Introduction
Methods
Study design and specific aims
Specific aims
Specific aims | Hypotheses | Process and outcome measures |
---|---|---|
To perform a multi-method, staged quality improvement intervention (better blood pressure measurement, patient care management and provider education) to increase guideline concordant hypertension care and to reduce racial disparities in blood pressure control. | • Better blood pressure measurement and better blood pressure data will lead to less clinical inertia and, ultimately, better blood pressure control and less racial disparities. | • % of patients with controlled BP and % of patients with uncontrolled BP with medication titration in the last 3 months |
• Each intervention will have an additive effect and the use of all three interventions will result in a higher percentage of patients receiving guideline-concordant hypertension care and a greater reduction in racial disparities than any single combination or any combination of two interventions. | • % of patients with controlled BP and racial disparity in controlled BP | |
• The care management intervention will have greater net improvement in blood pressure control at the clinic level than the provider education intervention. The provider education will have an additive and greater effect when implemented after the care management intervention than when employed without the care management intervention. | • % of patients with controlled BP and racial disparity in controlled BP | |
To determine the association of organizational functioning and organizational cultural competence with guideline concordant hypertension care and racial disparities in blood pressure control. | • Clinics will reflect their local surroundings and clinics with a higher percentage of minority persons will have lower organizational functioning. | • % of patients with BP control, stratified by race, compared across clinics |
• Clinics with greater organizational cultural competence will have greater guideline concordant hypertension care and less racial disparities in blood pressure control. | • Degree of racial disparity | |
To determine the association between organizational functioning and organizational cultural competence at the clinic and system level with the implementation and success of the quality improvement interventions. | • Clinics with higher organizational functioning will have a higher rate of implementation and more blood pressure control and reduction in racial disparities than clinics with lower organizational functioning. | • Degree of implementation for each of the interventions |
• Clinics with greater organizational cultural competence will have a higher rate of implementation and more blood pressure control and reduction in racial disparities than clinics with less cultural competence. | • Degree of implementation for each of the interventions |
Study populations and settings
Site A | Site B | Site C | Site D | Site E | Site F | |
---|---|---|---|---|---|---|
Clinic Characteristics
| ||||||
Primary care providers, n | 9 | 11 | 11 | 5 | 3 | 6 |
Patients, n | 7,755 | 4,733 | 14,887 | 3,681 | 5,628 | 6,161 |
AA patients, % | 65.6 | 90.1 | 23.3 | 18.4 | 17.7 | 20.2 |
White patients, % | 28.0 | 4.4 | 68.9 | 77.7 | 73.3 | 72.6 |
AA patients with HTN, n | 2,940 | 2,777 | 1,493 | 359 | 331 | 593 |
AA patients with uncontrolled HTN, % | 33.1 | 38.8 | 29.7 | 40.1 | 40.5 | 42.8 |
White patients with HTN, n | 705 | 80 | 4,209 | 1,362 | 650 | 1,477 |
White patients with uncontrolled HTN, % | 29.2 | 33.9 | 24.3 | 34.9 | 37.1 | 30.6 |
Local Characteristics
| ||||||
Medically underserved area+
| Yes | Yes | Yes | No | Yes | No |
Median income (in 2011 $US)*
| $47,472 | $36,652 | $58,488 | $50,459 | $47,472 | $99,155 |
% Below poverty line*
| 19.0 | 21.0 | 8.9 | 10.6 | 18.2 | 7.8 |
% Employed*
| 55.5 | 54.8 | 70.7 | 60.3 | 59.0 | 64.4 |
% Population AA*
| 71.7 | 59.1 | 19.5 | 16.9 | 34.1 | 27.6 |
% High school grad or equivalent*
| 81.4 | 76.9 | 85.6 | 78.7 | 78.2 | 92.7 |
% Vacant housing units*
| 16.7 | 19.6 | 6.7 | 10.6 | 14.5 | 5.6 |
Interventions
Intervention* | Blood pressure measurement | Care management | Provider education | |
---|---|---|---|---|
Goal
| • Improve accuracy and reliability of blood pressure measurement and reduce clinical uncertainty | • Add RDs and PharmDs to primary care teams to deliver culturally-sensitive patient education, promote self-management behaviors and improve access and team functioning | • Incorporate best practices in physician education by assessing PCP needs, delivering an interactive program to provide practical communications skills training and providing performance data feedback on blood pressure control among patients stratified by race/ethnicity | |
Participants and clinics
| • Medical assistants and providers | • Eligible patients (SBP ≥ 140 and/or DBP ≥ 90 mmHg) attending the clinic; providers and clinic staff in referral process | • Providers | |
• All six participating JHCP clinics | • All six participating JHCP clinics; staggered roll out between 2012-2015 | • All six participating JHCP clinics; staggered roll out between 2012-2015 | ||
Rationale
| ||||
• Standardizing and improving reliability of blood pressure measurements may improve PCP confidence in measures and reduce clinical inertia for treatment | • Audit and feedback approaches have been associated with improved quality metrics | |||
• Provides standardized measurement for other two interventions | ||||
Level of intervention
|
Patient
| • Providing posters in check-in and exam areas that demonstrate appropriate positioning and give reasons for new process | • Participating in three care management sessions, totaling two hours | • Promoting patient engagement indirectly by enhancing providers’ patient-centered communication and participatory decision-making skills |
• Intervening on lifestyle: exercise, weight loss, DASH diet, medication adherence | ||||
Provider and staff
| • Educating providers and medical assistants about proper blood pressure measurement through didactic and skills practice | • Referring eligible patients to care management team | • Providing audit and feedback via race-stratified hypertension dashboard and web based video training targeting communication skills that promote patient adherence | |
• Receiving reimbursements for panel review of eligible hypertension patients | ||||
