Tailored Interventions Lower Blood Pressure for Groups Experiencing Health Disparities

Five-year study shows effect of enhanced standard of care and collaborative care on hypertension control

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Health Equity
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Cardiovascular disease remains the leading cause of death in the US, significantly affecting racial, geographic, and socioeconomic disparities in mortality and life expectancy. Researchers at the Johns Hopkins Center for Health Equity have published a groundbreaking study in Circulation journal that reveals new strategies for combating hypertension disparities in underserved communities.  Led by Lisa A. Cooper, MD, MPH, and  Jill A. Marsteller, PhD, MPP,  the RICH LIFE Project is a 2-arm cluster randomized trial conducted from 2015 to 2021.  

The RICH LIFE project compared the effects of two programs on blood pressure control: enhanced standard of care alone and enhanced standard of care plus care management focusing on addressing patients’ health-related beliefs and social needs. RICH LIFE, or Reducing Inequities in Care of Hypertension: Lifestyle Improvement for Everyone, demonstrated that customized approaches developed and implemented in partnership with patients, clinicians, health-system leaders, and community partners prove effective in diverse real-world healthcare settings. 

After 12 months, patients in both intervention groups showed clinically significant improvements in blood pressure among participants, regardless of race, but patients receiving the collaborative care intervention reported better experiences of care than those receiving only enhanced standard of care. Patients living in rural areas and those with heart disease also achieved better blood pressure control in the collaborative care intervention group.  "Equitable Care for Hypertension: Blood Pressure and Patient-Reported Outcomes of the RICH LIFE Cluster of Randomized Trials" was published in Circulation on July 15, 2024.
Fifty-seven percent of patients in both programs achieved blood pressure control at one year. The two programs reduced systolic blood pressure (SBP)  by 13.8 mm Hg to 14.6 mm Hg and diastolic blood pressure by 5.5 mm HG to  6.9 mm Hg over 12 months of follow-up. Adding care managers and community health workers to primary care teams did not increase the effectiveness of an enhanced standard of care program for blood pressure, but it did improve patient assessments of chronic illness care. In both study programs, Black and White patients achieved blood pressure control at similar rates. Patients with heart disease and those living in rural areas had greater achievement of BP control in the enhanced standard of care plus care management program.

“Our study emphasizes the importance of comprehensive approaches to hypertension management and the possibility that more intensive approaches are needed for patients with greater social and medical needs.” ~ Lisa A. Cooper, MD, MPH

“The improvement in blood pressure control for both study groups in the RICH LIFE project is excellent news for patients, especially during a time when national blood pressure control rates have been declining,” said Lisa A. Cooper, MD, MPH, co-principal investigator of the study, and James F. Fries Professor of Medicine and Bloomberg Distinguished Professor, Johns Hopkins School of Medicine, School of Nursing and Bloomberg School of Public Health. “Our study emphasizes the importance of comprehensive approaches to hypertension management and the possibility that more intensive approaches are needed for patients with greater social and medical needs.”

Recent data from the National Health and Nutrition Examination Survey showed a decline in blood pressure control among older adults, women, and non-Hispanic Black adults. Despite these trends, the RICH LIFE project demonstrated that multilevel interventions can significantly enhance blood pressure control by combining focused training on equity and quality improvement for system leaders, clinical performance feedback for clinicians, and staff training in hypertension best practices. While adding a care management team did not improve BP control any further, it did result in better patient experiences of care—an important outcome with long-term implications for other outcomes. 

History of cardiovascular disease disparity 

Cardiovascular disease is the top cause of death and disability in the United States, despite the availability of many effective treatments. Each year, the US spends $231.1 billion on CVD, $83.9 billion on hypertension, and $51.8 billion on high cholesterol. African Americans, American Indians/Alaska Natives, Asian/Pacific Islanders, and Hispanics suffer more from heart disease than their share of the population would suggest. People with low income and those living in rural areas also face more challenges with hypertension and cardiovascular disease, including less access to quality care. Reducing disparities in hypertension is challenging due to a variety of barriers at different levels, including individual behaviors, family and social support, healthcare providers and systems, local communities, and broader policies. The COVID-19 pandemic exacerbated existing health disparities in hypertension treatment and control across the United States. 

Study design

Between 2015 and 2022, the RICH LIFE project compared two different ways of helping people with high blood pressure improve their health. It involved 1,820 adults with uncontrolled hypertension and other heart disease risk factors, treated at 30 primary care practices in Maryland and Pennsylvania. Of patients, 57 percent were non-Hispanic Black, 33 percent were non-Hispanic White, and 9 percent were Hispanic. The average age was 60, and 59 percent were women. 

