While racial/ethnic disparities in blood pressure control are documented, few interventions have successfully reduced these gaps. Under-prescribing, lack of treatment intensification, and suboptimal follow-up care are thought to be central contributors. Electronic health record (EHR) tools may help address these barriers and may be enhanced with behavioral science techniques.
To evaluate the impact of a multicomponent behaviorally-informed EHR-based intervention on blood pressure control.
Reducing Ethnic and racial Disparities by improving Undertreatment, Control, and Engagement in Blood Pressure management with health information technology (REDUCE-BP) (NCT05030467) is a two-arm cluster-randomized hybrid type 1 pragmatic trial in a large multi-ethnic health care system. Twenty-four clinics (>350 primary care providers [PCPs] and >10,000 eligible patients) are assigned to either multi-component EHR-based intervention or usual care. Intervention clinic PCPs will receive several EHR tools designed to reduce disparities delivered at different points, including a: (1) dashboard of all patients visible upon logging on to the EHR displaying blood pressure control by race/ethnicity compared to their PCP peers and (2) set of tools in an individual patient’s chart containing decision support to encourage treatment intensification, ordering home blood pressure measurement, interventions to address health-related social needs, default text for note documentation, and enhanced patient education materials. The primary outcome is patient-level change in systolic blood pressure over 12 months between arms; secondary outcomes include changes in disparities and other clinical outcomes.
REDUCE-BP will provide important insights into whether an EHR-based intervention designed using behavioral science can improve hypertension control and reduce disparities.
Racial disparities in hypertension control have been recognized for decades. Despite modest improvements in treatment initiation, , blood pressure control among Black and Hispanic/Latino adults remains substantially lower than non-Hispanic whites. Many factors contribute to these persistent care gaps. Racial differences in treatment intensification alone contribute to more than 20% of observed racial/ethnic variation in blood pressure control. Follow-up care is challenging for providers and health systems, in part because of inability to afford in-home blood pressure monitoring cuffs as well as differential recommendations by providers about self-monitoring. Further, social determinants of health, such as financial resource strain, are often more prevalent among Black and Hispanic/Latino patients and socially disadvantaged individuals and can compound issues of health system access. ,
A strategy to address some of these challenges is with the use of electronic health record (EHR)-embedded tools. , , Their widespread use by providers already in their clinical workflow enhances the potential for scalability. , Many EHRs systems contain a range of possible clinical decision support tools such as alerts, dashboards, reminders, and defaults. , Despite evidence supporting the ability of these interventions to improve health care quality, in many cases they have only been modestly effective, attributed to issues with their timing within the clinical workflow, the salience of the information, and alert fatigue. , To date, very few trials have evaluated whether EHR-based interventions can reduce racial/ethnic disparities. ,
Incorporating behavioral science principles into EHR tools could improve their performance and ability to improve health equity. , , For example, EHR alerts are often delivered when clinicians are actively using the medical record to provide care; while this outreach occurs in usual workflow, clinicians may be less likely to respond to new information at this point. Priming physicians by providing information outside of visits and using behavioral science techniques to increase salience, such as showing differences in blood pressure control by race/ethnicity compared to one’s peers (ie, a behavioral science principle called social norming), , may encourage clinicians to proactively engage with their patients. Adjusting the timing and presentation of tools also leverages a form of choice architecture. , Using priming and enhancing salience may also increase receptivity to tools that are subsequently delivered in a clinical encounter. , , However, despite the promise of these approaches, relatively few interventions have specifically incorporated behavioral science principles into EHR tools and evaluated them in randomized trials, especially in hypertension.
Further, in the specific context of racial/ethnic disparities in blood pressure control, existing EHR interventions have often addressed only 1 contributor to poor control (eg, treatment intensification); their scope could be expanded to encourage screening for social determinants of health, simplifying access to appropriate community resources, and facilitating routine clinical follow-up in tandem.
Accordingly, we launched Reducing Ethnic and racial Disparities by improving Undertreatment, Control, and Engagement in Blood Pressure management with health information technology (REDUCE-BP). The overall objective was to evaluate the impact of a multi-component behaviorally-informed EHR intervention on blood pressure control and racial/ethnic disparities in patients with hypertension and measure implementation outcomes to facilitate potential future dissemination.