The report is a product of the VA/HSR Evidence Synthesis Program.

Evidence Map: Prevalence of and Interventions to Reduce Health Disparities

Today's Veteran population is racially and ethnically diverse, and includes more women and individuals from vulnerable populations, such as those identifying as lesbian, gay, bisexual, and transgender (LGBT), than at any other time in history. While the equal access nature of the VA healthcare system may succeed in mitigating some of the disparities related to socioeconomic status (SES), it does not directly address the potential for disparities related to sociodemographic factors (i.e., race/ethnicity, gender, LGBT identity, age), geographic location, and mental health status. An understanding of whether disparities in utilization, health, or healthcare exist for Veterans belonging to vulnerable populations is vital. VA has emphasized the mitigation and elimination of health disparities in its strategic plan and has outlined specific goals in both the Health Equity Action Plan and the Blueprint for Excellence.

Despite VA's commitment to reducing disparities, the rate at which health and healthcare disparities affect Veterans remains unclear. In order to help guide future research and policy decisions, the VA Office of Health Equity partnered with HSR&D and QUERI's Evidence-based Synthesis Program (ESP) to examine the state of research on health disparities affecting vulnerable Veterans. The purpose of this report was to create evidence maps identifying and illustrating studies that:

• Assess the prevalence of disparities in the utilization, quality of healthcare, and/or health of Veterans;
• Evaluate the interventions designed to mitigate disparities within the VA healthcare system; or
• Examine studies on health disparities, funded through the VA Office of Research and Development that are currently ongoing or were recently closed.

Investigators with the ESP Center in Portland, Oregon searched several databases (i.e., PubMed, MEDLINE, and the Cochrane Library) from 2006 to February 2016 for studies examining health disparities related to the use or quality of VA healthcare in vulnerable populations. From 4,364 studies, 464 studies were included to address the following key questions.

Question 1: For what Veteran group/populations are health and healthcare disparities prevalent?

Of the studies included in this review, 362 met inclusion criteria for this question. Results show that studies examining the prevalence of disparities in Veterans of color were the most highly represented, followed by studies examining disparities in women, and in Veterans with a mental health condition. Very few studies examined disparities related to LGBT identity or homelessness, and only a limited number of studies examined the impact of socioeconomic status (SES) on utilization, health, or quality of care. Findings on healthcare disparities varied widely by population and outcome.

Note: Studies may be represented more than once. 135 studies examined more than one population, and studies often reported multiple outcomes that were included in more than one category; thus, the combined sum of studies across columns may exceed the total number of unique studies for a population. Quality of care studies included processes of care, intermediate outcomes, and patient evaluations of care.

Across all populations, 83 studies examined outcomes related to utilization, 184 studies examined the quality of care, and 150 studies examined patient health outcomes. In general, studies examining racial/ethnic disparities focused more heavily on outcomes related to the quality of care and patient health; whereas, studies examining disparities related to rural residence, distance, homelessness, military era of service, and disability more commonly reported outcomes related to utilization.

Race and Ethnicity
The 193 studies reporting data on the prevalence of healthcare or health disparities in Veterans by race or ethnicity largely compared the experiences of African Americans/Blacks to Whites (188 studies). Studies examining the prevalence of disparities affecting Hispanic/Latino Veterans (70 studies) were limited in comparison, and very few studies focused on American Indian/Alaska Natives, Asians, or Pacific Islanders. Across all racial and ethnic groups, patient health and quality of care related outcomes were more frequently reported, while utilization was the focus of relatively few studies. The majority of studies found no or mixed/unclear evidence of racial or ethnic disparities, although this varied somewhat with the outcome evaluated. The majority of studies examining health outcomes found no evidence of disparities. Findings among studies examining quality of care outcomes varied substantially with roughly equal proportions finding evidence for and against disparities.

Other Populations
Evidence maps also are provided for evidence-related disparities by gender, mental health status, age, rural residence, SES, disability, distance from a VA medical center, military era of service, LGBT identity, and homelessness. Findings varied widely by population and depended on the outcome category examined.

Question 2: What are the effects of interventions implemented within VA to reduce health disparities?

Of the studies included in this review, 64 met inclusion criteria for this question. Findings show that the largest number of intervention studies performed in the VA were designed to mitigate disparities experienced by Veterans living in rural areas (13 studies) and those experienced by Veterans who were homeless or had low-incomes (12 studies). No studies examined interventions designed to address disparities related to LGBT identity.

Question 3: What research projects designed to identify or mitigate health disparities are currently being funded by VA's Office of Research & Development (ORD)?

Investigators identified 40 ongoing and recent studies funded by VA ORD. Studies largely included Veterans seen in VHA settings. However, a handful of abstracts did not clearly identify the setting of care, and a few others clearly examined non-VHA settings (e.g., Choice, Indian Health Service). Studies examining racial and ethnic disparities were the most common, followed by studies targeting Veterans living in rural areas, and studies examining women. Investigators identified no open or recently closed studies funded by VA examining the prevalence of, or interventions designed to mitigate disparities related to era of military service, LGBT identity, or disability.

Future Research
The vast number of studies and comparisons that were examined precluded a formal evaluation of study quality and depth of knowledge. Although investigators searched for unpublished studies, it is unlikely that the list is complete. In addition, it is important to note that the reported findings our maps illustrate may be skewed as a result of publication bias. Further, given that investigators did not evaluate many important study-level factors that may influence conclusions related to the presence or absence of a disparity across studies (i.e., appropriateness of confounders, adjustments, outcomes, and sampling bias), the maps presented in this report should not serve as evidence upon which policy decisions affecting the health or healthcare of Veterans are formed, but instead should serve as a starting point – and provide the "lay of the land." The maps in this report inform areas in which more primary research is needed; for example, the limited number of prevalence studies examining disparities by SES highlights a need for additional research to determine whether the health disparities associated with low SES in the general U.S. population also are experienced by Veterans receiving care in VA settings. In addition, prevalence studies are needed to better understand our American Indian/Alaska Native, Asian, Pacific Islander, Native Hawaiian, and LGBT Veterans, followed by intervention studies to address the findings. Furthermore, these findings also inform us of the areas or populations for which the research is rich, and for which a traditional systematic review would enable a deeper understanding of not only what disparities exist, but also the context and mechanisms through which they occur. Finally, findings allow us to see VA's strengths and achievements, which, in turn, may serve to provide motivation to continue to work towards the goal of health equity for all Veterans.

Reference
Kondo K, Low A, Everson T, et al Prevalence of and Interventions to Reduce Health Disparities in Vulnerable Veteran Populations: A Map of the Evidence. VA ESP Project #05-225; 2017.

Please feel free to forward this information to others!

Read past HSR&D Management e-Briefs on the HSR&D website.

ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.

This Management e-Brief is provided to inform you about recent HSR&D findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR&D Resource Center charged with disseminating important HSR&D findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.

This report is a product of VA/HSR&D's Quality Enhancement Research Initiative's (QUERI) Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers – and to disseminate these reports throughout VA.

See all reports online.