Creating a transdisciplinary research center to reduce cardiovascular health disparities in Baltimore, Maryland: lessons learned

The RICH LIFE Project: A cluster randomized pragmatic trial comparing the effectiveness of health system only vs. health system Plus a collaborative/stepped care intervention to reduce hypertension disparities

Disparities in the control of hypertension and other cardiovascular disease risk factors are well-documented in the United States, even among patients seen regularly in the healthcare system. Few existing approaches explicitly address disparities in hypertension care and control. This paper describes the RICH LIFE Project (Reducing Inequities in Care of Hypertension: Lifestyle Improvement for Everyone) design.

METHODS

RICH LIFE is a two-arm, cluster-randomized trial, comparing the effectiveness of enhanced standard of care, "Standard of Care Plus" (SCP), to a multi-level intervention, "Collaborative Care/Stepped Care" (CC/SC), for improving blood pressure (BP) control and patient activation and reducing disparities in BP control among 1890 adults with uncontrolled hypertension and at least one other cardiovascular disease risk factor treated at 30 primary care practices in Maryland and Pennsylvania. Fifteen practices randomized to the SCP arm receive standardized BP measurement training; race/ethnicity-specific audit and feedback of BP control rates; and quarterly webinars in management practices, quality improvement and disparities reduction. Fifteen practices in the CC/SC arm receive the SCP interventions plus implementation of the collaborative care model with stepped-care components (community health worker referrals and virtual specialist-panel consults). The primary clinical outcome is BP control (<140/90 mm Hg) at 12 months. The primary patient-reported outcome is change from baseline in self-reported patient activation at 12 months.

DISCUSSION

This study will provide knowledge about the feasibility of leveraging existing resources in routine primary care and potential benefits of adding supportive community-facing roles to improve hypertension care and reduce disparities.

TRIAL REGISTRATION

Clinicaltrials.govNCT02674464.

Measuring Health Equity for Ambulatory Care Sensitive Conditions in a Large Integrated Health Care System: The Development of an Index

Disparities in outcomes for preventive and primary health care services often result when vulnerable patients rely on episodic encounters for emergency services that do not meet their long-term health needs. Understanding health outcomes in socially or economically disadvantaged subgroups is crucial to improving community health, and it requires innovative analytics and dynamic application of clinical and population data. While it is common practice to use proxy indicators, such as quality of life and mortality, when discussing health equity, these have shown limited utility and are rarely applied at a population-level within a health system. Therefore, we designed and implemented an index, calculated as the ratio of observed-to-expected encounters, to identify and quantify health inequalities in health care systems. Providing equitable care, as measured by health outcomes, is analogous to precision medicine applied to social determinants. For health systems, the use of this index will facilitate the development of specially-tailored interventions to address inequity and provides a tool to measure the impact of such programs.

Commentary: Training and Mentoring the Next Generation of Health Equity Researchers: Insights from the Field

During August 30-31, 2017, the National Heart, Lung, and Blood Institute's Center for Translation Research and Implementation Science (CTRIS) hosted a two-day workshop with thought leaders and experts in the fields of implementation science, prevention science, health inequities research, and training and research workforce development. The workshop addressed critical challenges and compelling questions from the NHLBI Strategic Vision, as well as the Department of Health and Human Services' Action Plan to Reduce Racial and Ethnic Health Disparities. Participants discussed: best practices for designing and executing implementation research training programs; approaches to increase participation in implementation research to address health inequities; innovative training methods and models, including team science approaches; and best practices for developing and sustaining a cadre of mentors for individuals who conduct implementation research. As part of this workshop, the Saunders-Watkins Memorial Lecture, named posthumously for Dr. Elijah Saunders, a Baltimore cardiologist, and Dr. Levi Watkins, a Baltimore cardiothoracic surgeon, was established. Both men dedicated their lives to patient care, teaching, research, and community service. The lecture honors them for their pioneering efforts to advance health equity for medically underserved communities in the United States and around the globe, at a time when it was neither popular nor safe to do so. The lecture is also designed to stimulate a future generation of researchers committed to advancing health equity research and the elimination of health iniquities. The inaugural lecture was delivered by Lisa A. Cooper, MD, MPH, Bloomberg Distinguished Professor and James F. Fries Professor of Medicine at Johns Hopkins University, and inaugural recipient of the American Heart Association's Watkins-Saunders Award, which recognizes excellence in clinical, medical, and community work focused on diminishing health care disparities in Maryland. This article captures the essence of that lecture.

