A Brief, Multifaceted, Generic Intervention to Improve Blood Pressure Control and Reduce Disparities Had Little Effect

Uses of Social Determinants of Health Data to Address Cardiovascular Disease and Health Equity: A Scoping Review

Background Cardiovascular disease is the leading cause of morbidity and mortality worldwide. Prior research suggests that social determinants of health have a compounding effect on health and are associated with cardiovascular disease. This scoping review explores what and how social determinants of health data are being used to address cardiovascular disease and improve health equity. Methods and Results After removing duplicate citations, the initial search yielded 4110 articles for screening, and 50 studies were identified for data extraction. Most studies relied on similar data sources for social determinants of health, including geocoded electronic health record data, national survey responses, and census data, and largely focused on health care access and quality, and the neighborhood and built environment. Most focused on developing interventions to improve health care access and quality or characterizing neighborhood risk and individual risk. Conclusions Given that few interventions addressed economic stability, education access and quality, or community context and social risk, the potential for harnessing social determinants of health data to reduce the burden of cardiovascular disease remains unrealized.

Intensifying approaches to address clinical inertia among cardiovascular disease risk factors: A narrative review

OBJECTIVE

Clinical inertia, the absence of treatment initiation or intensification for patients not achieving evidence-based therapeutic goals, is a primary contributor to poor clinical outcomes. Effectively combating clinical inertia requires coordinated action on the part of multiple representatives including patients, clinicians, health systems, and the pharmaceutical industry. Despite intervention attempts by these representatives, barriers to overcoming clinical inertia in cardiovascular disease (CVD) risk factor control remain.

METHODS

We conducted a narrative literature review to identify individual-level and multifactorial interventions that have been successful in addressing clinical inertia.

RESULTS

Effective interventions included dynamic forms of patient and clinician education, monitoring of real-time patient data to facilitate shared decision-making, or a combination of these approaches. Based on findings, we describe three possible multi-level approaches to counter clinical inertia - a collaborative approach to clinician training, use of a population health manager, and use of electronic monitoring and reminder devices.

CONCLUSION

To reduce clinical inertia and achieve optimal CVD risk factor control, interventions should consider the role of multiple representatives, be feasible for implementation in healthcare systems, and be flexible for an individual patient's adherence needs.

PRACTICE IMPLICATIONS

Representatives (e.g., patients, clinicians, health systems, and the pharmaceutical industry) could consider approaches to identify and monitor non-adherence to address clinical inertia.

Randomised controlled trial evaluating the effects of screening and referral for social determinants of health on Veterans' outcomes: protocol

INTRODUCTION

Health policy leaders recommend screening and referral (S&R) for unmet social needs (eg, food) in clinical settings, and the American Heart Association recently concluded that the most significant opportunities for reducing cardiovascular disease (CVD) death and disability lie with addressing the social determinants of CVD outcomes. A limited but promising evidence base supports these recommendations, but more rigorous research is needed to guide health care-based S&R efforts. Funded by the Veteran Health Administration (VA), the study described in this paper will assess the efficacy of S&R on Veterans' connections to new resources to address social needs, reduction of unmet needs and health-related outcomes (adherence, utilisation and clinical outcomes).

METHODS AND ANALYSIS

We will conduct a 1-year mixed-methods randomised controlled trial at three VA sites, enrolling Veterans with CVD and CVD-risk. 880 Veterans experiencing one or more social needs will be randomised within each site (n=293 per site) to one of three study arms representing referral mechanisms of varying intensity (screening only, screening and provision of resource sheet(s), screening and provision of resource sheet(s) plus social work assistance). For each Veteran, we will examine associations of unmet social needs with health-related outcomes at baseline, and longitudinally compare the impact of each approach on connection to new resources (primary outcome) and follow-up outcomes over a 12-month period. We will additionally conduct qualitative interviews with key stakeholders, including Veterans to identify potential explanatory factors related to the relative success of the interventions.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the VA Central Internal Review Board on 13 July 2021 (reference #: 20-07-Amendment No. 02). Findings will be disseminated through reports, lay summaries, policy briefs, academic publications, and conference presentations.

TRIAL REGISTRATION NUMBER

NCT04977583.

