Results Summary
What was the research about?
High blood pressure can cause health problems like stroke and heart disease. In the rural Southeast, Black Americans with high blood pressure who have lower incomes are more likely to die from these health problems than White Americans.
In this study, the research team compared four approaches to help Black patients control high blood pressure:
- Usual care alone. Clinics received a laptop computer, with a program to educate patients, and home blood pressure monitors for patients. Clinics also received tips to help control patients’ blood pressure.
- Practice facilitation plus usual care. The research team trained facilitators, who met with clinics monthly. The facilitator helped clinics improve teamwork, use their data to monitor patients’ progress on blood pressure control, and increase phone contact and education for patients.
- Peer coaching plus usual care. Peer coaches met with patients once a week for eight weeks, then once a month for one year. They discussed blood pressure control, blood pressure medicine, healthy eating, and exercise.
- Practice facilitation and peer coaching plus usual care. Clinics received practice facilitation, and patients received peer coaching.
What were the results?
After one year, the percentage of patients with controlled blood pressure increased in all approaches. The percentage of patients with controlled blood pressure didn’t differ between the approaches.
Compared with patients who received care at clinics with usual care alone:
- Patients who received care at clinics with practice facilitation had worse quality of life related to physical health. They also had a higher chance of a hospital stay.
- Patients who received peer coaching reported less stress.
The approaches didn’t differ in patients’:
- Average change in blood pressure
- Quality of life related to mental health
- Number of emergency room visits
Who was in the study?
The study included 1,209 Black adults with high blood pressure. The average age was 58; 62 percent were women and 45 percent had an income less than $20,000 per year. All received care at one of 69 rural clinics in Alabama and North Carolina.
What did the research team do?
The research team assigned clinics by chance to one of the four approaches. All approaches included usual care.
At the start of the study and again 6 and 12 months later, the research team collected patients’ home blood pressure measurements. Patients also completed surveys about quality of life and stress. The team reviewed health records to track hospital and emergency room visits.
Patients with high blood pressure, health coaches, and doctors helped design the study.
What were the limits of the study?
Of patients who received peer coaching, 57 percent completed sessions. Results may have differed if more patients completed peer coaching. Also, the study didn’t capture the full impact of practice facilitation at each clinic.
Future research could explore ways to encourage patients to continue with peer coaching. Studies could also look at the effects of practice facilitation.
How can people use the results?
Clinics can use the results when considering how to help Black patients control their blood pressure.
Professional Abstract
Objective
To compare four approaches to help control high blood pressure among Black patients with persistently uncontrolled hypertension
Study Design
Design Elements | Description |
---|---|
Design | Cluster randomized controlled trial |
Population | 1,209 Black American patients with persistently uncontrolled hypertension living in rural areas and receiving care at 1 of 69 clinics in Alabama and North Carolina |
Interventions/ Comparators |
|
Outcomes |
Primary: proportion of patients with controlled blood pressure, defined as having blood pressure under 140/90 mmHg Secondary: mean change in systolic and diastolic blood pressure, quality of life related to physical and mental health, stress Safety: hospitalizations, emergency department use |
Timeframe | 1-year follow-up for primary outcome |
This cluster randomized trial compared the effectiveness of enhanced usual care plus practice facilitation, peer coaching, or both versus enhanced usual care alone in improving blood pressure control and other quality of life and safety measures among Black patients.
All clinics provided enhanced usual care to patients with persistently uncontrolled hypertension. Clinics providing this care received a laptop computer with access to a web-based patient education platform, home blood pressure monitors for patients, and evidence-based tips for controlling hypertension.
Researchers randomly assigned clinics to one of four groups:
- Enhanced usual care plus practice facilitation. Researchers trained six facilitators who met with clinic staff once a month. Facilitators helped clinics select quality improvement exercises, which focused on improving team-based care, using data to monitor clinic progress on blood pressure control, and increasing outreach and education for patients.
- Enhanced usual care plus peer coaching. Peer coaches met with patients at eight weekly sessions to discuss hypertension, medication, healthy eating, and physical activity. Coaches then met with patients once a month for one year.
- Enhanced usual care plus practice facilitation and peer coaching. Clinics worked with facilitators; patients received peer coaching.
- Enhanced usual care alone. Clinics provided enhanced usual care without additional interventions.
The study included 1,209 Black patients with persistently uncontrolled hypertension. The average age was 58, 62% were female, and 45% had an annual income less than $20,000. Patients received care at one of 69 clinics in Alabama and North Carolina.
At baseline and 6 and 12 months later, patients submitted home-monitored blood pressure measurements and completed questionnaires about their quality of life and stress. Researchers reviewed health records to assess safety outcomes.
Patients with hypertension, health coaches, and clinicians helped design the study.
Results
At 12 months, the proportion of patients with controlled hypertension increased in all groups. The four groups did not differ significantly.
Compared with patients receiving care at clinics with enhanced usual care alone:
- Patients receiving care at clinics that also received practice facilitation had a higher risk of hospitalization (p=0.01) and worse physical health quality of life (p<0.02); the difference in quality of life was unlikely to be clinically meaningful.
- Patients who received peer coaching reported less stress (p<0.05).
The four groups did not differ significantly in patients’ mean change in systolic and diastolic blood pressure, mental health quality of life, or number of emergency department visits.
Limitations
Of patients receiving peer coaching, 57% completed the intervention. Results may have differed if more patients had completed peer coaching. Lack of practice-level data limited the ability to draw conclusions about practice facilitation effectiveness.
Conclusions and Relevance
In this study, clinics that received enhanced usual care with or without practice facilitation, peer coaching, or both had similar improvements in blood pressure control among Black patients.
Future Research Needs
Future research could explore strategies to retain patients in peer coaching and examine practice-level effects of practice facilitation.
Final Research Report
This project's final research report is expected to be available by November 2023.
Peer-Review Summary
Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.
The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.
Peer reviewers commented and the researchers made changes or provided responses. Those comments and responses included the following:
- The reviewers asked how generalizable the results of this study were to urban areas. The researchers expanded their discussion to note that although the project was conducted in a rural area, given the frequency of medication nonadherence and unhealthy lifestyle in urban as well as rural settings, the results may be generalizable to urban settings.
- The reviewers asked why the researchers included perceived stress as a separate outcome domain rather than including it within the mental functioning domain, given the high correlation between stress, anxiety, and depression. The researchers acknowledged this high correlation but explained that their community partners wanted stress prioritized because many feel that blood pressure is directly related to stress.
- The reviewers asked the researchers to discuss further their finding that peer coaching was effective for individuals under 60 with uncontrolled hypertension and to consider whether age concordance between the peer coaches and patients could have been a factor. The researchers considered this possible and extended their discussion of why peer coaching was more beneficial among younger patients in the discussion to include this hypothesis.
Conflict of Interest Disclosures
Project Information
Key Dates
Study Registration Information
*Monika M. Safford, MD, was the principal investigator of this study when it was funded.