Collaborative Transdisciplinary Research in a Small Institution: Challenges and Opportunities

Aim/Purpose

In this paper, we discuss how a Transdisciplinary (TD) and a Community Based Participatory Research (CBPR) initiative was conceptualized, developed, implemented, and sustained at a small academic institution with limited research infrastructure, emphasizing die role of capacity building.

Background

Most examples of die implementation of TD research come from large-scale initiatives in research-intensive institutions or centers widi multiple resources to establish collaborations among experts from different disciplines. However less is known about die implementation of TD and CBPR initiatives in small academic settings.

Methodology

This paper includes a discussion of the challenges and lessons learned of this process in a teaching-intensive Hispanic Serving Institution (HSI), which included a research component as part of the institutional priorities when it transitioned to a 4-year college in 2001.

Contribution

We hope diat our experience helps odier researchers in similar institutions to engage in diis type of research.

Findings

In this case, a collaborative TD and CBPR initiative was successfully implemented despite limited resources for capacity building and research infrastructure, as well as diversity among researchers and community members.

Recommendation for Researchers

To sustain institutional collaborative capacity in this type of institution, authors recommend continuous capacity building efforts and the development of modules and/or courses to provide formal TD training for junior faculty while encouraging researchers to interact and collaborate. In addition, the importance of the role of the community liaison is highlighted.

Impact on Society

Successful TD and CBPR initiatives may have a positive impact on the reduction or elimination of health disparities which involve complex phenomena that requires a broad view from different perspectives.

Future Research

Even though capacity building can facilitate the implementation of TD and CBPR, many challenges arise as an inherent result of community engagement and the integration of different disciplines. Thus, the need of continuous reflection to acknowledge them becomes critical for advancing TD and CBPR efforts.

Productivity, impact, and collaboration differences between transdisciplinary and traditionally trained doctoral students: A comparison of publication patterns

Transdisciplinary (TD) approaches are increasingly used to address complex public health problems such as childhood obesity. Compared to traditional grant-funded scientific projects among established scientists, those designed around a TD, team-based approach yielded greater publication output after three to five years. However, little is known about how a TD focus throughout graduate school training may affect students’ publication-related productivity, impact, and collaboration. The objective of this study was to compare the publication patterns of students in traditional versus TD doctoral training programs. Productivity, impact, and collaboration of peer-reviewed publications were compared between traditional (n = 25) and TD (n = 11) students during the first five years of the TD program. Statistical differences were determined by t-test or chi square test at p < 0.05. The publication rate for TD students was 5.2 ± 10.1 (n = 56) compared to 3.6 ± 4.5 per traditional student (n = 82). Publication impact indicators were significantly higher for TD students vs. traditional students: 5.7 times more citations in Google Scholar, 6.1 times more citations in Scopus, 1.3 times higher journal impact factors, and a 1.4 times higher journal h-index. Collaboration indicators showed that publications by TD students had significantly more co-authors (1.3 times), and significantly more disciplines represented among co-authors (1.3 times), but not significantly more organizations represented per publication compared to traditional students. In conclusion, compared to doctoral students in traditional programs, TD students published works that were accepted into higher impact journals, were more frequently cited, and had more cross-disciplinary collaborations.

The Role of Care Management as a Population Health Intervention to Address Disparities and Control Hypertension: A Quasi-Experimental Observational Study

OBJECTIVE

We studied whether care management is a pragmatic solution for improving population blood pressure (BP) control and addressing BP disparities between Blacks and Whites in routine clinical environments.

DESIGN

Quasi-experimental, observational study.

SETTING AND PARTICIPANTS

3,964 uncontrolled hypertensive patients receiving primary care within the last year from one of six Baltimore clinics were identified as eligible.

INTERVENTION

Three in-person sessions over three months with registered dietitians and pharmacists who addressed medication titration, patient adherence to healthy behaviors and medication, and disparities-related barriers.

