheumatology's Rheumatology Informatics System for Effectiveness (RISE) registry between January 1, 2016, and December 31, 2018. Analyses included all adult patients with a confirmed RA diagnosis (ie, had ≥2 encounters associated with RA International Classification of Diseases codes ≥30 days apart) and at least 1 FS score documented between 2016 and 2018 seen at participating rheumatology practices. Data analysis was conducted from April to December 2020.

EXPOSURES

The Area Deprivation Index (ADI), a zip code-based indicator of neighborhood poverty, was used as a proxy for SES. ADI scores were categorized into quintiles.

MAIN OUTCOMES AND MEASURES

FS measures included Multidimensional Health Assessment Questionnaire (MDHAQ), Health Assessment Questionnaire Disability index, and Health Assessment Questionnaire-II. Cross-sectionally, mean FS scores were compared across ADI quintiles. Longitudinally, among patients with at least 2 FS scores, multilevel multivariate regression computed the probability of functional decline, defined as a change greater than the minimum clinically important difference, across ADI quintiles. In a subgroup analysis, whether disease activity mediated the association between SES and functional decline was examined.

RESULTS

Of the 83 965 patients included in the study, 66 649 (77%) were women, and 60 037 (72%) were non-Hispanic White. Mean (SD) age was 63.4 (13.7) years. MDHAQ was the most reported FS measure (56 928 patients [67.8%]). For all measures, mean (SD) FS score was worse at lower SES levels (eg, for MDHAQ quintile 1: 1.79 [1.87]; quintile 5: 2.43 [2.17]). In longitudinal analyses, the probability of functional decline was 14.1% (95% CI, 12.5%-15.7%) in the highest SES quintile and 18.9% (95% CI, 17.1%-20.7%) in the lowest SES quintile. The association between SES and functional decline was partially mediated (7%; 95% CI, 4%-22%) by disease activity.

CONCLUSIONS AND RELEVANCE

In this cohort study of patients with RA, worse FS and faster declines in functioning over time were observed in patients with lower SES. These findings provide a framework for monitoring disparities in RA and for generating evidence to spur action toward achieving health equity.

Under‐recognition of pediatric hypertension diagnosis: Examination of 1 year of visits to community health centers

Pediatric hypertension is associated with significant target organ damage in children and cardiovascular morbidity in adulthood. Appropriate diagnosis and management per guideline recommendations are inconsistent. In this study, we determined the proportion of missed diagnosis of hypertension and prehypertension and appropriate follow‐up in pediatric patients, stratified by sex, age, race/ethnicity, and weight status. Based on the electronic health record (EHR) data from eight federally qualified health centers, among 62,982 children aged 3 to 18 years, 6233 (10%) had at least one abnormal blood pressure (BP) measurement over twelve months. Among those children whose recorded BPs met the criteria for prehypertension (N = 6178), 14.6% had a diagnosis in the EHR. These children were more likely to be White and have obesity compared with children who met the criteria but were not diagnosed with prehypertension. Among those who met the criteria for hypertension (N = 55), 41.8% had a diagnosis of hypertension in the EHR. Being diagnosed with hypertension was not associated with any examined patient characteristics. Over eleven months, 2837 children had BP ≥ 95th percentile on ≥ 1 visit. Only 13% had guideline‐adherent follow‐up within 1 month and were more likely to be older, female, and of Hispanic ethnicity or “other” race. Over six months, 2902 children had BP ≥ 90th percentile on one visit. 41% had guideline‐adherent follow‐up within 6 months and were more likely to be older, of either White, Hispanic, Asian race, or Hispanic ethnicity. In a community‐based setting, pediatric hypertension and prehypertension were persistently underdiagnosed with low adherence to recommended follow‐up.

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.

Neighborhood Environment Characteristics and Control of Hypertension and Diabetes in a Primary Care Patient Sample

BACKGROUND

Hypertension control and diabetes control are important for reducing cardiovascular disease burden. A growing body of research suggests an association between neighborhood environment and hypertension or diabetes control among patients engaged in clinical care.

OBJECTIVE

To investigate whether neighborhood conditions (i.e., healthy food availability, socioeconomic status (SES), and crime) were associated with hypertension and diabetes control.

