A Review of the Evidence: Interventions to Improve Minority Healthcare and Reduce Racial and Ethnic Disparities
Racial and ethnic disparities are widespread in the U.S. healthcare system. Similarly, a 2007 report from the Portland Evidence-Based Synthesis Program (ESP) found disparities were prevalent in numerous clinical arenas within the VA healthcare system and identified several promising areas for research on how to reduce disparities. The 2011 report sought to describe the state of disparities intervention research within VA, glean lessons from systematic reviews of research outside of VA settings, and develop an organizing framework to describe studies in this field of research.
Investigators at the Portland ESP, part of the Portland VA Medical Center, conducted a review of primary intervention studies of VA patients from 2006 through August 2010, as well as intervention studies conducted outside VA from database inception through November 2010. After reviewing a combined total of 3,417 articles, 115 were eligible to answer the following key questions.
What is the state of research on interventions to reduce racial/ethnic disparities or to improve health and healthcare in minority populations within VA settings?
- There were few published interventions in VA settings. As a result, investigators examined intervention studies not exclusive to VA populations because many of the interventions studied could potentially inform interventions implemented in VA settings.
- Of the five recently published primary studies of interventions involving minority VA populations, the effectiveness of the interventions varied. Only one of the studies was able to conclude that the intervention significantly reduced disparities.
What are the results of interventions (within and outside the VA) to reduce racial/ethnic disparities or to improve health and healthcare in minority populations?
- Results of systematic reviews of interventions conducted in settings not limited to VA are summarized by clinical area:
- Diabetes interventions:
- There was some evidence of benefit for interventions focused on community health workers, care managers, and culturally-tailored health education for patients.
- Provider-focused interventions reported improvements in process measures, although computerized reminders for physicians resulted in negligible or negative results.
- One small single-center VA study suggests a telemedicine/care coordination intervention may reduce disparities in African American Veterans with diabetes.
- Arthritis and Pain Management interventions:
- Limited evidence was found that exercise interventions may be effective in improving differences in pain and disability between white and African American patients.
- In one VA study, an educational intervention improved knowledge and expectations related to total knee replacement among African American patients but did not alter willingness to consider TKR among whites or African Americans.
- Preventive and Ambulatory Care interventions
- There is some evidence that community health workers may improve rates of preventive health service utilization.
- Cardiovascular Disease interventions
- On the whole, nurse-based interventions were associated with improvements in proximal health outcomes (e.g., blood pressure, lipid level, body mass index) for minority populations, but the addition of community health workers provided limited gains.
- Several small trials suggest intensive multi-component care management interventions led by nurses may reduce hospitalization in minority patients with heart failure.
- HIV/AIDS interventions
- Some evidence suggests that behavioral interventions can be effective in improving HIV/AIDS service utilization and healthcare outcomes for African American and Hispanic populations.
- Mental Health interventions
- There is good evidence suggesting that multi-component chronic disease management interventions are helpful in reducing health disparities related to depression.
- There is insufficient evidence for psychopharmacological, psychotherapeutic, and preventive interventions in ethnic minority populations.
- Cross-Cutting interventions
- Cultural competence interventions can improve provider knowledge, attitude, and skills, but there are few good quality studies of effects on patient outcomes.
Overall, interventions that employ dedicated personnel that help connect patients and their healthcare systems improved outcomes for racial and ethnic minorities. Though the strength of evidence is limited, the most promising interventions were care coordination, care management, community health workers, and culturally-tailored education interventions.
Suggestions for Future Research
Few interventions specifically targeting disparities have been implemented in the VA. Although a few race-specific intervention studies are underway, much more work is needed in this area. The barriers to implementing disparities intervention research in VA care settings are not entirely clear. Future steps emanating from this review will include conducting a survey and interviews of key VA informants to identify barriers to dissemination of interventions, in an effort to provide a better understanding of the obstructions in the VA disparities research pipeline.
This report is a product of the HSR&D 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.
Quiï¿½ones A, O'Neil M, Saha S, et al. Interventions to Reduce Racial and Ethnic Disparities. VA-ESP Project #05-225;2011.
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