MAIN MEASURES

We assessed the population impact of care management using the RE-AIM framework. To evaluate effectiveness in improving BP, we used unadjusted, adjusted, and propensity-score matched differences-in-differences models to compare those who completed all sessions with partial completers and non-participants.

RESULTS

Of all eligible patients, 5% participated in care management. Of 629 patients who entered care management, 245 (39%) completed all three sessions. Those completing all sessions on average reached BP control (mean BP 137/78) and experienced 9 mm Hg systolic blood pressure (P<.001) and 4 mm Hg DBP (P=.004) greater improvement than non-participants; findings did not vary in adjusted or propensity-score matched models. Disparities in systolic and diastolic BP between Blacks and Whites were not detectable at completion.

CONCLUSIONS

It may be possible to achieve BP control among both Black and White patients who participate in a few sessions of care management. However, the very limited reach and patient challenges with program completion should raise significant caution with relying on care management alone to improve population BP control and eliminate related disparities.

Reaching for Health Equity and Social Justice in Baltimore: The Evolution of an Academic-Community Partnership and Conceptual Framework to Address Hypertension Disparities

Cardiovascular health disparities persist despite decades of recognition and the availability of evidence-based clinical and public health interventions. Racial and ethnic minorities and adults in urban and low-income communities are high-risk groups for uncontrolled hypertension (HTN), a major contributor to cardiovascular health disparities, in part due to inequitable social structures and economic systems that negatively impact daily environments and risk behaviors. This commentary presents the Johns Hopkins Center to Eliminate Cardiovascular Health Disparities as a case study for highlighting the evolution of an academic-community partnership to overcome HTN disparities. Key elements of the iterative development process of a Community Advisory Board (CAB) are summarized, and major CAB activities and engagement with the Baltimore community are highlighted. Using a conceptual framework adapted from O'Mara-Eves and colleagues, the authors discuss how different population groups and needs, motivations, types and intensity of community participation, contextual factors, and actions have shaped the Center's approach to stakeholder engagement in research and community outreach efforts to achieve health equity.

A Dietary Intervention in Urban African Americans: Results of the "Five Plus Nuts and Beans" Randomized Trial

INTRODUCTION

Unhealthy diets, often low in potassium, likely contribute to racial disparities in blood pressure. We tested the effectiveness of providing weekly dietary advice, assistance with selection of higher potassium grocery items, and a $30 per week food allowance on blood pressure and other outcomes in African American adults with hypertension.

DESIGN

We conducted an 8-week RCT with two parallel arms between May 2012 and November 2013.

SETTING/PARTICIPANTS

We randomized 123 African Americans with controlled hypertension from an urban primary care clinic in Baltimore, Maryland, and implemented the trial in partnership with a community supermarket and the Baltimore City Health Department. Mean (SD) age was 58.6 (9.5) years; 71% were female; blood pressure was 131.3 (14.7)/77.2 (10.5) mmHg; BMI was 34.5 (8.2); and 28% had diabetes.

INTERVENTION

Participants randomized to the active intervention group (Dietary Approaches to Stop Hypertension [DASH]-Plus) received coach-directed dietary advice and assistance with weekly online ordering and purchasing of high-potassium foods ($30/week) delivered by a community supermarket to a neighborhood library. Participants in the control group received a printed DASH diet brochure along with a debit account of equivalent value to that of the DASH-Plus group.

MAIN OUTCOME MEASURES

The primary outcome was blood pressure change. Analyses were conducted in January to October 2014.

RESULTS

Compared with the control group, the DASH-Plus group increased self-reported consumption of fruits and vegetables (mean=1.4, 95% CI=0.7, 2.1 servings/day); estimated intake of potassium (mean=0.4, 95% CI=0.1, 0.7 grams/day); and urine potassium excretion (mean=19%, 95% CI=1%, 38%). There was no significant effect on blood pressure.

CONCLUSIONS

A program providing dietary advice, assistance with grocery ordering, and $30/week of high-potassium foods in African American patients with controlled hypertension in a community-based clinic did not reduce BP. However, the intervention increased consumption of fruits, vegetables, and urinary excretion of potassium.

