A multicomponent quality improvement intervention to improve blood pressure and reduce racial disparities in rural primary care practices.
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ABSTRACT:
SUBMITTER: Cene CW
PROVIDER: S-EPMC8031107 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:Racial disparities in blood pressure control have been well documented in the United States. Research suggests that many factors contribute to this disparity, including barriers to care at patient, clinician, healthcare system, and community levels. To date, few interventions aimed at reducing hypertension disparities have addressed factors at all of these levels. This paper describes the design of Project ReD CHiP (Reducing Disparities and Controlling Hypertension in Primary Care), a multi-level system quality improvement project. By intervening on multiple levels, this project aims to reduce disparities in blood pressure control and improve guideline concordant hypertension care.Using a pragmatic trial design, we are implementing three complementary multi-level interventions designed to improve blood pressure measurement, provide patient care management services and offer expanded provider education resources in six primary care clinics in Baltimore, Maryland. We are staggering the introduction of the interventions and will use Statistical Process Control (SPC) charting to determine if there are changes in outcomes at each clinic after implementation of each intervention. The main hypothesis is that each intervention will have an additive effect on improvements in guideline concordant care and reductions in hypertension disparities, but the combination of all three interventions will result in the greatest impact, followed by blood pressure measurement with care management support, blood pressure measurement with provider education, and blood pressure measurement only. This study also examines how organizational functioning and cultural competence affect the success of the interventions.As a quality improvement project, Project ReD CHiP employs a novel study design that specifically targets multi-level factors known to contribute to hypertension disparities. To facilitate its implementation and improve its sustainability, we have incorporated stakeholder input and tailored components of the interventions to meet the specific needs of the involved clinics and communities. Results from this study will provide knowledge about how integrated multi-level interventions can improve hypertension care and reduce disparities.ClinicalTrials.gov NCT01566864.
| S-EPMC3680084 | biostudies-literature
Project description:Initiatives to improve hypertension control within academic medical centers and closed health systems have been extensively studied, but large community-wide quality improvement (QI) initiatives have been both less common and less successful in the United States. The authors examined a community-wide QI initiative across 226 843 patients from 198 practices in nine counties across upstate New York to improve hypertension control and reduce disparities. The QI initiative focused on (a) providing population and practice-level comparative data, (b) community engagement, especially in underserved communities, and (c) practice-level quality improvement assistance, but was not designed to examine causality of specific components. Across the nine counties, hypertension control rates improved from 61.9% in 2011 to 69.5% in 2016. Improvements were greatest among whites (73.7%-81.5%) and more modest among black patients (58.8%-64.7%). The authors noted a considerable improvement in BP within the group of patients with the highest risk (defined as a BP ≥ 160/100) and a decrease in disparities within this group. The quality collaborative identified five key lessons to help guide future community initiatives: (a) anticipate a plateauing of response; (b) distinguish the needs of disparate populations and create subpopulation-specific strategies to address and reduce disparities; (c) recognize the variation across low SES practices; (d) remain open to the refinement of outcome measures; and (e) continually seek best practices and barriers to success. Overall, a large community-wide QI initiative, involving multiple different stakeholders, was associated with improvements in BP control and modest reductions in some targeted disparities.
| S-EPMC8030610 | biostudies-literature
Project description:Over the past decade, researchers have shifted their focus from documenting health care disparities to identifying solutions to close the gap in care. Finding Answers: Disparities Research for Change, a national program of the Robert Wood Johnson Foundation, is charged with identifying promising interventions to reduce disparities. Based on our work conducting systematic reviews of the literature, evaluating promising practices, and providing technical assistance to health care organizations, we present a roadmap for reducing racial and ethnic disparities in care. The roadmap outlines a dynamic process in which individual interventions are just one part. It highlights that organizations and providers need to take responsibility for reducing disparities, establish a general infrastructure and culture to improve quality, and integrate targeted disparities interventions into quality improvement efforts. Additionally, we summarize the major lessons learned through the Finding Answers program. We share best practices for implementing disparities interventions and synthesize cross-cutting themes from 12 systematic reviews of the literature. Our research shows that promising interventions frequently are culturally tailored to meet patients' needs, employ multidisciplinary teams of care providers, and target multiple leverage points along a patient's pathway of care. Health education that uses interactive techniques to deliver skills training appears to be more effective than traditional didactic approaches. Furthermore, patient navigation and engaging family and community members in the health care process may improve outcomes for minority patients. We anticipate that the roadmap and best practices will be useful for organizations, policymakers, and researchers striving to provide high-quality equitable care.