The study had two groups:

Enhanced Standard of Care (SCP) Group: 

  • 15 practices received training on how to measure blood pressure correctly.
  • They got feedback on their blood pressure control rates, specifically looking at different racial and ethnic groups.
  • Quarterly webinars on managing blood pressure, improving quality, and reducing disparities were held.

Collaborative Care/Stepped Care (CC/SC) Group: 

  • 15 practices received everything in the SCP group plus additional support.
  • A care management model that included referrals to community health workers.
  • Care managers and primary care clinicians consulted the remote specialists and then decided how to incorporate their recommendations into the patient’s care.
  • Regular coaching calls with other practices in the CC/SC group.

The study’s main goals were to see how well these methods improved blood pressure control and how engaged patients were in managing their health after 12 months, referred to as “patient activation.” 

Key findings:

The study found that the interventions led to clinically significant improvements in blood pressure control for patients in both groups:

Systolic Blood Pressure (SBP) Reductions:

  • CC/SC group: Average decrease of 13.8 mm Hg
  • SCP group: Average decrease of 14.6 mm Hg

Diastolic Blood Pressure (DBP) Reductions:

  • CC/SC group: Average decrease of 6.9 mm Hg
  • SCP group: Average decrease of 5.5 mm Hg

“The RICH LIFE project highlights the crucial policy implication of the importance of system-level leadership and engagement of practice-level leaders in enhancing hypertension management in primary care settings nationwide,” said Jill A. Marsteller, PhD, MPP, co-principal investigator and Professor of Health Policy and Management in the Johns Hopkins Bloomberg School of Public Health. “This study is unique in that it intervenes at the system level and demonstrates that providing race-stratified feedback on clinical performance, as well as leadership training in quality improvement and managerial skills, can yield significant benefits. These approaches act as equity champions and are essential complements to patient self-care and active monitoring by physicians and staff, ultimately leading to better patient health outcomes across the board.”

Other interesting findings: 

Each intervention approach effectively helped patients lower blood pressure by clinically significant levels. However, there was no clinically significant difference between the two groups regarding systolic or diastolic BP reduction. 

Patients in the CC/SC group reported better overall chronic illness care over the 12-month period than those in the SCP group. These patients had better “patient activation.” Both interventions improved patient care, but the CC/SC group showed slightly better patient experiences.

“The RICH LIFE study underscores the importance of a comprehensive care team, including case managers and community health workers, in improving patient experiences and outcomes,” Cooper said. “This is important information that should encourage health system leaders and policymakers to adopt these multilevel, patient-focused interventions to address health disparities in teaching hypertension and cardiovascular disease more effectively, particularly for high-risk patients and those in rural areas."

Cooper said the team plans to examine the sustainability of interventions beyond 12 months, investigate whether primary care practices are better equipped to address social determinants of health, and discover the cost-effectiveness of such interventions in the future. The RICH LIFE Project was funded by the National Heart, Lung, and Blood Institute and the Patient-Centered Outcomes Research Institute under grant 1UH2/UH3HL130688.

The complete list of authors and their affiliations are listed below: 

Lisa A. Cooper, MD, MPH1,2,3,4,5,6,a; Jill A. Marsteller, PhD, MPP1,2,3,5; Kathryn A. Carson, ScM1,2,3,6;Katherine B. Dietz, MPH1,2; Romsai T. Boonyasai, MD, MPH1,7; Carmen Alvarez, PhD2,8; Deidra C. Crews, MD, ScM1,2,6; Cheryl R. Dennison Himmelfarb1,2,4,9;Chidinma A. Ibe, PhD1,2,4; Lisa Lubomski, PhD1,2,5; Edgar R. Miller 3rd, MD, PhD1,2,3; Nae-Yuh Wang, PhD, MS1,3,6,10; Gideon D. Avornu, MS11; Deven Brown, MPA1,2; Debra Hickman, M.Div.2,12; Michelle Simmons2; Ariella Apfel Stein, MPH1,2 and Hsin-Chieh Yeh, PhD1,2,3 for the RICH LIFE Project Investigators

Affiliations

  1. Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
  2. Johns Hopkins Center for Health Equity, Johns Hopkins University, Baltimore, Maryland
  3. The Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
  4. Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
  5. Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
  6. Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
  7. Agency for Healthcare Research and Quality, Rockville, Maryland
  8. University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
  9. Johns Hopkins School of Nursing, Baltimore, Maryland
  10. Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
  11. Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland 
  12. Sisters Together and Reaching, Inc., Baltimore, MD