Identifying and testing a tailored strategy to achieve equity in blood pressure control in PACT

确定并测试量身定制的策略，以在 PACT 中实现血压控制的公平性

• 批准号: 10538513
• 负责人: April F Mohanty
• 金额: --
• 依托单位: VA SALT LAKE CITY HEALTHCARE SYSTEM
• 依托单位国家: 美国
• 财政年份: 2023
• 资助国家: 美国
• 起止时间: 2023-04-01 至 2027-03-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10538513
• 关键词: Address; Adherence; Adult; Affect; Age; American; Antihypertensive Agents; Black race; Blood Pressure; Blood Pressure Monitors; Cardiovascular Diseases; Caring; Chronic; Cities; Clinical; Clinical Practice Guideline; Color; Community Healthcare; Data; Department of Defense; Diagnosis; Disparity; Enrollment; Ensure; Equity; Ethnic Origin; Evaluation; Evaluation Studies; Event; Evidence based practice; Feedback; Frequencies; Geographic Locations; Goals; Guidelines; Hispanic; Hypertension; Inequity; Intervention; Interview; Judgment; Knowledge; Link; Medication Management; Methodology; Minority; Morbidity - disease rate; Patient Preferences; Patients; Performance; Pharmaceutical Preparations; Predictive Factor; Primary Care; Provider; Public Health; Race; Recommendation; Research; Risk Factors; Risk Reduction; Rural; Sodium Chloride; Stroke; Stroke prevention; Structure; Surgeon; Team Process; Techniques; Testing; Theoretical Domains framework; Update; Veterans; Veterans Health Administration; Visit; behavior change; blood pressure control; blood pressure reduction; blood treatment; cardiovascular disorder risk; cardiovascular risk factor; chronic care model; comorbidity; dashboard; design; disparities in morbidity; disparity reduction; ethnic difference; ethnic disparity; ethnic minority; evidence base; experience; follow-up; health equity; health inequalities; health management; hypertension control; hypertensive; implementation strategy; improved; innovation; insight; medical specialties; modifiable risk; mortality; mortality disparity; pilot test; population health; prototype; racial difference; racial minority; sex; sociodemographics; team-based care; tool; treatment disparity; uptake; usability; virtual healthcare

Background: Hypertension and blood pressure (BP) control inequities are a leading modifiable risk factor for the higher cardiovascular disease (CVD) morbidity and mortality experienced by racial/ethnic minority Americans. Team based care, an evidence-based practice, may be effective in reducing BP control disparities. However, despite VA Primary Aligned Care Team (PACT) implementation, BP control race/ethnic inequities persist. This highlights a need tailored bundle of implementation strategies (i.e., playbook) to address the unique needs of minority Veterans. The 2020 VA/DoD Hypertension Clinical Practice Guideline recommends a threshold for medication initiation in high CVD-risk patients and for medication intensification in all hypertensive patients be lowered by 10 mm Hg (vs older guidelines) to systolic BP 130 mm Hg (intensive BP control), if aligned with clinical judgement and patient preference. Achieving and maintaining intensive BP control could avert half a million CVD events in the US overall over 10 years, however there is a need for implementation playbooks that ensure the known benefits of intensive BP control are experienced equally. Significance: Our goal is to reduce hypertension-related morbidity and mortality disparities in VHA by optimizing antihypertensive medication management in PACT. Achieving and maintaining intensive BP control may avert half a million CVD events over 10 years in the US. Innovation and Impact: Our study will leverage the VHA Office of Health Equity Primary Care Equity Dashboard (PCED) launched in 2021, an audit feedback tool, may be an important strategy to a population health management approach, to support team-based playbooks designed to mitigate hypertension disparities and support evidence based practice update among race/ethnic minority Veterans. Specific Aims: Aim 1) Contrast patient-, provider-, and facility-level factors associated with intensive antihypertensive management (initiation, adherence, and intensification) and BP control by race/ethnicity; Aim 2) Using qualitative data, identify patient, provider- and facility-barriers and facilitators relevant to intensive antihypertensive management (initiation, adherence, and intensification) and BP control by race/ethnicity; and Aim 3) Codesign two intensive BP control population health management implementation playbooks tailored to reduce BP inequities and prototype and pilot test the playbooks in PACT. Methodology: In Aim 1, we will complete a hierarchical analysis of patient (e.g. sex, age, socio-demographics, comorbidities, non-VA community and virtual healthcare use), provider (e.g. specialty, patient-provider visit frequency), and facility (e.g. urban/rural status, geographic location, % racial minorities served, academic affiliation, PACT implementation) factors associated with intensive BP management. In Aim 2, applying the Theoretical Domains Framework in conjunction with the Chronic Care Model, we will collect and analyze semi- structured interview data from 120 Veterans and 60 PACT staff and providers from the Salt Lake City and DC VAMCs. In Aim 3, with our stakeholders we will identify and prioritize multilevel barriers improve equitable BP control. Next, we will link the barriers to evidence-based behavior change techniques and tools, such as leveraging the PCED. We will iteratively tailor and prototype two multilevel playbooks, one will focus on the facility/team level and the other on the provider/patient level. We will pilot both playbooks at the Salt Lake City and DC VAMCs to collect usability, feasibility, and acceptance data. Next Steps/Implementation: By completing these aims, we will provide an actionable, evidence-based, and comprehensive understanding of the gaps and barriers related to intensive BP control in the VHA. This knowledge will lead to an evaluation study of the tailored intensive BP management implementation playbooks.

