Center for Mental Healthcare & Outcomes Research, Central Arkansas Veterans Healthcare System, U.S. Department of Veterans Affairs, 2200 Fort Roots Drive, 152 NLR, North Little Rock, AR, 72114, USA.
Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
Implement Sci. 2019 Mar 12;14(1):26. doi: 10.1186/s13012-019-0861-y.
Researchers could benefit from methodological advancements to advance uptake of new treatments while also reducing healthcare disparities. A comprehensive determinants framework for healthcare disparity implementation challenges is essential to accurately understand an implementation problem and select implementation strategies.
We integrated and modified two conceptual frameworks-one from implementation science and one from healthcare disparities research to develop the Health Equity Implementation Framework. We applied the Health Equity Implementation Framework to a historical healthcare disparity challenge-hepatitis C virus (HCV) and its treatment among Black patients seeking care in the US Department of Veterans Affairs (VA). A specific implementation assessment at the patient level was needed to understand any barriers to increasing uptake of HCV treatment, independent of cost. We conducted a preliminary study to assess how feasible it was for researchers to use the Health Equity Implementation Framework. We applied the framework to design the qualitative interview guide and interpret results. Using quantitative data to screen potential participants, this preliminary study consisted of semi-structured interviews with a purposively selected sample of Black, rural-dwelling, older adult VA patients (N = 12), living with HCV, from VA medical clinics in the Southern part of the USA.
The Health Equity Implementation Framework was feasible for implementation researchers. Barriers and facilitators were identified at all levels including the patient, provider (recipients), patient-provider interaction (clinical encounter), characteristics of treatment (innovation), and healthcare system (inner and outer context). Some barriers reflected general implementation issues (e.g., poor care coordination after testing positive for HCV). Other barriers were related to healthcare disparities and likely unique to racial minority patients (e.g., testimonials from Black peers about racial discrimination at VA). We identified several facilitators, including patient enthusiasm to obtain treatment because of its high cure rates, and VA clinics that offset HCV stigma by protecting patient confidentiality.
The Health Equity Implementation Framework showcases one way to modify an implementation framework to better assess health equity determinants as well. Researchers may be able to optimize the scientific yield of research inquiries by identifying and addressing factors that promote or impede implementation of novel treatments in addition to eliminating healthcare disparities.
研究人员可以从方法学的进步中受益，以推进新治疗方法的应用，同时减少医疗保健差异。一个全面的医疗保健差异实施挑战决定因素框架对于准确理解实施问题和选择实施策略至关重要。
我们整合并修改了两个概念框架——一个来自实施科学，另一个来自医疗保健差异研究，以制定健康公平实施框架。我们将健康公平实施框架应用于一个历史上的医疗保健差异挑战——丙型肝炎病毒（HCV）及其在美国退伍军人事务部（VA）寻求治疗的黑人患者。需要在患者层面进行特定的实施评估，以了解增加 HCV 治疗接受度的任何障碍，而不考虑成本。我们进行了一项初步研究，以评估研究人员使用健康公平实施框架的可行性。我们应用该框架设计定性访谈指南并解释结果。使用定量数据筛选潜在参与者，这项初步研究包括对美国南部 VA 医疗诊所的 12 名患有 HCV 的黑人、农村居住、老年 VA 患者进行半结构化访谈，这些患者是根据目的选择的。
健康公平实施框架对于实施研究人员来说是可行的。在包括患者、提供者（接受者）、患者-提供者互动（临床接触）、治疗特征（创新）和医疗保健系统（内部和外部环境）在内的各个层面都确定了障碍和促进因素。一些障碍反映了一般实施问题（例如，HCV 检测呈阳性后的护理协调不善）。其他障碍与医疗保健差异有关，可能是少数族裔患者特有的（例如，VA 黑人患者对歧视的亲身体验）。我们确定了一些促进因素，包括患者因高治愈率而渴望获得治疗的热情，以及通过保护患者隐私来抵消 HCV 耻辱感的 VA 诊所。
健康公平实施框架展示了一种修改实施框架以更好地评估健康公平决定因素的方法。研究人员可以通过识别和解决促进或阻碍新型治疗方法实施的因素，除了消除医疗保健差异之外，还可以优化研究调查的科学收益。
