Access, Quality and Equity of Anticoagulants in Veterans with Atrial Fibrillation

房颤退伍军人抗凝药物的获取、质量和公平性

• 批准号: 10561671
• 负责人: Utibe R. Essien
• 金额: --
• 依托单位: VETERANS HEALTH ADMINISTRATION
• 依托单位国家: 美国
• 财政年份: 2021
• 资助国家: 美国
• 起止时间: 2021-02-01 至 2026-01-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10561671
• 关键词: Address; Adherence; Administrator; Adult; Affect; Aging; Anticoagulant therapy; Anticoagulants; Anticoagulation; Area; Arrhythmia; Atrial Fibrillation; Attenuated; Award; Cardiovascular Diseases; Cardiovascular system; Caring; Chronic; Clinic; Clinical; Consolidated Framework for Implementation Research; Data Sources; Death Rate; Detection; Disease; Disparity; Effectiveness; Ensure; Equitable healthcare; Equity; Ethnic Origin; Foundations; Frequencies; Goals; Health Services; Health Services Research; Healthcare; Heart failure; Hispanic; Hospitalization; Hybrids; Individual; Inequity; Internist; Interview; K-Series Research Career Programs; Leadership; Medical; Medical Care Costs; Mentors; Methodology; Methods; Minority; Minority Groups; Modeling; Monitor; Neighborhoods; Newly Diagnosed; Oral; Participant; Patients; Perception; Provider; Qualitative Research; Race; Research; Research Personnel; Research Support; Risk Reduction; Safety; Sampling; Site; Socioeconomic Status; Specific qualifier value; Testing; Training; Training Support; United States; Variant; Veterans; Warfarin; Work; adverse outcome; black patient; care outcomes; career; cohort; cost; design; disparity elimination; disparity reduction; effective therapy; effectiveness evaluation; effectiveness testing; ethnic disparity; ethnic health disparity; ethnic minority; evidence base; experience; feasibility testing; health care disparity; health equity; heart rhythm; high risk; implementation design; implementation science; implementation strategy; improved; innovation; medical specialties; medication safety; military veteran; mortality; novel; pilot test; primary care practice; racial determinant; racial disparity; racial minority; recruit; societal costs; sociodemographic factors; stroke risk; tool; treatment disparity

Background. Atrial fibrillation (AF) is a common cardiac arrhythmia, affecting up to 1 million Veterans. AF increases the risk of stroke by 5-fold and is associated with higher rates of death. Oral anticoagulation reduces the risk of stroke in AF by 60%, yet such therapy is underutilized. Further, racial and ethnic disparities in anticoagulation for AF exist, despite a 2-fold higher risk of stroke among racial and ethnic minorities with this condition. In pilot work conducted in >40,000 Veterans with newly diagnosed AF in FY 2017, black Veterans were significantly less likely than white Veterans to receive any form of anticoagulant, particularly safer, more effective therapy with direct-acting oral anticoagulants. In these analyses there was up to 2.5-fold facility-level variation in the frequency of anticoagulation and in racial and ethnic disparities in such therapy. With the detection of these treatment disparities documented in VA, this CDA-2 will quantitatively assess the multilevel determinants of these disparities, qualitatively identify barriers to and facilitators of equitable anticoagulation for AF, and use these findings to develop and pilot test implementation strategies to eliminate these disparities. Significance / Impact. Ensuring access to high-quality, equitable care for all Veterans are VA and VA HSR&D priority areas. This CDA-2 addresses underuse of an evidence-based therapy for racial and ethnic minority Veterans with AF—a common and costly condition. The significance of this problem is likely to increase with the aging of the Veteran population and the steadily increasing proportion of minority Veterans receiving health care within VA. Innovation. This CDA-2 is framed using blended health equity and implementation science conceptual models to understand and reduce racial and ethnic disparities in health care. This CDA-2 uses novel data sources to assess the association of underexamined determinants of racial and ethnic disparities in Veterans with AF and is among the first to qualitatively examine Veteran experiences with AF and anticoagulation. Finally, this research will be the first to develop and test implementation strategies to reduce disparities in anticoagulation for AF. Specific Aims. Aim 1 is a quantitative study to characterize the association between race, ethnicity, and oral anticoagulant initiation in Veterans with AF. Aim 2 is a qualitative study to examine stakeholder perceptions of the barriers to and facilitators of equitable oral anticoagulant initiation in Veterans with AF. Aim 3 proposes to design and pilot test an empirically-developed implementation strategy bundle to improve equitable oral anticoagulant initiation in Veterans with AF. Methodology. Aim 1 uses a national cohort of ~130,000 Veterans with incident AF in FYs 2010-2019 to assess the patient, provider, and facility-level determinants of the association of race, ethnicity and anticoagulation. Aim 2 will recruit and interview providers, administrators, and Veterans with AF about barriers to and facilitators of equitable anticoagulant initiation for AF in VA. Aim 3 uses the findings from Aims 1 and 2 to develop and pilot-test the feasibility of a set of implementation strategies to promote equitable anticoagulant initiation within a local VA primary care practice. Implementation / Next steps. Findings from research Aims 1-3 will set the stage for a hybrid type 3 trial to broadly test the effectiveness of the pilot-tested implementation strategies on equitable anticoagulant initiation in Veterans with AF. Candidate. Dr. Utibe Essien is a general internist and Core Investigator in the VA Center for Health Equity Research and Promotion. The short-term goal of this CDA-2 is to gain training and research experience in understanding and implementing strategies to reduce treatment disparities in Veterans with AF. This will be achieved through in-depth training in: (1) advanced quantitative research; (2) qualitative research; (3) implementation science; and (4) professional leadership. This CDA-2 will support his long-term goal of becoming an independent VA health services investigator focused on developing implementation strategies to reduce racial and ethnic disparities in the use of evidence-based medical therapies for Veterans with chronic cardiovascular diseases.

