Identifying and testing a tailored strategy to achieve equity in blood pressure control in PACT

背景：高血压和血压（BP）控制不公平是一个主要的可改变的危险因素， 少数种族/族裔的心血管疾病（CVD）发病率和死亡率较高 美国人基于团队的护理是一种基于证据的实践，可能有效地减少BP控制差异。 然而，尽管VA初级对齐护理团队（PACT）的实施，BP控制种族/民族不平等 坚持。这突出表明需要有一套量身定制的实施战略（即，行动手册）来解决 少数民族退伍军人的特殊需求。2020年VA/DoD高血压临床实践指南建议 高心血管疾病风险患者开始用药的阈值和所有高血压患者加强用药的阈值 患者降低10 mm Hg（与旧指南相比）至收缩压130 mm Hg（强化BP控制），如果 符合临床判断和患者偏好。实现和保持密集的BP控制可以 在10年内，美国总共避免了50万例心血管疾病事件，但需要实施 确保同等体验强化BP控制的已知益处的剧本。 意义：我们的目标是减少VHA中高血压相关的发病率和死亡率差异， 优化PACT中的降压药物管理。实现并保持强化BP控制 可能会在10年内避免美国50万例CVD事件。 创新和影响：我们的研究将利用VHA健康公平初级保健公平办公室 2021年推出的审计反馈工具仪表板（PCED）可能是一个重要的战略， 健康管理方法，以支持旨在减轻高血压差异的基于团队的剧本 并支持种族/少数民族退伍军人中基于证据的实践更新。 具体目标：目标1）对比与强化治疗相关的患者、提供者和机构层面的因素 按人种/种族列出的抗高血压管理（开始、依从性和强化）和血压控制;目的 2)使用定性数据，确定患者、提供者和机构的障碍以及与强化治疗相关的促进因素。 按人种/种族列出的抗高血压管理（开始、依从性和强化）和血压控制;以及 目标3）共同设计两个针对以下人群的强化BP控制人群健康管理实施剧本： 减少BP不公平现象，并对PACT中的剧本进行原型和试点测试。 方法：在目标1中，我们将完成患者的分层分析（例如，性别、年龄、社会人口统计学， 合并症、非VA社区和虚拟医疗保健使用）、提供者（例如专科、患者-提供者访视 频率）和设施（例如，城市/农村状况、地理位置、服务的少数民族百分比、学术 联系，PACT的实施）与BP强化管理相关的因素。在目标2中， 理论领域框架结合慢性病护理模式，我们将收集和分析半 来自湖城和华盛顿特区的120名退伍军人和60名PACT工作人员和供应商的结构化访谈数据 吸血鬼在目标3中，我们将与利益相关者一起确定并优先考虑多级障碍，以改善公平的BP 控制接下来，我们将把这些障碍与基于证据的行为改变技术和工具联系起来，例如 利用PCED。我们将反复定制和原型两个多层次的剧本，一个将侧重于 一个在医疗机构/团队层面，另一个在提供者/患者层面。我们将在湖城试行这两种战术手册 和DC VAMC收集可用性、可行性和验收数据。 下一步/实施：通过完成这些目标，我们将提供一个可操作的，基于证据的， 全面了解VHA中与强化BP控制相关的差距和障碍。这 知识将导致对量身定制的BP管理实施剧本进行评估研究。

Background: Hypertension and blood pressure (BP) control inequities are a leading modifiable risk factor for the higher cardiovascular disease (CVD) morbidity and mortality experienced by racial/ethnic minority Americans. Team based care, an evidence-based practice, may be effective in reducing BP control disparities. However, despite VA Primary Aligned Care Team (PACT) implementation, BP control race/ethnic inequities persist. This highlights a need tailored bundle of implementation strategies (i.e., playbook) to address the unique needs of minority Veterans. The 2020 VA/DoD Hypertension Clinical Practice Guideline recommends a threshold for medication initiation in high CVD-risk patients and for medication intensification in all hypertensive patients be lowered by 10 mm Hg (vs older guidelines) to systolic BP 130 mm Hg (intensive BP control), if aligned with clinical judgement and patient preference. Achieving and maintaining intensive BP control could avert half a million CVD events in the US overall over 10 years, however there is a need for implementation playbooks that ensure the known benefits of intensive BP control are experienced equally. Significance: Our goal is to reduce hypertension-related morbidity and mortality disparities in VHA by optimizing antihypertensive medication management in PACT. Achieving and maintaining intensive BP control may avert half a million CVD events over 10 years in the US. Innovation and Impact: Our study will leverage the VHA Office of Health Equity Primary Care Equity Dashboard (PCED) launched in 2021, an audit feedback tool, may be an important strategy to a population health management approach, to support team-based playbooks designed to mitigate hypertension disparities and support evidence based practice update among race/ethnic minority Veterans. Specific Aims: Aim 1) Contrast patient-, provider-, and facility-level factors associated with intensive antihypertensive management (initiation, adherence, and intensification) and BP control by race/ethnicity; Aim 2) Using qualitative data, identify patient, provider- and facility-barriers and facilitators relevant to intensive antihypertensive management (initiation, adherence, and intensification) and BP control by race/ethnicity; and Aim 3) Codesign two intensive BP control population health management implementation playbooks tailored to reduce BP inequities and prototype and pilot test the playbooks in PACT. Methodology: In Aim 1, we will complete a hierarchical analysis of patient (e.g. sex, age, socio-demographics, comorbidities, non-VA community and virtual healthcare use), provider (e.g. specialty, patient-provider visit frequency), and facility (e.g. urban/rural status, geographic location, % racial minorities served, academic affiliation, PACT implementation) factors associated with intensive BP management. In Aim 2, applying the Theoretical Domains Framework in conjunction with the Chronic Care Model, we will collect and analyze semi- structured interview data from 120 Veterans and 60 PACT staff and providers from the Salt Lake City and DC VAMCs. In Aim 3, with our stakeholders we will identify and prioritize multilevel barriers improve equitable BP control. Next, we will link the barriers to evidence-based behavior change techniques and tools, such as leveraging the PCED. We will iteratively tailor and prototype two multilevel playbooks, one will focus on the facility/team level and the other on the provider/patient level. We will pilot both playbooks at the Salt Lake City and DC VAMCs to collect usability, feasibility, and acceptance data. Next Steps/Implementation: By completing these aims, we will provide an actionable, evidence-based, and comprehensive understanding of the gaps and barriers related to intensive BP control in the VHA. This knowledge will lead to an evaluation study of the tailored intensive BP management implementation playbooks.