Patient education and follow-up as an intervention for hypertensive patients discharged from an emergency department: a randomized control trial study protocol

Background

Persistently elevated blood pressure (BP) is a leading risk factor for cardiovascular disease development, making effective hypertension management an issue of considerable public health importance. Hypertension is particularly prominent among African Americans, who have higher disease prevalence and consistently lower BP control than Whites and Hispanics. Emergency departments (ED) have limited resources for chronic disease management, especially for under-served patients dependent upon the ED for primary care, and are not equipped to conduct follow-up. Kiosk-based patient education has been found to be effective in primary care settings, but little research has been done on the effectiveness of interactive patient education modules as ED enhanced discharge for an under-served urban minority population.

Methods/Design

Achieving Blood Pressure Control Through Enhanced Discharge (AchieveBP) is a behavioral RCT patient education intervention for patients with a history of hypertension who have uncontrolled BP at ED discharge. The project will recruit up to 200 eligible participants at the ED, primarily African-American, who will be asked to return to a nearby clinical research center for seven, thirty and ninety day visits, with a 180 day follow-up. Consenting participants will be randomized to either an attention-control or kiosk-based interactive patient education intervention. To control for potential medication effects, all participants will be prescribed similar, evidenced-based anti-hypertensive regimens and have their prescription filled onsite at the ED and during visits to the clinic. The primary target endpoint will be success in achieving BP control assessed at 180 days follow-up post-ED discharge. The secondary aim will be to assess the relationship between patient activation and self-care management.

Discussion

The AchieveBP trial will determine whether using interactive patient education delivered through health information technology as ED enhanced discharge with subsequent education sessions at a clinic is an effective strategy for achieving short-term patient management of BP. The project is innovative in that it uses the ED as an initial point of service for kiosk-based health education designed to increase BP self-management. It is anticipated findings from this translational research could also be used as a resource for patient education and follow-up with hypertensive patients in primary care settings.

Trial registration

ClinicalTrials.gov Registration Number: NCT02069015. Registered February 19, 2014.

Rural Mexican-Americans' perceptions of family health history, genetics, and disease risk: implications for disparities-focused research dissemination

Disseminating the results of transdisciplinary health disparities research will increasingly involve discussing family health history and/or genetic information with study participants and their communities. Often, individuals' familiarity and comfort with these topics will be unclear. To inform the dissemination activities of a Center for Population Health and Health Disparities (CPHHD) studying multilevel determinants of breast cancer disparities in Latinas, we talked with Spanish-speaking Mexican-Americans from a rural agricultural community about family health history, genetics, and disease risk. We found that participants had limited genetic literacy but were familiar with some concepts related to family health history. Participants emphasized the role of individual behavior in shaping health and expressed a strong desire for health-related information. This included genetic information about future disease risk, which participants were previously unaware of but thought could be useful for disease prevention. These findings suggest that for research dissemination to facilitate health promotion, gaps in knowledge, particularly genetic knowledge, will need to be overcome. Outreach to underserved Latino communities should take advantage of this existing knowledge of family health history and strong desire for health information, but also take care to not overstate the significance of unreplicated or low-penetrance genetic associations.

Reducing racial and ethnic disparities in hypertension prevention and control: what will it take to translate research into practice and policy?

INTRODUCTION

Despite available, effective therapies, racial and ethnic disparities in care and outcomes of hypertension persist. Several interventions have been tested to reduce disparities; however, their translation into practice and policy is hampered by knowledge gaps and limited collaboration among stakeholders.

METHODS

We characterized factors influencing disparities in blood pressure (BP) control by levels of an ecological model. We then conducted a literature search using PubMed, Scopus, and CINAHL databases to identify interventions targeted toward reducing disparities in BP control, categorized them by the levels of the model at which they were primarily targeted, and summarized the evidence regarding their effectiveness.

RESULTS

We identified 39 interventions and several state and national policy initiatives targeted toward reducing racial and ethnic disparities in BP control, 5 of which are ongoing. Most had patient populations that were majority African-American. Of completed interventions, 27 demonstrated some improvement in BP control or related process measures, and 7 did not; of the 6 studies examining disparities, 3 reduced, 2 increased, and 1 had no effect on disparities.

