3098 — Quality of Care for Racial-ethnic Minorities in the Veterans Health Administration

Washington DL (VA Greater Los Angeles HSR&D Center of Excellence), Yano EM (VA Greater Los Angeles HSR&D Center of Excellence), Lee M (VA Greater Los Angeles HSR&D Center of Excellence), Mitchell M (VA Greater Los Angeles HSR&D Center of Excellence), Sun S (VA Greater Los Angeles HSR&D Center of Excellence), Wright SM (VA Office of Quality and Performance)

Objectives:
Racial-ethnic disparities have been noted within the VA for access to invasive procedures and receipt of selected quality indicators. Most studies were limited to African-American and white veterans. None assessed global VA quality.

Methods:
We determined the association between patient race-ethnicity and VA quality of care for patients selected by the External Peer Review Program (EPRP) for calculation of inpatient or outpatient quality indicators in fiscal years 2003 or 2004 who also responded to a Survey of Healthcare Experiences of Patients (SHEP) (n=84,181). Self-reported race-ethnicity (White, African-American, Hispanic, Asian, Native Hawaiian/Other Pacific Islander [NHOPI], and Native American) and other patient characteristics were obtained from SHEP. Global process and global intermediate outcome indicators were derived by aggregating 32 process and 9 intermediate outcome indicators, respectively. For each global indicator, we conducted logistic regression analyses, first using race-ethnicity as a predictor, then including additional covariates that may be associated with healthcare quality. Because a patient could have multiple observations, standard errors were computed adjusting for clustering at the patient level.

Results:
Achievement of process indicators was lower for African-American (odds ratio [O.R.]=0.85; 95% confidence interval [C.I.] 0.83-0.88), Hispanic (O.R.=0.79; 95% C.I. 0.75-0.82), NHOPI (O.R.=0.79; 95% C.I. 0.68-0.92), and Native American (O.R.=0.81; 95% C.I. 0.77-0.85) veterans, compared with Whites, whereas it was higher for Asian veterans (O.R.=1.17; 95% C.I. 1.01-1.35). Adjusting for socio-demographics, health status, healthcare use, and geographic region eliminated NHOPI-White and Native American-White differences, and reversed African-American-White differences (adjusted O.R.[A.O.R.] 1.04; 95% C.I. 1.00-1.08). Achievement of intermediate outcome indicators was lower for African-Americans (O.R.=0.74; 95% C.I. 0.70-0.79), Hispanics (O.R.=0.85; 95% C.I. 0.78-0.93), and Native Americans (O.R.=0.90; 95% C.I. 0.81-0.998). These differences persisted for African-Americans (A.O.R.=0.76; 95% C.I.=0.71-0.82) and Hispanics (A.O.R.=0.82; 95% C.I. 0.75-0.91) in adjusted analyses, but were eliminated for Native Americans.

Implications:
Patient characteristics other than race-ethnicity accounted for differences in process of care for all groups except Hispanics. Disparities in intermediate outcome indicators remained for both African-Americans and Hispanics.

Impacts:
Unmeasured patient or facility factors may mediate the observed relationships between patient race-ethnicity and intermediate outcomes. Identifying facility characteristics associated with achievement of better health outcomes may inform system-level interventions to eliminate disparities.