| S-EPMC3403142 | biostudies-literature
Project description:Despite advances in HIV prevention and care, African Americans and Latino Americans remain at much higher risk of acquiring HIV, are more likely to be unaware of their HIV-positive status, are less likely to be linked to and retained in care, and are less likely to have suppressed viral load than are Whites. The first National HIV/AIDS Strategy (NHAS) has reducing these disparities as one of its three goals by encouraging the implementation of combination high-impact HIV intervention strategies. Federal agencies have expanded their collaborations in order to decrease HIV-related disparities through better implementation of data-driven decision making; integration and consolidation of the continuum of HIV care; and the reorganization of relationships among public health agencies, researchers, community-based organizations, and HIV advocates. Combination prevention, the integration of evidence-based and impactful behavioral, biomedical, and structural intervention strategies to reduce HIV incidence, provides the tools to address the HIV epidemic. Unfortunately, health disparities exist at every step along the HIV testing-to-care continuum. This provides an opportunity and a challenge to everyone involved in HIV prevention and care to understand and address health disparities as an integral part of ending the HIV epidemic in the United States. To further reduce health disparities, successful implementation of NHAS and combination prevention strategies will require multidisciplinary teams, including psychologists with diverse cultural backgrounds and experiences, to successfully engage groups at highest risk for HIV and those already infected with HIV. In order to utilize the comprehensive care continuum, psychologists and behavioral scientists have a role to play in reconceptualizing the continuum of care, conducting research to address health disparities, and creating community mobilization strategies.
| S-EPMC3947902 | biostudies-other
Project description:ImportanceThe American Academy of Pediatrics recommends referring children at elevated risk of autism spectrum disorder (ASD) for Part C early intervention (EI) services, but notes that EI services often fail to provide ASD screening.ObjectiveTo evaluate the hypothesis that a multistage screening protocol for ASD implemented in 3 EI settings will increase autism detection, especially among Spanish-speaking families.Design, setting, and participantsDifference-in-differences analyses with propensity score weighting of a quasi-experimental design using administrative data on 3 implementation EI agencies and 9 comparison EI agencies from 2012 to 2018 provided by the Massachusetts Department of Public Health. Eligible children were aged 14 to 36 months, enrolled in EI, had no prior ASD diagnosis or medical condition precluding participation, and had parents who spoke English or Spanish. The final analytic sample included 33 326 unique patients assessed across 150 200 person-quarters.ExposuresMultistage ASD assessment protocol including ASD screening questionnaires, observational screener, and diagnostic evaluation.Main outcomes and measuresIncreased incidence of ASD diagnoses as documented in Department of Public Health records and reductions in language-associated health care disparities.ResultsImplementation of screening at 3 EI sites was associated with a significant increase in the rate of ASD diagnoses (incidence rate ratios [IRR], 1.6; 95% CI, 1.3-2.1; P < .001), representing an additional 8.1 diagnoses per 1000 children per quarter. Among Spanish-speaking families, screening was also associated with a significant increase in the rate of ASD diagnoses (IRR, 2.6; 95% CI, 1.6-4.3; P < .001), representing 15.4 additional diagnoses per 1000 children per quarter-a larger increase than for non-Spanish-speaking families (interaction IRR, 1.8; 95% CI, 1.0-3.1; P = .005). Exploratory analyses revealed that screening was associated with a larger increase in the rate of ASD diagnoses among boys (IRR, 1.8; 95% CI, 1.4-2.3; P < .001) than among girls (IRR, 1.1; 95% CI, 0.6-1.7; P = .84).Conclusions and relevanceIn this study, associations between increased rates of ASD diagnoses and reductions in disparities for Spanish-speaking households support the effectiveness of multistage screening in EI. This study provides a comprehensive evaluation of ASD screening in EI settings as well as a rigorous evaluation of ASD screening in any setting with a no-screening comparison condition. Given that the intervention included multiple components, mechanisms of action warrant further research, as do disparities by child sex.
