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Health Services Research & Development

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

Spotlight on Minority Health

February 2022

According to the National Center for Veteran Statistics and the VA Office of Health Equity, the racial and ethnic composition of Veterans will change significantly over the next 20 years [1]. Currently, minorities comprise approximately 26% of the Veteran population, and by 2040, that number is expected to increase to 39% of all Veterans.

Given the increasing proportion of minority Veterans —and understanding VA’s commitment to ensuring equitable care for all Veterans—research into health concerns specific to minority Veterans is of continuing importance. Investigators within VA’s Health Services Research and Development Service (HSR&D) conduct a variety of research studies designed to further the evidence base around concerns unique to minority Veterans. The following studies highlight just some of the recently concluded and ongoing work focused on healthcare for minority Veterans.

Racial Bias in a VA Algorithm for High-Risk Veterans

Racial Bias in a VA Algorithm for High-Risk Veterans

©iStock/FG Trade

Implications

African-American Veterans are at particular risk for adverse health outcomes—including mortality and hospitalization—due to adverse social determinants of health (SDoH) such as transportation challenges and housing instability. Identifying individuals at risk for adverse outcomes has been a priority for VA, and the Care Assessment Needs (CAN) score (a predictive risk algorithm) has been used to understand and assess Veterans’ primary care needs. The CAN score is currently used by patient-aligned care teams (PACTs) and nurse care navigators to direct high-risk Veterans to clinical programs and resources, including telehealth, palliative care, and home-based primary care. However, preliminary investigations show that the CAN score underestimates risk for African-Americans compared to white Veterans because race and SDoH are not routine inputs into the current algorithm. If successful, this study will yield a fair analytic model that will incorporate data related to SDoH into its predictive algorithm. Investigators will also examine the impact of mitigating existing algorithmic unfairness on expected African-American enrollment in VA clinical programs that target high-risk Veterans.

About the Study

VA has invested an average of 5% of total its spending towards health information technology to support such algorithms such as the CAN score, which is primarily based on laboratory, demographic, utilization, and other administrative data. Recent studies have shown that similar algorithms used in non-VA settings may mischaracterize risk for vulnerable patient subgroups—including African-Americans—whose health is heavily influenced by disproportionate exposure to adverse SDoH. There is a growing concern that algorithms like the CAN score could generate “algorithmically unfair” predictions that systematically mischaracterize risk for subgroups whose care is heavily influenced by SDoH. However, there has been no systematic investigation into any unfairness of the CAN score between African-American and White Veterans. In this study, investigators will systematically examine algorithmic unfairness in the VA CAN algorithm and develop approaches to mitigate it, including testing the incorporation of SDoH metrics that are available through VA screening efforts. Investigators will then use the improved “fair’ CAN score generated to determine how the mitigation of unfairness would change the racial composition of Veterans enrolled in clinical programs targeting high-risk Veterans.

Principal Investigator: Amol S. Navathe MD PhD, is an investigator with the HSR&D Center for Health Equity Research and Promotion in Philadelphia, PA.

Mitigating Racial/Ethnic and Socio-Economic Disparities in VA Care Quality and Patient Experience

Mitigating Racial/Ethnic and Socio-Economic Disparities in VA Care Quality and Patient Experience

©iStock/FatCamera

Implications

Racial/ethnic minority Veterans who have hypertension or diabetes are less likely to have these conditions under control than are white Veterans. Some of the factors that can lead to poor control of these conditions may be related to the type of healthcare the individual receives, whereas other factors may be outside the control of a healthcare system. Certain healthcare sites might deliver care in a way that will result in more patients achieving good control of their hypertension and diabetes, yet contributing factors to those successes are poorly understood. This research will fill a knowledge gap about the prevalence of VA disparities related to socio-economic vulnerability; provide evidence on clinical practice delivery arrangements associated with higher quality and lower disparities for vulnerable groups; and provide effective field-tested disparities-reduction approaches to inform evidence-based quality improvement initiatives and implementation research to improve clinical outcomes for vulnerable groups at low-performing or high disparity VA sites.

About the Study

The extent to which socio-economic status (SES)-related differences drive racial-ethnic disparities in diabetes and hypertension control is unknown. By using a national cohort of all Veterans who used VA care during FY17, investigators will characterize associations between SES and healthcare site quality among minority Veterans without good diabetes and hypertension control. Individual socio-demographics, diagnosed conditions, and residential characteristics will be linked with existing data on VA site and healthcare system characteristics, including site-level patient-aligned care team implementation and healthcare system-level patient experience as measured by VA quality metrics. These data will then be linked to electronic quality measures. Investigators will also determine site-specific performance for vulnerable and majority groups, and disparities between these groups. In addition, investigators will conduct key stakeholder interviews at those sites to explore local practices for achieving hypertension and diabetes control in their patients, and will include barriers, facilitators, and contextual factors influencing implementation of evidence-based practices.

