Mitigating Racial/Ethnic and Socio-Economic Disparities in VA Care Quality and Patient Experience

背景/原理：黑人和白人在控制高血压和糖尿病方面的差异有助于美国 预期寿命的种族差异。在VA中，不受控制的高血压或糖尿病的发生率较高， 与白色退伍军人相比，在几个种族/少数民族群体中发现。在多大程度上，社会- 经济地位（SES）相关的差异驱动这些种族-民族差异是未知的。患者对齐 护理小组（PACT）作为一种护理提供模式，有望减少差异，但是，实施工作仍有待于完成。 这是一个很大的变化，特别是在少数民族占很大比例的地方。虽然传统的医学模式不能 直接改变大多数健康的社会决定因素，如社会经济地位，设施可以调整其交付方法， 更好地满足患者的需求和医疗服务偏好，例如，纳入基于证据的 与改善弱势群体的高血压或糖尿病控制相关的干预措施， 间接影响结果。评估与以下因素相关的多水平因素（医疗保健系统、研究中心、患者） 改善弱势群体（种族/族裔少数群体和社会经济地位最低的五分之一人口）的结果，并说明 实施障碍，可以告知VA战略，解决低质量和改善高差距。 具体目标： 目标#1：描述弱势群体与质量之间的关联（通过中间临床 结果质量测量高血压和糖尿病控制）：（a）确定种族/民族的变化， SES在高血压和糖尿病护理质量中的作用;（B）检查SES作为高血压和糖尿病护理质量的中介和调节剂。 种族/族裔与质量之间的关系;（c）确定质量和差距的多层次预测因素。 目标#2：确定代表弱势群体质量和差异极端的VA站点-高质量-低质量 差异“正偏差”站点，高差异站点（多数群体的高质量，弱势群体的低质量 群体）和低性能网站（大多数人和弱势群体的低质量）-并描述 这些网站的特点。 目标#3：比较积极的偏差，高差异和低性能的网站：（a）评估临床实践交付 高血压和糖尿病护理安排，特别是与 减少差距，以及目标1中确定的背景因素;以及（B）确定 有效执行这些交付安排。 方法：我们提出了一个混合方法的观察性研究，使用主要和次要数据源， 实现这些目标。对于目标#1和#2，我们将使用财政年度使用VA的所有退伍军人的全国队列 2017年，他们的个人社会人口统计数据，诊断条件和居住特征与 关于VA站点和医疗保健系统特征的现有数据，包括站点级PACT实施， 从VA质量指标中获得医疗保健系统级患者体验，然后与电子质量相关联 措施我们将确定针对弱势群体和多数群体的特定地点绩效，以及差异 在这些群体之间，然后根据以下因素确定代表质量和差异的极端例子的地点： 应用于此数据的图形显示的决策规则。对于目标3，我们将进行关键利益相关者访谈 在这些地点，探索当地的做法，以实现高血压和糖尿病控制在他们的病人， 包括障碍、促进因素和影响循证实践实施的背景因素。 对退伍军人健康的预期影响：这项研究将填补关于VA患病率的知识空白 与社会经济脆弱性相关的差异，提供临床实践交付安排的证据 与弱势群体的更高质量和更低差距相关，并提供有效的实地测试 减少风险的方法，为循证质量改进倡议和实施提供信息 研究，以改善弱势群体在低性能或高差距VA网站的临床结果。

Background/Rationale: Black-White disparities in control of hypertension and diabetes contribute to U.S. racial disparities in life expectancy. Within VA, higher rates of uncontrolled hypertension or diabetes have been identified in several racial/ethnic minority groups, compared with white Veterans. The extent to which socio- economic status (SES)-related differences drive these racial-ethnic disparities is unknown. Patient Aligned Care Teams (PACT) hold promise as a care delivery model to reduce disparities, however, implementation is variable, particularly in sites with large proportions of minorities. Though traditional medical models cannot directly change most social determinants of health like SES, facilities can adapt their delivery approaches to better meet the needs and healthcare delivery preferences of their patients, e.g., incorporating evidence-based interventions associated with improved hypertension or diabetes control in vulnerable groups, and in that way influence outcomes indirectly. Appraisal of multi-level factors (healthcare system, site, patient) associated with improved outcomes in vulnerable groups (racial/ethnic minorities and the lowest quintile SES), and elucidation of implementation barriers, may inform VA strategies for tackling low quality and ameliorating high disparities. Specific Aims: Aim #1: Characterize associations between vulnerable group and quality (measured by intermediate clinical outcome quality measures hypertension and diabetes control): (a) Determine variations by race/ethnicity and SES in hypertension and diabetes care quality; (b) Examine SES as a mediator and moderator of the relationship between race/ethnicity and quality; and (c) Identify multi-level predictors of quality and disparities. Aim #2: Identify VA sites representing extremes in vulnerable group quality and disparities – high quality-low disparity “positive deviant” sites, high disparity sites (high quality for majority groups, low quality for vulnerable groups), and low performing sites (low quality for both majority and vulnerable groups) – and describe characteristics of those sites. Aim #3: Compare positive deviant, high disparity, and low performing sites: (a) Assess clinical practice delivery arrangements for hypertension and diabetes care, particularly evidence-based approaches associated with disparities reduction, and contextual factors identified in Aim #1; and (b) Identify barriers to and facilitators of effective implementation of those delivery arrangements. Methods: We propose a mixed-methods observational study using primary and secondary data sources to achieve these aims. For Aims #1 and #2, we will use a national cohort of all Veterans using VA in fiscal year 2017, with their individual socio-demographics, diagnosed conditions, and residential characteristics linked with existing data on VA site and healthcare system characteristics, including site-level PACT implementation and healthcare system-level patient experience from VA quality metrics, and then linked to electronic quality measures. We will determine site-specific performance for vulnerable and majority groups, and disparities between these groups, then identify sites representing extreme examples of quality and disparities based on decision rules applied to graphical displays of this data. For Aim #3, we will conduct key stakeholder interviews at those sites, to explore local practices for achieving hypertension and diabetes control in their patients, including barriers, facilitators, and contextual factors influencing implementation of evidence-based practices. Anticipated Impacts on Veterans Health: This research will fill a knowledge gap about the prevalence of VA disparities related to socio-economic vulnerability, provide evidence on clinical practice delivery arrangements associated with higher quality and lower disparities for vulnerable groups, and provide effective field-tested disparities-reduction approaches to inform evidence-based quality improvement initiatives and implementation research to improve clinical outcomes for vulnerable groups at low-performing or high disparity VA sites.