. Author manuscript; available in PMC: 2021 Aug 1.

Published in final edited form as: Am Heart J. 2020 May 8;226:94–113. doi: 10.1016/j.ahj.2020.05.001

Table III:

Study Patient Participant Inclusion and Exclusion Criteria

Inclusions (all criteria must be met)	Exclusions
≥21 years of age as of date of data extraction Identified in the EMR as non-Hispanic white, non-Hispanic African American or Hispanic Have a diagnosis of hypertension (defined by ICD-9 or ICD-10 code AND most recent systolic blood pressure (BP) measures ≥140 mm Hg) Have at least one of the following CVD risk factors: Have at least one of the following CVD risk factors: Diabetes mellitus (ICD 10: E10, E11 or ICD 9: 250) Hyperlipidemia (ICD 10: E78 or ICD 9: 272^) Diagnosis of coronary heart disease (ICD 10:125^ or ICD 9: 402^, 410–414, or 429.2) Current tobacco smokers (ICD-10: 305.1, F17^, Z72.0 or ICD-9: 305.1, or EMR note) Diagnosis of depression (ICD 10: F32^, F33^, F32.9 or ICD 9: 296.2, 296.3, 311) Receives primary medical care at participating practice	<21 years of age Diagnosis of end stage renal disease (ESRD) (ICD 10: N18.5, N18.6 or ICD 9: 585.5, 585.6) Condition which interferes with outcome measurement (e.g., dialysis) Serious medical condition which either limits life expectancy or requires active management (e.g., certain cancers) Patients with cognitive impairment or other condition preventing their participation in the intervention Those with an active alcohol or substance use disorder (i.e., not sober/abstinent for ≥ 30 days) Pregnant or planning pregnancy in the next 24 months Currently breastfeeding a child Current participation in another research study focused on reducing BP Current participation in a care management program related to health conditions (e.g. weight reduction, smoking cessation) Those planning to leave the practice or move out of the geographic area within 24 months Those who no longer consider the practice site the location where they receive primary care Unwillingness to provide informed oral consent

Inclusions (all criteria must be met)

Exclusions

≥21 years of age as of date of data extraction
Identified in the EMR as non-Hispanic white, non-Hispanic African American or Hispanic
- Have a diagnosis of hypertension (defined by ICD-9 or ICD-10 code AND most recent systolic blood pressure (BP) measures ≥140 mm Hg)
Have at least one of the following CVD risk factors:
Have at least one of the following CVD risk factors:
- Diabetes mellitus (ICD 10: E10, E11 or ICD 9: 250)
- Hyperlipidemia (ICD 10: E78 or ICD 9: 272^*)
- Diagnosis of coronary heart disease (ICD 10:125^* or ICD 9: 402^*, 410–414, or 429.2)
- Current tobacco smokers (ICD-10: 305.1, F17^*, Z72.0 or ICD-9: 305.1, or EMR note)
- Diagnosis of depression (ICD 10: F32^*, F33^*, F32.9 or ICD 9: 296.2, 296.3, 311)
Receives primary medical care at participating practice

<21 years of age
Diagnosis of end stage renal disease (ESRD) (ICD 10: N18.5, N18.6 or ICD 9: 585.5, 585.6)
Condition which interferes with outcome measurement (e.g., dialysis)
Serious medical condition which either limits life expectancy or requires active management (e.g., certain cancers)
Patients with cognitive impairment or other condition preventing their participation in the intervention
Those with an active alcohol or substance use disorder (i.e., not sober/abstinent for ≥ 30 days)
Pregnant or planning pregnancy in the next 24 months
Currently breastfeeding a child
Current participation in another research study focused on reducing BP
Current participation in a care management program related to health conditions (e.g. weight reduction, smoking cessation)
Those planning to leave the practice or move out of the geographic area within 24 months
Those who no longer consider the practice site the location where they receive primary care
Unwillingness to provide informed oral consent

Certain conditions in ICD-10 have a coding convention that require the underlying conditions be sequenced first followed by manifestation. Wherever such a combination exists, coders are required to use additional code. For our purposes, any of the conditions that follow the initial code are acceptable. To save space, we are listing these codes with an “^*” after the condition code.