COmmuNity-engaged SimULation Training for Blood Pressure Control (CONSULT-BP): A study protocol

Jennifer Tjia, Michele Pugnaire, Joanne Calista, Nancy Esparza, Olga Valdman, Maria Garcia, Majid Yazdani, Janet Hale, Jill Terrien, Ethan Eisdorfer, Valerie Zolezzi-Wyndham, Germán Chiriboga, Lynley Rappaport, Geraldine Puerto, Elizabeth Dykhouse, Stacy Potts, Andriana Foiles Sifuentes, Sylvia Stanhope, Jeroan Allison, Vennesa Duodo, Janice Sabin, Jennifer Tjia, Michele Pugnaire, Joanne Calista, Nancy Esparza, Olga Valdman, Maria Garcia, Majid Yazdani, Janet Hale, Jill Terrien, Ethan Eisdorfer, Valerie Zolezzi-Wyndham, Germán Chiriboga, Lynley Rappaport, Geraldine Puerto, Elizabeth Dykhouse, Stacy Potts, Andriana Foiles Sifuentes, Sylvia Stanhope, Jeroan Allison, Vennesa Duodo, Janice Sabin

Abstract

Background: Healthcare professionals have negative implicit biases toward minority and poor patients. Few communication skills interventions target implicit bias as a factor contributing to disparities in health outcomes. We report the protocol from the COmmuNity-engaged SimULation Training for Blood Pressure Control (CONSULT-BP), a trial evaluating a novel educational and training intervention targeting graduate medical and nursing trainees that is designed to mitigate the effects of implicit bias in clinical encounters. The CONSULT-BP intervention combines knowledge acquisition, bias awareness, and practice of bias mitigating skills in simulation-based communication encounters with racially/ethnically diverse standardized patients. The trial evaluates the effect of this 3-part program on patient BP outcomes, self-reported patient medication adherence, patient-reported quality of provider communication, and trainee bias awareness.

Methods: We are conducting a cluster randomized trial of the intervention among cohorts of internal medicine (IM), family medicine (FM), and nurse practitioner (NP) trainees at a single academic medical center. We are enrolling entire specialty cohorts of IM, FM, and NP trainees over a 3-year period, with each academic year constituting an intervention cycle. There are 3 cycles of implementation corresponding to 3 sequential academic years. Within each academic year, we randomize training times to 1 of 5 start dates using a stepped wedge design. The stepped wedge design compares outcomes within training clusters before and after the intervention, as well as across exposed and unexposed clusters. Primary outcome of blood pressure control is measured at the patient-level for patients clustered within trainees. Eligible patients for outcomes analysis are: English-speaking; non-White racial/ethnic minority; Medicaid recipient (regardless of race/ethnicity); hypertension; not have pregnancy, dementia, schizophrenia, bipolar illness, or other serious comorbidities that would interfere with hypertension self-control; not enrolled in hospice. Secondary outcomes include trainee bias awareness. A unique feature of this trial is the engagement of academic and community stakeholders to design, pilot test and implement a training program addressing healthcare.

Discussion: Equipping clinicians with skills to mitigate implicit bias in clinical encounters is crucial to addressing persistent disparities in healthcare outcomes. Our novel, integrated approach may improve patient outcomes.

Trial registration: NCT03375918.

Protocol version: 1.0 (November 10, 2020).

Conflict of interest statement

The authors have no competing interests to disclose.

Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.

Figures

Figure 1
Figure 1
The CONSULT-BP intervention model.

