Understanding Racial/Ethnic Disparities in Uterine Fibroid Outcomes among Women Veterans: A mixed-methods study

背景：子宫肌瘤（UF）是一种常见且昂贵的妇科疾病， 妇女的发病率，严重程度，治疗和结果。UF导致衰弱症状，包括骨盆 压力和疼痛，生殖问题，大量月经出血和严重贫血，是主要的 在退伍军人中女性子宫切除术的原因。虽然VA是一个关于健康的模范医疗保健系统， 在许多领域的公平，最近的数据表明，在UF治疗和结果存在实质性的黑人/白色差异 在VA。由于三分之一使用退伍军人管理局医疗保健的妇女是黑人，而且这一比例正在增加， 理解VA内部这些差异的潜在驱动因素至关重要。有限的研究 研究这些机制无论是外部或内部的VA。建立对UF差异的全面理解 解决这些问题的潜在机会将需要研究种族和种族主义在女性退伍军人中的作用。 UF的诊断和治疗途径及其UF治疗模式和经验。 目的：我们的目的是研究UF相关结果中黑人/白色人差异的潜在机制 在接受退伍军人事务部护理的女性中。在公共卫生关键种族实践的指导下， 是一种社会建构，当代种族主义的普遍存在的模式和结构造成种族不平等， 健康，我们建议：（1）检查黑人/白色的差异，在治疗模式的妇女退伍军人与UF和 确定可改变的决定因素;（2）检查黑人/白色人在临床和手术后结局方面的差异， 女性退伍军人接受治疗的UF在VA和确定可修改的决定因素;和（3）了解和 利用对黑人女退伍军人的定性探索，将目标1和2中确定的差异置于背景中， UF症状、寻求护理行为和治疗的经历，以及它们与白色患者的不同之处 女性退伍军人。 方法：我们将使用混合方法来解决我们的研究目标。所有这三个目标，将从一个 新诊断为症状性UF的VA医疗保健的黑人和白色女性退伍军人使用者的单一队列 2010财年（FY10）和FY12之间的数据，通过企业数据仓库（CDW）确定。目标1和2 是回顾性队列分析。我们将检查管理数据和图表摘要医疗记录数据 到2018财年，比较黑人/白色在治疗和结局方面的差异。目标1将比较从诊断开始的时间 初始治疗和手术治疗;初始治疗的类型（药物、非确定性手术、子宫切除术）; 和手术方式（微创vs腹部）。目标2将检查临床试验中的黑人/白色差异 （急诊室就诊、贫血住院、输血）和手术结果（手术并发症， 30-日再入院）的UF。目标3是一项定性研究，有目的地选择了多达30名黑人和30名 白色女退伍军人为我们的目标1和目标2的定量调查结果提供信息和背景。内容分析将 用于理解和确定种族和性别的结构如何相互作用，以影响女性退伍军人的生活。 UF经验、治疗途径、治疗决策和治疗模式。我们的传播 该计划包括一个利益相关者参与过程，该过程将使退伍军人、供应商和运营合作伙伴参与， 将我们的研究结果转化为可操作的实践和政策建议，以减少差距。 创新和后续步骤：该提案涉及妇女健康，健康公平， 获得医疗服务。创新的方法通过超越记录种族/族裔， 差异，以建立对潜在的和可能改变的原因的理解。完成后的后续步骤 研究和利益相关者参与过程将包括与VA妇女健康服务合作， 卫生公平VA办公室制定有针对性的干预措施，方案和政策，以解决UF的差距。 最终，这项研究有可能加速妇科质量和公平的进步， 生殖健康在内外。

Background: Uterine fibroids (UF) are a common and costly gynecologic condition that disproportionately affect Black women with regard to incidence, severity, treatment, and outcomes. UF result in debilitating symptoms including pelvic pressure and pain, problems with reproduction, heavy menstrual bleeding, and severe anemia, and are the leading cause of hysterectomy among women Veterans in VA. Although VA is a model healthcare system regarding health equity in many areas, recent data suggest that substantial Black/White disparities in UF treatment and outcomes exist within VA. As one-third of women Veterans using VA health care are Black and this proportion is increasing, understanding the underlying drivers of these disparities within VA is of critical importance. Limited research has examined these mechanisms either outside or within VA. Building a comprehensive understanding of UF disparities and potential opportunities to address them will require examining the role of race and racism in women Veterans’ pathways to diagnosis and treatment of UF and their UF treatment patterns and experiences. Objectives: Our objective is to investigate the mechanisms underlying Black/White disparities in UF-related outcomes among women Veterans receiving VA care. Guided by the Public Health Critical Race Praxis, which asserts that race is a social construct and that ubiquitous patterns and structures of contemporary racism shape racial disparities in health, we propose: (1) To examine Black/White differences in treatment patterns for women Veterans with UF and identify modifiable determinants; (2) To examine Black/White differences in clinical and post-surgical outcomes among women Veterans receiving treatment for UF in VA and identify modifiable determinants; and (3) To understand and contextualize differences identified in Aims 1 and 2 using qualitative exploration of Black women Veterans’ experiences with UF symptoms, care seeking behaviors, and treatment and how they differ from those of White women Veterans. Methods: We will use a mixed methods approach to address our study objectives. All three aims, will draw from a single cohort of Black and White women Veteran users of VA healthcare with newly diagnosed symptomatic UF between Fiscal Year 2010 (FY10) and FY12, identified through the Corporate Data Warehouse (CDW). Aims 1 and 2 are retrospective cohort analyses. We will examine administrative data and chart-abstracted medical record data through FY18 to compare Black/White differences in treatment and outcomes. Aim 1 will compare time from diagnosis to initial treatment and surgical treatments; type of initial treatment (medical, non-definitive procedure, hysterectomy); and mode of surgery (minimally invasive vs abdominal). Aim 2 will examine Black/White differences in clinical (emergency room visits, hospitalization for anemia, blood transfusion) and surgical outcomes (surgical complications, 30-day readmission) for UF. Aim 3 is a qualitative study with a purposively selected sample of up to 30 Black and 30 White women Veterans to inform and contextualize our quantitative findings from Aims 1 and 2. Content analysis will be used to understand and identify how the constructs of race and gender may interact to impact women Veterans’ experiences with UF, pathways to treatment, treatment decision making, and treatment patterns. Our dissemination plan includes a stakeholder engagement process which will engage Veterans, providers, and operational partners in translating our findings into actionable practice and policy recommendations to reduce disparities. Innovation and Next Steps: This proposal addresses key HSR&D priorities of women’s health, health equity, and healthcare access. The innovative approach ensures substantial impact by moving beyond documenting racial/ethnic disparities to building understanding of underlying and potentially modifiable causes. Next steps following completion of the research and stakeholder engagement process will include partnering with VA Women’s Health Services and VA Office of Health Equity to develop targeted interventions, programs, and policies to address UF disparities. Ultimately, this research has the potential to accelerate progress towards quality and equity in gynecology and reproductive healthcare both within and beyond VA.