COmmuNity-engaged SimULation Training for Blood Pressure Control (CONSULT-BP)

The goal of CONSULT-BP is to train early-stage healthcare providers, including residents and nurse practitioner (NP) students, to mitigate providers' bias, improve communication skills, and enhance providers' ability to develop authentic and meaningful therapeutic alliances with patients. The study setting is an academic safety net hospital that serves a large non-White and poor population. We hypothesize that patients' outcomes (blood pressure levels) will be lower after the training intervention compared with before training (control) periods.

CONSULT-BP will adapt and test a theory-based, 'awareness, exposure and skill-building' intervention, applied in the safety of a simulation-based learning center, to improve providers' interaction skills with minority and poor patients. We will use our established platform of community-based participatory research to implement CONSULT-BP in an academic medical center with a large, safety-net health system that serves a minority and poor population. The CONSULT-BP project will: 1. recruit and hire Community Advisors (CA) representing diverse underserved populations who will participate in the adaptation of evidence-based hypertension communication tools and the design, development, and implementation of the training curriculum; 2. use online self-assessments of clinicians' implicit bias for race and patient compliance to raise bias self-awareness and to examine the effect of bias on knowledge and skill development; and 3. hire Community SPs to (a) conduct face-to-face, simulated clinical encounters with medical trainees and NP students, and (b) provide evaluation and feedback about communication skills along with trained CA observers and faculty facilitators. The educational intervention is a program of two, 180-minute, sessions, spaced 5 weeks apart that combine online learning with in-person skill practice. To understand how much training exposure is required to 'move the needle' of clinical skills and patient outcomes, we will assess the effect of CONSULT-BP by conducting two, sequential, randomized trials. Trial 1 will evaluate the effectiveness of one-time CONSULT training on outcomes, and Trial 2 will evaluate the effect of repeat, booster training on outcomes. To support training feasibility in Trial 1, CONSULT-BP will train cohorts of IM, FM, and NP trainees over a 3-year period, and will target advanced (2nd or 3rd-year) trainees within a given academic year for one-time exposure to the training intervention. Within each academic year, we will randomize training times to 1 of 5 start dates using a stepped wedge design to accommodate pre-existing training schedules and to mitigate the effect of temporal trends in clinical skill proficiency. Trial 2 will randomly assign continuing trainee participants from Trial 1 to a second CONSULT-BP booster training exposure versus no booster training. The primary outcome for both trials will be patient BP control. Secondary process outcomes will include trainees' communication skills and patient adherence to medications, visits, and diet changes. We will also examine effect modification by patient characteristics (baseline BP control) and trainee characteristics (implicit bias and awareness of bias). Trainee measures will be from trainee self-report (implicit bias, bias awareness), community SP report (trainee communication skills), and clinic patient surveys (trainee communication quality and patient adherence). Clinical BP outcomes will be from the EMR. We will use analytic mixed effect models accounting for patient and clinician characteristics, patient correlations within randomization clusters and within clinicians, and repeated measures within patient. The CONSULT-BP multi-staged, community-engaged, education model will change how medical educators think about helping providers develop bias-aware, patient-centered, communication skills.

Clusters of clinical trainees [stratified by specialty (internal medicine (IM), family medicine (FM), NP students) and by training block] will be randomly assigned to 1 of 5 start dates. Clinical outcomes will be assessed at the patient level.

The primary outcome is blood pressure (BP) change as recorded in the electronic medical record (EMR) of racial/ethnic minority patients and Medicaid recipients of any race/ethnicity with controlled and uncontrolled hypertension. Secondary outcomes are patient-reported quality of care and clinician communication, and patient adherence to medications, visits and diet changes. Patient participants are masked to the intervention status of their provider trainees.

Within each academic year, trainee clusters are randomized to 1 of 5 start date training times for Other: CONSULT-BP Educational Intervention. Each arm has a pre-intervention (control) period and a post-intervention (exposure) period.

Within each academic year, trainee clusters are randomized to 1 of 5 start date training times for Other: CONSULT-BP Educational Intervention. Each arm has a pre-intervention (control) period and a post-intervention (exposure) period.

