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 将中风的风险增加了5倍，并且与较高的死亡率有关。口服抗凝可减少 AF的中风的风险增加了60％，但这种疗法却没有得到充分利用。此外，种族和种族差异 存在抗凝AF的抗凝治疗，dospite在种族和少数民族中的中风风险高2倍 健康）状况。在2017财年，在> 40,000名退伍军人中进行的飞行员工作，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，尤其是更安全，更多的可能性要小得多 直接作用口服抗凝剂的有效治疗。在这些分析中，最多有2.5倍的设施级别 这种疗法中抗凝频率以及种族和种族差异的变化。与 检测VA中记录的这些治疗分布，该CDA-2将对多级评估 这些分布的决定因素，定性地确定了公平抗凝的障碍和促进者 AF，并使用这些发现来制定和进行试验测试实施策略以消除这些分布。 意义 /影响。确保获得所有退伍军人的高质量，公平护理是VA和VA HSR＆D 优先区域。这种CDA-2解决了对种族和少数民族的循证疗法的缺乏 AF的退伍军人 - 一种常见且昂贵的状况。这个问题的意义可能会随着 退伍军人人口的老龄化以及接受健康的少数退伍军人的比例悄悄地增加 弗吉尼亚州内的护理。创新。该CDA-2使用混合健康公平与实施科学构建 理解和减少医疗保健中种族和种族差异的概念模型。此CDA-2使用 新的数据源，以评估不渗透性的种族和种族差异的确定词的关联 具有AF的退伍军人，是最早审查AF和AF的退伍军人经历的人之一 抗凝。最后，这项研究将是第一个制定和测试实施策略以减少的研究 AF的抗凝差异。具体目标。 AIM 1是一项定量研究，以表征 种族，种族和AF退伍军人口腔抗凝倡议之间的关联。 AIM 2是定性的 研究研究利益相关者对公平抗凝剂的障碍和促进者的看法 在AF的退伍军人中启动。 AIR 3建议设计和试验测试经验开发的实施 策略捆绑以改善AF退伍军人的公平口服抗凝剂倡议。方法论。目标1 使用大约130,000名退伍军人组成的国家队列，与2010-2019的FYS中发生AF的事件来评估患者，提供者， 以及种族，种族和抗凝关联的设施级别的决定者。 AIM 2将招募和 面试提供者，管理人员和退伍军人与AF有关公平的障碍和促进者 VA中AF的抗凝剂倡议。 AIM 3使用目标1和2的发现来开发和进行试验测试 一系列实施策略的可行性，以促进当地VA中的公平抗凝计划 初级保健实践。实施 /下一步。研究目标1-3的发现将为 混合3型试验，以广泛测试试点测试的实施策略对公平的有效性 AF退伍军人的抗凝倡议。候选人。 Utibe Essien博士是一名普通实习生和核心 VA卫生公平研究与促进中心的研究者。此CDA-2的短期目标是 获得理解和实施策略以减少治疗的培训和研究经验 AF退伍军人的差异。这将通过以下深度培训来实现：（1）高级定量 研究; （2）定性研究； （3）实施科学； （4）专业领导。这个CDA-2会 支持他成为专注于发展的独立VA卫生服务调查员的长期目标 实施策略，以减少使用循证医学的种族和种族差异 患有慢性心血管疾病的退伍军人的疗法。