References

    1. Maina I, Belton T, Ginzberg S, et al. A decade of studying implicit racial/ethnic bias in healthcare providers using the implicit associaiton test. Soc Sci Med 2018;199:219–29.
    1. FitzGerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. BMC Med Ethics 2017;18:19.
    1. Green AR, Carney DR, Pallin DJ, et al. Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients. J Gen Intern Med 2007;22:1231–8.
    1. Penner LA, Dovidio JF, West TV, et al. Aversive racism and medical interactions with black patients: A field study. J Exp Soc Psychol 2010;46:436–40.
    1. Sabin JA, Greenwald AG. The influence of implicit bias on treatment recommendations for 4 common pediatric conditions: pain, urinary tract infection, attention deficit hyperactivity disorder, and asthma. Am J Public Health 2012;102:988–95.
    1. Bogart LM, Catz SL, Kelley JA, et al. Factors influencing physicians’ judgments of adherence and treatment decisions for patients with HIV disease. Med Decis Making 2001;21:28–36.
    1. Cooper LA, Roter DL, Carson KA, et al. The associations of clinicians’ implicit attitudes about race with medical visit communication and patient ratings of interpersonal care. Am J Public Health 2012;102:979–87.
    1. Smedley B, Stith A, Nelson A. Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, D.C: National Academy Press; 2003.
    1. Cooper LA, Roter DL, Bone LR, et al. A randomized controlled trial of interventions to enhance patient-physician partnership, patient adherence and high blood pressure control among ethnic minorities and poor persons: study protocol NCT00123045. Implement Sci 2009;4:7.
    1. Beach MC, Gary TL, Price EG, et al. Improving health care quality for racial/ethnic minorities: a systematic review of the best evidence regarding provider and organization interventions. BMC Public Health 2006;6:104.
    1. Fisher NDL, Curfman G. Hypertension – a public health challenge of global proportions. JAMA 2018;320:1757–9.
    1. U.S. Department of Health and Human Services. The Surgeon General's Call to Action to Control Hypertension. Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General; 2020.
    1. Schoenthaler A, Chaplin WF, Allegrante JP, et al. Provider communication effects medication adherence in hypertensive African Americans. Patient Educ Couns 2009;75:185–91.
    1. Hanlin RB, Asif IM, Wozniak G, et al. Measure Accurately, Act Rapidly, and Partner With Patients (MAP) improves hypertension control in medically underserved patients: Care Coordination Institute and American Medical Association Hypertension Control Project Pilot Study results. J Clin Hypertens (Greenwich) 2018;20:79–87.
    1. Voils CI, Maciejewski ML, Hoyle RH, et al. Initial validation of a self-report measure of the extent of and reasons for medication nonadherence. Medical care 2012;50:1013–9.
    1. Peters RM, Templin TN. Measuring blood pressure knowledge and self-care behaviors of African Americans. Res Nurs Health 2008;31:543–52.
    1. Kasser VG, Ryan RM. The relation of psychological needs for autonomy and relatedness to vitality, well-being, and mortality in a nursing home1. J Appl Soc Psychol 1999;29:935–54.
    1. Safran DG, Kosinski M, Tarlov AR, et al. The Primary Care Assessment Survey: tests of data quality and measurement performance. Med Care 1998;36:728–39.
    1. Girod S, Fassiotto M, Grewal D, et al. Reducing implicit gender leadership bias in academic medicine with an educational intervention. Acad Med 2016;91:1143–50.
    1. Van Schaik E, Howson A, Sabin J. Healthcare disparities. MedEdPORTAL 2014;10: doi: 10.15766/mep_2374-8265.9675.
    1. Greenwald AG, McGhee DE, Schwartz JL. Measuring individual differences in implicit cognition: the implicit association test. J Pers Soc Psychol 1998;74:1464–80.
    1. Devine P, Forscher P, Austin A, et al. Long-term reductionin implicit race bias: a prejudice habit-breaking intervention. J Exp Soc Psychol 2012;48:1267–78.
    1. Ziv A, Wolpe PR, Small SD, et al. Simulation-based medical education: an ethical imperative. Simul Healthc 2006;1:252–6.
    1. Bennett MJ. A developmental approach to training for intercultural sensitivity. Int J Intercult Relat 1986;10:179–96.
    1. Teal CR, Gill AC, Green AR, et al. Helping medical learners recognise and manage unconscious bias toward certain patient groups. Med Educ 2012;46:80–8.
    1. Shute VJ, Gawlick LA. Practice effects on skill acquisition, learning outcome, retention, and sensitivity to relearning. Human Factors 1995;37:781–803.
    1. Dasgupta N, Greenwald AG. On the malleability of automatic attitudes: Combating automatic prejudice with images of admired and disliked individuals. J Pers Soc Psychol 2001;81:1–5.
    1. Hemming K, Haines T, Chilton P, et al. The stepped wedge cluster randomized trial: rationale, design, analysis, and reporting. BMJ 2015;350:h391.
    1. Kerfoot BP, Fu Y, Baker H, et al. Online spaced education generates transfer and improves long-term retention of diagnostic skills: a randomized controlled trial. J Am Coll Surg 2010;211:331–7. e331.
    1. Devine PG, Forscher PS, Austin AJ, et al. Long-term reduction in implicit race bias: a prejudice habit-breaking intervention. J Exp Soc Psychol 2012;48:1267–78.
    1. Sabin JA, Rivara FP, Greenwald AG. Physician implicit attitudes and stereotypes about race and quality of medical care. Med Care 2008;46:678–85.
    1. Howell JL, Ratliff KA. Not your average bigot: the better-than-average effect and defensive responding to Implicit Association Test feedback. Br J Soc Psychol 2017;56:125–45.
    1. James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA 2014;311:507–20.
    1. Gillespie C, Hurvitz K. Prevalence of Hypertension and Controlled Hypertension — United States, 2007–2010. MMWR - Suppl 2013;62:144–8e.
    1. Leykum LK, Pugh JA, Lanham HJ, et al. Implementation research design: integrating participatory action research into randomized controlled trials. Implement Sci 2009;4:69.
    1. Johnson RL, Roter DL, Powe NR, et al. Patient race/ethnicity and quality of patient-physician communication during medical visits. Am J Public Health 2004;94:2084–90.
    1. Morell VW, Sharp PC, Crandall SJ. Creating student awareness to improve cultural competence: creating the critical incident. Med Teach 2002;24:532–4.
    1. Rubix Life Sciences. COVID-19 and Minority Health Access.; 2020. . Accessed May 21, 2020.
    1. Eligon J, Burch ADS. Questions of Bias in Covid-19 Treatment Add to the Mourning for Black Families. NY Times. Published online May 10, 2020. Updated May 20, 2020.

Source: PubMed

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