DESIGN

Cross-sectional analyses using electronic medical record (EMR) data, U.S. Census data, and secondary data characterizing neighborhood food environments. Multivariate logistic regression analyses adjusted for potential confounders. Analyses were conducted in 2017.

PARTICIPANTS

Five thousand nine hundred seventy adults receiving primary care at three Baltimore City clinics in 2010-2011.

MAIN MEASURES

Census tract-level neighborhood healthy food availability, neighborhood SES, and neighborhood crime. Hypertension control defined as systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg. Diabetes control defined as HgbA1c < 7.

KEY RESULTS

Among patients with hypertension, neighborhood conditions were not associated with lower odds of blood pressure control after accounting for patient and physician characteristics. However, among patients with diabetes, in fully adjusted models accounting for patient and physician characteristics, we found that patients residing in neighborhoods with low and moderate SES had reduced odds of diabetes control (OR = 0.74 (95% CI = 0.57-0.97) and OR = 0.75 (95% CI = 0.57-0.98), respectively) compared to those living in high-SES neighborhoods.

CONCLUSIONS

Neighborhood disadvantage may contribute to poor diabetes control among patients in clinical care. Community-based chronic disease care management strategies to improve diabetes control may be optimally effective if they also address neighborhood SES among patients engaged in care.

Reducing Hypertension in a Poststroke Black and Hispanic Home Care Population: Results of a Pragmatic Randomized Controlled Trial

BACKGROUND

Uncontrolled hypertension (HTN) is a leading modifiable stroke risk factor contributing to global stroke disparities. This study is unique in testing a transitional care model aimed at controlling HTN in black and Hispanic poststroke, home health patients, an understudied group.

METHODS

A 3-arm randomized controlled trial design compared (i) usual home care (UHC), with (ii) UHC plus a 30-day nurse practitioner transitional care program, or (iii) UHC plus nurse practitioner plus a 60-day health coach program. The trial enrolled 495 black and Hispanic, English- and Spanish- speaking adults with uncontrolled systolic blood pressure (SBP ≥ 140 mm Hg) who had experienced a first-time or recurrent stroke or transient ischemic attack. The primary outcome was change in SBP from baseline to 3 and 12 months.

RESULTS

Mean participant age was 67; 57.0% were female; 69.7% were black, non-Hispanic; and 30.3% were Hispanic. Three-month follow-up retention was 87%; 12-month retention was 81%. SBP declined 9-10 mm Hg from baseline to 12 months across all groups; the greatest decrease occurred between baseline and 3 months. The interventions demonstrated no relative advantage compared to UHC.

CONCLUSION

The significant across-the-board SBP decreases suggest that UHC nurse/patient/physician interactions were the central component of SBP reduction and that additional efforts to lower recurrent stroke risk should test incremental improvements in usual care, not resource-intensive transitional care interventions. They also suggest the potential value of pragmatic home care programs as part of a broader strategy to overcome HTN treatment barriers and improve secondary stroke prevention globally.

CLINICAL TRIALS REGISTRATION

Trial Number NCT01918891.

Blood Pressure Measurement: A KDOQI Perspective

The majority of patients with chronic kidney disease (CKD) have elevated blood pressure (BP). In patients with CKD, hypertension is associated with increased risk for cardiovascular disease, progression of CKD, and all-cause mortality. New guidelines from the American College of Cardiology/American Heart Association (ACC/AHA) recommend new thresholds and targets for the diagnosis and treatment of hypertension in patients with and without CKD. A new aspect of the guidelines is the recommendation for measurement of out-of-office BP to confirm the diagnosis of hypertension and guide therapy. In this KDOQI (Kidney Disease Outcomes Quality Initiative) perspective, we review the recommendations for accurate BP measurement in the office, at home, and with ambulatory BP monitoring. Regardless of location, validated devices and appropriate cuff sizes should be used. In the clinic and at home, proper patient preparation and positioning are critical. Patients should receive information about the importance of BP measurement techniques and be encouraged to advocate for adherence to guideline recommendations. Implementing appropriate BP measurement in routine practice is feasible and should be incorporated in system-wide efforts to improve the care of patients with hypertension. Hypertension is the number 1 chronic disease risk factor in the world; BP measurements in the office, at home, and with ambulatory BP monitoring should adhere to recommendations from the AHA.

