Publication Briefs

Publication Briefs
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Veterans’ Perceptions of VA Healthcare by Race and Sex Investigators in this qualitative study focused on examining how Veterans’ perceptions of VA healthcare may differ by race and sex. Findings showed that, overall, there were differences in the perceived quality of interactions within the VA healthcare system by race and sex, with more positive experiences more likely to be reported by Veterans of White race and male sex. Some positive responses were salient across race and sex, including “good medical care” and telehealth as a “comfortable/great option,” as were some negative items, including “long waits/delays in getting care” and “transportation/traffic challenges.” Associations of VA with anxiety, stress, and fear were salient for all groups. However, it is unclear whether these were responses to extraordinary circumstances during the pandemic or were more deeply rooted experiences with VA care. Courtesy and respect were salient for White but not Black Veterans – and men but not women. While telehealth was seen as a good option, the perception of technology problems differed by race (reported by Black Veterans) and sex (reported by men), suggesting a digital divide. Divergent experiences of interpersonal care by race and sex provide insights for improving equitable, patient-centered VA healthcare. Date: February 19, 2024 Wide VA Facility-Level Variation in Anticoagulation for Veterans with Atrial Fibrillation, Including by Race This study sought to assess variation in anticoagulant initiation by race across 82 VA facilities. Findings showed that there was large (>28 percentile point) facility-level variation in any anticoagulant and direct oral anticoagulant therapy initiation, overall and by race. Overall unadjusted rates of any anticoagulant therapy ranged from 57% to 87% across facilities; corresponding rates for Black and White patients were 48% to 91% and 58% to 87%, respectively. Racial disparities in anticoagulation in excess of 10 percentile points were found in nearly one-quarter of VA facilities, though most facilities did not demonstrate a statistically significant difference in prescribing between Black and White Veterans. These findings may represent a target to reduce prescribing inequities and improve atrial fibrillation care. Date: February 2, 2024 Significant Increase in Telehealth for Primary Care among Homeless Veterans Following the Pandemic This study sought to examine the extent to which homeless-experienced Veterans used telehealth services in primary care – and to characterize users before and after the onset of the pandemic. Findings showed that despite decreased access to health information technology and low pre-pandemic telehealth use, Veterans experiencing homelessness sustained a high use of telehealth in primary care post-pandemic: 1 in 5 Veterans experiencing homelessness participated in video visits, and the majority contacted their primary care teams by phone. High telehealth use was also maintained beyond the first year of COVID-19. For example, compared to pre-pandemic, telehealth use increased substantially two years post-pandemic (video: 1% versus 21%; phone: 61% versus 77%). Women and racial-ethnic minorities had higher video uptake proportionately, suggesting that telehealth may address access disparities among these homeless-experienced patient groups. Date: January 22, 2024 Veterans with a Racial/Ethnic Minority Background, Rural Residence, or Mental Health Disability History Were Less Likely to Complete Preoperative Goals of Care Documentation This study assessed factors – including race, ethnicity, rurality, history of mental health disability, and VA facility type – that are known or hypothesized to be linked with disparities in preoperative life-sustaining treatment (LST) documentation. The study also described the COVID-19 pandemic’s effect on completion of preoperative LST. Findings showed that Veterans with a racial or ethnic minority background, rural residence, mental health disability history, or who were seen at low-complexity, low-volume facilities were significantly less likely to complete preoperative LST compared to Veterans who were white or non-Hispanic, urban residents, without a mental health disability history, or who had access to a high-complexity, high-volume facility. Of the 229,737 Veterans in the cohort, 13,408 (6%) completed preoperative LST documentation within 30 days prior to surgery. With each passing year, Veterans undergoing surgical procedures had greater likelihoods of completing LST before surgery, including during the COVID-19 pandemic. Findings suggest there is continued need for interventions that target Veteran groups at risk of not engaging in serious illness communication. Date: December 19, 2023 Study Suggests Racial Inequalities in VA Pancreatic Cancer Care This study examined whether there were significant racial disparities in the continuum of pancreatic cancer care in the VA system, hypothesizing that there would be no racial disparities in the receipt of pancreatic cancer care among Black and White Veterans. Findings showed that even in a healthcare system with equal access to care, racial inequalities exist in the timing of pancreatic cancer diagnosis and receipt of treatment. Black Veterans were 19% more likely to have late-stage disease and 25% less likely to undergo surgical resection. After adjusting for sociodemographic characteristics and medical comorbidities, Black Veterans had 13% higher mortality risk compared to White Veterans. However, this