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IIR 17-289 – HSR Study

IIR 17-289
Mitigating Racial/Ethnic and Socio-Economic Disparities in VA Care Quality and Patient Experience
Donna L Washington, MD MPH
VA Greater Los Angeles Healthcare System, West Los Angeles, CA
West Los Angeles, CA
Funding Period: September 2018 - August 2024


Background/Rationale: Black-White disparities in control of hypertension and diabetes contribute to U.S. racial disparities in life expectancy. Within VA, higher rates of uncontrolled hypertension or diabetes have been identified in several racial/ethnic minority groups, compared with white Veterans. The extent to which socio- economic status (SES)-related differences drive these racial-ethnic disparities is unknown. Patient Aligned Care Teams (PACT) hold promise as a care delivery model to reduce disparities, however, implementation is variable, particularly in sites with large proportions of minorities. Though traditional medical models cannot directly change most social determinants of health like SES, facilities can adapt their delivery approaches to better meet the needs and healthcare delivery preferences of their patients, e.g., incorporating evidence-based interventions associated with improved hypertension or diabetes control in vulnerable groups, and in that way influence outcomes indirectly. Appraisal of multi-level factors (healthcare system, site, patient) associated with improved outcomes in vulnerable groups (racial/ethnic minorities and the lowest quintile SES), and elucidation of implementation barriers, may inform VA strategies for tackling low quality and ameliorating high disparities. Specific Aims: Aim #1: Characterize associations between vulnerable group and quality (measured by intermediate clinical outcome quality measures hypertension and diabetes control): (a) Determine variations by race/ethnicity and SES in hypertension and diabetes care quality; (b) Examine SES as a mediator and moderator of the relationship between race/ethnicity and quality; and (c) Identify multi-level predictors of quality and disparities. Aim #2: Identify VA sites representing extremes in vulnerable group quality and disparities – high quality-low disparity “positive deviant” sites, high disparity sites (high quality for majority groups, low quality for vulnerable groups), and low performing sites (low quality for both majority and vulnerable groups) – and describe characteristics of those sites. Aim #3: Compare positive deviant, high disparity, and low performing sites: (a) Assess clinical practice delivery arrangements for hypertension and diabetes care, particularly evidence-based approaches associated with disparities reduction, and contextual factors identified in Aim #1; and (b) Identify barriers to and facilitators of effective implementation of those delivery arrangements. Methods: We propose a mixed-methods observational study using primary and secondary data sources to achieve these aims. For Aims #1 and #2, we will use a national cohort of all Veterans using VA in fiscal year 2017, with their individual socio-demographics, diagnosed conditions, and residential characteristics linked with existing data on VA site and healthcare system characteristics, including site-level PACT implementation and healthcare system-level patient experience from VA quality metrics, and then linked to electronic quality measures. We will determine site-specific performance for vulnerable and majority groups, and disparities between these groups, then identify sites representing extreme examples of quality and disparities based on decision rules applied to graphical displays of this data. For Aim #3, we will conduct key stakeholder interviews at those sites, to explore local practices for achieving hypertension and diabetes control in their patients, including barriers, facilitators, and contextual factors influencing implementation of evidence-based practices. Anticipated Impacts on Veterans Health: 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.

External Links for this Project

NIH Reporter

Grant Number: I01HX002515-01A1

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Journal Articles

  1. Breland JY, Wong MS, Steers WN, Yuan AH, Haderlein TP, Washington DL. BMI and Risk for Severe COVID-19 Among Veterans Health Administration Patients. Obesity (Silver Spring, Md.). 2021 May 1; 29(5):825-828. [view]
  2. Upchurch DM, Wong MS, Yuan AH, Haderlein TP, McClendon J, Christy A, Washington DL. COVID-19 Infection in the Veterans Health Administration: Gender-specific Racial and Ethnic Differences. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2022 Jan 1; 32(1):41-50. [view]
  3. Shannon EM, Jones KT, Moy E, Steers WN, Toyama J, Washington DL. Evaluation of regional variation in racial and ethnic differences in patient experience among Veterans Health Administration primary care users. Health services research. 2024 May 29. [view]
  4. Leung LB, Steers WN, Hoggatt KJ, Washington DL. Explaining racial-ethnic differences in hypertension and diabetes control among veterans before and after patient-centered medical home implementation. PLoS ONE. 2020 Oct 12; 15(10):e0240306. [view]
  5. Breland JY, Tseng CH, Toyama J, Washington DL. Influence of depression on racial and ethnic disparities in diabetes control. BMJ open diabetes research & care. 2023 Nov 1; 11(6). [view]
  6. Shannon EM, Steers WN, Washington DL. Investigation of the role of perceived access to primary care in mediating and moderating racial and ethnic disparities in chronic disease control in the veterans health administration. Health services research. 2023 Nov 16. [view]
  7. Cogan AM, Saliba D, Steers WN, Frochen S, Lynch KA, Ganz DA, Washington DL. Provider discussion of health goals and psychosocial needs: Comparing older to younger veteran experience. Health services research. 2023 Feb 1; 58 Suppl 1(Suppl 1):9-15. [view]
  8. Haderlein TP, Wong MS, Jones KT, Moy EM, Yuan AH, Washington DL. Racial/Ethnic Variation in Veterans Health Administration COVID-19 Vaccine Uptake. American journal of preventive medicine. 2022 Apr 1; 62(4):596-601. [view]
  9. Wong MS, Upchurch DM, Steers WN, Haderlein TP, Yuan AT, Washington DL. The Role of Community-Level Factors on Disparities in COVID-19 Infection Among American Indian/Alaska Native Veterans. Journal of racial and ethnic health disparities. 2022 Oct 1; 9(5):1861-1872. [view]
  10. Wong MS, Haderlein TP, Yuan AH, Moy E, Jones KT, Washington DL. Time Trends in Racial/Ethnic Differences in COVID-19 Infection and Mortality. International journal of environmental research and public health. 2021 May 1; 18(9). [view]
Online News Media Articles

  1. Washington DL. Health Affairs Briefing: Pursuing Health Equity. Presented to National Press Club, Washington DC. Health Affairs (Project HOPE), June 2017 Health Equity theme issue [Internet]. 2017 Jun 6. Available from: [view]
  2. Washington DL. Racial and ethnic disparities remain consistent at Veterans Health Administration patient-centered medical homes. Health Care Finance News [Internet]. 2017 Jun 6. Available from: [view]
  3. Washington DL. Racial Disparities Persist at VA Patient-Centered Medical Homes. Cambridge Medical Group [Internet]. 2017 Jun 12. Available from: [view]
VA Cyberseminars

  1. Breland JY, Washington DL, Uchendu US. Chronic Health Conditions among Vulnerable Veterans: Current Research and Action. Focus on Health Equity and Action [Cyberseminar]. VA Health Services Research & Development. 2017 Jun 29. [view]
  2. Washington DL. Using VA Data to Characterize Health and Healthcare Disparities in VA. Using Data & Information Systems in Partnered Research [Cyberseminar]. VA Information Resource Center (VIReC). 2017 Jun 20. [view]

DRA: Health Systems, Cardiovascular Disease, Diabetes and Other Endocrine Conditions
DRE: Treatment - Implementation, TRL - Applied/Translational
Keywords: Best Practices, Disparities, Patient Preferences, Quality of Care, Socioeconomic Factors
MeSH Terms: None at this time.

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