Reducing Disparities and Controlling Hypertension in Primary Care
Hypertension (HTN) is common in the U.S. In 2002, 28.6% of the U.S. population had HTN. Pharmacotherapy and observational studies have shown that maintaining a lower blood pressure (BP) is associated with less morbidity and mortality. However, 71% of U.S. persons with HTN are uncontrolled. Forty-five percent are not aware of their disease and 65% are not treated. Even when HTN is treated, the rates of control are suboptimal as 47% of those with treated HTN are uncontrolled.
There are many potential barriers to achieving adequate BP control at the health system, clinician and staff, and patient level. At the system and health professional/staff level, these include:
- System factors such as leadership, educational resources, other infrastructural support, staffing, team functioning, and orientation toward change, quality, patient-centeredness, and equity
- Clinician and staff factors such as unreliable clinic-based BP measurement technique and insufficient training to provide counseling focused on lifestyle change and medication adherence to patients
Racial disparities in BP control have been well documented even among patients seen regularly in a healthcare system. Clinics that care for racially diverse patients may have:
- Fewer resources such as medical assistants and nurse case managers to help physicians
- Fewer opportunities to refer patients to specialists for advancement of care because of limited access and cost concerns
Although Quality Improvement (QI) interventions have been proven effective for improving BP, the following remains unclear:
- Which interventions work best in combination?
- Does the method of implementation influence the effectiveness of the QI interventions?
- What is the effect of QI interventions on racial disparities?
- What role do clinic-level and health system-level factors play in the development of racial disparities?
- What impact will clinic-level and health system-level factors impact the success of QI interventions to reduce racial disparities?
To date, no group has attempted to pull existing approaches together into a coherent strategy to reduce BP-related health disparities in an African-American (AA) community. It is our overarching hypothesis that a comprehensive, multifaceted strategy for HTN detection and control will improve BP care and reduce HTN health disparities in an urban primary care network based in a predominantly AA community. In addition, we postulate that an in-depth understanding of the organizational context and implementation process will help maximize sustainability and the potential for dissemination.
Specific Aim 1: To implement a multi-method, staged QI intervention (better BP measurement; patient case management; provider education including audit and feedback and communication skills training) in order to increase guideline-concordant HTN care and to reduce racial disparities in BP control.
Hypothesis: We hypothesize that each intervention will increase guideline-concordant HTN care and reduce racial disparities in BP control, but that the combination of all three interventions will result in the greatest improvement in guideline-concordant HTN care and the largest reduction in disparities. In addition, we further hypothesize that provider education will be more effective in a system with established HTN management than in a system without the addition of HTN management support.
Specific Aim 2: To determine the association of organizational functioning and organizational cultural competence with guideline-concordant HTN care and racial disparities in BP control.
Hypothesis: Organizational functioning and organizational cultural competence will be associated with guideline-concordant care and racial disparities in HTN.
Specific Aim 3: To determine the association between organizational functioning and organizational cultural competence at the clinic and system level with the implementation (uptake) and effectiveness of the QI interventions (BP control, reduction in disparities).
Hypothesis: Organizational functioning and organizational cultural competence characteristics will be associated with greater uptake and more effective interventions at the clinic and system level.
Specific Aim 4: To examine the relationship of uptake of the quality improvement (QI) interventions with improvements in patient-level factors such as knowledge, attitudes, self-confidence, experiences, activation levels, and medication adherence; the relation of patient-level factors with effectiveness of the interventions, and the role of patient-level factors in explaining the relationship between uptake and effectiveness of the interventions.
Hypothesis: Implementation of a multi-method system level QI intervention will be associated with improvements in patient knowledge, attitudes, experience, activation levels, and medication adherence and those improvements will mediate the relationship of uptake with intervention effectiveness.