was no longer statistically significant after additionally adjusting for cancer stage and receipt of potentially curative treatment. Date: November 13, 2023 Equal-Access Healthcare Is Associated with Significantly Improved Clinical Outcomes in Black and Hispanic Veterans with Prostate Cancer This study examined clinical outcomes by race and ethnicity in Veterans with nonmetastatic castration-resistant prostate cancer (nmCRPC). Findings showed that among patients with nmCRPC in VA—an equal-access system—self-identified Black and Hispanic men had better clinical outcomes than White or other patients, including time to metastasis and overall survival. Median time elapsed from nmCRPC to metastasis or death was 5.96 years for Black Veterans, 5.62 years for Hispanic Veterans, 4.11 years for White Veterans, and 3.59 years for other Veterans. Median unadjusted overall survival was 6.26 years among all Veterans, 8.36 years for Black Veterans, 8.56 years for Hispanic Veterans, 5.48 years for White Veterans, and 4.48 years for other Veterans. Findings provide evidence that the racial and ethnic disparities long observed in prostate cancer might stem from systemic socioeconomic inequity rather than molecular or genetic factors. Black and Hispanic men may have considerably improved outcomes when treated in an equal-access setting. Date: October 11, 2023 Multi-Level VA System Improvements are Needed to Ensure Equitable and Accessible Gender-Affirming Hormone Therapy Investigators in this study conducted interviews with transgender and gender diverse (TGD) patients and with VA healthcare providers to determine barriers and facilitators to gender-affirming hormone therapy (GAHT) at the individual (i.e., knowledge, coping mechanisms), interpersonal (i.e., interactions with other individuals or groups), and structural (i.e., societal gender norms, institutional policies) level and also asked participants for recommendations for overcoming perceived barriers. Findings showed that multi-level system improvements are needed within and outside VA to ensure equitable and efficient access to GAHT. To overcome barriers, study participants recommended increasing provider capacity and support, providing opportunities for continual provider education in GAHT, and enhancing communication to both patients and providers around VA policy and training regarding GAHT. Date: July 12, 2023 Significant Racial Disparities Found in VA Uterine Fibroid Treatment This study examined differences in uterine fibroid (UF) treatment among Black and White Veterans in VA, including variation by UF severity as indicated by anemia. Findings showed that there were significant Black-White disparities in receipt of any treatment for symptomatic UF. Across age and UF severity subgroups, Black Veterans were less likely than White Veterans to receive any treatment. Racial disparities were most pronounced among Veterans with severe UF as indicated by anemia (<45 years: 60% of Black Veterans vs 71% of White Veterans received any treatment; >45 years: 46% of Black Veterans vs 67% of White Veterans received any treatment). Across age groups, among those who received any treatment, Black Veterans were less likely than White Veterans to have hysterectomy and more likely to have a fertility-sparing treatment as their first treatment. These disparities may indicate delays in care among Black Veterans, differential ability to access desired treatments, and/or differential or biased care. Date: July 1, 2023 Despite Equal Access and Use of VA Care, Black Veterans are More Likely to Experience Postpartum Rehospitalization and Low-Birthweight Infants This study sought to determine whether Black/white racial disparities in access, use, and outcomes are present among pregnant and postpartum Veterans and their infants using VA maternity care. Findings showed no statistically significant racial disparities in access or use of care during the perinatal period; nevertheless, Black Veterans were more likely than white Veterans to experience postpartum rehospitalization and to have a low-birthweight infant. After adjusting for age, rurality, and parity, Black Veterans were 67% more likely than white Veterans to have a postpartum rehospitalization and 67% more likely to have a low-birthweight infant. No other racial disparities in outcomes for birthing Veterans or their infants were detected. Approximately one-third of both Black and white Veterans reported needing mental healthcare during pregnancy. However, one in five Veterans were unable to access needed mental healthcare indicating there may be a persistent unmet need for perinatal mental healthcare. Study findings underscore the idea that access is necessary but not sufficient for ensuring health equity. Date: July 1, 2023 Early Months of Pandemic Increased Overall Death Rates Comparably for General Population and Veterans This study sought to quantify excess all-cause mortality during the first nine months of the COVID-19 pandemic among Veterans compared with the general US population. Findings showed that in 2020, 85% of the overall increase in the US death rate was directly associated with COVID-19. Comparable data are not yet available for VA. Veterans receiving VA healthcare had similar relative increases in mortality compared with the general US population during the first 9 months of the COVID-19 pandemic. However, the absolute pre-pandemic death rate was higher among VA patients, which translated to higher absolute excess death rates among Veterans. The relative increase in deaths was smaller among the White population than in other racial