patient, provider, and system interventions to …acknowledgements –it took a village...

PATIENT, PROVIDER, AND SYSTEM

INTERVENTIONS TO PROMOTE EQUITY

AMONG VULNERABLE VETERAN

POPULATIONS

Society of Behavioral Medicine 37th Annual Meeting

Washington, DC

April 2, 2016

Leg0fenris. Oh brother where art thou. https://flic.kr/p/9wuc1h / CC BY-NC-ND 2.0

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Peter Murphy. Me against myself.

https://flic.kr/p/9Q4xUk; CC BY-ND 2.0

Parker Knight. Long Beach VA Hospital.

https://flic.kr/p/7B5Cos; CC BY 2.0

Theodore Lee. War Veteran.

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The U.S. Army. Virginia.

https://flic.kr/p/4v3Py2; CC BY 2.0.

Don DeBold. Vietnam Veteran’s Memorial.

https://flic.kr/p/cm6L8Y; CC BY-NC-ND.

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https://flic.kr/p/7B5Cos

https://flic.kr/p/4v3Py2

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JnL. Bike Wheel. https://flic.kr/p/4JKSG; CC BY-SA 2.0.

Male Gringo. Funky Spokes Bike Repair. https://flic.kr/p/7RkwC5; CC BY-NC 2.0.

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EVALUATION OF A NETWORK-WIDE

EFFORT TO REDUCE RACIAL

DISPARITIES IN HYPERTENSION

Leslie R.M. Hausmann, PhD

Core Investigator, CHERP

VA Pittsburgh Healthcare System

Assistant Professor of Medicine

University of Pittsburgh

Disclosures/Funding

• The views expressed here are mine and do not represent

those of the Department of Veterans Affairs or the United

States Government.

• I have no financial conflicts to disclose.

• This work was undertaken as quality improvement

supported with funding from the VA Office of Health Equity

and VISN 4 (XVA 72-183; PI: Hausmann).

Acknowledgements – It took a village

• Operations, Clinical, and Research Partners:• VHA Office of Health Equity

• Veterans Integrated Service Network (VISN) 4

• VA Pittsburgh Healthcare System, Center for Health Equity Research

and Promotion (CHERP)

• Individuals:

Keri L. Rodriguez George Brown Christopher M. Mannozzi

Maria K. Mor Matthew J. Chinman Matthew F. Muldoon

Kelly H. Burkitt Charlene David Lisa Red

Walter J. Clark Beth Ann Gibson Genna Toth

David S. Macpherson Kenneth T. Jones Uchenna S. Uchendu

Michael J. Fine Judith Long

Goals for the Next 15 Minutes

• Review how this project came to be

• Summarize the evaluation aims and methods

• Report major qualitative and quantitative findings

• Share future recommendations

Veterans Integrated Service Network (VISN) 4

Project Origin

• VISN 4 included objectives to reduce disparities in

performance plan for Fiscal Year (FY) 2013

• Develop a VISN-wide Race Disparity Dashboard

• Use the Dashboard to identify opportunities for quality

improvement

VISN 4 Race Disparity Dashboard –

Initial Findings

Black-White Differences in 19 Primary Care Quality Measures as of April 20, 2013

VISN 4 Disparities Objectives for FY14

• Carry out a VISN-wide quality improvement effort to

reduce racial disparities in hypertension (HTN) control

• Specific target: Reduce the number black Veterans with

severe (i.e., Stage 2) HTN

• Why black Veterans?

• Target for HTN control (80% with BP<140/90) was met for

whites, but not blacks

• Why Stage 2 HTN (BP>160/100)?

• Greater risk for vascular morbidity

The VISN 4 Hypertension Racial

Disparities Project was Born

• VISN Project Lead appointed (based in Pittsburgh)

• Task: Coordinate efforts across VISN

• Facility Project Leads appointed at each VA Medical

Center (VAMC)

• Task: Oversee project activities at their VAMC and

Community Based Outpatient Clinics (CBOCs)

Step 1 – GAIR Analysis

• Identify factors underlying black-white HTN disparities at

each facility

• Providers not using current clinical GUIDELINES

• Lack of patient ADHERENCE to medication and lifestyle

modification

• Provider clinical INERTIA (a lack of urgency) in treating

patients with HTN

• Patient RESISTANCE to standard medication management

• Formulate local action plans based on GAIR analysis

Step 2 (and 3 and 4…) –

Implement Local Action Plans• VISN Project Lead served as a model and provided

support

• Facility Project Leads carried out local activities

• VISN provided tools to generate lists of patients with

Stage 2 HTN

• Lists could be sorted by race, last BP, provider, etc.