CONCLUSIONS

Several effective interventions exist to improve BP in racial and ethnic minorities; however, evidence that they reduce disparities is limited, and many groups are understudied. To strengthen the evidence and translate it into practice and policy, we recommend rigorous evaluation of pragmatic, sustainable, multilevel interventions; institutional support for training implementation researchers and creating broad partnerships among payers, patients, providers, researchers, policymakers, and community-based organizations; and balance and alignment in the priorities and incentives of each stakeholder group.

The current state of ethnic and racial disparities in cardiovascular care: lessons from the past and opportunities for the future

Significant racial/ethnic disparities have been documented in cardiovascular care. Although health care quality is improving for many Americans, differences in clinical outcomes have persisted between racial/ethnic minority patients and non-minorities, even when income, education level, and site of care are taken into consideration. Potential causes of disparities are complex and are related to differences in risk factor prevalence and control, use of evidence-based procedures and medications, and social and environmental factors. Minority patients are more likely to receive care from lower-quality health care providers and institutions and experience more barriers to accessing care. Factors such as stereotyping and bias in medicine are hard to quantify, but likely contribute to differences in treatment. Recent trends suggest that some disparities are decreasing. Opportunities for change and improvement exist for patients, providers, and health care systems. Promising interventions, such as health policy changes, quality improvement programs, and culturally targeted community and clinic-based interventions offer hope that high-quality health care in the USA can be provided to all patients.

Provider perspectives on essential functions for care management in the collaborative treatment of hypertension: the P.A.R.T.N.E.R. framework

BACKGROUND

Care management has become a widespread strategy for improving chronic illness care. However, primary care provider (PCP) participation in programs has been poor. Because the success of care management relies on provider engagement, understanding provider perspectives is necessary.

OBJECTIVE

Our goal was to identify care management functions most valuable to PCPs in hypertension treatment.

DESIGN

Six focus groups were conducted to discuss current challenges in hypertension care and identify specific functions of care management that would improve care.

PARTICIPANTS

The study included 39 PCPs (participation rate: 83 %) representing six clinics, two of which care for large African American populations and four that are in underserved locations, in the greater Baltimore metropolitan area.

APPROACH

This was a qualitative analysis of focus groups, using grounded theory and iterative coding.

KEY RESULTS

Providers desired achieving blood pressure control more rapidly. Collaborating with care managers who obtain ongoing patient data would allow treatment plans to be tailored to the changing life conditions of patients. The P.A.R.T.N.E.R. framework summarizes the care management functions that providers reported were necessary for effective collaboration: Partner with patients, providers, and the community; Arrange follow-up care; Resolve barriers to adherence; Track treatment response and progress; Navigate the health care system with patients; Educate patients & Engage patients in self-management; Relay information between patients and/or provider(s).

CONCLUSIONS

The P.A.R.T.N.E.R. framework is the first to offer a checklist of care management functions that may promote successful collaboration with PCPs. Future research should examine the validity of this framework in various settings and for diverse patient populations affected by chronic diseases.

A community-engaged cardiovascular health disparities research training curriculum: implementation and preliminary outcomes

To overcome cardiovascular disease (CVD) disparities impacting high-risk populations, it is critical to train researchers and leaders in conducting community-engaged CVD disparities research. The authors summarize the key elements, implementation, and preliminary outcomes of the CVD Disparities Fellowship and Summer Internship Programs at the Johns Hopkins University Schools of Medicine, Nursing, and Bloomberg School of Public Health. In 2010, program faculty and coordinators established a transdisciplinary CVD disparities training and career development fellowship program for scientific investigators who desire to conduct community-engaged clinical and translational disparities research. The program was developed to enhance mentorship support and research training for faculty, postdoctoral fellows, and predoctoral students interested in conducting CVD disparities research. A CVD Disparities Summer Internship Program for undergraduate and preprofessional students was also created to provide a broad experience in public health and health disparities in Baltimore, Maryland, with a focus on CVD. Since 2010, 39 predoctoral, postdoctoral, and faculty fellows have completed the program. Participating fellows have published disparities-related research and given presentations both nationally and internationally. Five research grant awards have been received by faculty fellows. Eight undergraduates, one postbaccalaureate, and two medical professional students representing seven universities have participated in the summer undergraduate internship. Over half of the undergraduate students are applying to or have been accepted into medical or graduate school. The tailored CVD health disparities training curriculum has been successful at equipping varying levels of trainees (from undergraduate students to faculty) with clinical research and public health expertise to conducting community-engaged CVD disparities research.

