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，对Black的影响不成比例 妇女在发病率、严重性、治疗和结果方面的差异。UF导致包括骨盆在内的虚弱症状 压力和疼痛、生殖问题、月经大出血和严重贫血是主要的 退伍军人女性子宫切除术的原因分析。尽管退伍军人事务部是一个关于健康的模范医疗系统 在许多领域，公平，最近的数据表明，在UF治疗和结果方面存在显著的黑人/白人差异 在退伍军人事务部。由于使用退伍军人医疗保健的女性退伍军人中有三分之一是黑人，而且这一比例还在增加， 了解退伍军人事务部内部这些差异的根本驱动因素至关重要。有限的研究已经 检查了退伍军人管理局外部或内部的这些机制。全面了解UF差异 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治疗模式和经验。 目标：我们的目标是调查UF相关结局中黑人/白人差异的机制 在接受退伍军人护理的女性退伍军人中。在公共卫生关键种族实践组织的指导下，该组织声称 是一种社会结构，当代种族主义无处不在的模式和结构在 健康，我们建议：(1)检查患有UF和UF的女性退伍军人在治疗模式上的黑/白差异 确定可修改的决定因素；(2)检查以下人群中临床和手术后结果的黑/白差异 在退伍军人中接受UF治疗的退伍军人，并确定可修改的决定因素；以及(3)了解和 利用黑人女性退伍军人的定性探索，将目标1和目标2中确定的差异联系起来 UF症状、寻求护理行为和治疗的经验以及它们与White的不同之处 女退伍军人。 方法：我们将使用混合方法来解决我们的研究目标。这三个目标都将从一个 黑人和白人女性退伍军人中新诊断为UF的VA医疗保健使用者的单一队列 在2010财年(2010财年)和2012财年之间，通过企业数据仓库(CDW)确定。目标1和目标2 是回溯性的队列分析。我们将检查管理数据和图表摘要的病历数据 通过18财年比较黑人和白人在治疗和结果方面的差异。目标1将比较从诊断到诊断的时间 初步治疗和外科治疗；初步治疗的类型(内科、非决定性手术、子宫切除术)； 以及手术方式(微创与腹部手术)。目标2将在临床上检查黑人和白人的差异 (急诊室就诊、贫血住院、输血)和手术结果(手术并发症、 30天重新入院)。目标3是一项定性研究，有目的地选择最多30个布莱克和30个样本 白人女性退伍军人向我们通报目标1和目标2的量化结果并将其联系起来。内容分析将 被用来理解和确定种族和性别的结构如何相互作用来影响女性退伍军人 UF的经验，治疗途径，治疗决策和治疗模式。我们的传播 计划包括利益相关者参与流程，该流程将让退伍军人、提供商和运营合作伙伴参与 将我们的调查结果转化为可操作的做法和政策建议，以减少差距。 创新和下一步：这项提案涉及妇女健康、健康公平和高铁发展的关键优先事项 医疗保健服务。创新的方法不仅记录种族/民族，还确保产生重大影响 在建立对潜在和潜在可改变原因的理解方面存在差异。完成后的下一步 研究和利益攸关方参与进程将包括与退伍军人事务部妇女健康服务和 弗吉尼亚州卫生公平办公室制定有针对性的干预措施、计划和政策，以解决UF差异。 归根结底，这项研究有可能加快妇科和妇科领域的质量和公平进程 退伍军人事务部内外的生殖保健。

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.