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

背景/理由：在高血压和糖尿病控制方面的黑白差异有助于美国 预期寿命的种族差异。在退伍军人事务部，未得到控制的高血压或糖尿病的发生率更高 与白人退伍军人相比，在几个种族/少数民族群体中被识别出来。在多大程度上社会- 与经济地位(SES)相关的差异导致这些种族-民族差异是未知的。患者对齐 护理团队(PACT)作为一种减少差异的护理提供模式前景光明，然而，实施 变化很大，特别是在少数民族占很大比例的地点。尽管传统的医学模式不能 直接改变大多数社会健康决定因素，如SES，设施可以调整其提供方法以 更好地满足患者的需求和医疗保健服务偏好，例如纳入循证医学 与改善易感人群高血压或糖尿病控制相关的干预措施，并以这种方式 间接影响结果。评估与以下各项相关的多层次因素(医疗保健系统、场所、患者) 改善弱势群体(种族/少数民族和最低五分之一的社会经济地位)的结果，并说明 关于实施障碍，可以为退伍军人管理局解决低质量和改善严重差距的战略提供参考。 具体目标： 目标#1：描述弱势群体和质量之间的关联(通过中级临床测量 结果质量衡量高血压和糖尿病控制)：(A)确定按种族/族裔和 SES在高血压和糖尿病护理质量中的作用；(B)检查SES作为 种族/族裔与质量之间的关系；以及(C)确定质量和差距的多层次预测因素。 目标2：确定在弱势群体质量和差异方面代表极端的退伍军人事务部站点-高质量-低 差距“积极偏离”网站，高度差距网站(高质量的多数群体，低质量的弱势群体 组)和低性能站点(多数群体和弱势群体的质量都很低)--并描述 这些地点的特点。 目标3：比较积极偏离、高度不一致和表现不佳的地点：(A)评估临床实践交付 高血压和糖尿病护理的安排，特别是与以下方面相关的循证方法 缩小差距，以及目标1中确定的背景因素；和(B)查明阻碍和促进 有效执行这些交付安排。 方法：我们提出了一种使用一次和二次数据源的混合方法观察性研究 实现这些目标。对于目标1和2，我们将在财政年度使用所有使用退伍军人的全国队列 2017年，其个人社会人口统计、诊断条件和与以下方面有关的居住特征 关于退伍军人事务部站点和医疗保健系统特征的现有数据，包括站点级别的PACT实施情况和 来自VA质量指标的医疗系统级患者体验，然后链接到电子质量 措施。我们将确定弱势群体和多数群体的现场特定表现，以及差异 在这些组之间，然后根据以下情况确定代表质量和差异的极端示例的站点 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，探索实现患者高血压和糖尿病控制的当地做法， 包括障碍、促进者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退伍军人疾病患病率的知识空白 与社会经济脆弱性有关的差异，为临床实践交付安排提供证据 为弱势群体提供更高质量和更小差距，并提供经过现场测试的有效 减少差距的方法，为基于证据的质量改进倡议和实施提供信息 旨在改善低绩效或高差异VA部位弱势群体的临床结果的研究。

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.