Race/ethnic differences in guideline recommended hypertension medications in VHA

在退伍军人中，高血压是最常见的慢性病，患病率为37% 并可能导致中风、心肌梗死、慢性肾脏疾病和心力衰竭。其中 黑人，高血压发生在生命的早期，更普遍和更严重，而且不太可能 控制住了。虽然高血压的控制在最近几年有了显著的改善， 退伍军人事务部(VA)，从2000年的46%上升到2010年的76%，黑人之间的差距依然存在，以及 原因还不是很清楚。联合全国委员会(JNC)发布了关于 高血压治疗的循证药物。然而，争议依然存在。 关于通过治疗达到的目标血压(BP)。最近出版的 收缩压干预试验(Sprint)是一项里程碑式的临床试验，预计将 导致心血管疾病增加患者的高血压实践发生变化 有风险且无糖尿病病史。研究人员报告称，收缩压降至120英镑。 毫米汞柱(VS&lt；140毫米汞柱)与较低的心血管事件发生率有关。 黑人和非黑人患者的死亡率和全因死亡率。在多大程度上 VA患者的收缩压控制在&lt；120 mm Hg是未知的。需要特别关注的是 退伍军人中患失控血压风险最高的群体，黑人退伍军人。这一群体预计将会增长 至少3%，从2014年的11%退伍军人增加到2034年的14%。本项目的目标是：目标1。 在退伍军人事件高血压诊断一年后，检查患者水平 (1)使用指南推荐的药物和(2)血压控制的预测因素 并描述这些预测因子的影响如何因种族而异；目标2。确定 使用指南建议的药物和BP的提供者和设施级别的预测者 对患有高血压的退伍军人进行控制并描述这些 使用混合方法预测因种族而异；以及目标3。开发和试行 以提供商/团队为重点的信息战略，通过增强的 针对少数族裔退伍军人的特写。目标1-2涉及一项纵向回顾队列研究 2007-2012年全国退伍军人中患有高血压事件的退伍军人中的黑人和白人 并检查(1)JNC7指南推荐药物的处方和结果 (2)高血压确诊后1年内控制高血压。使用回归 将确定符合以下条件的模型、患者(目标1)、提供者和设施级别(目标2)变量 不接受指南推荐的高血压和/或缺乏药物治疗的预测因素 在1年的随访中，BP控制组。目标1-2进一步研究这些预测因素如何通过 种族。对目标2的定性分析将包括使用自然语言的图表审查 处理方法和总共36次与患者对齐护理团队的电话采访 来自4个退伍军人事务部设施的(PACT)提供者(从目标1和目标2确定)，以确定原因 在确诊的患者中没有开出指南推荐的高血压药物 来自目标1-2的实施研究综合框架将用于 进行这些面谈。目标3包括开发经过训练和测试的算法 (来自回顾数据)，结合了Sprint和Aim 1-2的调查结果和增强功能 针对以少数族裔为基础的。盐湖城退伍军人医疗中心20个基于场景的样机 (SLCVAMC)PACT提供者将用于确定初始工具的可行性、可用性、 接受度、提供者兴趣、安全性和满意度。

Among Veterans, hypertension is the most common chronic condition with a prevalence of 37% and can lead to stroke, myocardial infarction, chronic kidney disease, and heart failure. Among blacks, hypertension occurs earlier in life, is more prevalent and severe, and is less likely to be controlled. While control of hypertension has significantly improved over recent years in the Veterans Affairs (VA), from 46% in 2000 to 76% in 2010, disparities persist among blacks, and reasons are not well understood. The Joint National Committee (JNC) publishes guidelines on evidence-based medications for hypertension treatment. However, controversy remains regarding the target blood pressure (BP) to achieve with therapy. The recently published Systolic Blood Pressure Intervention Trial (SPRINT), a landmark clinical trial, is anticipated to lead to changes in hypertension practices for patients with increased cardiovascular disease risk and without a history of diabetes. Investigators reported a reduction of systolic BP to <120 mm Hg (vs < 140 mm Hg) was associated with a lower incidence of cardiovascular-events, - mortality, and all-cause mortality for both black and nonblack patients. The extent to which systolic BP control of <120 mm Hg is achieved in VA is unknown. Special focus is needed for the VA group at highest risk for uncontrolled BP, black Veterans. This group is expected to grow at least 3% from 11% of Veterans in 2014 to 14% by 2034. The goals of this project are: Aim 1. To examine, one year following Veterans’ incident hypertension diagnosis, patient level predictors of (1) use of guideline-recommended medications and (2) BP control among Veterans and to describe how the effect of these predictors varies by race; Aim 2. To identify provider and facility level predictors of use of guideline-recommended medications and BP control among Veterans with incident hypertension and to describe how the effect of these predictors varies by race using mixed-methods; and Aim 3. To develop and pilot test a provider/team focused informatics strategy to facilitate hypertension control with enhanced features for racial minority Veterans. Aims 1-2 involve a longitudinal retrospective cohort study of black and white Veterans from VA facilities nationwide with incident hypertension 2007-2012 and examining outcomes of (1) prescriptions for JNC7 guideline-recommended medications and (2) controlled hypertension 1-year after incident hypertension diagnosis. Using regression models, patient- (Aim 1), provider- and facility-level (Aim 2) variables will be identified that are predictors for not receiving of guideline-recommended medications for hypertension and/or lack of BP control at 1-year of follow-up. Aims 1-2 further examine how these predictors vary by race. The qualitative analysis for Aim 2 will include chart review using natural language processing methods and a total of 36 telephone interviews with Patient Aligned Care Team (PACT) providers from 4 VA facilities (identified from Aim 1 and Aim 2) to ascertain reasons for not prescribing guideline-recommended hypertension medications among patients identified from Aims 1-2.The Consolidated Framework of Implementation Research will be used to conduct these interviews. Aim 3 includes the development of a trained and tested algorithm (from retrospective data) that incorporates SPRINT and Aim 1-2 findings and enhanced features for racial minorities based. A scenario based mockup with 20 Salt Lake City VA Medical Center (SLCVAMC) PACT providers will be used to determine initial tool feasibility, usability, acceptance, provider interest, safety, and satisfaction.