Multi-Method Health System Quality Improvement Intervention to Reduce Hypertension Disparities

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 in hypertension have been clearly documented 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 Johns Hopkins
Community Physicians (JHCP) healthcare system have been selected for participation in this
study. The sites are located within the metropolitan ara 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 patients' 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 and reducing racial
disparities in blood pressure control at the clinic level .

Inclusion Criteria: patients with an ICD9 diagnosis of hypertension or a BP >=120/>=80 who
have not been seen in the last 12 months and any patient with their most recent BP
>=140/>=90 or >=130/>=80 if they have diabetes mellitus or chronic kidney disease