Improving Blood Pressure Control and Tobacco Use Cessation Intervention In Primary Care: Protocol for the Alabama Cardiovascular Cooperative Heart Health Improvement Project
Authors: Foti Kathryn , Hubbard Demetria , Smith Kimberly A , Hearld Larry , Richman Joshua , Horton Trudi , Parker Sharon , Roughton Dodey , Craft Macie , Clarkson Stephen A , Jackson Elizabeth A , Cherrington Andrea L 
Published: September 2024

Background
Alabama has the second highest rate of cardiovascular disease (CVD) mortality of any US state and a high prevalence of CVD risk factors such as hypertension, diabetes, obesity, and smoking. Within the state, there are disparities in CVD outcomes and risk factors by race or ethnicity and geography. Many primary care practices do not have the capacity for full-scale quality improvement (QI) initiatives. The Alabama Cardiovascular Cooperative (ALCC), which includes academic and community stakeholders, was formed to support primary care practices to implement QI initiatives to improve cardiovascular health. The ALCC is implementing a Heart Health Improvement Project (HHIP) in primary care practices with suboptimal rates of blood pressure (BP) control and tobacco use screening.

Objective
The study aimed to support primary care practices to increase BP control among adults with hypertension and increase rates of tobacco use screening and cessation intervention.

Methods
We are using a type 1 hybrid design to test the effects of the HHIP on BP control among adults with hypertension and tobacco use screening and cessation intervention, while collecting information on implementation. Primary care practices were recruited through existing practice networks and additional electronic and in-person outreach. To ensure participation from a broad range of clinics, we required at least 50% of practices to be Federally Qualified Health Centers or look-alikes and to include representation from practices in rural areas. At baseline, we collected information about practice characteristics and preintervention rates of BP control and tobacco use screening and cessation intervention. The QI intervention includes quarterly activities conducted over a 12-month period. The HHIP uses a multipronged approach to QI, including practice facilitation and technical assistance, on-site and e-learning, and improvement through data transparency. We will conduct a pre-post analysis to estimate the effects of the HHIP and whether there is an enduring change in outcomes after the 12 months of HHIP activities beyond what would be expected due to secular trends.

Results
Practice recruitment took place between April 2021 and October 2022. After contacting 417 primary care practices, 51 were enrolled, including 28 Federally Qualified Health Centers or look-alikes; 47 practices implemented the HHIP. Among 45 practices that completed the baseline survey, 11 (24%) were solo practices, while 28 (62%) had 1-5 clinicians, and 6 (13%) had 6 or more clinicians. The median number of patient visits per year was 5819 (IQR 3707.3-8630.5). Practices had been in operation for a mean of 19.2 (SD 13.0) years. At baseline, the mean BP control rate was 49.6% and the rate of tobacco use screening and cessation intervention was 67.4%.

Conclusions
If successful, the ALCC and HHIP may improve the implementation of evidence-based guidelines in primary care and, subsequently, cardiovascular health and health equity in the state of Alabama.

International Registered Report Identifier (IRRID)
DERR1-10.2196/63685