Measuring Health Equity for Ambulatory Care Sensitive Conditions in a Large Integrated Health Care System: The Development of an Index

Disparities in outcomes for preventive and primary health care services often result when vulnerable patients rely on episodic encounters for emergency services that do not meet their long-term health needs. Understanding health outcomes in socially or economically disadvantaged subgroups is crucial to improving community health, and it requires innovative analytics and dynamic application of clinical and population data. While it is common practice to use proxy indicators, such as quality of life and mortality, when discussing health equity, these have shown limited utility and are rarely applied at a population-level within a health system. Therefore, we designed and implemented an index, calculated as the ratio of observed-to-expected encounters, to identify and quantify health inequalities in health care systems. Providing equitable care, as measured by health outcomes, is analogous to precision medicine applied to social determinants. For health systems, the use of this index will facilitate the development of specially-tailored interventions to address inequity and provides a tool to measure the impact of such programs.

A complex culturally targeted intervention to reduce Hispanic disparities in living kidney donor transplantation: an effectiveness-implementation hybrid study protocol

BACKGROUND

The shortage of organs for kidney transplantation for patients with end-stage renal disease (ESRD) is magnified in Hispanics/Latin Americans in the United States. Living donor kidney transplantation (LDKT) is the treatment of choice for ESRD. However, compared to their representation on the transplant waitlist, fewer Hispanics receive a LDKT than non-Hispanic whites. Barriers to LDKT for Hispanics include: lack of knowledge, cultural concerns, and language barriers. Few interventions have been designed to reduce LDKT disparities. This study aims to reduce Hispanic disparities in LDKT through a culturally targeted intervention.

METHODS/DESIGN

Using a prospective effectiveness-implementation hybrid design involving pre-post intervention evaluation with matched controls, we will implement a complex culturally targeted intervention at two transplant centers in Dallas, TX and Phoenix, AZ. The goal of the study is to evaluate the effect of Northwestern Medicine's® Hispanic Kidney Transplant Program's (HKTP) key culturally targeted components (outreach, communication, education) on Hispanic LDKT rates over five years. The main hypothesis is that exposure to the HKTP will reduce disparities by increasing the ratio of Hispanic to non-Hispanic white LDKTs and the number of Hispanic LDKTs. We will also examine other process and outcome measures including: dialysis patient outreach, education session attendance, marketing efforts, Hispanic patients added to the waitlist, Hispanic potential donors per potential recipient, and satisfaction with culturally competent care. We will use mixed methods based on the Promoting Action on Research Implementation in Health Services (revised PARIHS) and the Consolidated Framework for Implementation Research (CFIR) frameworks to formatively evaluate the fidelity and innovative adaptations to HKTP's components at both study sites, to identify moderating factors that most affect implementation fidelity, and to identify adaptations that positively and negatively affect outcomes for patients.

DISCUSSION

Our study will provide new knowledge about implementing culturally targeted interventions and their impact on reducing health disparities. Moreover, the study of a complex organizational-level intervention's implementation over five years is rare in implementation science; as such, this study is poised to contribute new knowledge to the factors influencing how organizational-level interventions are sustained over time.

TRIAL REGISTRATION

(ClinicalTrials.gov registration # NCT03276390 , date of registration: 9-7-17, retrospectively registered).

Reducing Cardiovascular Disparities Through Community-Engaged Implementation Research: A National Heart, Lung, and Blood Institute Workshop Report

Cardiovascular disparities remain pervasive in the United States. Unequal disease burden is evident among population groups based on sex, race, ethnicity, socioeconomic status, educational attainment, nativity, or geography. Despite the significant declines in cardiovascular disease mortality rates in all demographic groups during the last 50 years, large disparities remain by sex, race, ethnicity, and geography. Recent data from modeling studies, linked micromap plots, and small-area analyses also demonstrate prominent variation in cardiovascular disease mortality rates across states and counties, with an especially high disease burden in the southeastern United States and Appalachia. Despite these continued disparities, few large-scale intervention studies have been conducted in these high-burden populations to examine the feasibility of reducing or eliminating cardiovascular disparities. To address this challenge, on June 22 and 23, 2017, the National Heart, Lung, and Blood Institute convened experts from a broad range of biomedical, behavioral, environmental, implementation, and social science backgrounds to summarize the current state of knowledge of cardiovascular disease disparities and propose intervention strategies aligned with the National Heart, Lung, and Blood Institute mission. This report presents the themes, challenges, opportunities, available resources, and recommended actions discussed at the workshop.

