Dataset Information

Improving Regional Blood Pressure Control: a Positive Deviance Tiered Intensity Approach.

ABSTRACT:

Background

Accelerated translation of real-world interventions for hypertension management is critical to improving cardiovascular outcomes and reducing disparities.

Objective

To determine whether a positive deviance approach would improve blood pressure (BP) control across diverse health systems.

Design

Quality improvement study using 1-year cross sections of electronic health record data over 5 years (2013-2017).

Participants

Adults ≥ 18 with hypertension with two visits in 2 years with at least one primary care visit in the last year (N = 114,950 at baseline) to a primary care practice in Better Health Partnership, a regional health improvement collaborative.

Interventions

Identification of a "positive deviant" and dissemination of this system's best practices for control of hypertension (i.e., accurate/repeat BP measurement; timely follow-up; outreach; standard treatment algorithm; and communication curriculum) using 3 different intensities (low: Learning Collaborative events describing the best practices; moderate: Learning Collaborative events plus consultation when requested; and high: Learning Collaborative events plus practice coaching).

Main measures

We used a weighted linear model to estimate the pre- to post-intervention average change in BP control (< 140/90 mmHg) for 35 continuously participating clinics.

Key results

BP control post-intervention improved by 7.6% [95% confidence interval (CI) 6.0-9.1], from 67% in 2013 to 74% in 2017. Subgroups with the greatest absolute improvement in BP control included Medicaid (12.0%, CI 10.5-13.5), Hispanic (10.5%, 95% CI 8.4-12.5), and African American (9.0%, 95% CI 7.7-10.4). Implementation intensity was associated with improvement in BP control (high: 14.9%, 95% CI 0.2-19.5; moderate: 5.2%, 95% CI 0.8-9.5; low: 0.2%, 95% CI-3.9 to 4.3).

Conclusions

Employing a positive deviance approach can accelerate translation of real-world best practices into care across diverse health systems in the context of a regional health improvement collaborative (RHIC). Using this approach within RHICs nationwide could translate to meaningful improvements in cardiovascular morbidity and mortality.

SUBMITTER: Bolen SD

PROVIDER: S-EPMC8175516 | biostudies-literature | 2021 Jun

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Improving Regional Blood Pressure Control: a Positive Deviance Tiered Intensity Approach.

Bolen Shari D SD Love Thomas E TE Einstadter Douglas D Lever Jonathan J Lewis Steven S Persaud Harry H Fiegl Jordan J Liu Rujia R Ali-Matlock Wanda W Bar-Shain David D Caron Aleece A Misak James J Wagner Todd T Kauffman Erick E Cook Lloyd L Hebert Christopher C White Suzanne S Kobaivanova Nana N Cebul Randall R

Journal of general internal medicine 20210126 6

<h4>Background</h4>Accelerated translation of real-world interventions for hypertension management is critical to improving cardiovascular outcomes and reducing disparities.<h4>Objective</h4>To determine whether a positive deviance approach would improve blood pressure (BP) control across diverse health systems.<h4>Design</h4>Quality improvement study using 1-year cross sections of electronic health record data over 5 years (2013-2017).<h4>Participants</h4>Adults ≥ 18 with hypertension with two ...[more]

PMID: 33501526

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Project description:Agricultural development must integrate multiple objectives at the same time, including food security, income, and environmental sustainability. To help achieve these objectives, development practitioners need to prioritize concrete livelihood practices to promote to rural households. But trade-offs between objectives can lead to dilemmas in selecting practices. In addition, heterogeneity among farming households requires targeting different strategies to different types of households. Existing diversity of household resources and activities, however, may also bear solutions. We explored a new, empirical research method that identifies promising options for multi-objective development by focusing on existing cases of strong multi-dimensional household performance. The "Positive Deviance" approach signifies identifying locally viable livelihood practices from diverse households that achieve stronger performance than comparable households in the same area. These practices are promising for other local households in comparable resource contexts. The approach has been used in other domains, such as child nutrition, but has not yet been fully implemented for agricultural development with a focus on the simultaneous achievement of multiple objectives. To test our adapted version of the Positive Deviance approach, we used a quantitative survey of over 500 rural households in South-Eastern Tanzania. We identified 54 households with outstanding relative performance regarding five key development dimensions (food security, income, nutrition, environmental sustainability, and social equity). We found that, compared to other households with similar resource levels, these "positive deviants" performed strongest for food security, but only slightly better for social equity. We then re-visited a diverse sub-sample for qualitative interviews, and identified 14 uncommon, "deviant" practices that plausibly contributed to the households' superior outcomes. We illustrate how these practices can inform specific recommendations of practices for other local households in comparable resource contexts. The study demonstrates how, with the Positive Deviance approach, empirical observations of individual, outstanding households can inform discussions about locally viable agricultural development solutions in diverse household context.

Project description:BackgroundIn SPRINT (Systolic Blood Pressure Intervention Trial), patients with hypertension and high cardiovascular risk treated with intensive blood pressure (BP) control (<120 mm Hg) had fewer major adverse cardiovascular events (MACE) and deaths but higher rates of treatment-related serious adverse events (SAE) than patients randomized to standard BP control (<140 mm Hg). However, the degree of benefit or harm for an individual patient could vary because of heterogeneity in treatment effect.Methods and resultsUsing patient-level data from 9361 randomized patients in SPRINT, we developed models to predict risk for MACE or death and treatment-related SAE to allow for individualized BP treatment goals based on each patient's projected risk and benefit of intensive versus standard BP control. Models were internally validated using bootstrap resampling and externally validated on 4741 patients from the ACCORD-BP (The Action to Control Cardiovascular Risk in Diabetes blood pressure) trial. Among 9361 SPRINT patients, 755 patients (8.1%) had a MACE or death event and 338 patients (3.6%) had a treatment-related SAE during a median follow-up of 3.3 years. The MACE/death and the SAE model had C statistics of 0.72 and 0.70, respectively, in the derivation cohort and 0.69 and 0.65 in ACCORD. The MACE/death model had 10 variables including treatment interactions with age, baseline systolic BP, and diastolic BP, and the SAE model had 8 variables including treatment interaction with number of BP medications. Intensive BP treatment was associated with a mean 2.2±2.6% lower risk of MACE/death compared with standard treatment (range, 20.7% lower risk to 19.6% greater risk among individual patients) and a mean 2.2±1.2% higher risk for SAEs (range, 0.5%-15.8% more harm in individual patients).ConclusionsTo translate the findings from SPRINT to clinical practice, we developed prediction models to tailor the intensity of BP control based on the projected risk and benefit for each unique patient. This approach should be prospectively tested to better engage patients in shared medical decision making and to improve outcomes.Clinical trial registrationURL: https://clinicaltrials.gov. Unique identifier: NCT01206062.

Dataset Information

Improving Regional Blood Pressure Control: a Positive Deviance Tiered Intensity Approach.

Background

Objective

Design

Participants

Interventions

Main measures

Key results

Conclusions

Publications

Improving Regional Blood Pressure Control: a Positive Deviance Tiered Intensity Approach.

Similar Datasets

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