Cardiovascular disease (CVD) is a leading contributor to racial disparities in life expectancy and uncontrolled hypertension is a critical risk factor underlying this disparity. Despite interventions to overcome barriers to hypertension control, accumulating evidence demonstrates that well-meaning, egalitarian providers can harbor implicit biases that affect patient interactions, clinical decision-making, and the effectiveness of interventions to mitigate cross-cultural differences. We propose a program called COmmuNity-engaged SimULation Training for Blood Pressure Control (CONSULT-BP), a theory-based, multi-component, training intervention that targets medical residents and nurse practitioner students. CONSULT-BP will adapt and test a theory-based, `awareness, exposure and skill-building' intervention, applied in the safety of a simulation-based learning center, to improve providers' interaction skills with minority and poor patients. We will use our established platform of community-based participatory research to implement CONSULT-BP in an academic medical center with a large, safety-net health system that serves a minority and poor population. The CONSULT-BP project will: 1. recruit and hire Community Advisors (CA) representing diverse underserved populations who will participate in the adaptation of evidence-based hypertension communication tools and the design, development, and implementation of the training curriculum; 2. use online self-assessments of clinicians' implicit bias for race and patient compliance to raise bias self-awareness and to examine the effect of bias on knowledge and skill development; and 3. hire Community SPs to (a) conduct face-to-face, simulated clinical encounters with medical trainees and NP students, and (b) provide evaluation and feedback about communication skills along with trained CA observers and faculty facilitators. The educational intervention is a program of two, 90-minute, sessions, spaced 5 weeks apart that combine online learning with in-person skill practice. To understand how much training exposure is required to `move the needle' of clinical skills and patient outcomes, we will assess the effect of CONSULT-BP by conducting two, sequential, randomized trials. Trial 1 will evaluate the effectiveness of one-time CONSULT training on outcomes, and Trial 2 will evaluate the effect of repeat, booster training on outcomes. To support training feasibility in Trial 1, CONSULT-BP will train cohorts of IM, FM, and NP trainees over a 3-year period, and will target advanced (2nd or 3rd-year) trainees within a given academic year for one-time exposure to the training intervention. Within each academic year, we will randomize training times to 1 of 5 start dates using a stepped wedge design to accommodate pre-existing training schedules and to mitigate the effect of temporal trends in clinical skill proficiency. Trial 2 will randomly assign continuing trainee participants from Trial 1 to a second CONSULT-BP booster training exposure versus no booster training. The primary outcome for both trials will be patient BP control. Secondary process outcomes will include trainees' communication skills and patient adherence to medications, visits, and diet changes. We will also examine effect modification by patient characteristics (baseline BP control) and trainee characteristics (implicit bias and awareness of bias). Trainee measures will be from trainee self-report (implicit bias, bias awareness), community SP report (trainee communication skills), and clinic patient surveys (trainee communication quality and patient adherence). Clinical BP outcomes will be from the EMR. We will use analytic mixed effect models accounting for patient and clinician characteristics, patient correlations within randomization clusters and within clinicians, and repeated measures within patient. The CONSULT-BP multi-staged, community-engaged, education model will change how medical educators think about helping providers develop bias-aware, patient-centered, communication skills.
Cardiovascular disease (CVD) is a leading contributor to racial disparities in life expectancy, and uncontrolled hypertension is a critical risk factor underlying this disparity. Accumulating evidence demonstrates that well- meaning, egalitarian providers can harbor implicit biases that affect patient interactions, clinical decision- making, and health outcomes. We propose a theory-based, multi-component, `awareness, exposure and skill- building' intervention program, developed in partnership with our local community, and applied in the safety of a simulation-based learning center, to mitigate bias and improve providers' interaction skills with minority and poor patients.
