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

背景：高血压和血压(BP)控制不均是主要的可改变的危险因素 少数族裔的心血管疾病发病率和死亡率较高 美国人。基于团队的护理是一种循证实践，可能在减少BP控制差异方面有效。 然而，尽管退伍军人事务部实施了初级联合护理团队(PACT)，BP仍控制着种族/族裔不平等 坚持不懈。这突出了需要量身定做的实施策略捆绑包(即实战手册)，以解决 少数族裔退伍军人的独特需求。2020年退伍军人事务部/美国国防部高血压临床实践指南建议 心血管疾病高危患者开始用药的阈值和所有高血压患者的用药强化阈值 患者血压降低10 mm Hg(与旧指南相比)至收缩压130 mm Hg(强化血压控制)，如果 与临床判断和患者偏好保持一致。实现并保持对BP的强化控制可能会 在10年内在美国总体上避免50万起心血管事件，但有必要实施 确保强化BP控制的已知好处的剧本都得到了同样的体验。 意义：我们的目标是通过以下方式降低VHA中高血压相关的发病率和死亡率 在PACT中优化抗高血压药物管理。实现并保持对BP的强化控制 可能会在10年内在美国避免50万起心血管疾病事件。 创新和影响：我们的研究将利用VHA医疗公平办公室初级保健公平 2021年推出的Dashboard(PCED)是一种审计反馈工具，可能是一项重要的战略 健康管理方法，以支持旨在缓解高血压差异的基于团队的剧本 并支持在种族/少数民族退伍军人中进行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、提供者和设施层面的因素 抗高血压管理(初始、坚持和强化)和按种族/民族控制血压；目的 2)使用定性数据，确定与密集型相关的患者、提供者和设施障碍和促进者 抗高血压管理(启动、坚持和强化)和按种族/民族控制血压；以及 目标3)共同设计两个密集的BP控制人口健康管理实施攻略，以 减少BP的不平等，并在PACT中原型和试点测试剧本。 方法：在目标1中，我们将完成对患者的分层分析(例如，性别、年龄、社会人口学、 合并症、非退伍军人社区和虚拟医疗使用)、提供者(例如专科、患者-提供者访问 频率)和设施(例如，城市/农村地位、地理位置、服务的少数族裔百分比、学术 隶属关系、公约执行)与BP强化管理相关的因素。在目标2中，应用 理论领域框架与慢性护理模式相结合，我们将收集和分析半 来自盐湖城和华盛顿特区的120名退伍军人和60名PACT工作人员和提供者的结构化访谈数据 VAMCS。在目标3中，我们将与我们的利益相关者一起确定多级障碍并确定优先顺序，以改善公平的BP 控制力。接下来，我们将把基于证据的行为改变技术和工具的障碍联系起来，例如 利用PCED。我们将迭代地定制和制作两本多层次剧本的原型，其中一本将专注于 一个在设施/团队级别，另一个在提供者/患者级别。我们将在盐湖城试行这两个剧本 和DC VAM收集可用性、可行性和接受度数据。 下一步/实施：通过完成这些目标，我们将提供可操作的、以证据为基础的、 全面了解与VHA强化BP控制相关的差距和障碍。这 知识将导致对定制的BP集约化管理实施手册进行评估研究。

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.