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.

Electronic supplementary material

The online version of this article (10.1186/s12875-017-0682-5) contains supplementary material, which is available to authorized users.

Hypertension knowledge, heart healthy lifestyle practices and medication adherence among adults with hypertension

Objective

To assess patients' knowledge about hypertension and its association with heart healthy lifestyle practices and medication adherence.

Methods

We conducted a cross sectional survey of 385 adults with hypertension treated at 2 primary care clinics in Baltimore, Maryland, USA. We used an 11-item measure to assess hypertension knowledge and obtained self-reports on dietary changes, engagement in aerobic exercise and medication adherence.

Results

Approximately 85% of patients properly identified high blood pressure, but more than two-thirds were unaware that hypertension lasts a lifetime once diagnosed; one-third were unaware that hypertension could lead to renal disease. Patients with low hypertension knowledge were less likely to reduce their salt intake (OR=0.44 [95% CI: 0.24-0.72]) and eat less to lose weight (OR=0.48 [95% CI: 0.26-0.87]) than patients with high hypertension knowledge.

Conclusion

In general, patients were knowledgeable about hypertension, but most were unaware that hypertension is a lifelong condition and could lead to kidney disease. High knowledge of hypertension was associated with healthy lifestyle practices including eating less to lose weight and dietary salt reduction.

Practice Implications

Intensifying education strategies to improve patients' knowledge of hypertension may enhance their engagement in heart healthy lifestyle practices for optimal blood pressure control.

Design of a bilevel clinical trial targeting adherence in heart failure patients and their providers: The Congestive Heart Failure Adherence Redesign Trial (CHART)

BACKGROUND

Socioeconomically disadvantaged patients are at an increased risk for adverse heart failure (HF) outcomes based upon nonadherence to medications and diet. Physicians are also suboptimally adherent to prescribing evidence-based therapy for HF.

METHODS

Congestive Heart Failure Adherence Redesign Trial (CHART) (NCT01698242) is a multicenter, bilevel, cluster randomized behavioral efficacy trial designed to assess the impact of intervening simultaneously on physicians and their socioeconomically disadvantaged patients (annual income <$30,000) having HF with reduced ejection fraction. Treatment arm physicians received individualized feedback on their adherence to prescribing evidence-based therapy. Their patients received weekly home visits from community health workers aimed at promoting understanding of HF and integrating adherence into daily life. Control arm physicians received regular updates on advances in HF management, and patients received monthly HF educational tip sheets produced by the American Heart Association. The primary outcome was all-cause hospital days over 30 months.

RESULTS

A total of 72 physicians (treatment, 35; control, 37) and their 320 patients (treatment, 157; control, 163) were recruited within 2 years. Randomization of physicians with all of their patients being assigned to the same arm was feasible and did not compromise the comparability of patients by arm. Using 5 recruiting hospitals located within disadvantaged neighborhoods produced a cohort that was primarily African American and representative of low-income urban patients with HF with reduced ejection fraction.

CONCLUSION

CHART will determine the value of intervening on low adherence simultaneously in physicians and their socioeconomically disadvantaged patients in reducing all-cause hospitalization days.

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.

Reducing inequity in primary care clinics treating low socioeconomic Jewish and Arab populations in Israel

Background

An organization-wide inequity-reduction quality improvement (QI) initiative was implemented in primary care clinics serving disadvantaged Arab and Jewish populations. Using the Chronic Care Model (CCM), this study investigated the types of interventions associated with success in inequity reduction.

