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Health Services Research & Development

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Each week the monthly spotlight features a topic-related HSR&D study.

April 2021

Introduction

April is National Minority Health Month. Building upon the history of Booker T. Washington’s establishment of National Negro Health Week in 1915, Congress established the month-long observance in 2002 to promote education on the disparities in health problems that minority populations endure, and to promote healthfulness in those populations1. VA serves a large population of minority Veterans and estimates that by 2045 nearly 40% will be of racial/ethnic groups other than non-Hispanic white2. Additionally, VA recognizes minority populations other than racial/ethnic, who suffer health disparities3. In 2011 VA chartered a health care equality workgroup, which led to the establishment of the Office of Health Equity (OHE) the next year4. HSR&D collaborates with OHE on projects such as the QUERI Partnered Evaluation Initiative, and funds the Center for Health Equity Research and Promotion (CHERP)5 and Health Equity and Rural Outreach Innovation Center (HEROIC)6 among other endeavors to increase awareness of and address racial, ethnic, and other minority health disparities. Below is a selection of recent and ongoing HSR&D studies and projects aimed at continuing that effort.

Opening the Black Box of Cultural Competence

 Opening the Black Box of Cultural Competence

©iStock/FG Trade

Implications:

The purpose of this project is to provide evidence to inform effective cultural competence (CC) training, both within and outside VA. Evidence-based CC training is a priority for VA, as evidenced by its inclusion as part of the “Health Equity Action Plan,” developed by VA's Office of Health Equity (OHE). This study’s findings will inform national VA efforts to reduce racial and ethnic disparities in care delivery.

Overview:

Ensuring that care is delivered equitably across different Veteran populations has been a longstanding VA priority. In the last decade, cultural competence (CC) training has proliferated nationally in both community care and VA settings. However, most CC programs are delivered without a sound evidence base to inform their content. In a previous study "Measuring Cross-Cultural Competence in VA Primary Care" (ECV 04-296) - investigators found that primary care providers (PCPs) with higher levels of self-assessed CC received higher ratings of care from minority patients with diabetes, such that there were fewer racial disparities in the quality of care the provided. The current study seeks to assess how the attitudes captured in the measure of self-assessed provider CC translate into more equitable care.

Specifically, this study sought to:

1) Understand differences in patient-provider communication among high and low CC PCPs.

2) Understand patients' perceptions of their interactions and relationships with high and low CC PCPs and other patient-aligned care team (PACT) members.

3) Understand the contribution of CC among PCPs/PACTs to quality and equity of diabetes care.

Investigators recruited approximately 50 PCPs, with a targeted sample of 5 African American and 5 white Veterans with diabetes per provider at 4 VA medical centers. Cultural competence self-assessments by PCPs were collected and evaluated. Study investigators audio-recorded visits between each recruited patient and his/her PCP and quantitatively and qualitatively analyzed communication patterns in these visits. To understand patients' perceptions of these interactions and relationships with PCPs and PACT members, investigators also conducted brief surveys with each patient and interviewed a subsample of them. Lastly, investigators compared associations of PCP cultural competence with Veteran self-reported and clinical outcomes, to understand the contribution of CC to quality and equity of diabetes care.

Preliminary Findings:

  • Early qualitative data indicate that providers vary not only in the content of their communication (what they say) but also in communication style (how they say things).
  • Differences in provider communication and patient perceptions have led to additional funding for a pilot supplemental analysis using natural language processing (NLP) methods.

Principal Investigator: Somnath Saha, MD, MPH, is with HSR&D’s Center to Improve Veteran Involvement in Care (CIVIC) and is a staff physician at the Portland VA Medical Center, part of the VA Portland Health Care System, Portland OR.

Publications:

Saha S, Beach MC. Impact of Physician Race on Patient Decision-Making and Ratings of Physicians: a Randomized Experiment Using Video Vignettes. Journal of general internal medicine. 2020 Apr 1; 35(4):1084-1091.

