Disparities in Healthcare Quality Indicators Among Adults with Mental Illness
The burden of mental health diagnoses among Veterans is substantial, and medical conditions such as diabetes and cardiovascular disease affect a disproportionate number of people with a mental health diagnosis. Chronic medical conditions, when co-occurring with mental health diagnosis, are more detrimental to overall health, and people with both a mental health diagnosis and chronic medical conditions have higher hospitalization rates and healthcare costs than do those with comparable medical conditions alone. Disparities in health between people with and without a mental health diagnosis are likely due to a combination of factors such as the effect of mental health on an individual's capacity to maintain health, the adverse effects of medications used to treat a mental health diagnosis, individual-level modifiable risk factors (eg, smoking, physical inactivity), and lower quality of healthcare.
In order to guide future research and policy decisions for the VA, the VHA Office of Health Equity partnered with the Evidence-based Synthesis Program (ESP) and the ESP Center in the Durham Veterans Affairs Healthcare System to conduct a systematic review of healthcare disparities among adults with a mental health diagnosis. This review focused on differences in preventive care services and screening, differences in management of chronic conditions among those with mental health diagnoses compared to those without, and whether any observed disparities varied based on race/ethnicity, VA user status, geographic location, sex, or sexual orientation. Figure 1 highlights qualitative differences in identified disparities in diabetes care processes observed within the VA healthcare system compared to those seen outside VA.
Figure 1. Qualitative differences in diabetes care patterns for studies conducted inside versus outside the VA healthcare system.
- For composite indicators of diabetes care, one study conducted outside the VA reported significantly worse care for patients with mental illness while 2 studies conducted with VA users reported mixed results.
- Within VA, there was a positive trend for increased hemoglobin A1c monitoring for patients with serious mental illness (SMI) ; this trend was not observed in the non-VA study.
- Among VA users with diabetes, those with a diagnosis of SMI were significantly less likely to get eye exams than those without mental illness. In contrast, in the 2 studies conducted outside the VA diabetic patients with SMI were more likely to get eye exams , but only one estimate was statistically significant.
- For low-density lipoprotein cholesterol (LDL-C) control, VA studies demonstrated no significant differences between VA users with and without SMI. However, the one study that provided comparative estimates outside the VA reported significant and negative effects of SMI on achieving adequate LDL-C control.
This review found weak signals to suggest disparities in care for those with mental health diagnosis; however, results were generally inconsistent. Moreover, beyond diabetes care, the existing literature was sparse. While most studies were of fair quality, the strength of the evidence for these types of studies is low. The majority found some healthcare disparities; however, only one meta-analysis of disparities in cervical cancer screening was statistically significant. Although several of the included studies were conducted in VA user populations, there are notable gaps in in the evidence that the use of VA data may be well-positioned to address.
The selected studies included adults with bipolar disorder, schizophrenia, schizoaffective disorder, major depressive disorder (or depressive disorders), and posttraumatic stress disorder PTSD. These mental health diagnoses are either common in the VA healthcare system and/or significantly impact overall cost of care. The included studies recruited insured populations (or the studies controlled for insurance status in analyses). These eligibility requirements may have excluded some studies; however, this review attempted to include studies that were of greatest applicability to the VA healthcare system. Finally, of the 23 studies in this review, 12 were conducted within the VA healthcare system with Veteran users. Thus, these findings have relatively high applicability to VA populations.
Gaps in the current state of the evidence warrant future investigation. There is limited evidence for people with PTSD. Also, no studies described the sexual orientation of samples. Lesbian, gay, and transgender patients with a mental health diagnosis may be at elevated risk of disparities in receipt of preventive services and care for chronic medical illnesses. The review also found inconsistent or insufficient comparative evidence for ischemic heart disease care, screening and treatment for smoking cessation, immunizations, and hypertension. Further research is needed on the interaction of sex, race/ethnicity, Veteran status, sexual orientation, and geography with a mental health diagnosis on process of healthcare indicators.
Gierisch JM, Beadles C, Shapiro A, et al. Health Disparities in Quality Indicators of Healthcare Among Adults with Mental Illness. VA ESP Project #09-009;2014.
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