For younger Black patients living in rural parts of the Southeastern United States, peer coaching is more effective than traditional clinical care in controlling high blood pressure, according to a new study led by investigators at Weill Cornell Medicine and NewYork-Presbyterian. The investigators learned that for people under age 60 who have persistently uncontrolled hypertension, the benefits of working with a peer health coach were equivalent to what would be expected from taking a low dose of blood pressure medication.
The findings were published March 18 in JAMA Internal Medicine. The randomized clinical trial was conducted by a team of researchers from Weill Cornell Medicine, NewYork-Presbyterian, the University of North Carolina at Chapel Hill, East Carolina University and the University of Alabama at Birmingham, and included 1,592 Black patients with persistently uncontrolled high blood pressure who were being seen at 69 rural primary care practices.
“The improvements that we saw were important, especially because there was no new medication needed,” said first author and study lead Dr. Monika Safford, the John J. Kuiper Professor of Medicine and chief of the Division of General Internal Medicine at Weill Cornell Medicine and NewYork-Presbyterian/Weill Cornell Medical Center. “On a population level, this type of improvement translates into fewer strokes and heart attacks.”
Dr. Monika Safford Credit: John Abbott
Focusing on Preventive Healthcare in Underserved Populations
Dr. Safford and her collaborators focused on high blood pressure for this study because it was an area of concern for the healthcare providers they worked with on earlier research in underserved populations. The study was designed with four arms: practices were randomized to receive enhanced usual care alone or with the addition of peer coaching, practice facilitation, or a combination of peer coaching and practice facilitation, delivered over one year. The enhanced usual care approach provided each medical practice with educational information as well as blood pressure monitors to distribute to each enrolled patient. Peer coaching consisted of a structured educational/behavioral intervention provided over the phone. Practice facilitation consisted of a coach who helped practice staff to implement at least four hypertension-focused quality improvement activities.
Data analysis revealed that all groups showed some improvement, although across the entire study (patients aged 18-85) there was no significant difference among the four arms. Importantly, though, preplanned subgroup analysis showed that participants under age 60 in both the peer coaching and peer coaching/practice facilitation groups experienced a medically significant reduction in systolic blood pressure compared with those who received only enhanced usual care. The average reduction was 5 millimeters of mercury greater in this population subset than it was in other groups. Systolic blood pressure, the first and higher of the two numbers in a blood pressure reading, indicates how much pressure the blood exerts against artery walls when the heart contracts.
“We were not surprised to see this greater benefit in younger patients,” Dr. Safford said. “We know this is a population that has more room for improvement, because they are less likely to take their medications regularly.” The peer coaches were specially trained to educate patients on how to monitor and reduce their blood pressure. This included providing tips on limiting salt intake, increasing physical activity, and reducing stress in addition to taking medications daily.
Dr. Safford also noted an important trend in the practice facilitation intervention outside the confines of the study. The intervention focused on all patients with hypertension at each practice, not just the 25 patients enrolled in the study. And though practice facilitation didn’t prove more effective than enhanced usual care for the enrolled participants, the practice’s own estimates on how all their hypertensive patients were doing, regardless of whether they identified as Black or had persistently uncontrolled hypertension, showed a remarkable 6 percentage point increase in control, from 55 percent controlled at baseline to 61 percent controlled a year later, she said.
“Unfortunately, we did not have the resources to estimate practice-level blood pressure control at the practices that did not receive practice facilitation,” Dr. Safford said. “This finding still provides support for the promise of practice facilitation in these very under-resourced practices and warrants additional study.”
Leveraging Community-Academic Partnerships for Greater Benefit
An exciting feature of this trial was the community partnership model it used. Healthcare providers from across the 69 sites, peer coaches, and practice facilitators, as well as community advisory boards in Alabama and North Carolina provided valuable insights on trial design and on which interventions were most likely to benefit patients. “If we hadn’t had these strong partnerships, we would not have designed the study the way we did,” Dr. Safford said. “The peer coaches were able to suggest solutions that we never would have dreamed of, because they have such a deep understanding of their own communities.”
She added that peer coaching is a model that should be considered more broadly for helping underserved populations to manage chronic health conditions. “These populations have trust issues with the healthcare system, but they trust other people from their own community,” she said. “Leveraging that trust can have a very positive impact. It also helps create jobs for people in these communities.”
Many Weill Cornell Medicine physicians and scientists maintain relationships and collaborate with external organizations to foster scientific innovation and provide expert guidance. The institution makes these disclosures public to ensure transparency. For this information, see profile for Dr. Monika Safford.
Funds for this research were provided by the Patient Centered Outcomes Institute and by the National Heart Lung and Blood Institute, part of the National Institutes of Health, through grant UH2/UH3 HL130691.