Methods

Semi-structured interviews were conducted with 80 staff members from 26 target clinics, and information about intervention types was coded by CCM and clinical domains (e.g. diabetes, hypertension and lipid control; performance of mammography tests). Relationships between type and number of interventions implemented and inequity reduction were assessed.

Results

Target clinics implemented 454 different interventions, on average 17.5 interventions per clinic. Interventions focused on Decision support and Community linkages were positively correlated with improvement in the composite quality score (P < 0.05). Conversely, focusing on a specific clinical domain was not correlated with a higher quality score.

Conclusions

Focusing on training team members in selected QI topics and/or tailoring interventions to meet community needs was key to the interventions' success. Such findings, especially in light of the lack of association between QI and a focus on a specific clinical domain, support other calls for adopting a systems approach to achieving wide-scale inequity reduction.

Adherence to the Women's Preventive Services Guidelines in the Affordable Care Act

OBJECTIVE

To assess the adherence of women's health providers in New Mexico to the Women's Preventive Services Guidelines and to examine how providers' knowledge, attitudes, and external barriers are associated with adherence.

DESIGN

Cross-sectional, descriptive survey.

SETTING

New Mexico.

PARTICIPANTS

Women's health providers in New Mexico, including nurse practitioners, certified nurse-midwives, and family practice and obstetrician-gynecologist physicians.

METHODS

Participants completed a self-administered survey to measure knowledge, attitudes, external barriers, and adherence to each of the eight guidelines. Adherence was defined as following a guideline more than 90% of the time.

RESULTS

The response rate was 22% (399/1,798). Among the eight guidelines, participant adherence ranged from 17.2% to 88.4%. Only 39.7% of participants indicated adherence to most of the guidelines (four or more). Overall, provider adherence was directly associated with familiarity with the guidelines (odds ratio = 3.69; 95% confidence interval [1.96, 6.96]), self-efficacy to implement them (odds ratio = 4.25; 95% confidence interval [2.21, 8.20]), and younger age (odds ratio = 0.97; 95% confidence interval [0.94, 1.00]).

CONCLUSION

Adherence to the Women's Preventive Services Guidelines by providers in New Mexico is variable and, for many recommended practices, less than optimal. New targeted implementation strategies are needed to address barriers to adherence.

Development and Initial Validation of a New Practice Context Assessment Tool for Ambulatory Practices Engaged in Quality Improvement

Variable success with quality improvement (QI) efforts in ambulatory care is often attributed to differences in local contexts. Identifying and addressing patient-, practice-, or community-level contextual factors might improve implementation of QI projects. The authors developed and validated a framework for a Practice Context Assessment (PCA), and then created the PCA instrument to glean insights from staff on contextual factors and distributed it at 10 ambulatory practice sites. The PCA framework showed acceptable expert-assessed content validity, with content validity index scores ranging from 0.74 (community engagement) to 0.97 (leadership). The PCA instrument comprised several scales grouped into 7 domains with Cronbach α scores from 0.83 (leadership) to 0.95 (patient and family engagement). The PCA framework provides a valid construct to help ambulatory practices understand contextual issues that might influence QI projects. A revised version of the PCA instrument is now ready for further testing.

The Role of Care Management as a Population Health Intervention to Address Disparities and Control Hypertension: A Quasi-Experimental Observational Study

OBJECTIVE

We studied whether care management is a pragmatic solution for improving population blood pressure (BP) control and addressing BP disparities between Blacks and Whites in routine clinical environments.

DESIGN

Quasi-experimental, observational study.

SETTING AND PARTICIPANTS

3,964 uncontrolled hypertensive patients receiving primary care within the last year from one of six Baltimore clinics were identified as eligible.

INTERVENTION

Three in-person sessions over three months with registered dietitians and pharmacists who addressed medication titration, patient adherence to healthy behaviors and medication, and disparities-related barriers.

MAIN MEASURES

We assessed the population impact of care management using the RE-AIM framework. To evaluate effectiveness in improving BP, we used unadjusted, adjusted, and propensity-score matched differences-in-differences models to compare those who completed all sessions with partial completers and non-participants.