Clinic
| • Introducing tools to facilitate adherence to recommended techniques (e.g., Omron HEM-907XL) | • Embedding RDs and PharmDs in clinics as part of the provider support team | • Building hypertension dashboard on existing JHCP provider dashboard | |
• Redesigning patient intake protocols (proper patient positioning and multitasking during Omron use) | • Contracting with JHCP IT team to develop and refine hypertension dashboard | |||
Stakeholder input
|
Patients/ community
| • Suggested posters in exam rooms to explain new process | • Recommended specific educational materials and suggested changes to language, layout and images | • Provided suggestions to make patient stories more realistic for communication skills program |
Medical assistants
| • Focus groups informed intervention development and implementation plan | • Focus groups informed intervention development and implementation plan | N/A | |
• Identified and trained Master Trainers and Super-Users at each clinic to support adoption of devices | ||||
• Disseminated time-saving techniques developed by medical assistants to all sites | ||||
Provider
| • Focus groups informed intervention development and implementation plan | • Focus groups informed intervention development and implementation plan | • Focus groups informed intervention development and implementation plan | |
• Directed interviews to assess organizational culture | • Directed interviews to assess organizational culture | • Directed interviews to assess organizational culture | ||
• Identified JHCP provider champion | • Identified JHCP provider champion | • Identified JHCP provider champion | ||
JHCP leadership
| • Directed interviews to assess organizational culture | • Directed interviews to assess organizational culture | • Directed interviews to assess organizational culture | |
Johns Hopkins Health Care (JHHC)
| N/A | • Modified existing care manager job description for RDs • Subcontract with JHHC to hire and fund study RDs | N/A |
Blood pressure measurement | Care management | Provider education | ||
---|---|---|---|---|
Disparities Specific Rationale
| • Clinical uncertainty is believed to be a major contributor to healthcare disparities [23] | |||
• Standardization of healthcare processes may reduce clinical uncertainty and variations in care [30] | • The combination of cultural competency training and race-stratified performance reports increases clinician awareness of racial disparities in care [34] | |||
• Delivery of culturally and linguistically-tailored health information increases acceptability of interventions in minority populations [35] | • PCP communication skills training improves patient-reported outcomes and blood pressure control in ethnic minorities and poor persons [36] | |||
Disparities Tailoring
|
Patient
| • Poster messages and images reduce patient anxiety and promote trust | • Educational materials culturally and linguistically tailored | • Patient scenarios include individual and environmental determinants of disparities and demonstrate methods to address them |
• Motivational interviewing enhances patient engagement and addresses individual determinants of disparities | ||||
• Community resource guide addresses environmental determinants of disparities | ||||
Provider and Staff
| • Re-training videos use local staff as role models | • Care managers enhance providers’ ability to address patients’ complex psychosocial needs by providing additional counseling and support | • Dashboard increases provider awareness of disparities | |
• Communication skills training enhances provider participatory skills leading to increased patient trust and engagement | ||||
Clinic
| • Patient posters provide culturally and linguistically tailored communication | • Availability of phone contacts and flexible appointment times enhances access | • Financial incentives reward providers for reviewing disparities data | |
• Financial incentives encourage providers to make referrals |
Blood pressure measurement
Care management
Provider education
Data collection, outcome measures, and statistical analysis plan
Data collection
Outcome and process measures
Type | Measure+ | Notes and definitions |
---|---|---|
Primary process measure | % with uncontrolled BP with medication titration in last 3 months | Uncontrolled BP ≥140/≥90 (or ≥130/≥80 if DM or chronic kidney disease); titration can be dose increase or medication change/addition |
Secondary process measures | % with BP measure in EMR in last 12 months | |
% with history of pre-HTN with BP measure in last 12 months | Two clinic BPs ≥120-<140≥80-<90; not on HTN medication | |
% with HTN with measure in last 6 months | Two clinic BP ≥140/≥90 OR use of a HTN medication OR ICD9 diagnosis (401.xx) | |
% with HTN on a thiazide diuretic | ||
% with HTN and DM on ACE-I or ARB | DM defined by ICD9 code 250.xx | |
% with lipid panel performed in last 5 years*
| May not be possible as EMR only in all clinics since March 2006 | |
% with BP≥135/≥85 screened for DM in last 5 years*
| May not be possible as EMR only in all clinics since March 2006 | |
Implementation uptake process measures | % with BP measured with OMRON | |
% of SBP and DBP measures ending in zero | ||
% of eligible patients enrolled in care management | ||
% completion rate for those enrolled in care management | ||
Provider behavioral intention related to assessment and partnership skills | Measured at completion of the website review and at 6 months post-intervention | |
Change in provider self-reported use of assessment and partnership behaviors | Measured before the website review and at 6 months post-intervention | |
% of providers receiving web training at each site | Measured at 6 months post-intervention | |
Provider self-reported use of HTN dashboard | Measured at 6 months post-intervention | |
Primary outcome measure | % with controlled BP | Controlled BP defined as <140/<90 (or <130/<80 if DM or chronic kidney disease present) |
Secondary outcome measures | % with controlled LDL | Controlled LDL defined as <130 (or <100 if DM or coronary artery disease) |
% with controlled HDL | Controlled HDL defined as >50 in women or >40 in men | |
% with controlled triglycerides | Controlled triglycerides defined as <150 | |
% with controlled A1C | Controlled A1C defined as <7.0 | |
Mean SBP, DBP, LDL, HDL, triglycerides, A1C |