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2023 HSR&D/QUERI National Conference Abstract

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1054 — Incorporating a Health Equity Focus into Implementation and Evaluation of Evidence-Based Practices for High-Risk Patients

Lead/Presenter: Michelle Wong,  COIN - Los Angeles
All Authors: Wong MS (Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles), Rosland AM (Center for Health Equity Research & Promotion, VA Pittsburgh; Department of Internal Medicine, University of Pittsburgh) Stockdale SE (Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles; University of California, Los Angeles) Reddy A (Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle VA Puget Sound Healthcare; University of Washington School of Medicine, Seattle, WA) Jimenez EE (Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles; University of California, Los Angeles) Torrence NS (Center for Health Equity Research & Promotion, VA Pittsburgh) Chang ET (Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles; University of California, Los Angeles)

Implementing healthcare innovations may contribute to healthcare disparities if the innovation is less likely to be delivered to, is delivered with worse quality to, or results in worse outcomes for underserved populations. However, implementation science frameworks have rarely included domains related to health equity. This omission limits our understanding of the how implementation strategies may contribute to health disparities. The high-RIsk VETeran (RIVET) QUERI Program, which compares two strategies to implement evidence-based practices (EBPs) for high-risk, complex patients in primary care, is an important setting to incorporate a health equity focus into implementation efforts. Patients at high-risk for hospitalization and poor health outcomes often belong to underserved populations. We aimed to incorporate domains from emerging health-equity focused implementation frameworks into a tailored logic model that will guide RIVET Program evaluation.

We first developed a comprehensive logic model for RIVET, guided by the Implementation Research Logic Model (IRLM), with input from project staff and advisors. The IRLM includes implementation determinants and processes but does not explicitly account for health equity. We then used the Health Equity Implementation Framework (HEIF, Woodward et al) to provide guidance on incorporating three health equity domains as implementation determinants: 1) culturally relevant factors, 2) clinical encounters or patient-provider interactions, and 3) societal context. We also added equity-focused implementation outcomes to our model.

We incorporated 11 implementation determinants based on the HEIF into our RIVET logic model. Specifically, the culturally relevant factors domain was applied to the IRLM’s intervention characteristics (e.g., acceptability of EBP to diverse patient populations) and the inner setting (e.g., delivering the EBP equitably to diverse patients) determinants; the clinical encounters domain was applied to characteristics of individuals determinants (e.g., provider training in delivering EBP in a culturally sensitive way); and societal context was applied to inner setting (e.g., PACT resources), outer setting (e.g., Facility/VISN health equity goals), and characteristics of individuals (e.g., social determinants limit EBPs for patients) determinants. We also identified seven health equity-focused implementation outcomes—two based on HEIF domains (adaptation to diverse patients, adaptation to clinics with limited resources). From the resulting equity-focused logic model, we identified testable hypotheses to examine RIVET’s effect on health equity. For example, hypotheses will explore whether implementation strategies result in differing EBP acceptability to diverse high-risk patient populations.

A health equity implementation framework was successfully used to significantly alter the RIVET Program logic model, so that determinants of, and impacts on, equity will be prioritized in this implementation evaluation.

Health equity domains can be incorporated into any implementation logic model in a manner tailored to the topic and setting of the project, to help ensure that the potential positive and negative impacts of implementation strategies on health equity are considered, effects on health outcomes for vulnerable groups are examined, and addressable barriers to equitable implementation are identified.