The impact of training healthcare professionals' communication skills on the clinical care of diabetes and hypertension: a systematic review and meta-analysis

BACKGROUND

Diabetes and hypertension care require effective communication between healthcare professionals and patients. Training programs may improve the communication skills of healthcare professionals but no systematic review has examined their effectiveness at improving clinical outcomes and patient experience in the context of diabetes and hypertension care.

METHODS

We conducted a systematic review of randomized controlled trials to summarize the effectiveness of any type of communication skills training for healthcare professionals to improve diabetes and/or hypertension care compared to no training or usual care. We searched Medline, Embase, CINAHL, PsycINFO, Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews (CDSR), ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform from inception to August 2020 without language restrictions. Data on the country, type of healthcare setting, type of healthcare professionals, population, intervention, comparison, primary outcomes of glycated hemoglobin (HbA1c) and blood pressure, and secondary outcomes of quality of life, patient experience and understanding, medication adherence and patient-doctor relationship were extracted for each included study. Risk of bias of included studies was assessed by Cochrane risk of bias tool.

RESULTS

7011 abstracts were identified, and 19 studies met the inclusion criteria. These included a total of 21,762 patients and 785 health professionals. 13 trials investigated the effect of communication skills training in diabetes management and 6 trials in hypertension. 10 trials were at a low risk and 9 trials were at a high risk of bias. Training included motivational interviewing, patient centred care communication, cardiovascular disease risk communication, shared decision making, cultural competency training and psychological skill training. The trials found no significant effects on HbA1c (n = 4501, pooled mean difference -0.02 mmol/mol, 95% CI -0.10 to 0.05), systolic blood pressure (n = 2505, pooled mean difference -2.61 mmHg, 95% CI -9.19 to 3.97), or diastolic blood pressure (n = 2440, pooled mean difference -0.06 mmHg, 95% CI -3.65 to 2.45). There was uncertainty in whether training was effective at improving secondary outcomes.

CONCLUSION

The communication skills training interventions for healthcare professionals identified in this systematic review did not improve HbA1c, BP or other relevant outcomes in patients with diabetes and hypertension. Further research is needed to methodically co-produce and evaluate communication skills training for chronic disease management with healthcare professionals and patients.

Evaluation of a collaborative VA network initiative to reduce racial disparities in blood pressure control among veterans with severe hypertension

BACKGROUND

Compared to White patients in the United States, Black patients have a higher prevalence of hypertension and more severe forms of this condition.

OBJECTIVE

To decrease racial disparities in blood pressure (BP) control among Black veterans with severe hypertension within a regional network of Veterans Affairs Medical Centers (VAMCs).

METHODS

Health system leaders, clinicians, and health services researchers collaborated on a 12-month quality improvement (QI) project to: (1) examine project implementation and the QI strategies used to improve BP control and (2) assess the effect of the initiative on Black-White differences in BP control among veterans with severe hypertension.

RESULTS

Within 9 participating VAMCs, the most frequently used QI strategies involved provider education (n=9), provider audit and feedback (n=8), and health care team change (n=7). Among 141,124 veterans with a diagnosis of hypertension, 9,913 had severe hypertension [2,533 (25.6%) Black and 7380 (74.4%) White]. Over the course of the project, the proportion of Black veterans with severe hypertension decreased from 7.5% to 6.6% (p=.002) and the racial difference in proportions for this condition decreased 0.9 percentage points, from 2.9% to 2.0% (p=.01).

CONCLUSIONS

A multicenter, equity-focused QI project in VA reduced the proportion of Black veterans with severe hypertension and ameliorated observed racial disparities for this condition. Embedding health services researchers within a QI team facilitated an evaluation of the processes and effectiveness of our initiative, providing a successful model for QI within a learning health care system.

Is insurance instability associated with hypertension outcomes and does this vary by race/ethnicity?

BACKGROUND

Stable health insurance is often associated with better chronic disease care and outcomes. Racial/ethnic health disparities in outcomes are prevalent and may be associated with insurance instability, particularly in the context of health insurance reform.

METHODS

We examined whether insurance instability was associated with uncontrolled blood pressure (UBP) and whether this association varied by race/ethnicity. We used a retrospective longitudinal observational cohort study of patients diagnosed with hypertension who obtained care within two health systems in Massachusetts. We measured the UBP, insurance instability, and race of 43,785 adult primary care patients, age 21-64 with visits from 1/2005-12/2013.