背景。心房颤动 (AF) 是一种常见的心律失常，影响多达 100 万退伍军人。 AF 中风的风险增加 5 倍，并与更高的死亡率相关。口服抗凝药物可降低 AF 导致中风的风险增加 60%，但这种疗法并未得到充分利用。此外，种族和民族差异 尽管少数种族和族裔中风的风险高出两倍，但仍存在针对 AF 的抗凝治疗 健康）状况。 2017 财年，在超过 40,000 名新诊断 AF 的退伍军人中进行的试点工作中，黑人退伍军人 与白人退伍军人相比，接受任何形式的抗凝剂的可能性显着降低，特别是更安全、更有效 直接作用的口服抗凝剂的有效治疗。在这些分析中，设施水平高达 2.5 倍 抗凝治疗频率的差异以及此类治疗中种族和民族的差异。随着 检测 VA 中记录的这些治疗差异，该 CDA-2 将定量评估多级别 这些差异的决定因素，定性地确定公平抗凝的障碍和促进因素 AF，并利用这些发现来制定和试点测试实施策略，以消除这些差异。 意义/影响。 VA 和 VA HSR&D 确保所有退伍军人获得高质量、公平的护理 优先领域。本 CDA-2 解决了针对少数种族和族裔的循证疗法使用不足的问题 患有 AF 的退伍军人是一种常见且代价高昂的疾病。这个问题的重要性可能会随着 退伍军人人口老龄化以及接受健康服务的少数族裔退伍军人比例稳步上升 弗吉尼亚州内的护理。创新。该 CDA-2 采用混合健康公平和实施科学的框架 理解和减少医疗保健方面的种族和民族差异的概念模型。该 CDA-2 使用 用于评估种族和民族差异的未经充分审查的决定因素之间的关联的新数据源 患有 AF 的退伍军人，是最早定性研究 AF 退伍军人经历的人之一 抗凝。最后，这项研究将是第一个开发和测试减少的实施策略 房颤抗凝治疗的差异。具体目标。目标 1 是一项定量研究，旨在表征 患有 AF 的退伍军人中种族、民族和口服抗凝剂开始使用之间的关联。目标 2 是定性的 研究调查利益相关者对公平口服抗凝剂的障碍和促进因素的看法 患有 AF 的退伍军人的启动。目标 3 提出设计并试点测试一个凭经验开发的实施方案 改善房颤退伍军人公平口服抗凝药物启动的策略组合。方法论。目标1 使用 2010-2019 财年约 130,000 名发生 AF 的退伍军人的全国队列来评估患者、提供者、 以及种族、民族和抗凝相关的设施层面的决定因素。目标 2 将招募和 与 AF 的提供者、管理人员和退伍军人进行访谈，了解公平性的障碍和促进因素 VA 中 AF 的抗凝启动。目标 3 使用目标 1 和 2 的发现来开发和试点测试 一套实施策略的可行性，以促进当地 VA 内公平的抗凝治疗 初级保健实践。实施/后续步骤。研究目标 1-3 的结果将为 混合型 3 试验，广泛测试试点实施战略在公平方面的有效性 患有房颤的退伍军人开始抗凝治疗。候选人。 Utibe Essien 博士是一名普通内科医生和核心医生 退伍军人管理局健康公平研究与促进中心研究员。 CDA-2 的短期目标是 获得理解和实施减少治疗策略的培训和研究经验 患有 AF 的退伍军人之间存在差异。这将通过以下方面的深入培训来实现：（1）高级定量 研究; (2) 定性研究； （三）实施科学； （四）专业领导。该 CDA-2 将 支持他成为一名独立的退伍军人事务部卫生服务调查员的长期目标，专注于开发 减少使用循证医学方面的种族和族裔差异的实施战略 治疗患有慢性心血管疾病的退伍军人。