Park J, Beach MC, Han D, Moore RD, Korthuis PT, Saha S. Racial disparities in clinician response to patient emotions. Patient Educ Couns. 2020 Sep;103(9):1736-1744.




Communication and Activation in Pain to Enhance Relationships and Treat Pain with Equity (COOPERATE)

  Communication and Activation in Pain to Enhance Relationships and Treat Pain with Equity (COOPERATE)

©iStock/Rawpixel

Implications:

Research shows that minority patients are often offered fewer options for pain treatments compared to their White counterparts. Moreover, research indicates that minority patients have lower levels of patient activation (i.e., having the knowledge, confidence, and skills to self-manage) and more negative experiences communicating with their healthcare providers. These skills are critical, particularly considering VA patient care improvement efforts such as the Opioid Safety Initiative and the emphasis on multi-modal care—both of which require patients to explore and discuss treatment options to find approaches that are feasible for their individual lifestyles and consistent with treatment goals. Using a coaching model, COOPERATE focuses on strengthening patient activation and communication skills for African American Veterans with chronic pain.

Overview:

Chronic pain affects up to 70% of Veterans and amounts to over $600 billion per year in direct medical costs and lost worker productivity. Racial disparities in pain treatment have been extensively documented. Minority patients, including Veterans, are more likely to be undertreated for pain. Minority Veterans have been shown to have pain documented less frequently, undergo more urine drug tests, and are more likely to be referred for substance abuse evaluation than white Veterans. Compounding these pain care disparities, minority Veterans exhibit lower levels of patient activation than white Veterans. Patient activation, defined as having knowledge, confidence, and skills to manage health, is associated with better health experiences, self-management, and outcomes. Low activation is frequently manifested in poorer communication among minority patients. Minority patients are less likely to share their concerns with providers, ask questions, and prepare for their clinic visits. This poor communication is associated with lower quality care, poorer patient-provider relationships, and treatment non-adherence. The poorer communication experienced by minorities is exacerbated by the documented difficulties in patient-provider communication about chronic pain and its treatment, particularly where opioids are concerned.

This study, funded through June 2022, seeks to compare a 6-session telephone-delivered patient activation and communication (COOPERATE) intervention with an “attention” (receiving attention only, through check-in phone calls) control group. Investigators are currently enrolling 250 Black Veterans with chronic musculoskeletal pain from primary care clinics. Veterans are randomized either to the COOPERATE intervention or to the attention control arm. Specific aims are:

  • Test the effects of COOPERATE on key Veteran outcomes. Investigators hypothesize that at 3, 6, and 9 months from baseline, Black Veterans randomized to the COOPERATE intervention will report greater increases in patient activation and communication self-efficacy, as well as improvements in pain scores and psychological functioning.
  • Examine mediating and moderating effects of COOPERATE. Aim 2 will examine patient activation as a mediator of clinical outcomes and working alliance as a moderator of COOPERATE's effect on patient activation.
  • Understand facilitators and barriers to implementing COOPERATE. Investigators will conduct pre-implementation qualitative interviews with a purposefully selected subsample of intervention Veterans, and clinicians from primary care and the chronic pain clinic, to better prepare for implementing COOPERATE.

Study Progress:

  • Through HSR&D COVID-19 rapid response funding, qualitative interviews with a subset of COOPERATE completers were conducted to better understand the effects of the COVID-19 pandemic on African American Veterans. Specific factors include the disease itself, stay-at-home orders, and changes in healthcare delivery. Interviews are currently being analyzed.
  • Recruitment is ongoing and anticipated to be completed by early to mid-summer 2021.

