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: 10983208
• 负责人: Utibe R. Essien
• 金额: --
• 依托单位: VA GREATER LOS ANGELES HEALTHCARE SYSTEM
• 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/10983208
• 关键词: Access; Quality; Equity; Anticoagulants; Veterans

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.

背景资料。房颤(房颤)是一种常见的心律失常，影响多达100万退伍军人。房颤 使中风的风险增加5倍，并与更高的死亡率相关。口服抗凝降低 房颤患者发生中风的风险降低了60%，然而这种治疗方法没有得到充分利用。此外，中国的种族和民族差距 房颤的抗凝治疗是存在的，尽管在种族和少数民族中中风的风险增加了2倍 条件。在2017财年在40,000名新诊断为房颤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要小得多，尤其是更安全、更 使用直接作用的口服抗凝剂进行有效治疗。在这些分析中，设施级别最高可达2.5倍 抗凝频率的差异以及这种治疗中的种族和民族差异。与 检测VA中记录的这些治疗差异，CDA-2将定量评估多个水平 这些差异的决定因素，定性地确定公平抗凝的障碍和促进者 AF，并利用这些发现来开发和试点测试实施战略，以消除这些差异。 重要性/影响力。确保所有退伍军人获得高质量、公平的护理是退伍军人和退伍军人高铁和退伍军人 优先领域。这项CDA-2针对的是对种族和少数民族的循证治疗使用不足的问题。 患有房颤的退伍军人--这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和少数民族退伍军人健康比例稳步上升 退伍军人事务部的护理。创新。这份CDA-2的框架采用了健康公平和实施科学相结合的方法 理解和减少卫生保健中种族和民族差异的概念模型。这台CDA-2使用 评估未得到充分研究的种族和族裔差距决定因素之间的联系的新数据来源 患有房颤的退伍军人，是第一批定性检查退伍军人房颤经验的人之一 抗凝剂。最后，这项研究将第一次制定和测试减少 房颤在抗凝方面的差异。明确的目标。目标1是一项定量研究，以表征 退伍军人合并房颤患者的种族、民族和口服抗凝治疗方案之间的关系。目标2是一个定性的 调查利益相关者对公平口服抗凝剂的障碍和促进者的看法的研究 患有房颤的退伍军人的入门治疗。目标3建议设计和试点测试一个经验开发的实现 改善患有房颤的退伍军人公平口服抗凝治疗的策略包。方法论。目标1 使用2010-2019财年发生房颤事件的全国约130,000名退伍军人队列来评估患者、提供者、 以及与种族、民族和抗凝相关的设施层面的决定因素。目标2将招募和 就公平的障碍和促进者与AF的提供者、管理人员和退伍军人进行访谈 VA中房颤的抗凝启动。目标3使用目标1和目标2的结果来开发和试点测试 促进当地退伍军人管理局公平启动抗凝剂的一套实施战略的可行性 初级保健实践。实施/后续步骤。研究目标1-3的发现将为 混合类型3试验，以广泛测试经试点测试的公平执行战略的有效性 退伍军人房颤患者的抗凝剂启动。候选人。Utibe Essien博士是一名普通内科医生和核心 退伍军人事务部健康公平研究和促进中心的调查员。CDA-2的短期目标是 在理解和实施减少治疗的战略方面获得培训和研究经验 患有房颤的退伍军人的差异。这将通过以下方面的深入培训来实现：(1)高级量化 研究；(2)定性研究；(3)实施科学；(4)专业领导力。这架CDA-2将 支持他成为一名独立的退伍军人健康服务调查员的长期目标，专注于开发 减少在使用循证医疗方面的种族和族裔差异的执行战略 为患有慢性心血管疾病的退伍军人提供治疗。