| S-EPMC8728657 | biostudies-literature
Project description:Racial-ethnic disparities in acute stroke care can contribute to inequality in stroke outcomes. We examined race-ethnic disparities in acute stroke performance metrics in a voluntary stroke registry among Florida and Puerto Rico Get With the Guidelines-Stroke hospitals.Seventy-five sites in the Florida Puerto Rico Stroke Registry (66 Florida and 9 Puerto Rico) recorded 58 864 ischemic stroke cases (2010-2014). Logistic regression models examined racial-ethnic differences in acute stroke performance measures and defect-free care (intravenous tissue plasminogen activator treatment, in-hospital antithrombotic therapy, deep vein thrombosis prophylaxis, discharge antithrombotic therapy, appropriate anticoagulation therapy, statin use, smoking cessation counseling) and temporal trends. Among ischemic stroke cases, 63% were non-Hispanic white (NHW), 18% were non-Hispanic black (NHB), 14% were Hispanic living in Florida, and 6% were Hispanic living in Puerto Rico. NHW patients were the oldest, followed by Hispanics, and NHBs. Defect-free care was greatest among NHBs (81%), followed by NHWs (79%) and Florida Hispanics (79%), then Puerto Rico Hispanics (57%) (P<0.0001). Puerto Rico Hispanics were less likely than Florida whites to meet any stroke care performance metric other than anticoagulation. Defect-free care improved for all groups during 2010-2014, but the disparity in Puerto Rico persisted (2010: NHWs=63%, NHBs=65%, Florida Hispanics=59%, Puerto Rico Hispanics=31%; 2014: NHWs=93%, NHBs=94%, Florida Hispanics=94%, Puerto Rico Hispanics=63%).Racial-ethnic/geographic disparities were observed for acute stroke care performance metrics. Adoption of a quality improvement program improved stroke care from 2010 to 2014 in Puerto Rico and all Florida racial-ethnic groups. However, stroke care quality delivered in Puerto Rico is lower than in Florida. Sustained support of evidence-based acute stroke quality improvement programs is required to improve stroke care and minimize racial-ethnic disparities, particularly in resource-strained Puerto Rico.
| S-EPMC5523741 | biostudies-other
Project description:IntroductionThe purpose of this study is to incorporate behavioural economic principles and user-centred design principles into a multicomponent intervention for the management of uncontrolled hypertension (HTN) in chronic kidney disease (CKD) in primary care.Methods and analysisThis is a multicentre, pragmatic, controlled trial cluster-randomised at the clinician level at The Brigham and Women's Practice -Based Research Network of 15 practices. Of 220 total clinicians, 184 were eligible to be enrolled, and the remainder were excluded (residents and clinicians who see urgent care or walk-in patients); no clinicians opted out. The intervention consists of a clinical decision support system based in behavioural economic and user-centred design principles that will: (1) synthesise existing laboratory tests, medication orders and vital sign data; (2) increase recognition of CKD, (3) increase recognition of uncontrolled HTN in CKD patients and (4) deliver evidence-based CKD and HTN management recommendations. The primary endpoint is the change in mean systolic blood pressure between baseline and 6 months compared across arms. We will use the Reach Effectiveness Adoption Implementation Maintenance framework. At the conclusion of this study, we will have: (1) validated an intervention that combines laboratory tests, medication records and clinical information collected by electronic health records to recognise uncontrolled HTN in CKD patients and recommend a course of care, (2) tested the effectiveness of said intervention and (3) collected information about the implementation of the intervention that will aid in dissemination of the intervention to other practice settings.Ethics and disseminationThe Human Subjects Institutional Review Board at Brigham and Women's Hospital provided an expedited review and approval for this study protocol, and a Data Safety Monitoring Board will ensure the ongoing safety of the trial.Trial registration numberNCT03679247.
| S-EPMC8705218 | biostudies-literature
Project description:ObjectiveTo assess race-ethnic differences in acute blood pressure (BP) following intracerebral hemorrhage (ICH) and the contribution to disparities in ICH outcome.MethodsBPs in the field (emergency medical services [EMS]), emergency department (ED), and at 24 hours were compared and adjusted for group differences between non-Hispanic black (black), non-Hispanic white (white), and Hispanic participants in the Ethnic Racial Variations of Intracerebral Hemorrhage case-control study. Outcome was obtained by modified Rankin Scale (mRS) score at 3 months. We analyzed race-ethnic differences in good outcome (mRS ≤ 2) and mortality after adjusting for baseline differences and included BP recordings in this model.ResultsOf 2,069 ICH cases enrolled, 30% were white, 37% black, and 33% Hispanic. Black and Hispanic patients had higher EMS and ED systolic and diastolic BPs compared with white patients (p = 0.0001). Although attenuated, at 24 hours after admission, black patients had higher systolic and diastolic BPs. After adjusting for baseline differences, significant race/ethnic differences persisted for EMS systolic, ED systolic and diastolic, and 24-hours diastolic BP. Only ED systolic and diastolic BP was associated with poor functional outcome, and no BP predicted mortality. We found no race-ethnic differences in 3-month functional outcome or mortality after adjusting for group differences, including acute BPs.ConclusionsAlthough black and Hispanic patients had higher BPs than white patients at presentation, we did not find race-ethnic disparities in 3-month functional outcome or mortality. ED systolic and diastolic BP was associated with poor functional outcome, but not mortality, in this race-ethnically diverse population.
