Multilevel Care Fails to Narrow Hypertension Medication-Adherence Racial Gap

A pragmatic clinical trial found that a multilevel collaborative-care intervention did not measurably reduce racial disparities in medication adherence among adults with uncontrolled hypertension. In the RICH LIFE Project, 12-month adherence was nearly identical for Black participants assigned to Collaborative Care/Stepped Care and Standard of Care Plus, while differences for White participants were also not statistically significant. The estimated effect on the racial disparity was -3.9%, with a 95% confidence interval from -15.8% to 9.4%.

The analysis focused on medication adherence, a prespecified secondary outcome from a cluster-randomized trial conducted in 30 primary care practices in Maryland and Pennsylvania. The trial compared Collaborative Care/Stepped Care, or CC/SC, with Standard of Care Plus, or SCP. Its participants were non-Hispanic Black and non-Hispanic White adults whose hypertension was treated but remained uncontrolled. Adherence was assessed 12 months after enrollment using a four-item scale adapted from Morisky, Green, and Levine, with responses classified as adherent or nonadherent.

The study included 1,555 participants: 64.2% were Black and 35.8% were White. The groups differed in several characteristics. Black participants had a mean age of 58.0 years, compared with 65.2 years among White participants, and a greater proportion were female. These differences matter when interpreting the trial results because the analysis examined outcomes within racial groups and estimated the average effect of the assigned intervention on the disparity between them.

At 12 months, 45.4% of Black participants in the CC/SC arm were classified as adherent, compared with 46.1% in the SCP arm. For White participants, adherence was 66.9% in the CC/SC arm and 63.7% in the SCP arm. Neither between-arm difference was statistically significant. The researchers used a weighting-based approach to estimate average potential outcomes within each racial group under the assigned intervention and then estimated the intervention’s average effect on the racial adherence disparity.

The overall estimate did not show a significant disparity reduction. An effect of -3.9 percentage points was compatible with a reduction of 15.8 percentage points or an increase of 9.4 percentage points at the 95% confidence level, meaning the analysis could not distinguish a meaningful narrowing of the gap from no effect or an increase in disparity. Sensitivity analyses that divided adherence into high, medium, and low categories, as well as analyses limited to the pre-pandemic follow-up period, produced similar findings.

The findings do not establish that collaborative and stepped care can improve medication adherence or that it worsens it. The trial measured adherence only at 12 months in this secondary analysis, and adherence was summarized through a dichotomous classification despite sensitivity analyses considering gradations of adherence. The broad confidence interval also limits the conclusions that can be drawn from the estimated disparity effect.

Taken together, the results show that the multilevel intervention tested in RICH LIFE did not narrow the racial difference in medication adherence for adults with uncontrolled hypertension. Black participants in both study arms had lower observed adherence than White participants, and the trial provided no statistically significant evidence that assigning practices to Collaborative Care/Stepped Care changed that pattern. The authors concluded that additional evidence-based strategies are needed to reduce disparities in medication adherence.

Subject of Research: A secondary-outcome analysis of medication adherence and racial disparities in the RICH LIFE cluster-randomized hypertension trial.

Article Title: Effect of a Multilevel Intervention on Racial Disparities in Medication Adherence: An Analysis of the Rich Life Project

Article References: Meche, A., Cooper, L. A., Mehta, H. B., Alexander, G. C., & Jackson, J. W. (2026). Effect of a Multilevel Intervention on Racial Disparities in Medication Adherence: An Analysis of the Rich Life Project. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10951-0

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10951-0

Keywords: hypertension, medication adherence, racial disparities, collaborative care, cluster-randomized trial, health equity, primary care, patient activation, RICH LIFE, Effect, Multilevel, Intervention