The University of Alabama at Birmingham has been awarded a $9.4 million grant to lead a trial in an effort to improve blood pressure in the Black Belt of the United States.The central objective of the “Collaboration to Improve Blood Pressure in the U.S. Black Belt – Addressing the Triple Threat” is to rigorously compare two strategies designed to improve blood pressure control in primary care practices serving rural Southeastern African-Americans with low socioeconomic status. The project was developed in response to a call for proposals that focus on hypertension control among rural dwellers, minorities or people who are socio-economically disadvantaged.
The trial, led by UAB, is a collaboration with the University of North Carolina and East Carolina University.
The “Black Belt” region stretches from eastern Texas in an arc to Maryland and includes residents with the three characteristics of interest for the sponsors — rural residence, minority ethnicity and low socioeconomic status. The UAB proposal will engage people who meet these three characteristics, otherwise known as the “Triple Threat.” Black Belt residents typically are among the highest risks for poor health outcomes in the United States.
Professor of Diabetes Prevention and Outcomes Research Monika Safford, M.D., says that one of the goals of this trial is to provide patients with a better understanding of how to lead a healthy life. Recent studies have shown that intensive blood pressure management may save lives.
“In many cases, patients do not have a good understanding of what is needed to optimize their health,” Safford said. “Patients may not understand the need for frequent blood pressure checks, and therefore skip doctor visits. Or, they may not understand how to take their medications, or not know what the medications are supposed to do, so they don’t take them. The goal would be to get more patients to take medications as directed, and to self-monitor their blood pressure.”
Two effective strategies that will be used in this trial to improve cardiovascular disease risk factors are practice facilitation and the use of peer coaches.
Practice facilitation is a highly customized and staged approach to helping a practice implement process and structural changes to enhance the quality of care and improve patient and staff satisfaction. Growing evidence has shown that practice facilitation can speed the transition to high-quality, evidence-based care.
“Practice facilitation is designed to create changes in the way care is provided,” Safford said. “Right now, patients come in when they are asked or if they feel the need. Practice facilitators will help practices use their electronic health record data to create lists of patients who have missed appointments and whose blood pressure was not controlled at the last visit. We’d like facilitators to help practices offer additional new services, such as group visits, or to gain specific skills in how to engage minority patients. The plan is that these types of changes will be durable beyond the study period.”
Research has shown that the use of peer coaches is another effective approach to improving cardiovascular disease risk factors in Black Belt communities, where mistrust of the health care system is common. With peer coaches, patients have the opportunity to build positive relationships with their health care providers.
To measure the performance of peer coaches, researchers will use study cellphones that track the number of minutes spent with each participant on the phone. Workbooks that collect data will also be used in addition to random auditing of phone contacts.
The trial aims to:
- Engage rural primary care practices, hypertension patients, peer coaches and community advisory boards in Alabama and North Carolina to collaboratively finalize a practice facilitation intervention and a peer coaching intervention
- Create the data systems for the trial
- Enroll 80 practices and 25 African-American patients with hypertension at each practice
- Establish scalability of the intervention throughout the entire Black Belt region using extensive process data intended to facilitate future implementation across a wide variety of practices
“It is uncommon to find an African-American middle-aged or older person with diabetes who does not also have high blood pressure,” she said. “The poor outcomes of diabetes are accelerated in the presence of uncontrolled blood pressure, so it is very important to pay attention to both, along with cholesterol. We have learned over the last 20 years that attention to blood pressure and cholesterol in diabetes patients is as important as attending to blood sugar in optimizing the overall health of these patients.”
Safford will be joined by co-principal investigator Joshua S. Richman, M.D., Ph.D., and investigators Mike Herrington, M.D., Tamela Turner, Ph.D., Susan Andreae, MPH, Lynn Andreae, MPH, and Jean White from the UAB School of Medicine. George Howard, MPH, Joan Hilner, MPH, and Richard Mailhot from the UAB School of Public Health will also serve on the team.
The study is a partnership with two Black Belt community-based organizations, the Livingston Health and Wellness Center, and the West Central Alabama Health Improvement League (WCAHIL), as well as the West Central and Southeast Alabama Area Health Education Centers.
Safford’s team has collaborated with the Livingston Health and Wellness Center and the WCAHIL for the past six years on the completed “Encourage” and “Living Healthy” trials, as well as the ongoing Patient-Centered Outcomes Research Institute (PCORI)-funded “Living Well with Diabetes” trial. The “Triple Threat” trial will be the fourth and largest trial the team will undertake.
This project is one of only two awarded after a highly competitive national selection process. The other awardee is a team from Johns Hopkins University.
Both studies will use unique stakeholder-engaged approaches to conduct their activities, engaging stakeholders at every stage of the research process, reflective of PCORI’s involvement.
The project was conceived in its earliest stages with community members. Although the studies will be administered through the National Heart, Lung and Blood Institute with involvement of the National Institute for Neurologic Disorders and Stroke, the funds to support the projects are provided by PCORI.