Equitable Care for Hypertension: Blood Pressure and Patient-Reported Outcomes of the RICH LIFE Cluster Randomized Trial

Abstract

Background: Disparities in hypertension control are well documented but underaddressed.

Methods: RICH LIFE (Reducing Inequities in Care of Hypertension: Lifestyle Improvement for Everyone) was a 2-arm, cluster randomized trial comparing the effect on blood pressure (BP) control (systolic BP ≤140 mm Hg, diastolic BP ≤90 mm Hg), patient activation, and disparities in BP control of 2 multilevel interventions, standard of care plus (SCP) and collaborative care/stepped care (CC/SC). SCP included BP measurement standardization, audit and feedback, and equity-leadership training. CC/SC added roles to address social or medical needs. Primary outcomes were BP control and patient activation at 12 months. Generalized estimating equations and mixed-effects regression models with fixed effects of time, intervention, and their interaction compared change in outcomes at 12 months from baseline.

Results: A total of 1820 adults with uncontrolled BP and ≥1 other risk factors enrolled in the study. Their mean age was 60.3 years, and baseline BP was 152.3/85.5 mm Hg; 59.4% were women; 57.4% were Black, 33.2% were White, and 9.4% were Hispanic; 74% had hyperlipidemia; and 45.1% had type 2 diabetes. CC/SC did not improve BP control rates more than SCP. Both groups achieved statistically and clinically significant BP control rates at 12 months (CC/SC: 57.3% [95% CI, 52.7%-62.0%]; SCP: 56.7% [95% CI, 51.9%-61.5%]). Pairwise comparisons between racial and ethnic groups showed overall no significant differences in BP control at 12 months. Patients with coronary heart disease showed greater achievement of BP control in CC/SC than in SCP (64.0% [95% CI, 54.1%-73.9%] versus 50.8% [95% CI, 42.6%-59.0%]; P=0.04), as did patients in rural areas (67.3% [95% CI, 49.8%-84.8%] versus 47.8% [95% CI, 32.4%-63.2%]; P=0.01). Individuals in both arms experienced statistically and clinically significant reductions in mean systolic BP (CC/SC: -13.8 mm Hg [95% CI, -15.2 to -12.5]; SCP: -14.6 mm Hg [95% CI, -15.9 to -13.2]) and diastolic BP (CC/SC: -6.9 mm Hg [95% CI, -7.8 to -6.1]; SCP: -5.5 mm Hg [95% CI, -6.4 to -4.6]) over time. The difference in diastolic BP reduction between CC/SC and SCP over time was statistically significant (-1.4 mm Hg [95% CI, -2.6 to -0.2). Patient activation did not differ between arms. CC/SC showed greater improvements in patient ratings of chronic illness care (Patient Assessment of Chronic Illness Care score) over 12 months (0.12 [95% CI, 0.02-0.22]).

Conclusions: Adding a collaborative care team to enhanced standard of care did not improve BP control but did improve patient ratings of chronic illness care.

Keywords: blood pressure; community health workers; disease management; healthcare disparities; hypertension; patient care management; primary health care.

Figure 1.

Health System and Participant Flow Abbreviations: SCP, Standard of Care Plus; CC/SC arm, Collaborative Care/Stepped Care arm; PAM-13, 13-item Patient Activation Measure; BP, blood pressure * Patient reported survey data only ^† Out of 893 patients ^‡ Out of 927 patients ^§ 12-month retention numbers are based off the entire sample, not off the numbers presented at 6 months. Participants who may have missed the 6-month follow-up visit could re-engage and complete the 12-month follow-up visit. Additionally, participant withdrawal from survey does not necessarily indicate a withdrawal from blood pressure data.

Figure 2.

Intervention Effects on Blood Pressure Control at 12 Months by Subgroup Abbreviations: SCP, Standard of Care Plus; CC/SC, Collaborative Care/Stepped Care; CI, confidence interval; CM, care manager; CHW, community health worker * Estimated Probabilities, in percent. Results are from models including baseline systolic and diastolic blood pressure, age, Medicaid insurance status, diabetes diagnosis, and health system as covariates and controlling for clustering within practice. ^† P-for-interaction of subgroup variable and intervention arm