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Equitable Care for Hypertension: RICH LIFE Project Outcomes
Quick Takes
- Enhanced standard of care plus care management and stepped care did not improve BP control.
- Of note, although collaborative care did not improve BP control or levels, it did result in better patient experiences of care, an important outcome with long-term implications for other health outcomes.
- Additional prospective studies are indicated to assess whether collaborative care to address greater social and medical needs will reduce disparities in hypertension control.
Study Questions:
What is the impact of enhanced standard of care plus care management and stepped care on blood pressure (BP) control?
Methods:
The investigators conducted the RICH LIFE (Reducing Inequities in Care of Hypertension: Lifestyle Improvement for Everyone) two-arm, cluster randomized trial comparing the effect on BP control (systolic BP ≤140 mm Hg, diastolic BP ≤90 mm Hg), patient activation, and disparities in BP control of two multilevel interventions, standard of care plus (SCP) and collaborative care/stepped care (CC/SC). SCP included BP measurement standardization, audit and feedback, and equity-leadership training. CC/SC added roles to address social or medical needs. Primary outcomes were BP control and patient activation at 12 months. Generalized estimating equations and mixed-effects regression models with fixed effects of time, intervention, and their interaction compared change in outcomes at 12 months from baseline.
Results:
A total of 1,820 adults with uncontrolled BP and ≥1 other risk factors enrolled in the study. Their mean age was 60.3 years, and baseline BP was 152.3/85.5 mm Hg; 59.4% were women, 57.4% were Black, 33.2% were White, and 9.4% were Hispanic; 74% had hyperlipidemia; and 45.1% had type 2 diabetes. CC/SC did not improve BP control rates more than SCP. Both groups achieved statistically and clinically significant BP control rates at 12 months (CC/SC: 57.3% [95% CI, 52.7%–62.0%]; SCP: 56.7% [95% CI, 51.9%–61.5%]). Pairwise comparisons between racial and ethnic groups showed overall no significant differences in BP control at 12 months.
Patients with coronary heart disease showed greater achievement of BP control in CC/SC than in SCP (64.0% [95% CI, 54.1%–73.9%] vs. 50.8% [95% CI, 42.6%–59.0%]; p = 0.04), as did patients in rural areas (67.3% [95% CI, 49.8%–84.8%] vs. 47.8% [95% CI, 32.4%–63.2%]; p = 0.01). Individuals in both arms experienced statistically and clinically significant reductions in mean systolic BP (CC/SC: −13.8 mm Hg [95% CI, −15.2 to −12.5]; SCP: −14.6 mm Hg [95% CI, −15.9 to −13.2]) and diastolic BP (CC/SC: −6.9 mm Hg [95% CI, −7.8 to −6.1]; SCP: −5.5 mm Hg [95% CI, −6.4 to −4.6]) over time. The difference in diastolic BP reduction between CC/SC and SCP over time was statistically significant (−1.4 mm Hg [95% CI, −2.6 to −0.2]).
Patient activation did not differ between arms. CC/SC showed greater improvements in patient ratings of chronic illness care (Patient Assessment of Chronic Illness Care score) over 12 months (0.12 [95% CI, 0.02–0.22]).
Conclusions:
The authors report that adding a collaborative care team to enhanced standard of care did not improve BP control but did improve patient ratings of chronic illness care.
Perspective:
This study reports that enhanced standard of care plus care management and stepped care (additional supports for patients with greater social or medical needs) reduced BP, but BP control in this group was not different from that in the enhanced standard of care alone group. Furthermore, Black and White patients achieved BP control at similar rates in both study arms and reductions in systolic and diastolic BP over 12 months that were clinically meaningful but not consistent across arms. Of note, although collaborative care did not improve BP control or levels, it did result in better patient experiences of care, an important outcome with long-term implications for other health outcomes. Additional prospective studies are indicated to assess whether collaborative care to address greater social and medical needs will reduce disparities in hypertension control.
Clinical Topics: Cardiovascular Care Team, Prevention
Keywords: Blood Pressure, Healthcare Disparities, Standard of Care
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