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RRP 09-123 – QUERI Project

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RRP 09-123
Better Hypertension and lipid care in racially diverse, veterans at risk
Jeffrey C Whittle MD MPH
Clement J. Zablocki VA Medical Center, Milwaukee, WI
Milwaukee, WI
Funding Period: July 2009 - January 2011

BACKGROUND/RATIONALE:
Studies of persons hospitalized with acute myocardial infarction (AMI) have found that African Americans (AA) are as likely to survive their initial hospitalization as whites; however, mortality differences emerge after discharge. AA are less likely than whites to have well controlled BP and diabetes or to receive optimal lipid lowering therapy post AMI. Prior studies have focused on factors associated with such shortfalls in care. We hypothesized that open-ended input from clinicians and patients regarding causes of such shortfalls, which will suggest specific solutions.

OBJECTIVE(S):
Our overall objectives in the present, pilot study was to establish the overall relationship of racial differences in CVD outcomes to differences in process after diagnosis and demonstrate the feasibility of identifying actionable steps from medical records, self report and provider input. We conducted two parallel observational studies to 1) Examine the pattern of adherence to use of evidence based medical therapy among AA and white veterans who are discharged from VHA hospitals following an ACS admit and 2) Evaluate the barriers and facilitators to optimizing the use of evidence based therapies and control of lipid disorders and hypertension.

METHODS:
We conducted parallel studies to develop two types of pilot data. In the first, we used a linked database created by the IHD QUERI to identify AA and white veterans with ACS and follow their subsequent patterns of risk factor control and evidence based therapy use. We linked data regarding the initial hospitalization to DSS and CDW data regarding the use of specific evidence based therapies and risk factor control. In the second study, we identified all black and white individuals admitted to the Milwaukee VA with an acute coronary syndrome (ACS). We interviewed these patients and their VA primary care provider (PCP) at baseline and 6 months. We used chart review to identify instances of poor risk factor control and nonuse of key medical therapies, then asked both providers and patients to identify contributors to these shortfalls.

FINDINGS/RESULTS:
We identified over 30,000 white persons and 6,000 AA who had ACS and were entered into the EPRP database. In adjusted analyses, AA more likely to die during follow up than whites. We are looking at further possible adjustments to these results, since they are so different than those seen in prior work.

In study 2, we enrolled and interviewed 18 patients and their PCPs. Of these 8, 7, and 3 had 0, 1, or 2 shortfalls at baseline. Similarly, of the 16 who survived to their follow up, 7, 6, and 3 had 0, 1, or 2 shortfalls at follow up. Clinicians of consenting patients uniformly agreed to be surveyed. This demonstrates that direct interview of patients and physcians to understand reasons for apparent deficiencies in ongoing CVD care is a feasible approach.

IMPACT:
This study has demonstrated the feasibility of a cohort study that uses case by case analysis to identify actionable causes of poor processes of CVD care.

It has demonstrated that previously described racial disparities in survival following ACS do not seem to be evident in a carefully defined VA population, at least during the first 5 years of follow up.

PUBLICATIONS:
None at this time.


DRA: Cardiovascular Disease
DRE: Treatment - Observational, Prevention, Research Infrastructure
Keywords: Access, Cardiovasc’r disease, Quality assessment, QUERI Implementation
MeSH Terms: none

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