Health disparities are defined as significant differences in healthcare or health status between distinct, vulnerable populations linked with social, economic, and/or environmental disadvantage—and an elevated burden of ill health or premature mortality. Within the VA healthcare system, health equity and disparity research focuses on concerns specific to unique groups of Veterans (such as veterans living in rural areas, women, and minorities) and those who have served in specific deployment periods (such as Iraq and Afghanistan, or Viet Nam).
VA is committed to ensuring that all Veterans have barrier-free access to the same high-quality, evidence-based care. Understanding and eliminating disparities in care is a key component of that goal. To support these efforts, VA’s Health Services Research & Development Service (VA HSR&D) investigators conduct a variety of studies to help improve healthcare equity among Veterans. In addition to individually funded studies, VA HSR&D supports two Centers of Innovation that focus specifically on issues related to health equity: the Charleston Health Equity and Rural Outreach Innovation Center (HEROIC) and the Center for Health Equity Research & Promotion (CHERP). In addition, VA’s Quality Enhancement Research Initiative has several programs that focus on aspects of healthcare disparities including those faced by rural-dwelling Veterans, and Veterans dealing with social justice issues and housing challenges. The following studies represent just a few examples of the impactful research being conducted by HSR&D investigators.
In September 2016, two HSR&D Centers for Innovation focused on health equity—CHERP and HEROIC—hosted a state-of-the-science conference, “Field-based Meeting to Engage Diverse Stakeholders and Operational Partners in Advancing Health Equity in the VA Healthcare System.” This meeting brought together health equity investigators, representatives of vulnerable Veteran populations, and operational leaders to identify strategies to advance implementation of evidence-based interventions to improve the quality and equity of health and healthcare. The journal Medical Care produced a special supplement featuring commentary, discussion, and several original research studies resulting from this conference. Three of those studies are described here.
Patient satisfaction is an important dimension of healthcare quality, and VA is committed to providing high-quality care to an increasingly diverse patient population. In two contiguous, recently-concluded studies, investigators sought to assess Veteran satisfaction with VA healthcare by race/ethnicity and gender. Using telephone interviews with Black, white, and Hispanic Veterans from 25 predominantly minority-serving VA medical centers from June 2013 to January 2015, researchers assessed satisfaction with VA care across 16 domains, comparing the proportion of Veterans who were very satisfied, somewhat satisfied, or less than satisfied (that is, neither satisfied nor dissatisfied; somewhat dissatisfied; or very dissatisfied) in each domain.
Interviews were completed for 1222 of the 1929 Veteran participants (421 white, 389 Black, and 396 Hispanic Veterans). Of the participating group, 616 were female. Multisite interviews with Veterans at primarily minority-serving sites showed generally high levels of health care satisfaction across 16 domains, with few quantitative differences by race/ethnicity or gender. The highest satisfaction ratings were reported for costs, outpatient facilities, and pharmacy (74-76% very satisfied); the lowest ratings were reported for access, pain management, and mental health care (21-24% less than satisfied). None of the joint tests of racial/ethnic or gender differences showed any statistically significant difference in satisfaction.
Implications. Given VA's commitment to providing high quality care to all patients, capturing evidence about the unique concerns of a diverse group of male and women Veterans is a critical component in supporting health system changes that improve care among minority patient populations.
Zickmund S, Burkitt K, Gao S, et al. Racial, ethnic, and gender equity in Veteran satisfaction with health care in the Veterans Affairs health care system. Journal of General Internal Medicine. March 2018;33(3):305-331.
Arthritis is a prevalent and disabling source of chronic pain for which African Americans bear a disproportionate burden. This study tested a patient-centered, non-invasive intervention to improve pain outcomes and reduce disparities in African American and white Veterans with knee arthritis. The intervention is designed to help Veterans develop positive psychological skills such as gratitude and kindness, the health benefits of which are well-documented.
In a pilot test of this intervention, a small group of patients (N = 42) were randomized to a six-week program containing positive skill-building activities or neutral control activities tailored to the patient population. Adherence was assessed by telephone each week. Osteoarthritis symptom severity was assessed, as well as measures of well-being (positive affect, negative affect, and life satisfaction) at baseline and by telephone one, three, and six months after the program ended.
Results showed that the majority (64%) of patients completed more than 80% of their weekly activities. Patients in the positive (vs neutral) program reported significantly more improvement over time in osteoarthritis symptom severity, negative affect, and life satisfaction. The intervention is now being tested in a larger study to determine whether these benefits generalize to a broader sample of Veterans with arthritis.
Implications. Since Veterans with knee osteoarthritis are open to participating in a six-week non-pharmacological intervention to build positive psychological skills, this approach may have potential, wider application for a diverse group of Veterans with other chronic pain conditions.
Hausmann LRM, Youk A, Kwoh CK, et al. Testing a positive psychological intervention for osteoarthritis. Pain Medicine. 2017 Oct 1; 18(10):1908-1920.
Hausmann LRM, Ibrahim SA, Kwoh CK, et al. Rationale and design of the staying positive with arthritis (SPA) study: A randomized controlled trial testing the impact of a positive psychology intervention on racial disparities in pain. Contemporary Clinical Trials. 2017 Sep 8; (64):243-253.