背景：高血压和血压 (BP) 控制不平等是导致高血压的主要可改变风险因素 少数族裔的心血管疾病 (CVD) 发病率和死亡率较高 美国人。基于团队的护理是一种基于证据的实践，可能有效减少血压控制差异。 然而，尽管 VA 主要协调护理团队 (PACT) 实施，BP 仍然控制着种族/民族不平等 坚持。这突出表明需要定制一系列实施策略（即行动手册）来解决 少数族裔退伍军人的独特需求。 2020 年 VA/DoD 高血压临床实践指南推荐 高 CVD 风险患者开始用药的阈值以及所有高血压患者强化用药的阈值 如果患者的收缩压降低 10 毫米汞柱（与旧指南相比）至 130 毫米汞柱（强化血压控制）， 符合临床判断和患者偏好。实现并维持强化血压控制可以 10 年内美国总共避免了 50 万起 CVD 事件，但仍需要实施 确保强化血压控制的已知益处得到平等体验的手册。 意义：我们的目标是通过以下方式减少 VHA 中与高血压相关的发病率和死亡率差异： 优化 PACT 中的抗高血压药物管理。实现并维持强化血压控制 可以在 10 年内避免美国 50 万起 CVD 事件。 创新和影响：我们的研究将利用 VHA 健康公平初级保健公平办公室 2021 年推出的 Dashboard（PCED）是一种审计反馈工具，对大众来说可能是一项重要策略 健康管理方法，支持旨在缩小高血压差异的基于团队的行动手册 并支持少数族裔退伍军人基于证据的实践更新。 具体目标： 目标 1) 对比与强化治疗相关的患者、提供者和设施层面的因素 按种族/民族进行抗高血压管理（开始、坚持和强化）和血压控制；目的 2) 使用定性数据，确定与强化治疗相关的患者、提供者和设施障碍和促进因素 按种族/民族进行抗高血压管理（开始、坚持和强化）和血压控制；和 目标 3) 共同设计两本针对以下人群量身定制的强化血压控制人群健康管理实施手册 减少 BP 的不平等，并在 PACT 中对剧本进行原型测试和试点测试。 方法：在目标 1 中，我们将完成对患者的分层分析（例如性别、年龄、社会人口统计、 合并症、非 VA 社区和虚拟医疗保健使用）、提供者（例如专业、患者提供者就诊 频率）和设施（例如城市/乡村状况、地理位置、服务的少数族裔百分比、学术水平 隶属关系、PACT 实施）与强化 BP 管理相关的因素。在目标 2 中，应用 理论领域框架与慢性护理模型相结合，我们将收集和分析半 来自盐湖城和华盛顿特区 120 名退伍军人和 60 名 PACT 工作人员和提供者的结构化访谈数据 VAMC。在目标 3 中，我们将与我们的利益相关者一起确定多层障碍并确定优先顺序，以提高公平的 BP 控制。接下来，我们将把障碍与基于证据的行为改变技术和工具联系起来，例如 利用 PCED。我们将迭代地定制和原型化两本多层次的剧本，其中一本将重点关注 设施/团队级别，另一个在提供者/患者级别。我们将在盐湖城试行这两本剧本 和 DC VAMC，用于收集可用性、可行性和验收数据。 后续步骤/实施：通过完成这些目标，我们将提供一个可操作的、基于证据的、 全面了解 VHA 中与强化血压控制相关的差距和障碍。这 知识将导致对定制的强化 BP 管理实施手册进行评估研究。