Principal Investigator: Donna L. Washington MD, MPH, is an investigator with the HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy in Los Angeles, CA.

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/Igor Vershinsky

Implications

Racial disparities in pain care are well-documented, both within and outside of VA. Minorities are offered fewer pain treatment options, yet are subject to more urine drug tests, and are referred for substance abuse evaluation more frequently than whites. Compounding these pain care disparities, minority Veterans exhibit lower levels of patient activation than white Veterans. Patient activation—having knowledge, confidence, and skills to manage health—is associated with better health outcomes. Among minority Veterans, lower patient activation often takes the form of poorer communication, with minority Veterans less likely to share their concerns with providers, ask questions, and prepare for their clinic visits. Data from this study will be used to support an intervention designed to improve Black Veterans’ patient activation and communication around their chronic pain concerns, ideally improving overall chronic pain management and health outcomes for these Veterans.

About the Study

The COOPERATE study is a randomized, controlled trial of an intervention to improve patient activation and communication with providers for Black Veterans with chronic pain. Investigators expect to enroll 250 Black Veterans with chronic musculoskeletal pain, recruiting participants from primary care clinics. Veterans will be randomized to either the COOPERATE intervention (telephone counseling in six sessions—four weekly sessions followed by two booster session—over a period of 12 weeks) or to an attention-focused control group. The primary aims of COOPERATE (increases in patient activation and communication self-efficacy; improvements in pain intensity, pain interference, and psychological functioning) will be tested at three, six, and nine months. Further, investigators will examine patient activation as a mediator of clinical outcomes, and working alliance as a moderator of COOPERATE’s effect on patient activation. Investigators will also use qualitative methods to understand facilitators and barriers to implementing COOPERATE.

Principal Investigator:  Marianne Matthias, PhD, MS, is an investigator with the HSR&D Center for Health Information and Communication in Indianapolis, IN.

Study Shows Changes in the Association between Race and Urban Residence with COVID-19 Outcomes among Veterans

Study Shows Changes in the Association between Race and Urban Residence with COVID-19 Outcomes among Veterans

©iStock/Grandbrothers

Implications

Black, American Indian/Alaska Native (AI/AN), and Hispanic individuals experience both higher risk for, and mortality from COVID-19 infection. In this study, investigators used VA data to assess changes to minority Veterans' sociodemographic factors and comorbidity burden relative to their risk for COVID-19 infection. Results indicated that understanding these changing patterns of risk factors is important in informing population-based approaches to prevent infection and reduce mortality in the current pandemic. These data may also serve to inform public health responses in minority communities to future pandemics.

About the Study

This population-based cohort study examined whether key sociodemographic and clinical risk factors for COVID-19 infection and mortality changed between February 2020 and March 2021 among more than 9 million Veterans enrolled in VA healthcare. Included in the cohort were 216,046 Veterans who tested positive and 10,230 who had died of COVID-19 during the study period. Using VA data, investigators also assessed Veterans' sociodemographic factors and comorbidity burden.

Findings showed strong positive associations for Black and AI/AN racial and ethnic minorities and urban residence with COVID-19 infection, mortality, and case fatality. The magnitude of the association between being Black and the risk for COVID-19 infection or mortality declined steadily from February/March 2020 to November 2020, when it was no longer significant. The association between being AI/AN and COVID-19 infection declined steadily over time to a negative association in March 2021. Similarly, the association between urban vs. rural location and COVID-19 infection or mortality also declined steadily over time, shifting from a positive association in February/March 2020 to a negative association in September/October 2020 – and to a non-significant association in March 2021.

Throughout the study period, high comorbidity burden, younger age, Hispanic ethnicity, and obesity were consistently associated with COVID-19 infection, while high comorbidity burden, older age, Hispanic ethnicity, obesity, and male sex were consistently associated with mortality.

References

Ioannou G, Ferguson J, O’Hare A, et al. Changes in the associations of race and rurality with SARS-CoV-2 infection, mortality and case fatality in the United States from February 2020 to March 2021: A Population-based Cohort Study. PLoS Medicine. October 21, 2021;18(10): e1003807.

[1] National Veteran Health Equity Report (https://vha-healthequity.shinyapps.io/NVHER_Shiny)


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