Improving Regional Blood Pressure Control: a Positive Deviance Tiered Intensity Approach

Background Accelerated translation of real-world interventions for hypertension management is critical to improving cardiovascular outcomes and reducing disparities. Objective To determine whether a positive deviance approach would improve blood pressure (BP) control across diverse health systems. Design Quality improvement study using 1-year cross sections of electronic health record data over 5 years (2013–2017). Participants Adults ≥ 18 with hypertension with two visits in 2 years with at least one primary care visit in the last year ( N = 114,950 at baseline) to a primary care practice in Better Health Partnership, a regional health improvement collaborative. Interventions Identification of a “positive deviant” and dissemination of this system’s best practices for control of hypertension (i.e., accurate/repeat BP measurement; timely follow-up; outreach; standard treatment algorithm; and communication curriculum) using 3 different intensities ( low : Learning Collaborative events describing the best practices; moderate : Learning Collaborative events plus consultation when requested; and high : Learning Collaborative events plus practice coaching). Main Measures We used a weighted linear model to estimate the pre- to post-intervention average change in BP control (< 140/90 mmHg) for 35 continuously participating clinics. Key Results BP control post-intervention improved by 7.6% [95% confidence interval (CI) 6.0–9.1], from 67% in 2013 to 74% in 2017. Subgroups with the greatest absolute improvement in BP control included Medicaid (12.0%, CI 10.5–13.5), Hispanic (10.5%, 95% CI 8.4–12.5), and African American (9.0%, 95% CI 7.7–10.4). Implementation intensity was associated with improvement in BP control (high: 14.9%, 95% CI 0.2–19.5; moderate: 5.2%, 95% CI 0.8–9.5; low: 0.2%, 95% CI−3.9 to 4.3). Conclusions Employing a positive deviance approach can accelerate translation of real-world best practices into care across diverse health systems in the context of a regional health improvement collaborative (RHIC). Using this approach within RHICs nationwide could translate to meaningful improvements in cardiovascular morbidity and mortality.