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

背景心房颤动（AF）是一种常见的心律失常，影响多达1百万退伍军人。AF 中风的风险增加5倍，并与更高的死亡率相关。口服抗凝剂减少 房颤患者中风的风险降低了60%，但这种治疗尚未得到充分利用。此外，种族和族裔不平等， 房颤抗凝治疗存在，尽管少数种族和民族中风风险高出2倍， 条件在2017财年对> 40，000名新诊断为AF的退伍军人进行的试点工作中，黑人退伍军人 与白色退伍军人相比， 直接作用口服抗凝剂的有效治疗。在这些分析中，有高达2.5倍的设施水平， 抗凝频率的变化以及此类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，本CDA-2将定量评估多水平 这些差异的决定因素，定性识别公平抗凝治疗的障碍和促进因素， AF，并利用这些发现来制定和试点测试实施战略，以消除这些差距。 意义/影响。确保所有退伍军人获得高质量，公平的护理是VA和VA HSR&D 优先领域。该CDA-2解决了少数种族和少数民族循证治疗的使用不足问题 退伍军人与AF-一个共同的和昂贵的条件。这个问题的重要性可能会随着 退伍军人人口的老龄化和少数民族退伍军人接受医疗保健的比例稳步上升 在VA中护理。创新该CDA-2采用混合健康公平和实施科学的框架 概念模型，以了解和减少种族和民族的差距，在医疗保健。CDA-2使用 新的数据来源，以评估种族和民族差异的未充分审查的决定因素之间的关联， 退伍军人与AF，是第一个定性研究退伍军人与AF的经验， 抗凝最后，本研究将首次开发和测试实施策略，以减少 房颤抗凝治疗的差异。特定目的。目的1是定量研究，以表征 在退伍军人房颤患者中，种族、民族和口服抗凝剂开始治疗之间的相关性。 一项研究，旨在检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 目标3建议设计和试点测试一个实验性开发的实施方案， 改善退伍军人房颤患者公平口服抗凝剂治疗策略。要求1 使用2010-2019财年约130，000例AF事件退伍军人的全国队列，评估患者，提供者， 以及种族、民族和抗凝相关性的设施水平决定因素。目标2将招募和 采访供应商，管理人员和退伍军人与AF有关的障碍和促进者的公平 在VA中开始抗凝治疗AF。目标3利用目标1和目标2的研究结果， 一套实施策略的可行性，以促进当地VA内公平的抗凝剂启动 初级保健实践。执行/后续步骤。研究目标1-3的结果将为 混合第三类试验，以广泛测试经试点测试的公平竞争实施战略的成效。 房颤退伍军人的抗凝治疗。Utibe Essien博士是一名普通内科医生， VA健康公平研究和促进中心的研究员。CDA-2的短期目标是 获得培训和研究经验，了解和实施减少治疗的战略 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;（3）实施科学;（4）专业领导。CDA-2将 支持他的长期目标，成为一个独立的VA卫生服务调查员，专注于发展 实施战略，减少在使用循证医学 为患有慢性心血管疾病的退伍军人提供治疗。

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.