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Health Services Research & Development

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February 2020

Spotlight on Health Equity

Introduction

Ensuring that all Veterans using VA care receive the same quality and access to services is a central part of VA’s mission. This concept—health equity—means that all people are able to attain the highest level of healthcare. Achieving health equity throughout the VA healthcare system requires valuing all Veterans equally and eliminating health disparity—a type of health difference that is closely linked with social or economic disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater social or economic obstacles to health. Health disparities may be based on:

  • Racial or ethnic group
  • Gender
  • Age
  • Geographic location
  • Religion
  • Socio-economic status
  • Sexual orientation
  • Mental health
  • Military era
  • Cognitive, sensory, or physical disability
  • Other characteristics historically linked to discrimination or exclusion

Within VA, research plays a key role in understanding those factors that contribute to health disparities and that support health equity. Investigators with VA’s Health Services Research and Development Service  (VA HSR&D) conduct a wide variety of research that seeks to ensure equitable, quality care across the VA healthcare system. In addition to individual studies, VA HSR&D also funds the Center of Innovation for Health Equity Research and Promotion (CHERP) [add link], which is dedicated to addressing questions of health equity and health disparity. The following are just a few of the ongoing and recently concluded studies focused on ensuring equitable care in VA.


Opening the Black Box of Cultural Competence

Opening the Black Box of Cultural Competence

© Stock/katleho Seisa

Implications for Care
Evidence-based cultural competency (CC) training is a priority for the VA—yet the evidence base informing what such training programs should include is not well developed. It is hoped that data from this study will provide evidence that supports and informs effective CC training, both within and outside VA. Study results are also expected to inform national VA efforts to reduce racial and ethnic disparities in care delivery.

Study Questions

Previous research has found that primary care providers (PCPs) with higher levels of CC receive higher ratings of care from minority patients with diabetes, such that there were fewer racial disparities in the quality of care delivered by high CC providers. This study will attempt to address three questions about CC: How do high-CC PCPs communicate and interact with patients from diverse backgrounds differently from low-CC PCPs? What are patients' perceptions of their interactions and relationships with high and low CC PCPs and other patient-aligned care team (PACT) members? What does CC contribute among PCPs/PACTs to quality and equity of diabetes care?

About the Study

Investigators are conducting a mixed-methods investigation at four geographically diverse VA medical centers, recruiting approximately 50 PCPs and PACTs. Study patients include approximately 400 patients with diabetes who receive primary care from the recruited PCPs. Data include: 1) self-assessed CC among recruited PCPs and PACT members; 2) audio-recording of visits between each recruited patient and his/her PCP (to be quantitatively and qualitatively analyzed for communication behaviors and patterns); 3) brief surveys with each patient evaluating their perceptions of their PCPs communication and cultural competence; and 4) in-depth interviews with a subsample of patients, playing back their audio-recorded visits and exploring their perceptions of the visit; 5) measures of patients’ diabetes self-management and glycemic control.

Findings

Final study data are still being compiled.

Principal Investigator

Somnath Saha MD MPH, is an investigator with the HSR&D Center to Improve Veteran Involvement in Care in Portland, OR.


A Proactive Walking Trial to Reduce Pain in Black Veterans

A Proactive Walking Trial to Reduce Pain in Black Veterans

© Stock/adamkaz

Implications for Care

Chronic musculoskeletal (MSK) pain affects approximately 60% Veterans seen in VA primary care. However, Veterans’ perceptions’ of chronic pain treatment’s effectiveness is low—particularly among black patients. Black Veterans are also are more likely to experience functional limitations due to pain. Because of the widespread nature of chronic pain treatment in VA primary care, treatments that do not involve pharmacological interventions remain ideal. This study examines the use of a telephone-based, non-pharmacological intervention (promoting walking), and investigators expect that data will show reduced pain and improved functioning among black patients with MSK pain.

Study Questions

Investigators seek to address the following questions:

  • What is the effectiveness of a multi-component intervention (ACTION) that specifically targets known barriers to effective pain care among black Veterans with chronic MSK pain?
  • Will a telephone delivered intervention which emphasizes walking and incorporates Action Planning, Motivational Interviewing (MI) and Cognitive Behavioral Therapy (CBT) techniques, and the use of pedometers, improve core chronic pain outcomes in black Veterans?
  • Does this intervention benefit other Veterans with MSK?

About the Study

The study uses a randomized trial to test the effectiveness of the ACTION intervention compared with usual care (UC) among 250 black and 250 non-black patients with chronic MSK pain. Patients from the Atlanta VA Medical Center were identified using administrative data. Patients were screened by phone, and, if eligible, received the baseline survey by mail.

Eligible patients who completed the baseline survey were randomly assigned to the UC or intervention condition (IC). Intervention participants received a pedometer-mediated walking intervention that incorporated Action Planning and the use of MI and CBT techniques. The intervention was delivered in six telephone counseling sessions over three months. Patients in the UC condition received an informational brochure and a pedometer. The study is powered to find a difference between the IC and UC groups within the black group. The primary outcome is chronic pain-related physical functioning, assessed by the revised Roland and Morris Disability Questionnaire, a measure recommended by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT). Investigators will also examine whether the intervention improves other IMMPACT recommended domains (pain intensity, emotional functioning, and ratings of overall improvement).

Findings

None at this time.