RESULTS

Of all eligible patients, 5% participated in care management. Of 629 patients who entered care management, 245 (39%) completed all three sessions. Those completing all sessions on average reached BP control (mean BP 137/78) and experienced 9 mm Hg systolic blood pressure (P<.001) and 4 mm Hg DBP (P=.004) greater improvement than non-participants; findings did not vary in adjusted or propensity-score matched models. Disparities in systolic and diastolic BP between Blacks and Whites were not detectable at completion.

CONCLUSIONS

It may be possible to achieve BP control among both Black and White patients who participate in a few sessions of care management. However, the very limited reach and patient challenges with program completion should raise significant caution with relying on care management alone to improve population BP control and eliminate related disparities.

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.

A Dietary Intervention in Urban African Americans: Results of the "Five Plus Nuts and Beans" Randomized Trial

INTRODUCTION

Unhealthy diets, often low in potassium, likely contribute to racial disparities in blood pressure. We tested the effectiveness of providing weekly dietary advice, assistance with selection of higher potassium grocery items, and a $30 per week food allowance on blood pressure and other outcomes in African American adults with hypertension.

DESIGN

We conducted an 8-week RCT with two parallel arms between May 2012 and November 2013.

SETTING/PARTICIPANTS

We randomized 123 African Americans with controlled hypertension from an urban primary care clinic in Baltimore, Maryland, and implemented the trial in partnership with a community supermarket and the Baltimore City Health Department. Mean (SD) age was 58.6 (9.5) years; 71% were female; blood pressure was 131.3 (14.7)/77.2 (10.5) mmHg; BMI was 34.5 (8.2); and 28% had diabetes.

INTERVENTION

Participants randomized to the active intervention group (Dietary Approaches to Stop Hypertension [DASH]-Plus) received coach-directed dietary advice and assistance with weekly online ordering and purchasing of high-potassium foods ($30/week) delivered by a community supermarket to a neighborhood library. Participants in the control group received a printed DASH diet brochure along with a debit account of equivalent value to that of the DASH-Plus group.

MAIN OUTCOME MEASURES

The primary outcome was blood pressure change. Analyses were conducted in January to October 2014.

RESULTS

Compared with the control group, the DASH-Plus group increased self-reported consumption of fruits and vegetables (mean=1.4, 95% CI=0.7, 2.1 servings/day); estimated intake of potassium (mean=0.4, 95% CI=0.1, 0.7 grams/day); and urine potassium excretion (mean=19%, 95% CI=1%, 38%). There was no significant effect on blood pressure.

CONCLUSIONS

A program providing dietary advice, assistance with grocery ordering, and $30/week of high-potassium foods in African American patients with controlled hypertension in a community-based clinic did not reduce BP. However, the intervention increased consumption of fruits, vegetables, and urinary excretion of potassium.

Sustained Reduction in Health Disparities Achieved through Targeted Quality Improvement: One-Year Follow-up on a Three-Year Intervention

OBJECTIVE

To assess a quality improvement disparity reduction intervention and its sustainability.

DATA SOURCES/STUDY SETTING

Electronic health records and Quality Index database of Clalit Health Services in Israel (2008-2012).

STUDY DESIGN

Interrupted time-series with pre-, during, and postintervention disparities measurement between 55 target clinics (serving approximately 400,000 mostly low socioeconomic, minority populations) and all other (126) clinics.

DATA COLLECTION/EXTRACTION METHODS

Data on a Quality Indicator Disparity Scale (QUIDS-7) of 7 indicators, and on a 61-indicator scale (QUIDS-61).

PRINCIPAL FINDINGS

The gap between intervention and nonintervention clinics for QUIDS-7 decreased by 66.7 percent and by 70.4 percent for QUIDS-61. Disparity reduction continued (18.2 percent) during the follow-up period.

CONCLUSIONS

Quality improvement can achieve significant reduction in disparities in a wide range of clinical domains, which can be sustained over time.

Transdisciplinary cardiovascular and cancer health disparities training: experiences of the centers for population health and health disparities

The Centers for Population Health and Health Disparities program promotes multilevel and multifactorial health equity research and the building of research teams that are transdisciplinary. We summarized 5 areas of scientific training for empowering the next generation of health disparities investigators with research methods and skills that are needed to solve disparities and inequalities in cancer and cardiovascular disease. These areas include social epidemiology, multilevel modeling, health care systems or health care delivery, community-based participatory research, and implementation science. We reviewed the acquisition of the skill sets described in the training components; these skill sets will position trainees to become leaders capable of effecting significant change because they provide tools that can be used to address the complexities of issues that promote health disparities.

