A community-wide quality improvement initiative to improve hypertension control and reduce disparities

Disparities in the Timeliness of Addressing Patient-Initiated Telephone Calls in a Primary Care Clinic: The Impact of Quality Improvement Interventions

A timely response to patient-initiated telephone calls can affect many aspects of patient health, including quality of care and health equity. Historically, at a family medicine residency clinic, at least 1 out of 4 patient calls remained unresolved three days after the call was placed. We sought to explore whether there were differential delays in resolution of patient concerns for certain groups and how these were affected by quality improvement interventions to increase responsiveness to patient calls. A multidisciplinary team at a primary care residency clinic applied Lean education and tools to improve the timeliness of addressing telephone encounters. Telephone encounter data were obtained for one year before and nine months after the intervention. Data were stratified by race, ethnicity, preferred language, sex, online portal activation status, age category, zip code, patient risk category, and reason for call. Stratified data revealed consistently worse performance on telephone encounter closure by 72 hours for Black/African American patients compared to Hispanic and non-Hispanic White patients pre-intervention. Interventions resulted in statistically significant overall improvement, with an OR of 2.9 (95% CI: 2.62 to 3.21). Though interventions did not target a specific population, pre-intervention differences based on race and ethnicity resolved post-intervention. Telephone calls serve as an important means of patient communication with care teams. General interventions to improve the timeliness of addressing telephone encounters can lead to sustainable improvement in a primary care academic clinic and may also alleviate disparities.

Long-term Outcomes of a 1-year Hypertension Quality Improvement Initiative in a Large Health System

BACKGROUND

Understanding whether practices retain outcomes attained during a quality improvement (QI) initiative can inform resource allocation.

OBJECTIVE

We report blood pressure (BP) control and medication intensification in the 3 years after a 2016 QI initiative ended.

RESEARCH DESIGN

Retrospective cohort.

SUBJECTS

Adults with a diagnosis of hypertension who had a primary care visit in a large-integrated health system between 2015 and 2019.

MEASURES

We report BP control (<140/90 mm Hg) at the last reading of each year. We used a multilevel regression to identify the adjusted propensity to receive medication intensification among patients with an elevated BP in the first half of the year. To examine variation, we identified the average predicted probability of control for each practice. Finally, we grouped practices by the proportion of their patients whose BP was controlled in 2016: lowest performing (<75%), middle (≥75%-<85%), and highest performing (≥85%).

RESULTS

The dataset contained 184,981 patients. From 2015 to 2019, the percentage of patients in control increased from 74% to 82%. In 2015, 38% of patients with elevated BP received medication intensification. This increased to 44% in 2016 and 50% in 2019. Practices varied in average BP control (from 62% to 91% in 2016 and 68% to 90% in 2019). All but one practice had a substantial increase from 2015 to 2016. Most maintained the gains through 2019. Higher-performing practices were more likely to intensify medications than lower-performing practices.

CONCLUSIONS

Most practices maintained gains 3 years after the QI program ended. Low-performing practices should be the focus of QI programs.

Prevalence, Treatment, and Control of Hypertension Among US Women of Reproductive Age by Race/Hispanic Origin

BACKGROUND

To explore the prevalence, pharmacologic treatment, and control of hypertension among US nonpregnant women of reproductive age by race/Hispanic origin to identify potential gaps in care.

METHODS

We pooled data from the 2011 to March 2020 (prepandemic) National Health and Nutrition Examination Survey cycles. Our analytic sample included 4,590 nonpregnant women aged 20-44 years who had at least 1 examiner-measured blood pressure (BP) value. We estimated prevalences and 95% confidence intervals (CIs) of hypertension, pharmacologic treatment, and control based on the 2003 Joint Committee on High Blood Pressure (JNC 7) and the 2017 American College of Cardiology and the American Heart Association (ACC/AHA) guidelines. We evaluated differences by race/Hispanic origin using Rao-Scott chi-square tests.

RESULTS

Applying ACC/AHA guidelines, hypertension prevalence ranged from 14.0% (95% CI: 12.0, 15.9) among Hispanic women to 30.9% (95% CI: 27.8, 34.0) among non-Hispanic Black women. Among women with hypertension, non-Hispanic Black women had the highest eligibility for pharmacological treatment (65.5%, 95% CI: 60.4, 70.5); current use was highest among White women (61.8%, 95% CI: 53.8, 69.9). BP control ranged from 5.2% (95% CI: 1.1, 9.3) among women of another or multiple non-Hispanic races to 18.6% (95% CI: 12.1, 25.0) among Hispanic women.

