Hypertension is common in the US. From efficacy and observational studies, we know that achieving blood pressure control can reduce morbidity and mortality, however, less than one-third of persons with hypertension achieve control as defined by national guidelines. Furthermore, racial disparities have been clearly documented in hypertension with African American patients being less likely than Caucasians to achieve adequate control. The objective of this study is to study the implementation of a multi-method quality improvement intervention in a pragmatic clinical trial. Six clinic sites within the John Hopkins Community Physicians (JHCP) healthcare system have been selected for participation in this study. The sites are located within the metropolitan area of Baltimore, Maryland, yet differ greatly. We will define the context and local characteristics of each study site and determine which characteristics are associated with blood pressure control and racial disparity at the clinic (micro-system) and health system (macro-system) level. We will deploy a three part quality improvement intervention to 1) improve the clinic-based measurement of blood pressure, 2) introduce a care management system to promote self-management behaviors and rapidly titrate medications by algorithms developed in accord with guidelines and 3) introduce an interactive, needs-based, longitudinal provider education system that promotes patient-centered care and provides practical examples of patient-provider communication strategies. Using statistical process control charting, we will determine the stability of blood pressure control in the system prior to intervention and after the introduction of each intervention. We will vary the order of the interventions among the six clinical sites to determine if each intervention is independently effective in each local context and if the effect is repeatable in other contextual situations within the same macro-system. In addition, we will study the organizational characteristics and features of the local context that are associated with implementation, uptake of the interventions and success of each intervention in achieving blood pressure control at the clinic level and reducing racial disparities in blood pressure control.
The reasons for the high rates of uncontrolled blood pressure and racial disparity in blood pressure control are likely multi-factorial. However, little is known about the organization factors associated with blood pressure control and disparities and how organization factors affect interventions for blood pressure control and disparity reduction. If successful, the interventions in this study could be disseminated widely in other clinical systems to improve blood pressure control and reduce racial disparities in hypertension.
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