Principal Investigator: Marianne S. Matthias, PhD, is with the HSR&D Center for Health Information and Communication (CHIC) at the Richard L. Roudebush VA Medical Center, Indianapolis, IN




Understanding Hormone Therapy Care Received by Transgender Veterans in VHA

 Understanding Hormone Therapy Care Received by Transgender Veterans in VHA

©iStock/eyewave

Implications:

VA has an imperative to provide high-quality care to all Veterans, and it is a primary goal of the Lesbian, Gay, Bisexual, and Transgender (LGBT) Health Program in the Office of Patient Care Services to ensure that extends to transgender Veterans (trans Veterans). This study was the first to provide an assessment of the quality of hormone therapy care received by trans Veterans served by VA, as well as to refine methods to identify in VA data trans Veterans who receive hormone therapy.

Overview:

The prevalence of transgender Veterans is on the rise. Transgender individuals experience discord between their self-identified gender and biological sex, defined as gender dysphoria (GD). Untreated and/or undertreated GD is associated with increased mortality and morbidity including depression, anxiety, and suicidality. Hormone therapy is generally the first, and often the only, medical intervention accessed by trans persons with GD who seek to masculinize or feminize their body to be consistent with their gender identity. In 2012, VA’s Pharmacy Benefits Management (PBM) issued Criteria for Use (CFU) for trans Veteran hormone therapy care. In pilot work, this study’s investigators identified that from FY 2005-17, of nearly 8,000 trans Veterans with GD, approximately 5,000 were on hormone therapy. In order to identify gaps in delivery of this care, investigators determined three specific aims:

1: Refine methods for identifying trans Veterans on hormone therapy using VA data and validate by chart reviews.

2: Examine the hormone therapy care provided to trans Veterans in VA, describing its current state and determining the degree that hormone care is concordant with PBM CFU and non-VA guidelines.

3: Identify patient-, clinician-, and site-level predictors of guideline-concordant hormone therapy care for trans Veterans.

Using national VA data, investigators identified a population of gender identity disorder (GID) documented trans Veterans receiving hormone therapy. Additional non-GID criteria of identification included receipt of hormones by opposite sex, endocrine disorder, and change in coded gender over time. Both GID and non-GID criteria were validated by chart reviews. Investigators then characterized the study cohort in terms of demographics, proportion of those receiving each type of hormone therapy (estrogen vs. testosterone vs. none), route of administration (oral, transdermal, injectable), dosage, and duration of therapy. Key aspects of care recommended by PBM CFU and non-VA guidelines (e.g. adequacy of laboratory monitoring) were determined, against which the current care could be measured. Finally, investigators examined factors associated with both receipt of hormone therapy and guideline-concordant hormone therapy at the patient- (e.g. housing instability), provider- (e.g. availability of trans electronic consultations), and site-level (e.g. trans specialty training offered at site).

Preliminary Findings:

  • Though both GID and non-GID approaches were applied to identify trans status, validation after chart review revealed that non-GID approaches alone were not reliable to detect transgender identity. Findings suggest that GID diagnosis codes are the most reliable criteria to identify transgender individuals in VA.
  • Data suggest that age, race, comorbidities, and social stressors can affect receipt of hormone therapy among transgender patients in VA. Veterans who were younger with fewer comorbidities and social stressors were more likely to receive hormone therapy.
  • Study investigators have been invited to present findings related to identification and characteristics of trans Veterans during poster sessions at upcoming Academy Health and Endocrine Society 2021 meetings.

Principal Investigator: Guneet K. Jasuja, PhD, is an investigator and epidemiologist at the HSR&D Center for Healthcare Organization & Implementation Research (CHOIR) at the Edith Nourse Rogers Memorial Veterans Hospital, Bedford MA.

Publications:

Wolfe HL, Reisman JI, Yoon S, et al. Validating data-driven methods to identify transgender individuals in the Veterans Affairs. Am J Epidemiol. In press. 




A Proactive Walking Trial to Reduce Pain in Black Veterans

 Prehabilitation  Services Improve the Perioperative Care of Frail Veterans Following Major Abdominal Surgery

©iStock/adamkaz

Implications:

This trial of a walking-focused, proactive coaching intervention for chronic pain, aimed at addressing contributors to racial disparities in pain, fills important gaps in the literature. Results were promising, with the intervention leading to global improvement in pain among black participants. Through its proactive outreach approach, this trial also demonstrated the feasibility of enrolling a large number of Black participants with high levels of mental and physical health comorbidities and functional limitations into a trial of a nonpharmacological treatment for chronic pain. Qualitative findings suggested barriers related to mental health and social determinants of health as reasons for lower than optimal completion of the program.

