Evidence Brief: Racial and Ethnic Disparities Within VA

A recent Evidence-based Synthesis Program Coordinating Center (ESP CC) rapid review of evidence on racial and ethnic differences in outcomes for VA patients found moderate- and low-strength evidence to suggest gaps in morbidity and mortality outcomes among vulnerable Veteran populations with major conditions. (A partial listing of the moderate- and low-strength evidence appears in Table A. See the full Evidence Brief for other outcomes with moderate-, low-, and high-strength evidence.) The report also found that the few interventions that have improved racial/ethnic disparities within the VA have focused primarily on African Americans and have covered a narrow scope of clinical areas.

As part of its mission to advance health equity, the Veterans Health Administration (VHA) Office of Health Equity (OHE) is partnering with the Quality Enhancement Research Initiative (QUERI) to evaluate gaps in morbidity and mortality outcomes and to examine trends in quality of care across these conditions. To help inform selection of operational and research priorities for the Partnered Evaluation Center (PEC), the OHE requested that the ESP CC provide an evidence brief update on what research and implementation priorities have emerged since (1) the 2007 ESP publication "Racial and Ethnic Disparities in the VA Healthcare System" that reviewed in which clinical areas racial and ethnic disparities are prevalent within the VA, and (2) the 2011 ESP review "Interventions to Improve Minority Health Care and Racial and Ethnic Disparities."

Because this was an evidence brief with a shortened timeline (as opposed to a full systematic review), only studies of race- and ethnicity-based mortality and morbidity differences were evaluated; these are key areas of the OHE's -priority indicators of health care quality. The sources of differences were not evaluated. A disparity was defined as "any instance of worse mortality or morbidity outcomes for the racial/ethnic minority groups."

Evidence Gaps/Limitations
To more completely capture the totality of patients' care, future studies should supplement VHA data with Medicare data whenever possible. For morbidity outcomes, and to maximize generalizability to the broadest disease populations, studies should examine multiple relevant outcomes, not just a single rare outcome in isolation. For example, future studies of rates of end-stage renal disease in HIV should be done in the context of other more common outcomes, such as severe bacterial infections or AIDS events. Additionally, inclusion and analysis of all the groups within a sub-population is necessary to avoid perpetuating the disparity in knowledge about small subset. For instance white vs non-white studies do not inform about the subgroups within the non-white population.

Conclusion
This evidence brief update identified several research priorities for OHE's Partnered Evaluation Center, although the moderate-strength evidence of mortality or morbidity disparities for African American Veterans with colon cancer, HIV, and CKD – and for Hispanics with hepatitis C were based on VA cohorts from the early 2000s, and changes are possible in the past 10 years. More research is needed to establish the presence or absence of a mortality or morbidity disparity for African Americans with diabetes, stroke, or VTE, American Indians or Alaskan Natives following major non-cardiac surgery, and African American and American Indian or Alaskan Native pregnant women with PTSD. As most of the mortality and morbidity disparity prevalence studies focused on African Americans or Hispanic minority groups and on cancer, heart disease, or acute care conditions, more work is needed to evaluate prevalence of disparities in other racial/ethnic minority groups and for OHE - QUERI PEC's other priority conditions, including HIV, hepatitis C, mental illness, spinal cord injury, substance use disorders, polytrauma, and blast-related injuries.

Reference:
Peterson K, McCleery E, and Waldrip K. Evidence Brief: Update on Prevalence of and Interventions to Reduce Racial and Ethnic Disparities within the VA. ESP Report, May 2015.

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This report is a product of VA/HSR&D's Quality Enhancement Research Initiative's (QUERI) Evidence-Based Synthesis Program (ESP). 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.

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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.

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