Cultural competence and perceptions of community health workers' effectiveness for reducing health care disparities

INTRODUCTION

Community health worker (CHW) interventions improve health outcomes of patients from underserved communities, but health professionals' perceptions of their effectiveness may impede integration of CHWs into health care delivery systems. Whether health professionals' attitudes and skills, such as those related to cultural competence, influence perceptions of CHWs, is unknown.

METHODS

A questionnaire was administered to providers and clinical staff from 6 primary care practices in Maryland from April to December 2011. We quantified the associations of self-reported cultural competence and preparedness with attitudes toward the effectiveness of CHWs using logistic regression adjusting for respondent age, race, gender, provider/staff status, and years at the practice.

RESULTS

We contacted 200 providers and staff, and 119 (60%) participated. Those reporting more cultural motivation had higher odds of perceiving CHWs as helpful for reducing health care disparities (odds ratio [OR] = 9.66, 95% confidence interval [CI] = 3.48-28.80). Those reporting more frequent culturally competent behaviors also had higher odds of believing CHWs would help reduce health disparities (OR = 3.58, 95% CI = 1.61-7.92). Attitudes toward power and assimilation were not associated with perceptions of CHWs. Cultural preparedness was associated with perceived utility of CHWs in reducing health care disparities (OR = 2.33, 95% CI = 1.21-4.51).

CONCLUSIONS

Providers and staff with greater cultural competence and preparedness have more positive expectations of CHW interventions to reduce healthcare disparities. Cultural competency training may complement the use of CHWs and support their effective integration into primary care clinics that are seeking to reduce disparities.

Adapting hypertension self-management interventions to enhance their sustained effectiveness among urban African Americans

African Americans suffer disproportionately poor hypertension control despite the availability of efficacious interventions. Using principles of community-based participatory research and implementation science, we adapted established hypertension self-management interventions to enhance interventions' cultural relevance and potential for sustained effectiveness among urban African Americans. We obtained input from patients and their family members, their health care providers, and community members. The process required substantial time and resources, and the adapted interventions will be tested in a randomized controlled trial.

A multi-level system quality improvement intervention to reduce racial disparities in hypertension care and control: study protocol

Background

Racial disparities in blood pressure control have been well documented in the United States. Research suggests that many factors contribute to this disparity, including barriers to care at patient, clinician, healthcare system, and community levels. To date, few interventions aimed at reducing hypertension disparities have addressed factors at all of these levels. This paper describes the design of Project ReD CHiP (Reducing Disparities and Controlling Hypertension in Primary Care), a multi-level system quality improvement project. By intervening on multiple levels, this project aims to reduce disparities in blood pressure control and improve guideline concordant hypertension care.

Methods

Using a pragmatic trial design, we are implementing three complementary multi-level interventions designed to improve blood pressure measurement, provide patient care management services and offer expanded provider education resources in six primary care clinics in Baltimore, Maryland. We are staggering the introduction of the interventions and will use Statistical Process Control (SPC) charting to determine if there are changes in outcomes at each clinic after implementation of each intervention. The main hypothesis is that each intervention will have an additive effect on improvements in guideline concordant care and reductions in hypertension disparities, but the combination of all three interventions will result in the greatest impact, followed by blood pressure measurement with care management support, blood pressure measurement with provider education, and blood pressure measurement only. This study also examines how organizational functioning and cultural competence affect the success of the interventions.

Discussion

As a quality improvement project, Project ReD CHiP employs a novel study design that specifically targets multi-level factors known to contribute to hypertension disparities. To facilitate its implementation and improve its sustainability, we have incorporated stakeholder input and tailored components of the interventions to meet the specific needs of the involved clinics and communities. Results from this study will provide knowledge about how integrated multi-level interventions can improve hypertension care and reduce disparities.

Trial Registration

ClinicalTrials.gov NCT01566864