Hypertension is the most important modifiable risk factor for cardiovascular disease.
Black Americans have the highest prevalence of hypertension and the lowest rates of blood
pressure (BP) control of any racial or ethnic group in the U.S., contributing to
cardiovascular disease disparities. Low-income Americans are also disproportionally
burdened by hypertension. To achieve health equity, new approaches to hypertension
management leveraging safety-net healthcare systems to reach underserved populations are
needed.
One approach to addressing the hypertension epidemic is to identify and treat people
undiagnosed, untreated, or with undertreated hypertension - people who have fallen
through the cracks in the healthcare system. We did this in Reach Out 1 (R01MD011516), a
mobile health (mHealth) 8-arm factorial trial of hypertensive patients recruited from a
safety-net ED. Overall, systolic BP declined by 9.2 mmHg (95% CI -12.2 to - 6.3) after 6
months, without differences across treatment arms. Reach Out 1 successfully enrolled a
hypertensive, medically underserved population into a mHealth intervention. Despite a
very large reduction in BP overall, the efficacy of the Reach Out mHealth intervention is
uncertain, given the lack of a control group.
Reach Out 2 proposes to test the most promising components of Reach Out 1 in a randomized
open, blinded-endpoint (PROBE) controlled trial. Reach Out 2, continues our work with the
same safety-net ED and Federally Qualified Health Centers. In Reach Out 2, we will
compare usual care, to 6-months of prompted self-monitored blood pressure (SMBP)
monitoring with tailored feedback and facilitated primary care appointment and
transportation. The usual care group will receive instructions to follow up with a
primary care provider after ED discharge. After 6 months, the intervention participants
will enter an extended treatment period of long-term SMBP monitoring. To contextualize
our findings, we will use our chronic disease agent-based simulation model to estimate
the reduction in myocardial infarction, stroke, and dementia if Reach Out 2 were to be
implemented in safety-net EDs across the US. The overarching goal of our proposal is to
determine whether a low-tech mHealth intervention will reduce BP more than usual care
among patients recruited from a safety-net ED and to understand the potential national
impact of such an intervention. Because safety-net EDs are anchor institutions that care
for large populations of medically underserved hypertensive people, mHealth strategies
initiated here have tremendous potential to reduce cardiovascular inequities. To reach
this potential, evidence based interventions to reduce BP must be identified (aim 1),
long-term engagement evaluated (aim 2), and their impact understood (aim 3).