Overview:

Chronic musculoskeletal (MSK) pain is one of the most common conditions among Veterans, affecting approximately 60% of those seen in VA primary care. Although perceived effectiveness of chronic pain treatment is low among all VA patients, black patients are less likely than whites to perceive their treatment as effective and are more likely to experience functional limitations due to pain. There is growing consensus that chronic pain is best addressed by a biopsychosocial approach that acknowledges the role of psychological

and environmental contributors to pain, some of which differ by race and hence contribute to disparities. For example, black individuals experience greater pain-related fear and lower self-efficacy in coping with pain (psychological contributors), and neighborhoods that make physical activity difficult (environmental contributors). However, there is a lack of effective interventions to improve pain treatment among minority patients, particularly those that target psychological and environmental contributors.

This study sought to test the effectiveness of a multi-component intervention specifically targeting known barriers to pain care among black Veterans with chronic MSK pain. The primary hypothesis was that a walking-focused, proactive coaching intervention aimed at addressing contributors to racial disparities in pain would improve chronic pain outcomes among Black Veterans. Veterans with at least one hip, back, or knee diagnosis code in the previous year, and another within 18 months were proactively recruited from the Atlanta VA Healthcare System into usual care and intervention condition groups. Both groups received a brochure encouraging walking and a pedometer. The intervention group received the ACTION program, which consists of six 30-60 minute telephone coaching sessions delivered by counselors trained in Action Planning and Motivational Interviewing (MI). Counselors coached participants to create and write action plans to overcome specific barriers. Walking was measured by the number of daily steps recorded by the pedometers.

Key Findings:

  • Black Veterans in the intervention group rated their overall pain improvement significantly higher than those in the control group.
  • Among the 194 Black Veterans in the intervention group, 47% completed all 6 sessions, 11% completed 5-3 sessions, 15% only completed 1-2 sessions, and 26% failed to complete any sessions.
  • 96% of Black participants reported that they would recommend the program to a friend with similar pain.

Principal Investigator: Diana J. Burgess, PhD, is a Core Investigator at the HSR&D Center for Care Delivery and Outcomes Research (CCDOR) and Co-Director of the Minneapolis VA Advanced Fellowship Program in Health Services Research at the Minneapolis VA Health Care System, Minneapolis MN.

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.

References

  1. National Minority Health Month. [Internet]. Washington (DC): US National Institutes of Health; 2021. [cited 2021 March 25]. Available from: https://www.nimhd.nih.gov/programs/edu-training/nmhm/
  2. Population Page - Racial and Ethnic Minority Veterans. [Internet]. Washington (DC): US Department of Veterans Affairs; 2020. [cited 2021 March 30]. Available from: https://www.va.gov/HEALTHEQUITY/Facts_About_OHE.asp
  3. VA Improves Care for Sexual and Gender Minority Veterans. [Internet]. Washington (DC): US Department of Veterans Affairs; 2016. [cited 2021 March 30]. Available from: /news/research_news/kauth-050216.cfm
  4. About Office of Health Equity. [Internet]. Washington (DC): US Department of Veterans Affairs; 2020. [cited 2021 March 25]. Available from: https://www.va.gov/HEALTHEQUITY/Facts_About_OHE.asp
  5. Center for Health Equity Research and Promotion. [Internet]. Washington (DC): US Department of Veterans Affairs; 2021. [cited 2021 March 30]. Available from: https://www.cherp.research.va.gov/
  6. COIN: Charleston Health Equity and Rural Outreach Innovation Center. [Internet]. Washington (DC): US Department of Veterans Affairs; 2020. [cited 2021 March 30]. Available from: /centers/heroic.cfm

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