Improvement in Blood Pressure Control in Safety Net Clinics Receiving 2 Versions of a Scalable Quality Improvement Intervention: BP MAP A Pragmatic Cluster Randomized Trial

Abstract

Background Uncontrolled blood pressure (BP) remains a leading cause of death in the United States. The American Medical Association developed a quality improvement program to improve BP control, but it is unclear how to efficiently implement this program at scale across multiple health systems. Methods and Results We conducted BP MAP (Blood Pressure Measure Accurately, Act Rapidly, and Partner With Patients), a comparative effectiveness trial with clinic-level randomization to compare 2 scalable versions of the quality improvement program: Full Support (with support from quality improvement expert) and Self-Guided (using only online materials). Outcomes were clinic-level BP control (<140/90 mm Hg) and other BP-related process metrics calculated using electronic health record data. Difference-in-differences were used to compare changes in outcomes from baseline to 6 months, between intervention arms, and to a nonrandomized Usual Care arm composed of 18 health systems. A total of 24 safety-net clinics in 9 different health systems underwent randomization and then simultaneous implementation. BP control increased from 56.7% to 59.1% in the Full Support arm, and 62.0% to 63.1% in the Self-Guided arm, whereas BP control dropped slightly from 61.3% to 60.9% in the Usual Care arm. The between-group differences-in-differences were not statistically significant (Full Support versus Self-Guided=+1.2% [95% CI, -3.2% to 5.6%], P=0.59; Full Support versus Usual Care=+3.2% [-0.5% to 6.9%], P=0.09; Self-Guided versus Usual Care=+2.0% [-0.4% to 4.5%], P=0.10). Conclusions In this randomized trial, 2 methods of implementing a quality improvement intervention in 24 safety net clinics led to modest improvements in BP control that were not statistically significant. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03818659.

Keywords: blood pressure; comparative effectiveness; hypertension; quality improvement; quasi‐experimental design.

Figure 1. Consort diagram and study design.

BP indicates blood pressure; MAP, Measure Accurately, Act Rapidly, and Partner with Patients; PCORnet, Patient‐Centered Clinical Research Network; and RCT, randomized controlled trial.

Figure 2. Difference‐in‐differences in blood pressure control.

This figure illustrates blood pressure control at baseline and 6 months for each intervention arm, and the differences in pre‐post changes in % blood pressure control by arm (difference‐in‐differences) with P values for each contrast, including Full Support versus Self‐Guided (A), Full Support versus Usual Care (B), and Self‐Guided versus Usual Care (C). BP indicates blood pressure.

Figure 3. Forest plot of difference‐in‐differences in % blood pressure control by subgroup.

Mean (CI) change in % BP control from baseline to 6 months are presented overall, and stratified by sex, age, race, and research network. P values for heterogeneity across subgroups are presented. BP indicates blood pressure; and CRN, clinical research network.