BP REACH: Blood Pressure disparities Reduction, Equity, and Access among safety net patients with Cardiovascular Health risk

Project Summary/Abstract - P50 Study #1 (BP REACH) Hypertension (HTN) is the leading contributor to preventable death, and a major risk factor for cardiovascular (CV) events. Suboptimal blood pressure (BP) control is the most common attributable CV risk factor, accounting for 56% of the burden of ischemic heart disease and 57% of stroke burden. BP control is also critical for reducing risk of recurrent CV events and improving outcomes after stroke and myocardial infarction (MI), yet control rates in these patients remain suboptimal, particularly for racial/ethnic minority populations served by safety net health systems. In addition to a higher burden of HTN and poor awareness, treatment, and control rates for these vulnerable communities, social determinants of health (SDOH) like low socioeconomic status (SES), limited English proficiency (LEP), and underinsurance- pose additional challenges to BP control. Thus, to reduce racial/ethnic and SDOH-rooted disparities in BP control after stroke or MI, innovative interventions are needed, addressing healthcare system, patient, and community level factors. Past health system interventions have been effective, particularly those that utilize chronic care model-based interventions, pharmacist-led medication management, and team-based management like community health workers (CHWs). Interventions that have succeeded at the patient level include those designed to expand health care access (telehealth: patient portal, remote BP self-monitoring), health literacy, and improve health behaviors (exercise and diet). Los Angeles County, with a population of 11 million, is ethnically and racially diverse, with stark socioeconomic and health disparities. Nearly half of adults are born outside the United States and 18% have incomes <100% federal poverty level. The Los Angeles County Department of Health Services (LAC-DHS) system, the 2nd largest municipal health system in the United States serves LAC's most vulnerable residents through 4 hospitals and 23 ambulatory care centers. We have conducted prior randomized controlled trials (RCTs) to improve post-stroke BP control in this safety net, and are currently conducting a primary prevention trial among individuals with HTN. Building upon our experience testing multilevel complex interventions for improving BP control in this low-income multi-ethnic setting, we propose the BP REACH study (Blood Pressure disparities Reduction, Equity, and Access among safety net patients with Cardiovascular Health risk) to: 1) Design a multilevel, culturally and linguistically tailored, complex intervention that seeks health equity for vulnerable safety net patients by prioritizing pharmacist-med medication management and CHW chronic disease education and outreach based in the SDOH, to reduce BP among multi-racial, multi-ethnic individuals with a history of stroke or MI in the LAC-DHS safety-net; 2) Test the impact of this intervention on SBP for individuals with a history of stroke or MI in a randomized trial in LAC-DHS cardiology and neurology care clinics and 3) Determine the effect of mediators on the primary outcome of systolic BP in the intervention.