| S-EPMC4999322 | biostudies-literature
Project description:BackgroundThe US kidney allocation system (KAS) changed in 2014, but dialysis facility staff (including nephrologists, social workers, nurse managers, and facility administrators) had low awareness of how this policy change could affect their patients' access to transplant. We assessed the effectiveness of a multicomponent and multilevel educational and outreach intervention targeting US dialysis facilities with low waitlisting, with a goal of increasing waitlisting and reducing Black versus White racial disparities in waitlisting.MethodsThe Allocation System Changes for Equity in Kidney Transplantation (ASCENT) study was a cluster-randomized, pragmatic, multilevel, effectiveness-implementation trial including 655 US dialysis facilities with low waitlisting, randomized to receive either the ASCENT intervention (a performance feedback report, a webinar, and staff and patient educational videos) or an educational brochure. Absolute and relative differences in coprimary outcomes (1-year waitlisting and racial differences in waitlisting) were reported among incident and prevalent patients.ResultsAmong 56,332 prevalent patients, 1-year waitlisting decreased for patients in control facilities (2.72%-2.56%) and remained the same for patients in intervention facilities (2.68%-2.75%). However, the proportion of prevalent Black patients waitlisted in the ASCENT interventions increased from baseline to 1 year (2.52%-2.78%), whereas it remained the same for White patients in the ASCENT intervention facilities (2.66%-2.69%). Among incident patients in ASCENT facilities, 1-year waitlisting increased among Black patients (from 0.87% to 1.07%) but declined among White patients (from 1.54% to 1.27%). Significant racial disparities in waitlisting were observed at baseline, with incident Black patients in ASCENT facilities less likely to waitlist compared with White patients (adjusted odds ratio [aOR], 0.56; 95% confidence interval [CI], 0.35 to 0.92), but 1 year after the intervention, this racial disparity was attenuated (aOR, 0.84; 95% CI, 0.49 to 1.42).ConclusionsThe ASCENT intervention may have a small effect on extending the reach of the new KAS policy by attenuating racial disparities in waitlisting among a population of US dialysis facilities with low waitlisting.Clinical trial registry name and registration numberNational Institutes of Health ( NCT02879812 ).PodcastThis article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/CJASN/2023_03_08_CJN09760822.mp3.
| S-EPMC10103253 | biostudies-literature
Project description:BackgroundReal or perceived discrimination contributes to lower quality of care for Black compared to white patients. Some forms of discrimination come from non-physician and non-nursing (non-MD/RN) staff members (e.g., receptionists).MethodsUtilizing the Burgess Model as a framework for racial bias intervention development, we developed an online intervention with five, 30-min modules: (1) history and effects of discrimination and racial disparities in healthcare, (2) implicit bias and how it may influence interactions with patients, (3) strategies to handle stress at work, (4) strategies to improve communication and interactions with patients, and (5) personal biases. Modules were designed to increase understanding of bias, enhance internal motivation to overcome bias, enhance emotional regulation skills, and increase empathy in patient interactions. Participants were non-MD/RN staff in nine primary care clinics. Effectiveness of the intervention was assessed using Implicit Association Test and Symbolic Racism Scale, to measure implicit and explicit racial bias, respectively, before and after the intervention. Acceptability was assessed through quantitative and qualitative feedback.ResultsFifty-eight non-MD/RN staff enrolled. Out of these, 24 completed pre- and post-intervention assessments and were included. Among participants who reported characteristics, most were Black, with less than college education and average age of 43.2 years. The baseline implicit bias d-score was 0.22, indicating slight pro-white bias. After the intervention, the implicit bias score decreased to -0.06 (p=0.01), a neutral score indicating no pro-white or Black bias. Participant rating of the intervention, scored from 1 (strongly disagree) to 5 (strongly agree), for questions including whether "it was made clear how to apply the presented content in practice" and "this module was worth the time spent" was ≥4.1 for all modules.ConclusionsThere was a decrease in implicit pro-white bias after, compared with before, the intervention. Intervention materials were highly rated.
| S-EPMC9198170 | biostudies-literature