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Health Spotlight


Improving Disparities in Health Care

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According to the National Healthcare Disparities Report, developed by the Agency for Healthcare Research and Quality (AHRQ), "…racial, ethnic, and socioeconomic disparities are national problems that affect health care at all points in the process, at all sites of care, and for all medical conditions…." The Report goes on to cite several problem areas in healthcare disparities, including: patients with less income are less likely to receive recommended services for diabetes; many racial and ethnic minorities are more likely to die from HIV; and African Americans and poorer patients have higher rates of avoidable hospital admissions.1

VA is committed to identifying and understanding the reasons for disparities and to develop interventions to eliminate them for all veterans receiving care in the VA healthcare system. Research on health care disparities has been and remains a priority.

HSR&D research is an important part of this effort. For example, HSR&D supports the Center for Health Equity Research and Promotion (CHERP), located in Pittsburgh and Philadelphia, which is devoted to research on disparities related to race/ethnicity, socioeconomic status, and comorbid illness, as well as the Targeted Research Enhancement Program (TREP), Understanding Racial and Ethnic Variations in Health Outcomes for Chronic Diseases in Charleston, SC. For more information about HSR&D Centers of Excellence and TREPs, please visit http://www.hsrd.research.va.gov/about/centers/.

Related Resources

VA HSR&D

Following are a few examples of recent and ongoing work by HSR&D investigators in the important area of healthcare disparities.

Older African American Veterans have Lower Hospital Mortality Rates than White Veterans for Six Common Conditions

In contrast to much of the literature documenting worse health outcomes among African Americans than whites throughout the healthcare system, a number of studies found that African Americans in VA hospitals have better outcomes than whites, or that there are no differences based on race/ethnicity. This HSR&D study sought to determine if racial disparities in 30-day mortality exist for six specific conditions among veterans who were in VA hospitals during FY96-FY02 (284,974 veterans treated at 120 VA sites). Investigators focused on six conditions: acute myocardial infarction, hip fracture, stroke, congestive heart failure, gastrointestinal bleeding, and pneumonia. Findings show that for each of the six conditions, unadjusted 30-day mortality rates were significantly lower for African American veterans compared to white veterans. Among veterans older than age 65, African Americans consistently had significantly lower odds of risk-adjusted mortality than whites.2

Rates of Coronary Revascularization for Medicare Patients with AMI are Lower in African Americans Compared to Whites

Racial differences in care after acute myocardial infarction (AMI) have been widely reported. These differences appear to be greater for costly and invasive procedures such as coronary revascularization - coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI). This study compared rates of hospital transfer, coronary revascularization, and mortality after AMI for African American (n=85,069) and white patients (n=1,130,855) admitted to 4627 U.S. hospitals (non-VA), with and without revascularization services. Findings showed that African American patients admitted to hospitals with or without revascularization services were less likely to undergo revascularization than white patients (34.3% vs. 50.2% and 18.3% vs. 25.9%), and had higher 1-year mortality (35.5% vs. 30.3% and 39.8% vs. 37.6%). African American patients admitted to hospitals without revascularization were less likely to be transferred to a hospital with this service than white patients (25.2% vs. 31.0%). After adjusting for sociodemographics, comorbidity, and illness severity, African Americans remained less likely to be transferred and to undergo revascularization.3

No Disparities in Care between African-American and White Veterans with HIV

HIV infection and HIV-related mortality disproportionately affect African-Americans compared to whites in the United States. Moreover, even though we now have more effective HIV treatment (e.g., highly active antiretroviral therapy), national CDC data show that mortality for African-American patients after an AIDS diagnosis is higher than for white patients who develop AIDS. This study examined the survival of veterans with HIV who were cared for in a setting with few barriers to HIV care - the VA healthcare system (VA is the largest single provider of HIV care in the country) - in order to determine if there are any race-based disparities in survival. Overall, both hospital and long-term survival rates were similar among African-American veterans with HIV compared to white veterans with HIV. However, compared to whites, African-American veterans had more severe HIV disease and more non-HIV related comorbidities, e.g., hepatitis C, psychiatric and substance use disorders.4

