Mathews Lena, Miller Edgar R, Cooper Lisa A, Marsteller Jill A, Ndumele Chiadi E, Antoine Denis G, Carson Kathryn A, Ahima Rexford, Daumit Gail L, Oduwole Modupe, Onuoha Chioma, Brown Deven, Dietz Katherine, Avornu Gideon D, Chung Suna, Crews Deidra C
Author Affiliations: Johns Hopkins Center for Health Equity (Drs Mathews, Miller, Cooper, Marsteller, Ndumele, Antoine, Carson, Ahima, Daumit, Oduwole, Onuoha, Brown, Dietz, Avornu, Chung and Crews), Welch Center for Epidemiology, Prevention, and Clinical Research (Drs Mathews, Miller, Cooper, Ndumele, Carson, Ahima, Daumit, and Crews), Department of Medicine (Drs Mathews, Miller, Cooper, Marsteller, Ndumele, Ahima, Daumit, and Crews), Department of Psychiatry and Behavioral Medicine (Dr Antoine), Department of Emergency Medicine, Johns Hopkins University School of Medicine (Dr Avornu), Baltimore, Maryland; Department of Epidemiology (Dr Cooper and Carson), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; and University of California, San Francisco School of Medicine (Ms Onuoha), San Francisco, California.
Qual Manag Health Care. 2024 Nov 29. doi: 10.1097/QMH.0000000000000500.
Individuals with low income or from minoritized racial or ethnic groups experience a high burden of hypertension and other chronic conditions (eg, diabetes, chronic kidney disease, and mental health conditions) and often lack access to specialist care when compared to their more socially advantaged counterparts. We used a mixed-methods approach to describe the deployment of a Remote Collaborative Specialist Panel intervention aimed at the comprehensive and coordinated management of patients with hypertension and comorbid conditions to address health disparities.
Participants of the collaborative care/stepped care arm of the Reducing Inequities in Care of Hypertension: Lifestyle Improvement for Everyone (RICH LIFE) Project, a cluster-randomized trial comparing the effectiveness of enhanced standard of care to a multilevel intervention (collaborative care/stepped care) for improving blood pressure control and reducing disparities, were included. Participants were eligible for referral by their care manager to the Specialist Panel if they continued to have poorly controlled hypertension or had uncontrolled comorbid conditions (eg, diabetes, hyperlipidemia, depression) after 3 months in the RICH LIFE trial. Referred participant cases were discussed remotely with a panel of specialists in internal medicine, cardiology, nephrology, endocrinology, and psychiatry. Qualitative data on the Specialist Panel recommendations and interviews with care managers to understand barriers and facilitators to the intervention were collected. We used available components of the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework to examine the impact of the intervention.
Of 302 participants in the relevant RICH LIFE arm who were potentially eligible for the Specialist Panel, 19 (6.3%) were referred. The majority were women (53%) and of Black race (84%). Referral reasons included uncontrolled blood pressure, diabetes, and other concerns (eg, chronic kidney disease, life-stressors, medication side effects, and medication nonadherence). Panel recommendations centered on guideline-recommended diagnostic and management algorithms, minimizing intolerable medication side effects and costs, and recommendations for additional referrals. Panel utilization was limited. Barriers reported by care managers were lack of perceived need by clinicians due to redundant specialists, a cumbersome referral process, the remote nature of the panel, and the sensitivity of relaying recommendations back to the primary care physician. Care managers who made panel referrals reported it was overwhelmingly valuable.
The use of a Remote Collaborative Specialist Panel was limited but well-received by referring clinicians. With modifications to enhance uptake, the Remote Collaborative Specialist Panel may be a practical care model for addressing some disparities in hypertension and multi-morbidity care.
与社会经济地位较高的人群相比，低收入或少数族裔个体承受着高血压和其他慢性疾病（如糖尿病、慢性肾脏病和精神疾病）的沉重负担，且往往难以获得专科护理。我们采用混合方法描述了一种远程协作专家小组干预措施的实施情况，该干预旨在对高血压及合并症患者进行全面、协调的管理，以消除健康差距。
纳入了“降低高血压护理不平等：人人改善生活方式（RICH LIFE）项目”中协作护理/逐步护理组的参与者，这是一项整群随机试验，比较强化标准护理与多级干预（协作护理/逐步护理）在改善血压控制和减少差距方面的有效性。如果参与者在RICH LIFE试验3个月后仍存在高血压控制不佳或合并症未得到控制（如糖尿病、高脂血症、抑郁症），其护理经理可将其转介至专家小组。被转介参与者的病例由内科、心脏病学、肾脏病学、内分泌学和精神病学专家小组进行远程讨论。收集了关于专家小组建议的定性数据，并与护理经理进行访谈，以了解干预措施的障碍和促进因素。我们使用RE-AIM（覆盖范围、有效性、采用率、实施情况和维持情况）框架的现有组成部分来评估干预措施的影响。
在RICH LIFE项目相关组中，有302名可能符合专家小组条件的参与者，其中19名（6.3%）被转介。大多数是女性（53%），黑人种族（84%）。转介原因包括血压控制不佳、糖尿病以及其他问题（如慢性肾脏病、生活压力源、药物副作用和药物不依从）。专家小组的建议集中在指南推荐的诊断和管理算法、尽量减少难以忍受的药物副作用和成本，以及进一步转诊的建议。专家小组的利用率有限。护理经理报告的障碍包括临床医生认为由于专家冗余而没有必要、转诊过程繁琐、专家小组的远程性质以及将建议反馈给初级保健医生的敏感性。进行专家小组转诊的护理经理表示这非常有价值。
远程协作专家小组的使用有限，但受到转诊临床医生的好评。通过改进以提高接受度，远程协作专家小组可能是一种解决高血压和多种合并症护理中一些差距的实用护理模式。