CONCLUSIONS

These findings highlight the importance of monitoring hypertension, pharmacologic treatment, and control by race/Hispanic origin and addressing barriers to equitable hypertension care among women of reproductive age.

All Quality Improvement Is Health Equity Work: Designing Improvement to Reduce Disparities

Quality improvement (QI) can be a critical means by which to achieve equity in health and health care. QI efforts, however, often fail to be designed and implemented through the lens of health equity. In this article, we will discuss the current state of the intersection between QI and health equity, then lay out specific steps researchers and practitioners can take to ensure that their QI work reduces, rather than increases or maintains, existing disparities. These steps include first, understanding existing disparities and, second, utilizing community engagement to ensure that QI enhances health equity. Before embarking on QI work, QI practitioners should first examine their metric of interest by patient characteristics, starting with race and ethnicity, language, and markers of access to care and socioeconomic status. Developing an understanding of existing disparities relevant to the QI project will ensure that the QI interventions can be designed to be most effective in the disadvantaged populations, thus increasing the likelihood that the intervention reduces existing disparities. In designing QI interventions, practitioners must also plan engagement with stakeholder populations ahead of time, to carefully understand their needs and priorities and how best to address them through QI efforts.

Evaluating the efficacy of telephone-based outreach in addressing hypertension control among black men with severe hypertension: An observational study

BACKGROUND

The high prevalence of uncontrolled hypertension (systolic blood pressure [SBP] ≥140 mmHg or diastolic blood pressure [DBP] ≥90 mmHg) in Black patients represents a significant racial health disparity in the United States.

AIMS

This study evaluated the efficacy of a telephone-based strategy for inviting high-risk patients with severe hypertension to weekly self-management education classes. Further, the study assessed how the outreach intervention correlated with relevant quality improvement outcomes, including improved blood pressure and primary care follow-up among our clinic population of Black men with severe hypertension.

METHODS

A cohort of 265 Black men aged ≥18 years with SBP ≥160 mmHg or DBP ≥100 mmHg at the most recent clinic visit were identified using Epic reports formatted for Federal Uniformed Data Set annual reporting. Telephone outreach was used to invite the cohort to attend weekly in-person classes facilitated by various healthcare professionals. Logistic regression was performed to determine the associations between being reached by phone with (1) class attendance and (2) follow-up appointment attendance.

RESULTS

Most of the Black men were single (57.4%, n = 152), 49.1% had history of alcohol or substance use (n = 130), and 35.8% (n = 95) was uninsured. The average age was 55.6 years (SD = 11.6). After controlling for sociodemographic factors, being reached by phone was significantly associated with an increased likelihood of patient attendance at follow-up appointments (OR = 1.91, p = .038) but not with class attendance (OR = 2.45, p = .155). Patients who attended a follow-up appointment experienced significant reductions in both SBP and DBP at 9 months.

LINKING EVIDENCE TO ACTION

Telephone outreach was labor-intensive but effective in keeping under-resourced patient populations engaged in primary care. Future work should aim to develop more efficient strategies for engaging high-risk patients in self-monitoring education to manage hypertension.

Health information technology and equity: Applying history's lessons to tomorrow's innovations

Health and health care disparities are widespread with major impacts on outcomes for children and families. Inequitable care is poor quality care. Though health IT has the potential to improve disparities, health IT implementation can have unintended consequences of widening, maintaining, or creating disparities by disproportionately benefiting advantaged children, adolescents, and their caregivers. Narrowing disparities can be achieved by embracing an approach that places marginalized patients at the center of health IT design and implementation. Health care systems can leverage the disparity-reducing potential of health information technologies by housing innovation within an equity framework. Initial steps include evaluating for disparities exacerbated by health IT, implementing universal precautions to prevent health IT intervention-generated inequalities, and co-designing future innovations with marginalized communities. By directly addressing community needs, health IT systems designed to effectively benefit underserved children, adolescents, and their caregivers have the potential to yield more equitable health care IT, and better outcomes for our young patients.

Personalized hypertension management based on serial assessment and telemedicine (PHMA): a cluster randomize controlled trial protocol in Anhui, China

BACKGROUND

Despite tremendous investment worldwide, hypertension treatment and control rates remain low. The complexity and long-term dynamics of influencing factors make personalized management inevitable and challenging. This protocol describes Personalized Hypertension Management in Anhui, China (PHMA), a project that uses a package of innovative approaches in tailoring interventions to individual patient's dynamic complications and contexts.

