Background. Atrial fibrillation (AF) is a common cardiac arrhythmia, affecting up to 1 million Veterans. AF increases the risk of stroke by 5-fold and is associated with higher rates of death. Oral anticoagulation reduces the risk of stroke in AF by 60%, yet such therapy is underutilized. Further, racial and ethnic disparities in anticoagulation for AF exist, despite a 2-fold higher risk of stroke among racial and ethnic minorities with this condition. In pilot work conducted in >40,000 Veterans with newly diagnosed AF in FY 2017, black Veterans were significantly less likely than white Veterans to receive any form of anticoagulant, particularly safer, more effective therapy with direct-acting oral anticoagulants. In these analyses there was up to 2.5-fold facility-level variation in the frequency of anticoagulation and in racial and ethnic disparities in such therapy. With the detection of these treatment disparities documented in VA, this CDA-2 will quantitatively assess the multilevel determinants of these disparities, qualitatively identify barriers to and facilitators of equitable anticoagulation for AF, and use these findings to develop and pilot test implementation strategies to eliminate these disparities. Significance / Impact. Ensuring access to high-quality, equitable care for all Veterans are VA and VA HSR&D priority areas. This CDA-2 addresses underuse of an evidence-based therapy for racial and ethnic minority Veterans with AF?a common and costly condition. The significance of this problem is likely to increase with the aging of the Veteran population and the steadily increasing proportion of minority Veterans receiving health care within VA. Innovation. This CDA-2 is framed using blended health equity and implementation science conceptual models to understand and reduce racial and ethnic disparities in health care. This CDA-2 uses novel data sources to assess the association of underexamined determinants of racial and ethnic disparities in Veterans with AF and is among the first to qualitatively examine Veteran experiences with AF and anticoagulation. Finally, this research will be the first to develop and test implementation strategies to reduce disparities in anticoagulation for AF.
Specific Aims. Aim 1 is a quantitative study to characterize the association between race, ethnicity, and oral anticoagulant initiation in Veterans with AF.
Aim 2 is a qualitative study to examine stakeholder perceptions of the barriers to and facilitators of equitable oral anticoagulant initiation in Veterans with AF.
Aim 3 proposes to design and pilot test an empirically-developed implementation strategy bundle to improve equitable oral anticoagulant initiation in Veterans with AF. Methodology.
Aim 1 uses a national cohort of ~130,000 Veterans with incident AF in FYs 2010-2019 to assess the patient, provider, and facility-level determinants of the association of race, ethnicity and anticoagulation.
Aim 2 will recruit and interview providers, administrators, and Veterans with AF about barriers to and facilitators of equitable anticoagulant initiation for AF in VA.
Aim 3 uses the findings from Aims 1 and 2 to develop and pilot-test the feasibility of a set of implementation strategies to promote equitable anticoagulant initiation within a local VA primary care practice. Implementation / Next steps. Findings from research Aims 1-3 will set the stage for a hybrid type 3 trial to broadly test the effectiveness of the pilot-tested implementation strategies on equitable anticoagulant initiation in Veterans with AF. Candidate. Dr. Utibe Essien is a general internist and Core Investigator in the VA Center for Health Equity Research and Promotion. The short-term goal of this CDA-2 is to gain training and research experience in understanding and implementing strategies to reduce treatment disparities in Veterans with AF. This will be achieved through in-depth training in: (1) advanced quantitative research; (2) qualitative research; (3) implementation science; and (4) professional leadership. This CDA-2 will support his long-term goal of becoming an independent VA health services investigator focused on developing implementation strategies to reduce racial and ethnic disparities in the use of evidence-based medical therapies for Veterans with chronic cardiovascular diseases.

Public Health Relevance

Atrial fibrillation (AF) is an increasingly common heart rhythm disorder, affecting nearly 1 million Veterans engaged in VA health care. AF is associated with an increased risk of stroke, heart failure, and hospitalization, and results in substantial medical and societal costs. Although oral anticoagulant therapy reduces the risk of stroke from AF by 60%, it is often underutilized, particularly for racial and ethnic minorities who have an even higher risk of this adverse outcome. These inequities are particularly pronounced for a newer class of direct oral anticoagulants (DOACs) ? which have greater effectiveness, safety, and adherence compared to traditional warfarin anticoagulation. This project will use quantitative and qualitative research to understand the multilevel determinants of racial and ethnic disparities in anticoagulant therapy initiation for Veterans with AF and use the findings to empirically develop and test implementation strategies to reduce or eliminate these well-documented disparities.

National Institute of Health (NIH)
Veterans Affairs (VA)
Veterans Administration (IK2)
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Veterans Health Administration
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