Shari D Bolen1,2,3,4, Thomas E Love5,6,7,8, Douglas Einstadter5,6,7,8, Jonathan Lever6, Steven Lewis5,7, Harry Persaud8, Jordan Fiegl9, Rujia Liu10, Wanda Ali-Matlock6, David Bar-Shain5,6,11, Aleece Caron5,7, James Misak12, Todd Wagner13, Erick Kauffman14, Lloyd Cook15, Christopher Hebert16, Suzanne White17, Nana Kobaivanova18, Randall Cebul5,6,8. 1. Center for Health Care Research and Policy, Population Health Research Institute, Case Western Reserve University at The MetroHealth System, Cleveland, OH, USA. sdb73@case.edu. 2. Better Health Partnership, Cleveland, OH, USA. sdb73@case.edu. 3. Department of Medicine, Case Western Reserve University at The MetroHealth System, Cleveland, OH, USA. sdb73@case.edu. 4. Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, USA. sdb73@case.edu. 5. Center for Health Care Research and Policy, Population Health Research Institute, Case Western Reserve University at The MetroHealth System, Cleveland, OH, USA. 6. Better Health Partnership, Cleveland, OH, USA. 7. Department of Medicine, Case Western Reserve University at The MetroHealth System, Cleveland, OH, USA. 8. Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, USA. 9. Department of Data Science and Analytics, University Hospitals, Cleveland, OH, USA. 10. Medpace Inc., Cincinnati, OH, USA. 11. Department of Pediatrics, Case Western Reserve University at The MetroHealth System, Cleveland, OH, USA. 12. Department of Family Medicine, Case Western Reserve University at The MetroHealth System, Cleveland, OH, USA. 13. Signature Health, Mentor, OH, USA. 14. Neighborhood Family Practice, Cleveland, OH, USA. 15. Medical Mutual, Cleveland, OH, USA. 16. Mercy Health, Cincinnati, OH, USA. 17. Northeast Ohio Neighborhood Health Services, Inc., Cleveland, OH, USA. 18. The Cleveland Clinic, Cleveland, OH, USA.
Abstract
BACKGROUND: Accelerated translation of real-world interventions for hypertension management is critical to improving cardiovascular outcomes and reducing disparities. OBJECTIVE: To determine whether a positive deviance approach would improve blood pressure (BP) control across diverse health systems. DESIGN: Quality improvement study using 1-year cross sections of electronic health record data over 5 years (2013-2017). PARTICIPANTS: Adults ≥ 18 with hypertension with two visits in 2 years with at least one primary care visit in the last year (N = 114,950 at baseline) to a primary care practice in Better Health Partnership, a regional health improvement collaborative. INTERVENTIONS: Identification of a "positive deviant" and dissemination of this system's best practices for control of hypertension (i.e., accurate/repeat BP measurement; timely follow-up; outreach; standard treatment algorithm; and communication curriculum) using 3 different intensities (low: Learning Collaborative events describing the best practices; moderate: Learning Collaborative events plus consultation when requested; and high: Learning Collaborative events plus practice coaching). MAIN MEASURES: We used a weighted linear model to estimate the pre- to post-intervention average change in BP control (< 140/90 mmHg) for 35 continuously participating clinics. KEY RESULTS: BP control post-intervention improved by 7.6% [95% confidence interval (CI) 6.0-9.1], from 67% in 2013 to 74% in 2017. Subgroups with the greatest absolute improvement in BP control included Medicaid (12.0%, CI 10.5-13.5), Hispanic (10.5%, 95% CI 8.4-12.5), and African American (9.0%, 95% CI 7.7-10.4). Implementation intensity was associated with improvement in BP control (high: 14.9%, 95% CI 0.2-19.5; moderate: 5.2%, 95% CI 0.8-9.5; low: 0.2%, 95% CI-3.9 to 4.3). CONCLUSIONS: Employing a positive deviance approach can accelerate translation of real-world best practices into care across diverse health systems in the context of a regional health improvement collaborative (RHIC). Using this approach within RHICs nationwide could translate to meaningful improvements in cardiovascular morbidity and mortality.
BACKGROUND: Accelerated translation of real-world interventions for hypertension management is critical to improving cardiovascular outcomes and reducing disparities. OBJECTIVE: To determine whether a positive deviance approach would improve blood pressure (BP) control across diverse health systems. DESIGN: Quality improvement study using 1-year cross sections of electronic health record data over 5 years (2013-2017). PARTICIPANTS: Adults ≥ 18 with hypertension with two visits in 2 years with at least one primary care visit in the last year (N = 114,950 at baseline) to a primary care practice in Better Health Partnership, a regional health improvement collaborative. INTERVENTIONS: Identification of a "positive deviant" and dissemination of this system's best practices for control of hypertension (i.e., accurate/repeat BP measurement; timely follow-up; outreach; standard treatment algorithm; and communication curriculum) using 3 different intensities (low: Learning Collaborative events describing the best practices; moderate: Learning Collaborative events plus consultation when requested; and high: Learning Collaborative events plus practice coaching). MAIN MEASURES: We used a weighted linear model to estimate the pre- to post-intervention average change in BP control (< 140/90 mmHg) for 35 continuously participating clinics. KEY RESULTS: BP control post-intervention improved by 7.6% [95% confidence interval (CI) 6.0-9.1], from 67% in 2013 to 74% in 2017. Subgroups with the greatest absolute improvement in BP control included Medicaid (12.0%, CI 10.5-13.5), Hispanic (10.5%, 95% CI 8.4-12.5), and African American (9.0%, 95% CI 7.7-10.4). Implementation intensity was associated with improvement in BP control (high: 14.9%, 95% CI 0.2-19.5; moderate: 5.2%, 95% CI 0.8-9.5; low: 0.2%, 95% CI-3.9 to 4.3). CONCLUSIONS: Employing a positive deviance approach can accelerate translation of real-world best practices into care across diverse health systems in the context of a regional health improvement collaborative (RHIC). Using this approach within RHICs nationwide could translate to meaningful improvements in cardiovascular morbidity and mortality.
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