Hypertension, or high blood pressure, is one of the most common health issues in the United States and around the world. If not treated, it can lead to severe health issues, like advanced congestive heart failure, heart attacks, and chronic kidney disease. High blood pressure disproportionately affects adults who are Black or Hispanic, rural, uninsured, or low-income. Individuals must get screened regularly because high blood pressure is often asymptomatic.
Erica Spatz, MD, MHS, associate professor of medicine (cardiovascular medicine) and associate professor of epidemiology (chronic diseases) at Yale School of Medicine, is focused on eliminating disparities in blood pressure control. She recently received a nearly $20 million funding award from the Patient-Centered Outcomes Research Institute (PCORI) for a new study called Pressure Check. The study aims to improve health equity by comparing three intervention strategies to control blood pressure. Rafael Pérez-Escamilla, PhD, professor of public health (social and behavioral sciences), is the dual principal investigator.
The study includes four sites: Yale New Haven Health in New Haven, Conn., Massachusetts General/Brigham in Boston, Mass., Sentara Health in Norfolk, Va., and Houston Methodist in Houston, Texas.
“One of the most powerful things about these four sites is that we are a diverse group,” said Spatz. “While Yale has been working in the community for years, many of the other sites are starting from scratch. Some partners are well-versed in using remote patient monitoring for blood pressure, but others needed to create this system from the ground up. We are all learning from one another. I’m proud to have helped facilitate that work.”
Each site partners with ten community-based organizations (CBOs), like barbershops, nail studios, and churches, with deep ties to local communities. Health advocates are stationed at each of the 40 CBOs. They work alongside CBO leaders to educate people on the importance of lowering elevated blood pressure. The health advocates screen people for high blood pressure and enroll people who meet the study criteria.
“We’re leveraging the trust of the CBOs and health advocates to educate community members. They help us explain why controlling blood pressure is important and help participants decide what to do next,” said Spatz. “It’s exciting to see entire communities show up for this study and throw their support behind the project.”
Comparing Interventions to Control Blood Pressure
The study compares three different strategies for controlling blood pressure.
In one phase of the study, participants receive education about blood pressure, a wireless blood pressure cuff for monitoring at home, and a referral to a primary care provider (PCP).
In the second phase of the study, enrolled patients also receive telehealth visits with the Pressure Check blood pressure team every other week until their blood pressure is in good control. The Pressure Check team helps adjust medications and provides support with lifestyle and nutrition changes.
The third arm of the study includes telehealth visits and remote monitoring, but also adds a community health worker to support the patients through their health care journey.
“Our experience shows that many people need help making appointments, remembering to take their blood pressure, or reinforcing the care plan we developed,” Spatz said. “People may face social barriers, such as not having enough food or transportation. These issues can make it hard for them to take care of their health. The community health workers help bring in that social support.”
Now, six months into the enrollment period, CBOs have already screened nearly 2,000 individuals and enrolled more than 330 people in the study. Each person enrolled in the study will receive regular check-ins at six, 12, and 18 months to help Spatz and her team determine which approach best controls blood pressure.
Spatz and her colleagues will be out in each community in late October to meet with CBO leaders. During these meetings, they will hear about what’s working and discuss new ideas to improve screening and care. For example, they’ve learned that there is deep mistrust around research in many communities. In response, the research team is creating more ways for researchers and community members to have conversations. Spatz and Pérez-Escamilla have long been active in the community, engaging community members in all phases of the research, including its conception, implementation, analysis, and dissemination.
“We’re working closely with our community partners to acknowledge historical practices and show that we are focused on true community-engaged research,” said Spatz.
“Pressure Check is indeed being implemented following community-engaged principles, including strong continuous input from authentic Community Advisory Boards at each site,” said Pérez-Escamilla.
Remote Blood Pressure Monitoring
Participants receive a free cellular-enabled blood pressure cuff and a device from Stel, the technology partner in the study. The Stel device directly moves blood pressure readings into the medical record safely and securely.
“We couldn’t have done this study without Stel. They are committed to tech equity and making digital care accessible for people with low digital literacy,” Spatz said. “Participants do not need a smartphone, a special app, or Wi-Fi to send data. These have always been barriers for doing this type of work in a clinical setting.”
Participants will also journal their blood pressure with a pen and paper to see their blood pressure and notice trends.
“This model of remote blood pressure management with our Pressure Check team will not be right for everyone,” Spatz said. “Some will prefer to have their care managed by their primary care physician alone, and that’s okay. Ultimately, we hope this program shines a light on the importance of blood pressure control by meeting people where they are to receive the care they need and want.”
The Department of Internal Medicine at Yale School of Medicine is among the nation's premier departments, bringing together an elite cadre of clinicians, investigators, educators, and staff in one of the world's top medical schools. To learn more, visit Internal Medicine.