Effectiveness of Implementing an Intensive Blood Pressure Reduction Intervention on Cognitive Decline in Low-income and Minority Hypertensive Patients

实施强化降压干预措施对低收入和少数民族高血压患者认知功能下降的有效性

• 批准号: 10467065
• 负责人: Jiang He
• 金额: $ 129.57万
• 依托单位: TULANE UNIVERSITY OF LOUISIANA
• 依托单位国家: 美国
• 财政年份: 2020
• 资助国家: 美国
• 起止时间: 2020-08-01 至 2025-07-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10467065
• 关键词: Adopted; Adoption; Adult; Adverse effects; African American; Age-Years; Algorithms; Blood Pressure; Clinic; Clinical; Clinical Trials; Clinical Trials Data Monitoring Committees; Cluster randomized trial; Cognitive; Consent Forms; Data; Data Collection; Dementia; Development; Diastolic blood pressure; Effectiveness; Electronic Health Record; Enrollment; Ensure; Evaluation; Federally Qualified Health Center; Feedback; Global Change; Health; Home Blood Pressure Monitoring; Hypertension; Impaired cognition; Institutional Review Boards; Intensive Care; Intervention; Intervention Studies; Intervention Trial; Interview; Journals; Louisiana; Low Income Population; Low income; Memory; Meta-Analysis; Minority; Minority Groups; Mississippi; Outcome; Outcome Measure; Outcome Study; Participant; Patients; Penetrance; Phase; Primary Health Care; Protocols documentation; Public Health; Published Comment; Quality of life; Reach Effectiveness Adoption Implementation and Maintenance; Research Design; Resources; Review Committee; Risk; Rural Population; Sample Size; Sampling; Side; Surveys; Testing; Time; Ursidae Family; adjudicate; aged; base; blood pressure control; blood pressure intervention; blood pressure reduction; cognitive function; cognitive testing; collaborative care; control trial; cost; cost effectiveness; design; effectiveness implementation study; effectiveness outcome; effectiveness testing; executive function; follow-up; hypertension control; hypertensive; implementation evaluation; implementation outcomes; implementation strategy; implementation trial; improved; intervention delivery; mild cognitive impairment; multi-component intervention; patient oriented; prevent; primary care setting; primary outcome; public health relevance; racial minority; recruit; retention rate; scale up; secondary outcome; shared decision making; staff intervention; treatment as usual; treatment strategy

African American and low-income populations bear a disproportionate burden of dementia and have been underrepresented in trials of cognitive impairment. The Systolic Blood Pressure Intervention Trial (SPRINT) showed that an intensive blood pressure (BP) intervention (target systolic BP <120 mmHg) lowered the risk of cognitive impairment compared to a standard BP intervention (systolic BP target <140 mmHg). The next important step is to determine how the successful SPRINT intensive blood pressure intervention can be implemented in a real-world clinic setting to prevent cognitive decline. The overall objective of the proposed study is to test a multifaceted strategy for implementing an intensive BP intervention protocol adapted from SPRINT targeting systolic BP <120 mmHg on cognitive decline in racial minority and low-income hypertensive patients in resource-constrained primary care practices in Louisiana and Mississippi. The RE-AIM (Reach Effectiveness Adoption Implementation Maintenance) framework has been used to guide the development and evaluation of the multifaceted implementation strategy, including protocol-based treatment that employs the SPRINT stepped-care intensive BP management algorithm, dissemination of SPRINT findings, shared- decision making, team-based collaborative care, BP audit and feedback, home BP monitoring, and patient health coaching. Building on the ongoing Implementation of Multifaceted Patient-Centered Treatment Strategies for Intensive Blood Pressure Control (IMPACTS-BP) trial, we will cost-effectively conduct a cluster- randomized trial in 36 Federally Qualified Health Center clinics that serve low-income populations in Louisiana and Mississippi. The primary outcome in the proposed trial is the net difference in mean change of global cognitive composite z-score over an average of 42 months between the intervention and enhanced usual care groups. Secondary outcomes include net difference in mean change of executive function and memory composite z-scores, systolic and diastolic BP, adverse effects, and quality of life. Implementation outcomes, including acceptability, adaptation, adoption, feasibility, fidelity, penetrance, and cost-effectiveness, will also be collected and used to improve intervention delivery during the trial. The proposed trial, with a sample size of 36 clinics (35 patients/clinic), has 85% statistical power to detect a 0.30 or higher difference in the global cognitive composite z-score at a 2-sided significance level of 0.05 assuming 20% loss to follow-up and an intra-cluster correlation of 0.05. In a meta-analysis of 5 clinical trials, the pooled effect size was 0.35 (95% CI 0.32, 0.38) for the global cognitive composite z-score. This study will generate urgently needed data on effective, adoptable, and equitable intervention strategies to reduce blood pressure-related cognitive decline in low-income and minority populations. If proven effective, the implementation strategy for intensive blood pressure reduction could be adapted and scaled up in diverse primary care settings to prevent cognitive decline and clinical dementia.

非洲裔美国人和低收入人群承受着不成比例的痴呆症负担，在认知障碍试验中代表性不足。收缩压干预试验(Sprint)表明，与标准血压干预(目标收缩压140 mmHg)相比，强化血压干预(目标收缩压120 mmHg)降低了认知障碍的风险。下一个重要的步骤是确定如何在现实世界的临床环境中实施成功的Sprint强化血压干预，以防止认知能力下降。这项拟议研究的总体目标是测试一种多方面的策略，以实施从Sprint改编的强化BP干预方案，该方案针对路易斯安那州和密西西比州资源有限的初级保健实践中少数民族和低收入高血压患者的认知功能下降。REACH有效性采用实施维护(RE-AIM)框架已被用于指导多方面实施战略的开发和评估，包括采用Sprint分级护理重症BP管理算法的基于协议的治疗、Sprint结果的传播、共享决策、基于团队的协作护理、BP审计和反馈、家庭BP监测和患者健康指导。在持续实施多方面以患者为中心的强化血压控制治疗策略(Impact-BP)试验的基础上，我们将在36家联邦合格的健康中心诊所进行成本效益高的整群随机试验，这些诊所服务于路易斯安那州和密西西比州的低收入人群。在拟议的试验中，主要结果是干预组和增强型常规护理组之间平均42个月的全球认知综合z分数平均变化的净差异。次要结果包括执行功能和记忆综合Z分数、收缩压和舒张压、不良反应和生活质量的平均变化的净差异。还将收集实施结果，包括可接受性、适应性、采纳性、可行性、保真度、外显性和成本效益，并在试验期间用于改进干预交付。拟议的试验样本规模为36家诊所(35名患者/诊所)，具有85%的统计能力，可以在双侧显着性水平0.05下检测全球认知综合z得分0.30或更高的差异，假设随访损失20%，组内相关性为0.05。在对5项临床试验进行的荟萃分析中，全球认知综合z分数的汇集效应大小为0.35(95%可信区间0.32，0.38)。这项研究将产生关于有效、可采用和公平的干预策略的迫切需要的数据，以减少低收入和少数群体中与血压相关的认知下降。如果被证明有效，强化降压的实施战略可以在不同的初级保健环境中进行调整和扩大，以防止认知能力下降和临床痴呆。