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CDA 20-049 – HSR&D Study

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CDA 20-049
Access, Quality and Equity of Anticoagulants in Veterans with Atrial Fibrillation
Utibe R. Essien MD MPH
Pittsburgh, PA
Funding Period: February 2021 - January 2026

Abstract

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.

NIH Reporter Project Information: https://projectreporter.nih.gov/project_info_description.cfm?aid=10068044

PUBLICATIONS:

Journal Articles

  1. Shankar M, Henderson K, Garcia R, Li G, Titer K, Acholonu RG, Essien UR, Brown-Johnson C, Cox J, Shaw JG, Haverfield MC, Taylor K, Israni ST, Zulman D. Presence 5 for Racial Justice Workshop: Fostering Dialogue Across Medical Education to Disrupt Anti-Black Racism in Clinical Encounters. MedEdPORTAL : the journal of teaching and learning resources. 2022 Feb 10; 18:11227.
  2. Vyas DA, James A, Kormos W, Essien UR. Revising the atherosclerotic cardiovascular disease calculator without race. The Lancet. Digital health. 2022 Jan 1; 4(1):e4-e5.
  3. Duvalyan A, Pandey A, Vaduganathan M, Essien UR, Halm EA, Fonarow GC, Sumarsono A. Trends in Anticoagulation Prescription Spending Among Medicare Part D and Medicaid Beneficiaries Between 2014 and 2019. Journal of the American Heart Association. 2021 Dec 21; 10(24):e022644.
  4. Wurcel AG, Essien UR, Ortiz C, Fu X, Mancini C, Zhang Y, Blumenthal KG. Variation by Race in Antibiotics Prescribed for Hospitalized Patients With Skin and Soft Tissue Infections. JAMA Network Open. 2021 Dec 1; 4(12):e2140798.
  5. Essien UR, Kim N, Magnani JW, Good CB, Litam TMA, Hausmann LRM, Mor MK, Gellad WF, Fine MJ. Association of Race and Ethnicity and Anticoagulation in Patients With Atrial Fibrillation Dually Enrolled in Veterans Health Administration and Medicare: Effects of Medicare Part D on Prescribing Disparities. Circulation. Cardiovascular quality and outcomes. 2022 Feb 1; 15(2):e008389.
  6. Essien UR, Dusetzina SB, Gellad WF. A Policy Prescription for Reducing Health Disparities-Achieving Pharmacoequity. JAMA. 2021 Nov 9; 326(18):1793-1794.
  7. Guo J, Gabriel N, Magnani JW, Essien UR, Gellad WF, Brooks MM, Trinquart L, Benjamin EJ, Hernandez I. Racial and Urban-Rural Difference in the Frequency of Ischemic Stroke as Initial Manifestation of Atrial Fibrillation. Frontiers in public health. 2021 Nov 5; 9:780185.
  8. Swart ECS, Good CB, Henderson R, Manolis C, Huang Y, Essien UR, Neilson LM. Identifying outcome measures for atrial fibrillation value-based contracting using the Delphi method. Research in social & administrative pharmacy : RSAP. 2021 Oct 29.
  9. Delaney SW, Essien UR, Navathe A. Disparate Impact: How Colorblind Policies Exacerbate Black-White Health Inequities. Annals of internal medicine. 2021 Oct 1; 174(10):1450-1451.
  10. Silva RL, Guhl EN, Althouse AD, Herbert B, Sharbaugh M, Essien UR, Hausmann LRM, Magnani JW. Sex differences in atrial fibrillation: patient-reported outcomes and the persistent toll on women. American journal of preventive cardiology. 2021 Dec 1; 8:100252.
  11. Guhl EN, Zhu J, Johnson A, Essien U, Thoma F, Mulukutla SR, Magnani JW. Area Deprivation Index and Cardiovascular Events: CAN CARDIAC REHABILITATION MITIGATE THE EFFECTS?. Journal of cardiopulmonary rehabilitation and prevention. 2021 Sep 1; 41(5):315-321.
  12. Borker PV, Carmona E, Essien UR, Saeed GJ, Nouraie SM, Bakker JP, Stitt CJ, Aloia MS, Patel SR. Neighborhoods with Greater Prevalence of Minority Residents Have Lower Continuous Positive Airway Pressure Adherence. American journal of respiratory and critical care medicine. 2021 Aug 1; 204(3):339-346.
  13. Teufel F, Seiglie JA, Geldsetzer P, Theilmann M, Marcus ME, Ebert C, Arboleda WAL, Agoudavi K, Andall-Brereton G, Aryal KK, Bicaba BW, Brian G, Bovet P, Dorobantu M, Gurung MS, Guwatudde D, Houehanou C, Houinato D, Jorgensen JMA, Kagaruki GB, Karki KB, Labadarios D, Martins JS, Mayige MT, McClure RW, Mwangi JK, Mwalim O, Norov B, Crooks S, Farzadfar F, Moghaddam SS, Silver BK, Sturua L, Wesseh CS, Stokes AC, Essien UR, De Neve JW, Atun R, Davies JI, Vollmer S, Bärnighausen TW, Ali MK, Meigs JB, Wexler DJ, Manne-Goehler J. Body-mass index and diabetes risk in 57 low-income and middle-income countries: a cross-sectional study of nationally representative, individual-level data in 685 616 adults. Lancet (London, England). 2021 Jul 17; 398(10296):238-248.
  14. Essien UR, McCabe ME, Kershaw KN, Youmans QR, Fine MJ, Yancy CW, Khan SS. Association Between Neighborhood-Level Poverty and Incident Atrial Fibrillation: A Retrospective Cohort Study. Journal of general internal medicine. 2021 Jul 8.
  15. Essien UR, Kim N, Hausmann LRM, Mor MK, Good CB, Magnani JW, Litam TMA, Gellad WF, Fine MJ. Disparities in Anticoagulant Therapy Initiation for Incident Atrial Fibrillation by Race/Ethnicity Among Patients in the Veterans Health Administration System. JAMA Network Open. 2021 Jul 1; 4(7):e2114234.
  16. Johnson AE, Talabi MB, Bonifacino E, Culyba AJ, Davis EM, Davis PK, De Castro LM, Essien UR, Maria Gonzaga A, Hogan MV, James AJ, Jonassaint CR, Jonassaint NL, Matheo L, Nance MA, Napoé GS, Olafiranye O, Owusu-Ansah S, Pierson-Brown TN, Conrad Smith AJ, Suber TL, Torres O, Tripp R, Ufomata E, Wilson JD, South-Paul JE. Racial Diversity Among American Cardiologists: Implications for the Past, Present, and Future. Circulation. 2021 Jun 15; 143(24):2395-2405.
  17. Essien UR, Kornej J, Johnson AE, Schulson LB, Benjamin EJ, Magnani JW. Social determinants of atrial fibrillation. Nature reviews. Cardiology. 2021 Nov 1; 18(11):763-773.
  18. Tertulien T, Chen Y, Althouse AD, Essien UR, Johnson A, Magnani JW. Association of income and educational attainment in hospitalization events in atrial fibrillation. American journal of preventive cardiology. 2021 Sep 1; 7:100201.
  19. Eberly LA, Yang L, Eneanya ND, Essien U, Julien H, Nathan AS, Khatana SAM, Dayoub EJ, Fanaroff AC, Giri J, Groeneveld PW, Adusumalli S. Association of Race/Ethnicity, Gender, and Socioeconomic Status With Sodium-Glucose Cotransporter 2 Inhibitor Use Among Patients With Diabetes in the US. JAMA Network Open. 2021 Apr 1; 4(4):e216139.
  20. McClendon J, Essien UR, Youk A, Ibrahim SA, Vina E, Kwoh CK, Hausmann LRM. Cumulative Disadvantage and Disparities in Depression and Pain Among Veterans With Osteoarthritis: The Role of Perceived Discrimination. Arthritis care & research. 2021 Jan 1; 73(1):11-17.
Journal Other

