Reducing ethnic and racial disparities by improving undertreatment, control, and engagement in blood pressure management with health information technology (REDUCE-BP) hybrid effectiveness-implementation pragmatic trial: Rationale and design

Racial disparities in hypertension control have been recognized for decades. 12345 Despite modest improvements in treatment initiation, 6 , 7 blood pressure control among Black and Hispanic/Latino adults remains substantially lower than non-Hispanic whites. 7891011 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. 2 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. 12 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. 13 , 14

A strategy to address some of these challenges is with the use of electronic health record (EHR)-embedded tools. 2 , 15 , 16 Their widespread use by providers already in their clinical workflow enhances the potential for scalability. 15 , 17 Many EHRs systems contain a range of possible clinical decision support tools such as alerts, dashboards, reminders, and defaults. 18 , 19 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. 18 , 202122 To date, very few trials have evaluated whether EHR-based interventions can reduce racial/ethnic disparities. 23 , 24

Incorporating behavioral science principles into EHR tools could improve their performance and ability to improve health equity. 18 , 21 , 25262728 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. 18 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), 18 , 25 may encourage clinicians to proactively engage with their patients. Adjusting the timing and presentation of tools also leverages a form of choice architecture. 18 , 29 Using priming and enhancing salience may also increase receptivity to tools that are subsequently delivered in a clinical encounter. 18 , 29 , 30 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. 22

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); 31 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. 32

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.