Collaboration to Improve Blood Pressure in the US Black Belt- Addressing the Triple Threat

这项提案的中心目标是严格比较两种旨在改善血液的策略 为低收入的东南部非洲裔美国人提供初级保健服务的压力(BP)控制 生活在“黑带”的社会经济地位。黑带位于中风带的中心，这是一个地理上 长期以来被认为是美国心血管疾病死亡率最高的地区。我们利用不断增长的 有证据表明，实践促进(PF)是一种高度定制的阶段性方法，帮助实践 实施流程和结构改革，可以提高护理质量，改善患者和工作人员 令人满意，但关于它是否有能力改善结果，如BP控制，证据较少。替补 改善心血管疾病风险因素的方法，更加注重关系，并有越来越多的证据表明 有效性涉及到同行教练的使用。我们和其他人已经证明，同伴教练在 黑带社区，那里对医疗保健系统的不信任很普遍。使用成熟的 根据以社区为基础的伙伴关系和RE-AIM实施框架，我们的UH2具体目标是：1. 参与农村初级保健实践、高血压(HTN)患者、同伴辅导和社区咨询 AL和NC的董事会协作敲定PF干预和同伴教练干预，两者都是 旨在改善非裔美国人的BP。2.创建试验数据系统。我们的UH3特定目标 是：3.每个诊所招募80个诊所和25名患有不受控制的HTN的非裔美国患者(总计 N=2000)在一项整群随机、受控的语用实施试验中，比较了两个多目标 构成部分，多层次干预措施在UH2阶段完成，并使用2x2加强日常护理 析因设计。我们假设，这两种干预措施比加强常规护理更能改善BP，而且 两种干预措施一起实施将比任何一种干预措施带来更大的BP改善 独自一人。虽然我们的目标是总体上控制75%参与干预的患者的血压，但该试验旨在 检测联合干预和强化干预在血压控制(主要结果)方面的15%差异 照常看护手臂。次要结果将包括基线和随访之间的组平均血压差异- UP；生活质量；患者满意度；医疗保健利用率；以及提供者和员工满意度。这项研究是 旨在检查性别、年龄、抑郁症和健康素养/算术能力的差异。目标4.建立 使用旨在实现以下目的的大量流程数据，在整个黑带地区实现干预的可扩展性 促进未来的实施，包括实践特征、患者特征、干预 实施变量和保真度措施，以及焦点小组和与患者、同行的访谈 教练、辅导员、实习人员和临床医生。我们在基于社区的同行方面有丰富的经验 教练干预；PF干预；心血管疾病的健康差异研究；大型多点随机研究 受控试验采用了现实世界的做法，确保了项目的成功。

The central objective of this proposal is to rigorously compare two strategies designed to improve blood pressure (BP) control in primary care practices serving rural Southeastern African Americans with low socioeconomic status living in the “Black Belt”. The Black Belt is in the heart of the Stroke Belt, a geographic area long recognized to have the highest cardiovascular disease mortality in the US. We draw on the growing evidence that practice facilitation (PF), a highly customized, staged approach to helping practices to implement process and structural changes, can enhance the quality of care and improve patient and staff satisfaction, but there is less evidence on its ability to improve outcomes such as BP control. An alternate approach to improving CVD risk factors that is more relationship-focused and with growing evidence of effectiveness involves the use of peer coaches. We and others have shown that peer coaches are effective in Black Belt communities, where mistrust of the healthcare system is common. Using well-established community-based partnerships and the RE-AIM implementation framework, our UH2 Specific Aims are: 1. Engage rural primary care practices, hypertension (HTN) patients, peer coaches, and Community Advisory Boards in AL and NC to collaboratively finalize a PF intervention and a peer coaching intervention, both designed to improve BP in African Americans. 2. Create the data systems for the trial. Our UH3 Specific Aims are: 3. Enroll 80 practices and 25 African American patients with uncontrolled HTN at each practice (total n=2000) in a cluster-randomized, controlled pragmatic implementation trial to compare the two multi- component, multi-level interventions finalized in the UH2 phase with enhanced usual care using a 2 x 2 factorial design. We hypothesize that both interventions will improve BP more than enhanced usual care, and that both interventions delivered together will result in greater improvements in BP than either intervention alone. While we aim to control BP in 75% of participating intervention patients overall, the trial is designed to detect >15% difference in BP control (primary outcome) between the combined intervention and the enhanced usual care arms. Secondary outcomes will include group mean BP differences between baseline and follow- up; quality of life; patient satisfaction; healthcare utilization; and provider and staff satisfaction. The study is designed to examine differences by sex, age, depression, and health literacy/numeracy. Aim 4. Establish scalability of the intervention throughout the entire Black Belt region using extensive process data intended to facilitate future implementation, including practice characteristics, patient characteristics, intervention implementation variables and fidelity measures, as well as focus groups and interviews with patients, peer coaches, facilitators, practice staff, and clinicians. We have extensive experience with community-based peer coaching interventions; PF interventions; health disparities research in CVD; and large multi-site randomized controlled trials engaging real-world practices, assuring the success of the project.