Improving BP Control in Diverse Populations Using BP MAP

University of California, San Francisco1,238,835 enrolled

Overview

BP-MAP is a cluster randomized controlled trial (RCT) designed to compare the effectiveness of BP lowering from a clinic-based quality improvement program with Full Support (dedicated practice facilitation) vs. a Self-Guided version of the program. The American Medical Association (AMA) developed the framework for the interventions. The trial will be conducted within the National Patient-Centered Clinical Research Network (PCORnet) that enables distributed querying of electronic health record data in a common data model. The primary outcome will be change in clinic-level blood pressure (BP) control at 6 months. Secondary outcomes will include other blood pressure (BP) control metrics, other time points (12 and 18 months), and process measures such as BP measurement accuracy, medication intensification, and average systolic blood pressure (SBP) reduction after a medication intensification, and repeat visit within 4 weeks after a visit with elevated BP. The investigators hypothesize clinics randomized to the Full Support version will achieve a larger increase from baseline in the proportion of their hypertensive patients with controlled BP at 6 months as compared to clinics randomized to the Self-Guided version, and also as compared with usual care. The investigators will also conduct non-randomized comparisons of BP control in the Full Support and Self-Guided intervention arms to BP control in non-participating "Usual Care" institutions in PCORnet. This study was submitted to the IRB at UCSF, determined to be quality improvement and exempt from further review.

Study Type

INTERVENTIONAL

Allocation

RANDOMIZED

Purpose

TREATMENT

Masking

NONE

Enrollment

1,238,835

Conditions

Hypertension

Interventions

Self-Guided M.A.P. BP Improvement ProgramOTHER

Active Clinics randomized to the Self-Guided Arm will receive access to an AHA/AMA web platform that includes the posted M.A.P. materials and limited access to AMA Staff who are available to answer questions. The study team will facilitate access to staff by hosting a kick-off webinar for program participants that will include an orientation to the materials on the website, general advice and practical tips about what works for implementation, and time for answering questions and discussion with the group.

Full Support M.A.P. BP Improvement ProgramOTHER

Active Clinics randomized to the Full Support Arm will receive online access to M.A.P. materials and orientation webinar and also a Practice Change Facilitator who will lead the health center clinical staff, site champions and physician leads at each clinic over the course of 6 months to support the implementation of the MAP Program. With support from an AMA "Improvement Advisor", the Practice Change Facilitators will perform a baseline assessment of current workflows and assess each domain of M.A.P. The goal of the Full Support program is to help care teams develop skills and sustainable workflows that are effective at attaining and maintaining high levels of BP control.

Eligibility

Sex: ALLMin age: 18 YearsMax age: 85 Years

Medical Language ↔ Plain English

ACTIVE CLINICS For inclusion as an Active Clinic in this study, clinics may participate must be able to identify: * A Site Champion who works at the clinic and who is willing to take primary responsibility for implementing the M.A.P. intervention * A Physician Champion who works at the clinic and who is willing to advocate actively for the M.A.P. intervention * A Practice Change Facilitator willing to attend a 1-day training and help guide implementation of the M.A.P intervention for Full Support sites, with the support of AMA staff (may be the Site Champion or Physician Champion, or a person with regional responsibilities who can support multiple sites) Sites will be excluded if they: * Have implemented any high blood pressure quality improvement component from the M.A.P. BP improvement program as part of Target: BP or from the AMA or Target: BP websites * Are currently involved in an ongoing clinical trial or grant funded project related to high blood pressure or hypertension USUAL CARE CLINICS: Usual Care Clinics will include PCORnet Datamarts participating in BP TRACK, a concurrently-running BP Control Registry within PCORnet that will provide quarterly datamart-level estimates of BP control and other aggregate metrics relevant to BP control. All participating datamarts will be included, with the following exceptions: * Datamarts with any Active Clinics participating in BP MAP will be excluded * Datamarts that obscure dates via date-shifting will be excluded, as this will not allow for control of concurrent secular trends PATIENTS Within clinics (Active or Usual Care), patients will be eligible (and identified from the electronic health record) if they meet National Quality Forum BP Control Metric (NQF 0018) criteria: * Age 18-85 on the date of analysis * At least one outpatient encounter with a diagnosis of hypertension during the first six months of the measurement year (ending on the date of analysis) * No diagnosis or evidence of end-stage renal disease on or prior to the end of the measurement year * No pregnancy during the measurement year * No admission to an inpatient setting during the measurement year

Locations (24)

Outcomes

Primary Outcomes

Change in Blood Pressure Control, % of Patients

The primary outcome will be clinic-level change in the proportion of patients with controlled BP from baseline to 6 months after the start of the intervention. BP control will be defined according to NQF 0018 as the percent of eligible patients (defined below) with SBP \<140 mmHg and DBP \< 90 mmHg, based on measurements obtained at the most recent ambulatory clinical encounter at baseline (using the lowest measures of SBP and DBP at that encounter) and similarly at the 6-month time point after initiation of the intervention.

Time frame: baseline and 6 months

Secondary Outcomes

Change in Improvement in Blood Pressure, % of Patients

This overall measure of BP improvement implements CMS065v4\[ref\], which defines BP improvement as either a reduction of 10 mmHg in SBP or achievement of SBP that is "adequately controlled" (SBP \< 140 mmHg) in months 12 of the measurement period, among hypertensive patients not previously controlled.

Time frame: baseline and 12 months

Change in Confirmatory Repeated Blood Pressure Measurement, % of Visits

This process measure is designed to capture the practice of repeating a blood pressure measurement in the same visit when the first measurement done in clinic is high (SBP≥140 mmHg or DBP≥90 mmHg).

Time frame: baseline and 6 months

Change in Medication Intensification, % of Visits

This process measure captures the proportion of visits where BP is uncontrolled where a medication is ordered that is of a different class of medication than had previously been used. Note that this explicitly does not give credit for ordering a simple refill or medication dose increase, or use of a different medication in the same class.

Time frame: baseline and 6 months

Change in Average Systolic Blood Pressure (SBP) Reduction After a Medication Intensification Visit, mmHg

Data from ClinicalTrials.gov

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