RESULTS

We found higher rates of UBP for blacks and Hispanics at each time point over the entire 9 years. Insurance instability was associated with greater rates of UBP. Always uninsured black patients fared worst, while white and Hispanic patients with consistent public insurance fared best.

CONCLUSIONS

Stable insurance of any type was associated with better hypertension control than no or unstable insurance.

Provider- and Patient-Related Barriers to and Facilitators of Digital Health Technology Adoption for Hypertension Management: Scoping Review

Background

The uptake of digital health technology (DHT) has been surprisingly low in clinical practice. Despite showing great promise to improve patient outcomes and disease management, there is limited information on the factors that contribute to the limited adoption of DHT, particularly for hypertension management.

Objective

This scoping review provides a comprehensive summary of barriers to and facilitators of DHT adoption for hypertension management reported in the published literature with a focus on provider- and patient-related barriers and facilitators.

Methods

This review followed the methodological framework developed by Arskey and O’Malley. Systematic literature searches were conducted on PubMed or Medical Literature Analysis and Retrieval System Online, Cumulative Index to Nursing and Allied Health Literature, and Excerpta Medica database. Articles that reported on barriers to and/or facilitators of digital health adoption for hypertension management published in English between 2008 and 2017 were eligible. Studies not reporting on barriers or facilitators to DHT adoption for management of hypertension were excluded. A total of 2299 articles were identified based on the above criteria after removing duplicates, and they were assessed for eligibility. Of these, 2165 references did not meet the inclusion criteria. After assessing 134 studies in full text, 98 studies were excluded (full texts were either unavailable or studies did not fulfill the inclusion criteria), resulting in a final set of 32 articles. In addition, 4 handpicked articles were also included in the review, making it a total of 36 studies.

Results

A total of 36 studies were selected for data extraction after abstract and full-text screening by 2 independent reviewers. All conflicts were resolved by a third reviewer. Thematic analysis was conducted to identify major themes pertaining to barriers and facilitators of DHT from both provider and patient perspectives. The key facilitators of DHT adoption by physicians that were identified include ease of integration with clinical workflow, improvement in patient outcomes, and technology usability and technical support. Technology usability and timely technical support improved self-management and patient experience, and positive impact on patient-provider communication were most frequently reported facilitators for patients. Barriers to use of DHTs reported by physicians include lack of integration with clinical workflow, lack of validation of technology, and lack of technology usability and technical support. Finally, lack of technology usability and technical support, interference with patient-provider relationship, and lack of validation of technology were the most commonly reported barriers by patients.

Conclusions

Findings suggest the settings and context in which DHTs are implemented and individuals involved in implementation influence adoption. Finally, to fully realize the potential of digitally enabled hypertension management, there is a greater need to validate these technologies to provide patients and providers with reliable and accurate information on both clinical outcomes and cost effectiveness.

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

Initiatives to improve hypertension control within academic medical centers and closed health systems have been extensively studied, but large community-wide quality improvement (QI) initiatives have been both less common and less successful in the United States. The authors examined a community-wide QI initiative across 226 843 patients from 198 practices in nine counties across upstate New York to improve hypertension control and reduce disparities. The QI initiative focused on (a) providing population and practice-level comparative data, (b) community engagement, especially in underserved communities, and (c) practice-level quality improvement assistance, but was not designed to examine causality of specific components. Across the nine counties, hypertension control rates improved from 61.9% in 2011 to 69.5% in 2016. Improvements were greatest among whites (73.7%-81.5%) and more modest among black patients (58.8%-64.7%). The authors noted a considerable improvement in BP within the group of patients with the highest risk (defined as a BP ≥ 160/100) and a decrease in disparities within this group. The quality collaborative identified five key lessons to help guide future community initiatives: (a) anticipate a plateauing of response; (b) distinguish the needs of disparate populations and create subpopulation-specific strategies to address and reduce disparities; (c) recognize the variation across low SES practices; (d) remain open to the refinement of outcome measures; and (e) continually seek best practices and barriers to success. Overall, a large community-wide QI initiative, involving multiple different stakeholders, was associated with improvements in BP control and modest reductions in some targeted disparities.