Among Veterans, hypertension is the most common chronic condition with a prevalence of 37% and can lead to stroke, myocardial infarction, chronic kidney disease, and heart failure. Among blacks, hypertension occurs earlier in life, is more prevalent and severe, and is less likely to be controlled. While control of hypertension has significantly improved over recent years in the Veterans Affairs (VA), from 46% in 2000 to 76% in 2010, disparities persist among blacks, and reasons are not well understood. The Joint National Committee (JNC) publishes guidelines on evidence-based medications for hypertension treatment. However, controversy remains regarding the target blood pressure (BP) to achieve with therapy. The recently published Systolic Blood Pressure Intervention Trial (SPRINT), a landmark clinical trial, is anticipated to lead to changes in hypertension practices for patients with increased cardiovascular disease risk and without a history of diabetes. Investigators reported a reduction of systolic BP to <120 mm Hg (vs < 140 mm Hg) was associated with a lower incidence of cardiovascular-events, - mortality, and all-cause mortality for both black and nonblack patients. The extent to which systolic BP control of <120 mm Hg is achieved in VA is unknown. Special focus is needed for the VA group at highest risk for uncontrolled BP, black Veterans. This group is expected to grow at least 3% from 11% of Veterans in 2014 to 14% by 2034. The goals of this project are:
Aim 1. To examine, one year following Veterans? incident hypertension diagnosis, patient level predictors of (1) use of guideline-recommended medications and (2) BP control among Veterans and to describe how the effect of these predictors varies by race;
Aim 2. To identify provider and facility level predictors of use of guideline-recommended medications and BP control among Veterans with incident hypertension and to describe how the effect of these predictors varies by race using mixed-methods;
and Aim 3. To develop and pilot test a provider/team focused informatics strategy to facilitate hypertension control with enhanced features for racial minority Veterans.
Aims 1 -2 involve a longitudinal retrospective cohort study of black and white Veterans from VA facilities nationwide with incident hypertension 2007-2012 and examining outcomes of (1) prescriptions for JNC7 guideline-recommended medications and (2) controlled hypertension 1-year after incident hypertension diagnosis. Using regression models, patient- (Aim 1), provider- and facility-level (Aim 2) variables will be identified that are predictors for not receiving of guideline-recommended medications for hypertension and/or lack of BP control at 1-year of follow-up.
Aims 1 -2 further examine how these predictors vary by race. The qualitative analysis for Aim 2 will include chart review using natural language processing methods and a total of 36 telephone interviews with Patient Aligned Care Team (PACT) providers from 4 VA facilities (identified from Aim 1 and Aim 2) to ascertain reasons for not prescribing guideline-recommended hypertension medications among patients identified from Aims 1-2.The Consolidated Framework of Implementation Research will be used to conduct these interviews.
Aim 3 includes the development of a trained and tested algorithm (from retrospective data) that incorporates SPRINT and Aim 1-2 findings and enhanced features for racial minorities based. A scenario based mockup with 20 Salt Lake City VA Medical Center (SLCVAMC) PACT providers will be used to determine initial tool feasibility, usability, acceptance, provider interest, safety, and satisfaction.

Public Health Relevance

Over 1 million racial/ethnic minority Veterans are served by the Veterans Health Administration (VHA) (21% of Veterans in 2008). The prevalence of hypertension is highest in blacks in the US, 44.9% among males and 46.1% among females, based on 2009-2012 data. Understanding potential reasons for differences by race in the treatment and outcomes in these Veterans with hypertension is a high VA priority. The proposed research will address the root causes of these disparities and ultimately develop interventions to support high quality equitable healthcare for all Veterans. This research is consistent with the VA Blueprint for Excellence Transformational Actions: ?to understand and eliminate health inequalities? and the VHA Strategic Objective on Quality & Equity to ensure that Veterans receive ?timely, high quality, personalized, safe effective and equitable health care.?

National Institute of Health (NIH)
Veterans Affairs (VA)
Veterans Administration (IK2)
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VA-ORD Historically Black College and University Research Scientist Training Program (HBCU)
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VA Salt Lake City Healthcare System
Salt Lake City
United States
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