  1. Essien UR, Dusetzina SB, Gellad WF. Reducing Health Disparities Through Achieving Pharmacoequity-Reply. JAMA. 2022 Feb 8; 327(6):590.
  2. Essien UR, Youmans QR. Burning in "Other Suns": The Effects of Residential Segregation on Cardiovascular Health. [Editorial]. Circulation. Cardiovascular quality and outcomes. 2022 Feb 2; CIRCOUTCOMES121008694.
  3. Tertulien T, Magnani JW, Essien UR. Racial and Ethnic Representation in Atrial Fibrillation Trials: CABANA and Beyond. Journal of the American College of Cardiology. 2021 Nov 9; 78(19):e163-e164.
  4. Essien UR, Ifidon A, Sue KL. Black Pain Matters: Prioritizing Antiracism and Equity in the Opioid Epidemic. [Editorial]. Journal of hospital medicine. 2021 Oct 1; 16(10):638-639.
  5. Borker PV, Carmona E, Essien UR, Saeed GJ, Nouraie SM, Bakker JP, Stitt CJ, Aloia MS, Patel SR. Reply to Spector and Iweala. American journal of respiratory and critical care medicine. 2021 Sep 1; 204(5):615-616.
  6. Magnani JW, Kinloch V, Essien UR. Separate and Unequal: The Cost of Coronavirus Disease 2019 on Childhood Health and Well-Being. Health equity. 2021 Feb 25; 5(1):72-75.
  7. Breathett K, Spatz ES, Kramer DB, Essien UR, Wadhera RK, Peterson PN, Ho PM, Nallamothu BK. The Groundwater of Racial and Ethnic Disparities Research: A Statement From . Circulation. Cardiovascular quality and outcomes. 2021 Feb 1; 14(2):e007868.
  8. Kamal S, Trivedi SP, Essien UR, Nematollahi S. Podcasting: A Medium for Amplifying Racial Justice Discourse, Reflection, and Representation Within Graduate Medical Education. Journal of graduate medical education. 2021 Feb 1; 13(1):29-32.
  9. Essien UR, Tipirneni R, Leung LB, Sterling MR. Surviving and Thriving as Leaders in General Internal Medicine-Reply. Journal of general internal medicine. 2021 May 1; 36(5):1435-1436.
Online News Media Articles

  1. Essien UR. Pharmacoequity: New Goal for Ending Disparities in US Health Care. Stat News [Internet]. 2021 Jul 28:(First Opinion):1. Available from: https://www.statnews.com/2021/07/28/pharmacoequity-new-goal-ending-disparities-us-health-care/.
  2. Essien UR. 5 Ways to Sustain the Antiracism in Medicine Momentum in 2021. Forbes [Internet]. 2021 Jan 15:Editor's Pick(Healthcare):1. Available from: https://www.forbes.com/sites/utibeessien/2021/01/15/5-ways-to-sustain-the-antiracism-in-medicine-momentum-in-2021/?sh=d622361fa7d3.


DRA: Cardiovascular Disease
DRE: None at this time.
Keywords: None at this time.
MeSH Terms: None at this time.

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