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

背景：高血压和血压控制不公平是糖尿病的主要可改变危险因素

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.