Blood pressure (BP) control among hypertensive patients reduces cardiovascular morbidity and mortality. Yet, BP is controlled at only 56% of hypertension-related office visits. Worse control of BP among Blacks is a key contributor to racial disparities in cardiovascular disease. The Seventh Joint National Committee on the Diagnosis, Prevention and Treatment of Hypertension (JNC VII) address hypertension management. While clinician adoption of JNC VII guidelines has steadily improved relevant to initiation of BP treatment and medication selection, clinicians have largely failed to implement the JNC recommendation for monthly visits for patients with uncontrolled BP. This translational gap represents a potential opportunity to improve suboptimal BP control while also addressing disparities in BP control. The primary aim of this research project is to improve clinician implementation of the JNC guideline for monthly visits for hypertensive patients with uncontrolled BP. Our secondary aim is improved BP control. We propose to accomplish these aims using a theoretically informed and evidence-based multimodal quality improvement intervention implemented within the Clinical Directors Network, a practice based research network of federally qualified health centers (FQHCs). Our central hypothesis is that targeting clinician awareness, attitudes, skills and routines relevant to this recommendation will improve patient visit frequency. Our secondary hypothesis is that improving visit frequency will improve BP control. We propose to rigorously test these important hypotheses through a pragmatic randomized trial that uses a stepped wedge phase-in of the intervention in participating FQHCs. We will assess visit frequency and BP through abstraction of data from electronic medical records of participating practices.
Our specific aims are:
Aim 1 : To implement the JNC recommendation for monthly visits for hypertensive patients with uncontrolled BP using a theoretically-informed, empirically grounded, multimodal QI intervention.
Aim 2 : To improve BP control and reduce disparity in BP through implementation of monthly visits.
Aim 3 : To assess potential mediators and moderators of the intervention. Findings have national implications for best strategies for effective implementation of this guideline. If successful, implementation of monthly visits represents a simple and feasible means for improving BP control, and potentially, for addressing racial disparities in BP control. To our knowledge, this project will be the first randomized trial of implementation of monthly visits to improve BP. Our team, which includes experts in hypertension, pragmatic trials, FQHC research, and clinician-patient communication, is well suited to undertake this study and disseminate findings through formal and informal networks.

Public Health Relevance

This project aims to promote clinician adoption of a national (JNC) guideline for monthly office visits for hypertensive patients whose blood pressure is not controlled. Using rigorous scientific methods, the project will assess the impact of a multipronged strategy implemented within a network of community health centers. Project findings offer promise for helping to achieve the national goal for improved blood pressure control and reduction in racial disparity in blood pressure control.

National Institute of Health (NIH)
National Heart, Lung, and Blood Institute (NHLBI)
Research Demonstration and Dissemination Projects (R18)
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Special Emphasis Panel (ZHL1-CSR-K (F1))
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Einhorn, Paula
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University of Rochester
Family Medicine
Schools of Dentistry
United States
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Fiscella, Kevin; Ogedegbe, Gbenga; He, Hua et al. (2015) Blood Pressure Visit Intensification Study in Treatment: Trial design. Am Heart J 170:1202-10
Fiscella, Kevin; Tobin, Jonathan N; Carroll, Jennifer K et al. (2015) Ethical oversight in quality improvement and quality improvement research: new approaches to promote a learning health care system. BMC Med Ethics 16:63