Principal Investigator

Diana Burgess, PhD, is an investigator with the HSR&D Center for Care Delivery and Outcomes Research, in Minneapolis, MN.

Publications

This study has resulted in the following publications:

Bhimani RH, Cross LJ, Taylor BC, et al. Taking ACTION to reduce pain: ACTION study rationale, design and protocol of a randomized trial of a proactive telephone-based coaching intervention for chronic musculoskeletal pain among African Americans. BMC Musculoskeletal Disorders. 2017 Jan 13; 18(1):15.


Racial and Ethnic Disparities in End-of-Life Care

Racial and Ethnic Disparities in End-of-Life Care

© Stock/Wavebreakmedia

Implications for Care

As the Veteran population continues to grow in age and diversity, greater focus on care at the end of life (EOL) will become imperative. Currently, there is a dearth of evidence to guide culturally-tailored, Veteran-and family-centered EOL care in VA Medical Centers. Investigators expect that data from this study will improve our understanding of the needs and preferences of minority VA patients at EOL and their families.


Study Questions

Racial/ethnic disparities are well-documented in the VA healthcare system; however, little is known in the area of end-of-life (EOL) care. Racial/ethnic minorities are more likely to prefer life-prolonging, intensive measures near EOL and may be more likely to experience burdensome transitions as compared to non-minorities. These care patterns may contribute to overall dissatisfaction with care when rated by patients and their families; however, the nature of these relationships in VA is not known. This study addresses the following questions:

  • What EOL care patterns (i.e., burdensome transitions and intensive EOL care) emerge when comparing racial/ethnic minority to non-minority Veteran populations?
  • What are the organizational nursing characteristics of VA Medical Centers where minority and non-minority Veterans are cared for at the EOL?
  • What is the extent to which racial/ethnic differences in family perceptions of the quality of EOL care are associated with modifiable aspects of nursing care (i.e., staffing and racial/ethnic diversity of nursing staff)?
  • What are the perspectives of bereaved family members of racial/ethnic minority and non-minority Veterans on factors that influence the quality of EOL care?

About the Study

Investigators will use a variety of VA secondary data (VA’s Clinical Data Warehouse and the VA Nursing Outcomes Database) collected between Fiscal Years (FY) 2011-2015. The sample will include nearly all inpatient deaths in 142 VA Medical Centers nationally during the study period. In addition, for nearly 60% of decedents, a Bereaved Family Survey is available. Several forms of analysis will be used to examine the main effects of end-of-life care patterns and VA Medical Center organizational factors on EOL racial/ethnic disparities in family perceptions of EOL care quality, as well as any potential cross-level interactions between patient- and facility- level factors. Finally, the Bereaved Family Survey from the same period will be used to explore bereaved family members’ perceptions of the quality of EOL care.

Findings

There are currently no findings to report.

Principal Investigator

Ann Kutney Lee, PhD, RN, is an investigator with the HSR&D Center for Health Equity Research and Promotion in Philadelphia, PA


Understanding LGBT Veterans' Experiences of Care

Understanding LGBT Veterans' Experiences of Care

© Stock/andrei_r

Implications for Care

Creating a safe and welcoming environment for women Veterans seeking VA care is important in general, but findings indicate that for LGBT women, this is an even more serious concern. Despite VA's ongoing efforts to educate employees and change the culture toward a more inclusive environment, more targeted work addressing the needs of LGBT women Veterans may be needed.

About this Study

In general, LGBT women report experiencing discrimination, rejection, and/or poor care following disclosure of their sexuality or gender identity in healthcare settings. Further, research suggests that the stress of concealment, discrimination, and stigma contribute to poorer health and earlier deaths among LGBT people. Women Veterans who identify as LGBT may be more susceptible to the impact of minority stress, given their dual minority status in VA (female and LGBT). This study sought to examine LGBT women Veterans' experiences within the VA healthcare system, and whether their experiences impact their use of VA care. Investigators surveyed 1,391 women Veterans (86% non-LGBT, 14% LGBT) by phone from 1/15 to 3/15 who had at least three primary care visits in the past year at 12 VA facilities across 9 states. Participants were asked about feeling welcome and about feeling unsafe at VA, as well as about harassment experiences and delayed/missed care.

Findings

The majority of women Veterans reported feeling welcome at their VA. However, fewer LGBT women reported feeling welcome and safe at VA compared with non-LGBT women Veterans. After controlling for demographics, health status, and positive trauma screens, LGBT identity was predictive of women Veterans experiencing harassment from male Veterans at VA in the past 12 months, as well as feeling unwelcome or unsafe at VA.

LGBT women Veterans were about 3 times more likely than non-LGBT women Veterans to attribute missing needed care in the previous 12 months to concerns about interacting with other Veterans.

Study participant descriptions of harassment indicated that male Veterans' comments and actions were distressing and influenced LGBT women Veteran's healthcare accessing behavior.

(Note: This paper was based on an investigation funded as part of the HSR&D Women’s Health Collaborative Research to Enhance and Advance Transformation and Excellence (CREATE) initiative. Dr. Shipherd is part of VA's LGBT Health Program, Office of Patient Care Services, and VA's National Center for PTSD, Women's Health Sciences Division, in Boston, MA. Drs. Darling, Klap, Rose, and Yano are part of the HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy in Los Angeles, CA.)


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