Reducing racial and ethnic disparities in hypertension prevention and control: what will it take to translate research into practice and policy?

INTRODUCTION

Despite available, effective therapies, racial and ethnic disparities in care and outcomes of hypertension persist. Several interventions have been tested to reduce disparities; however, their translation into practice and policy is hampered by knowledge gaps and limited collaboration among stakeholders.

METHODS

We characterized factors influencing disparities in blood pressure (BP) control by levels of an ecological model. We then conducted a literature search using PubMed, Scopus, and CINAHL databases to identify interventions targeted toward reducing disparities in BP control, categorized them by the levels of the model at which they were primarily targeted, and summarized the evidence regarding their effectiveness.

RESULTS

We identified 39 interventions and several state and national policy initiatives targeted toward reducing racial and ethnic disparities in BP control, 5 of which are ongoing. Most had patient populations that were majority African-American. Of completed interventions, 27 demonstrated some improvement in BP control or related process measures, and 7 did not; of the 6 studies examining disparities, 3 reduced, 2 increased, and 1 had no effect on disparities.

CONCLUSIONS

Several effective interventions exist to improve BP in racial and ethnic minorities; however, evidence that they reduce disparities is limited, and many groups are understudied. To strengthen the evidence and translate it into practice and policy, we recommend rigorous evaluation of pragmatic, sustainable, multilevel interventions; institutional support for training implementation researchers and creating broad partnerships among payers, patients, providers, researchers, policymakers, and community-based organizations; and balance and alignment in the priorities and incentives of each stakeholder group.

Provider perspectives on essential functions for care management in the collaborative treatment of hypertension: the P.A.R.T.N.E.R. framework

BACKGROUND

Care management has become a widespread strategy for improving chronic illness care. However, primary care provider (PCP) participation in programs has been poor. Because the success of care management relies on provider engagement, understanding provider perspectives is necessary.

OBJECTIVE

Our goal was to identify care management functions most valuable to PCPs in hypertension treatment.

DESIGN

Six focus groups were conducted to discuss current challenges in hypertension care and identify specific functions of care management that would improve care.

PARTICIPANTS

The study included 39 PCPs (participation rate: 83 %) representing six clinics, two of which care for large African American populations and four that are in underserved locations, in the greater Baltimore metropolitan area.

APPROACH

This was a qualitative analysis of focus groups, using grounded theory and iterative coding.

KEY RESULTS

Providers desired achieving blood pressure control more rapidly. Collaborating with care managers who obtain ongoing patient data would allow treatment plans to be tailored to the changing life conditions of patients. The P.A.R.T.N.E.R. framework summarizes the care management functions that providers reported were necessary for effective collaboration: Partner with patients, providers, and the community; Arrange follow-up care; Resolve barriers to adherence; Track treatment response and progress; Navigate the health care system with patients; Educate patients & Engage patients in self-management; Relay information between patients and/or provider(s).

CONCLUSIONS

The P.A.R.T.N.E.R. framework is the first to offer a checklist of care management functions that may promote successful collaboration with PCPs. Future research should examine the validity of this framework in various settings and for diverse patient populations affected by chronic diseases.

Perceptions of health system orientation: quality, patient centeredness, and cultural competency

As part of a pragmatic trial to reduce hypertension disparities, we conducted a baseline organizational assessment to identify aspects of organizational functioning that could affect the success of our interventions. Through qualitative interviewing and the administration of two surveys, we gathered data about health care personnel's perceptions of their organization's orientations toward quality, patient centeredness, and cultural competency. We found that personnel perceived strong orientations toward quality and patient centeredness. The prevalence of these attitudes was significantly higher for these areas than for cultural competency and varied by occupational role and race. Larger percentages of survey respondents perceived barriers to addressing disparities than barriers to improving safety and quality. Health care managers and policy makers should consider how we have built strong quality orientations and apply those lessons to cultural competency.