METHODS/DESIGN

PHMA strives to reduce hypertension harms by eight "objective behaviors" (e.g., self-monitoring and reporting, healthy diet, physical exercise/activities). These objective behaviors are promoted through five intervention measures: support for self- monitoring, supervised machine communications, daily education or reminder messages, weekly blood pressure notification, and quarterly signed feedback. PHMA uses ten categories and over 300 variables in selecting and refining intervention procedures and content for individual patients. Efficacy of the intervention package is evaluated using a cluster randomized controlled trial design involving a total of 60 site communities and 3352 hypertension patients. Primary measure for the evaluation is systolic and diastolic blood pressure; while secondary evaluation measures include quality of life (EQ5D-5L), occurrence of hypertension-related complications (such as cerebral hemorrhage, coronary heart disease, myocardial or cerebral infarction), healthcare utilization and scores of objective behaviors.

DISCUSSION

PHMA uses novel, low cost and sustainable approaches to tailor interventions to the dynamic conditions and contexts of individual patients. Unlike contemporary approaches to hypertension management which are mainly population based, each participant patient in PHMA applies a unique intervention package and all messages, feedbacks and other materials sent out to individual patients are different from each other. PHMA is the first project that adopts comprehensive tailoring and if proved effective, it should have important implications for future research, practice and policy-making. Trial registration ISRCTN10999269. July 17, 2020; https://doi.org/10.1186/ISRCTN10999269 .

Strategies to improve blood pressure control: A step forward to winning the battle

OBJECTIVE

Hypertension represents a common risk factor for all major cardiovascular diseases. The issue of inappropriate blood pressure control in the hypertensive population is a worldwide still unsolved problem, with heavy consequences on the health care systems. A call to action is required to optimize blood pressure control and to reduce the cardiovascular risk.

METHODS AND RESULTS

In this issue of the journal a new study presents the results of a multifaceted complex approach, in the context of a quality improvement program, through the involvement of a high functioning multidisciplinary team. A patient population largely underprivileged, urban and 75% African American, referring to an Internal Medicine Clinic, included a large majority of hypertensive patients with inappropriate blood pressure control. By addressing identified barriers to achieve optimal blood pressure control, the current improvement program pursued the education of physicians, nurses and patients as a key driver to optimize patients-provider communication and to achieve a satisfactory final result.

CONCLUSIONS

The strategy described in the study by Sadeghi et al. allowed to maintain positive results for one year and thereafter. Despite some weaknesses, this multifaceted complex approach deserves particular attention since it describes relevant findings that represent a significant step forward to improving blood pressure control in the hypertensive population.

Health informatics and health equity: improving our reach and impact

Health informatics studies the use of information technology to improve human health. As informaticists, we seek to reduce the gaps between current healthcare practices and our societal goals for better health and healthcare quality, safety, or cost. It is time to recognize health equity as one of these societal goals-a point underscored by this Journal of the American Medical Informatics Association Special Focus Issue, "Health Informatics and Health Equity: Improving our Reach and Impact." This Special Issue highlights health informatics research that focuses on marginalized and underserved groups, health disparities, and health equity. In particular, this Special Issue intentionally showcases high-quality research and professional experiences that encompass a broad range of subdisciplines, methods, marginalized populations, and approaches to disparities. Building on this variety of submissions and other recent developments, we highlight contents of the Special Issue and offer an assessment of the state of research at the intersection of health informatics and health equity.

Reframing implementation science to address inequities in healthcare delivery

BACKGROUND

Research has generated valuable knowledge in identifying, understanding, and intervening to address inequities in the delivery of healthcare, yet these inequities persist. The best available interventions, programs and policies designed to address inequities in healthcare are not being adopted in routine practice settings. Implementation science can help address this gap by studying the factors, processes, and strategies at multiple levels of a system of care that influence the uptake, use, and the sustainability of these programs for vulnerable populations. We propose that an equity lens can help integrate the fields of implementation science and research that focuses on inequities in healthcare delivery.

MAIN TEXT

Using Proctor et al.' (12) framework as a case study, we reframed five elements of implementation science to study inequities in healthcare. These elements include: 1) focus on reach from the very beginning; 2) design and select interventions for vulnerable populations and low-resource communities with implementation in mind; 3) implement what works and develop implementation strategies that can help reduce inequities in care; 4) develop the science of adaptations; and 5) use an equity lens for implementation outcomes.

CONCLUSIONS

The goal of this paper is to continue the dialogue on how to critically infuse an equity approach in implementation studies to proactively address healthcare inequities in historically underserved populations. Our examples provide ways to operationalize how we can blend implementation science and healthcare inequities research.