Search

Importance: Rural Black participants need effective intervention to achieve better blood pressure (BP) control., Objective: Among Black rural adults with persistently uncontrolled hypertension attending primary care clinics, to determine whether peer coaching (PC), practice facilitation (PF), or both (PCPF) are superior to enhanced usual care (EUC) in improving BP control., Design, Setting, and Participants: A cluster randomized clinical trial was conducted in 69 rural primary care practices across Alabama and North Carolina between September 23, 2016, and September 26, 2019. The participating practices were randomized to 4 groups: PC plus EUC, PF plus EUC, PCPF plus EUC, and EUC alone. The baseline EUC approach included a laptop for each participating practice with hyperlinks to participant education on hypertension, a binder of practice tips, a poster showing an algorithm for stepped care to improve BP, and 25 home BP monitors. The trial was stopped on February 28, 2021, after final data collection. The study included Black participants with persistently uncontrolled hypertension. Data were analyzed from February 28, 2021, to December 13, 2022., Interventions: Practice facilitators helped practices implement at least 4 quality improvement projects designed to improve BP control throughout 1 year. Peer coaches delivered a structured program via telephone on hypertension self-management throughout 1 year., Main Outcomes and Measures: The primary outcome was the proportion of participants in each trial group with BP values of less than 140/90 mm Hg at 6 months and 12 months. The secondary outcome was a change in the systolic BP of participants at 6 months and 12 months., Results: A total of 69 practices were randomized, and 1209 participants' data were included in the analysis. The mean (SD) age of participants was 58 (12) years, and 748 (62%) were women. In the intention-to-treat analyses, neither intervention alone nor in combination improved BP control or BP levels more than EUC (at 12 months, PF vs EUC odds ratio [OR], 0.94 [95% CI, 0.58-1.52]; PC vs EUC OR, 1.30 [95% CI, 0.83-2.04]; PCPF vs EUC OR, 1.02 [95% CI, 0.64-1.64]). In preplanned subgroup analyses, participants younger than 60 years in the PC and PCPF groups experienced a significant 5 mm Hg greater reduction in systolic BP than participants younger than 60 years in the EUC group at 12 months. Practicewide BP control estimates in PF groups suggested that BP control improved from 54% to 61%, a finding that was not observed in the trial's participants., Conclusions and Relevance: The results of this cluster randomized clinical trial demonstrated that neither PC nor PF demonstrated a superior improvement in overall BP control compared with EUC. However, PC led to a significant reduction in systolic BP among younger adults., Trial Registration: ClinicalTrials.gov Identifier: NCT02866669.

Background: Impoverished African Americans (AA) with hypertension face poor health outcomes., Purpose: To conduct a cluster-randomized trial testing two interventions, alone and in combination, to improve blood pressure (BP) control in AA with persistently uncontrolled hypertension., Methods: We engaged primary care practices serving rural Alabama and North Carolina residents, and in each practice we recruited approximately 25 AA adults with persistently uncontrolled hypertension (mean systolic BP >140 mmHg over the year prior to enrollment plus enrollment day BP assessed by research assistants ≥140/90 mmHg). Practices were randomized to peer coaching (PC), practice facilitation (PF), both PC and PF (PC + PF), or enhanced usual care (EUC). Coaches met with participants from PC and PC + PF practices weekly for 8 weeks then monthly over one year, discussing lifestyle changes, medication adherence, home monitoring, and communication with the healthcare team. Facilitators met with PF and PC + PF practices monthly to implement ≥1 quality improvement intervention in each of four domains. Data were collected at 0, 6, and 12 months., Results: We recruited 69 practices and 1596 participants; 18 practices (408 participants) were randomized to EUC, 16 (384 participants) to PF, 19 (424 participants) to PC, and 16 (380 participants) to PC + PF. Participants had mean age 57 years, 61% were women, and 56% reported annual income <$20,000., Limitations: The PF intervention acts at the practice level, possibly missing intervention effects in trial participants. Neither PC nor PF currently has established clinical reimbursement mechanisms., Conclusions: This trial will fill evidence gaps regarding practice-level vs. patient-level interventions for rural impoverished AA with uncontrolled hypertension., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Alyssa Adams - None. Muna Anabtawi, DDS – None. Lynn Andreae, PhD – None. Elizabeth Baquero, EDD – chair of education advisory board of MedExplain, Inc., a company commercializing a patient education platform based on the Patient Activated Learning System (palsforhealth.com). Joanna Bryan, MS – None. Andrea Cherrington, MD, MPH – None. Debra Clark, MPH – None. Doyle Cummings, PharmD – None. Jacqueline Halladay, MD, MPH - None. James Hollenberg, MD – None. Ethel Johnson – None. Suzanne Oparil – research funding from CinCor Pharma Inc. (site PI for a primary aldosterone study), George Clinical Pty (site PI for GMRx2 treatment of hypertension), and Higi (site PI for a blood pressure validation study); advisory roles for CinCor Pharma Inc. (Scientific Advisory Board for primary aldosteronism and hypertension) and Preventric Diagnostics, LLC (Chair of the Medical and Technology Committee, 2019–2022); and Editor-in-Chief of Current Hypertension Reports (Springer Science Business Media LLC) until 12/2023. Erica Richman, PhD - None. Joshua Richman, PhD, MD – None. Monika Safford, MD – owner of MedExplain, Inc., a company commercializing a patient education platform based on the Patient Activated Learning System (palsforhealth.com). James Shikany, Dr.P·H - None. Orysya Soroka, PhD – None. James Tillman – None., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)