Within each academic year, trainee clusters are randomized to 1 of 5 start date training times for Other: CONSULT-BP Educational Intervention. Each arm has a pre-intervention (control) period and a post-intervention (exposure) period.

Within each academic year, trainee clusters are randomized to 1 of 5 start date training times for Other: CONSULT-BP Educational Intervention. Each arm has a pre-intervention (control) period and a post-intervention (exposure) period.

Within each academic year, trainee clusters are randomized to 1 of 5 start date training times for Other: CONSULT-BP Educational Intervention. Each arm has a pre-intervention (control) period and a post-intervention (exposure) period.

The CONSULT-BP intervention includes two, 180-minute, in-persons sessions 5 weeks apart. Each session has 3 parts: 1. Pre-"Clinical Practice Simulation" Learning; 2. Trainee Self-Assessments of implicit bias; and 3. In-Person "Clinical Practice Simulations" to practice communication skills, trigger reflection, and frame group-based reflections on bias.

Health Care Climate Questionnaire Six-item scale assesses beliefs regarding perceived provider support for autonomy and provider communicated care. Each item is evaluated on 7-point Likert scale (1 - 5 strongly agree, neutral, strongly disagree). Scores are calculated by averaging individual item scores. (Williams 1998 (a); Williams 1998(b)) Reference. Williams GC, Rodin GC, Ryan RM, Grolnick WS, Deci EL. Autonomous regulation and long-term medication adherence in adult outpatients. Health Psychol. 1998;17(3):269-276. doi:10.1037/0278-6133.17.3.269. Williams GC, Freedman ZR, Deci EL. Supporting autonomy to motivate patients with diabetes for glucose control. Diabetes Care. 1998;21(10):1644-1651. doi:10.2337/diacare.21.10.1644

The Primary Care Assessment Survey - Trust sub-scale Eight-item subscale of the the Primary Care Assessment measuring patient trust in their healthcare provider; each item is rated on a 5-point Likert Scale and transformed to a 100 point scale with higher scores indicating greater trust. The reported mean score is 75.68 (SD 16.04). Reference. Safran DG, Kosinski M, Tarlov AR, et al. The Primary Care Assessment Survey: tests of data quality and measurement performance. Med Care. 1998;36(5):728-739.

Twenty-four item scale assess extent and reasons for non-adherence to medication. Each item is rated on a 5-point Likert scale. Summary scores are calculated separately for reason and extent of adherence. Reference: Voils CI, Maciejewski ML, Hoyle RH, Reeve BB, Gallagher P, Bryson CL, Yancy WS Jr. Initial validation of a self-report measure of the extent of and reasons for medication nonadherence. Med Care. 2012;50(12):1013-9.

Ten-item scale assesses knowledge and self-care practices on a 7-point Likert scale. Total scores are determined as the average of the scores on each item. Reference: Peters, R. M., & Templin, T. N. Measuring blood pressure knowledge and self-care behaviors of African Americans. Research in Nursing & Health, 2008; 31(6), 543-552.

For Healthcare Trainees - Inclusion Criteria: Practice at a clinical site supported by an EMR to allow clinical data collection for outcome measurement 15-week clinical look-back period No prior completion of the CONSULT-BP intervention Exclusion Criteria: 1. All 1st year trainees For Patient Participants - Inclusion Criteria: English-speaking Non-White racial/ethnic minority or Medicaid recipient (regardless of race/ethnicity) Hypertension identified in the EMR Exclusion Criteria: Enrolled in hospice. Pregnancy, dementia, schizophrenia, bipolar illness, or other serious medical co-morbidity that would interfere with hypertension self-control

Tjia J, Pugnaire M, Calista J, Esparza N, Valdman O, Garcia M, Yazdani M, Hale J, Terrien J, Eisdorfer E, Zolezzi-Wyndham V, Chiriboga G, Rappaport L, Puerto G, Dykhouse E, Potts S, Sifuentes AF, Stanhope S, Allison J, Duodo V, Sabin J. COmmuNity-engaged SimULation Training for Blood Pressure Control (CONSULT-BP): A study protocol. Medicine (Baltimore). 2021 Feb 5;100(5):e23680. doi: 10.1097/MD.0000000000023680.