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

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)

Using Simulation-Based Learning with Standardized Patients (SP) in an Implicit Bias Mitigation Clinician Training Program

“…Details for the overall randomized trial, including full description of hypotheses and outcome measures, are published elsewhere. 17 Briefly, between 2018 and 2022, we conducted a cluster randomized trial of a clinician training intervention to address implicit bias in healthcare encounters. The study setting was an academic medical center that serves a large low-income, publicly insured, person of color (POC) population in Central Massachusetts.…”

“…These inclusion criteria and recruiting approach were designed to provide a total sample of at least 205 clinical trainees who practiced at eligible clinical sites over 3 academic years, which provided a greater than 90% power to detect a change in clinical outcomes (ie 3 mm Hg difference systolic blood pressure between control and post-training periods) of patients nested within trainees. 17 …”

“…16 Despite these challenges, our research group has used a community-engaged partnership to create and implement an in-person simulation-based training to mitigate the effects of implicit bias in clinician-patient encounters in a randomized clinical trial. 17 The training program combined three core elements: 1. didactics to increase knowledge about social determinants of health, racism, implicit bias, and skills to mitigate bias; 2. self-administered IATs with feedback to increase bias awareness; and 3. clinical simulation encounters with racially and ethnically diverse SPs to facilitate skills practice.…”

Design and pilot test of an implicit bias mitigation curriculum for clinicians

“…Educational programs are widespread across sectors of society, including healthcare. Previously described frameworks and curricula ( 15 , 18 , 20 , 22 – 27 ) generally endorse enhancing internal motivation, increasing knowledge and awareness, and teaching skills known to interrupt the activation and/or expression of IB. The impact of IB educational programs is unclear and variable ( 27 – 29 ).…”