• VISN also distributed monthly progress reports

Evaluation Opportunity –

VISN 4 / CHERP / OHE Partnership

• CHERP partnered with VHA

Office of Health Equity

(OHE) and VISN 4 to

document the process and

impact of this network-wide

effort to reduce race

disparities in HTN

Evaluation Aims

• Describe HTN control intervention strategies implemented

and barriers to implementation

• Assess impact of intervention strategies on disparities in BP

control among black and white Veterans with HTN

Methods – Qualitative

• CHERP qualitative expert documented VISN and local

facility project-related calls

• Conducted semi-structured telephone interviews with

facility project leaders

• Coded meeting and interview notes for barriers and

strategies using modified grounded theory approach

Methods – Quantitative

• Used data abstracted from electronic medical records to

assess change in BP for black and white Veterans

• Used multi-level regression models to examine how

intervention strategies were related to changes in BP

disparities

Qualitative Findings, Part 1 –

Barriers to Implementation

• 19 different barriers identified

• Range=2-9, Median=4

• Fell into 4 categories (# facilities)

• Project implementation barriers (8)

• Patient-level barriers related to HTN management (6)

• Provider-level barriers related to HTN management (5)

• System-level barriers related to HTN management (6)

Qualitative Findings, Part 2 –

Strategies Used to Reduce Disparities

• 22 specific strategies identified

• Range=4-10, Median=6

• Fell into 7 broad categories (# facilities)

• Provider education (9)

• Use lists of patients with Stage 2 HTN (8)

• Patient outreach (5)

• Patient education about BP management (4)

• Increase uptake of existing services (3)

• Establish new type of HTN appointment (2)

• Modify Computerized Patient Record System to prompt

action (2)

Quantitative Findings –

Did BP Change?

Time Trends in Stage 2 HTN among

Black and White Veterans in VISN 4

Adjusted Odds of Changes in Stage 2 HTN Overall and in Disparities

Predictors

Model 1*†

OR (95% CI)

Black Race 1.80 (1.73-1.87)

1 Year Change in HTN 0.96 (0.93-0.99)

Change in HTN by # Strategies

3 Strategy Categories -- --



1 Year Change in Disparity 0.84 (0.78-0.89)

Change in Disparity by #

Strategies



5 Strategy Categories -- --*Random intercept for facility accounted for differences across facilities in proportion of Veterans with Stage 2 HTN.

†Adjusted for age, sex, marital status, and eligibility.

Reduction in black-

white disparity in

Stage 2 HTN

between 10/1/13 and

10/1/14

Adjusted Odds of Change in Stage 2 HTN and Change in Disparities

Predictors

Model 1*†

OR (95% CI)

Model 2**†

OR (95% CI)

Black Race 1.80 (1.73-1.87) 1.81 (1.53-2.14)

1 Year Change in HTN 0.96 (0.93-0.99) -- --

Change in HTN by # Strategies

3 Strategy Categories -- -- 1.01 (0.96-1.07)



1 Year Change in Disparity 0.84 (0.78-0.89) -- --

Change in Disparity by #

Strategies



5 Strategy Categories -- -- 0.39 (0.27-0.56)*Random intercept for facility accounted for differences across facilities in proportion of Veterans with Stage 2 HTN.

**Facility-level random intercept for effect for Black race added to account for differences across facilities in proportion

of Black Veterans with Stage 2 HTN.

†Adjusted for age, sex, marital status, and eligibility.

Summary

• There were small VISN-wide reductions in the black-white

disparity in Stage 2 HTN over time.

• Facilities that used strategies from more intervention

categories showed significantly larger reductions in

disparities.

Future Recommendations

• Ensure that race, ethnicity, and other potential risk factors are

systematically recorded and made available.

• Include goals to reduce disparities in annual performance plans.

• Provide structure, leadership, and resources to support quality

improvement efforts that target disparities.

• Allow facilities to adopt action plans that fit their specific needs.

• Design performance metrics to ensure that they are acceptable

and interpretable to those who will be carrying out efforts.

• Incorporate a “formative evaluation” into project plans to identify

and address early implementation barriers.

THANKS!Leslie R.M. Hausmann, PhD

[email protected]

mailto:[email protected]

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