Overall Gaps in Medical Care Quality Overshadow those Due to Race and Ethnicity

It has been reported that American adults receive about half of their recommended care processes, and little is known about how much variation exists between population subgroups (e.g., gender and racial disparities). This study compared recommended quality of care processes for multiple conditions among population subgroups. Investigators analyzed medical data for more than 6,000 people living in 12 communities, comparing quality of care indicators for numerous chronic and acute health problems, as well as preventive care. Overall, the study found that participants received 54.9% of recommended care, and that the proportion of recommended care declined with age. They also found that women received better overall care than men; individuals with incomes greater than $50,000 a year received better care than those with incomes of less than $15,000; and both African Americans and Hispanics received slightly better quality of care scores than whites.5

Disparities in Smoking Cessation Treatment

Estimates of current cigarette use among adults with alcohol disorders range between 35% and 95%, and adults who smoke and abuse alcohol have higher levels of nicotine dependence and a lower likelihood of quitting smoking. There has been an ongoing debate in the literature with regard to the best way to treat concurrent alcohol and tobacco dependence. This article reports on a study that assessed ethnic differences in alcohol and tobacco cessation outcomes. Investigators compared data for 381 whites and 78 African Americans who were alcohol dependent and participated in smoking interventions that were concurrent (during alcohol treatment) or delayed (6 months later) in relation to alcohol treatment. Investigators assessed both alcohol and smoking abstinence. Findings showed no evidence of significant ethnic differences in the use or success of concurrent or delayed smoking cessation treatment interventions for patients in intensive alcohol treatment. However, among white patients, concurrent smoking cessation treatment was found to increase the risk of resuming alcohol use compared to delayed treatment. These findings suggest that concurrent alcohol and smoking cessation treatment adversely affects alcohol cessation outcomes for whites, but not necessarily for African Americans.6

Evaluating Racial and Ethnic Disparities in the VA Healthcare System

Numerous studies have demonstrated racial and ethnic disparities in U.S. health care. VA is committed to delivering high-quality care in an equitable manner, and, thus to eliminating racial and ethnic disparities in health care. To further inform the research agenda on racial and ethnic disparities, a systematic review was conducted through HSR&D's Evidence-Based Synthesis Program (ESP). The ESP report on racial and ethnic disparities in the VA healthcare system sought to:

  1. determine in which clinical areas racial and ethnic disparities are prevalent,
  2. describe what is known about the sources of those disparities, and
  3. synthesize that knowledge to determine the most promising areas for future research aimed at improving quality in VA healthcare.
The ESP program is facilitated by HSR&D. The full report on racial and ethnic disparities is available at http://www.hsrd.research.va.gov/publications/esp/.7

References:

  1. National Healthcare Disparities Report. 2006. Agency for Healthcare Research and Quality.
  2. Volpp K, Stone R, Lave J, et al. Is thirty-day hospital mortality really lower for black veterans compared with white veterans? Health Services Research August 2007;42(4):1613-1631.
  3. Popescu I, Vaughan-Sarrazin M, and Rosenthal G. Differences in mortality and use of revascularization in black and white patients with acute MI admitted to hospitals with and without revascularization services. Journal of the American Medical Association (JAMA) June 13, 2007;297(22):2489-95.
  4. Giordano T, Morgan R, Kramer J, et al. Is there a race-based disparity in the survival of veterans with HIV? Journal of General Internal Medicine June 2006;21(6):613-617.
  5. Asch S, Kerr, E, Keesy J, et al. Who is at greatest risk for receiving poor quality health care? The New England Journal of Medicine March 16 2006;354(11):1147-1156.
  6. Fu S, Kodl M, Willenbring M, Nelson D, et al. Ethnic differences in alcohol treatment outcomes and the effect of concurrent smoking cessation treatment. Drug and Alcohol Dependence January 2008;92(1-3):61-68.
  7. Saha S, Freeman M, Toure J, Tippens K and Weeks C. "Racial and ethnic disparities in the VA Healthcare System: A systematic review." June 2007. Department of Veterans Affairs, Health Services Research & Development Service -- Evidence Synthesis Pilot Program.