and ethnic groups. These patterns were consistent between the general and VA populations, but the disparities were less pronounced in VA, particularly among young age groups. Date: May 8, 2023 Rural-Urban Telemedicine Disparity among Veterans Worsens Following Onset of COVID-19 Pandemic This study examined changes over time in rural-urban differences in telemedicine use for primary care and mental health integration services among nearly 64 million primary care and 4 million mental health integration visits. Findings showed that the pandemic exacerbated the rural-urban telemedicine divide across VA, possibly because underlying causes of digital inequity were not addressed as initiatives to expand telemedicine use across VA were instituted. Prior to the pandemic, telemedicine use for primary care services was higher at rural VA healthcare systems than urban ones (34% vs. 29%). Following the onset of the pandemic, usage rates switched (55% vs. 60%). The rural-urban telemedicine gap was even larger post pandemic for mental health integration than for primary care services, with unadjusted analyses showing 76% rural vs. 84% urban telemedicine use. Future telemedicine research, implementation efforts, and policy must address rural-urban structural disparities (e.g., internet bandwidth) and possibly tailor technology to encourage telemedicine adoption among rural users at the patient, provider, and healthcare system level. Date: March 7, 2023 Black and Hispanic Veterans Experienced Greater Access Barriers to VA Care During Pandemic This study sought to determine whether wait times increased differentially for Black and Hispanic compared with White Veterans for VA outpatient orthopedic and cardiology services from the pre–COVID-19 to COVID-19 periods. Findings showed that national wait time disparities increased significantly for Black and Hispanic Veterans for orthopedic services. During the COVID-19 period, Black and Hispanic Veterans’ mean wait times exceeded those of White Veterans by 2.45 days for Black Veterans and 1.98 days for Hispanic Veterans. There were only modest national disparities for cardiology services (<1-day difference). There was variation in wait times across the 140 VA facilities. For example, pre-COVID, there were Black/White differences for cardiology at 6 facilities (Black Veterans waited longer at 4 facilities, White Veterans waited longer at 2 facilities). During COVID, 21 facilities had Black/White differences for cardiology (Black Veterans waited longer at 14 facilities, while White Veterans waited longer at 7 facilities). Although differences in wait times were only a few days, any wait time disparity is concerning. It will be important for future work to monitor these trends, understand their sources, and implement appropriate interventions as needed. Findings also underscore the critical importance of facility-level analyses for highlighting opportunities to reduce disparities and target quality improvement efforts. Date: January 23, 2023 Factors Associated with Refusal of Lung Cancer Screening When Offered by VA Physicians This study sought to determine how frequently patients decline lung cancer screening (LCS) when it is offered by a physician – and to define patient and facility-level factors associated with their decision. Findings showed that in this study cohort of more than 43,200 Veterans, approximately one-third declined lung cancer screening following a discussion with their physician. The physician and facility offering LCS accounted for 19% and 36% of the variation in declining LCS, respectively. Rates of declining LCS varied from 4% to 62% across VA facilities. Older Veterans or those with serious comorbidities (e.g., mental health or cardiovascular conditions) were more likely to decline LCS. Variation in declining LCS was accounted for more by the facility and physician than by patient factors, suggesting a need to improve the quality of physician-patient discussions about LCS to increase the patient-centeredness of care. Groups that have long experienced worse lung cancer care and outcomes, including Black and Hispanic individuals and those receiving full VA benefits due to poverty, were more likely to accept screening. This suggests that screening may be a pathway to improve long-standing disparities. Date: August 16, 2022 Pulse Oximetry More Likely to Miss Hypoxemia in Black Veterans than White Veterans Among General and Surgical Inpatients The objective of this study was to evaluate measurement discrepancies by race between pulse oximetry and arterial oxygen saturation as measured in arterial blood gas among inpatients not in the intensive care unit. Findings showed a significant difference in the ability of pulse oximetry to detect clinically relevant hypoxemia in patients of different races. Black Veterans had higher odds than white Veterans of having occult hypoxemia noted on arterial blood gas but not detected by pulse oximetry (unadjusted rates of 20% vs 16%, respectively). The absolute adjusted probability of occult hypoxemia was 4% higher in Black Veterans than in White Veterans. Measurements of racial differences in occult hypoxemia were not sensitive to differences in the timing of the arterial blood gas and the recorded pulse oximeter readings, up to at least 10 minutes apart. There may be a role for large integrated health systems, such as VA, to use only pulse oximeters proven to provide equivalent accuracy in Black patients rather than devices of unproven equity. Date: July 6, 2022 Documented Clinical Diagnoses Underestimate Prevalence of Substance Use Disorders in Younger, Hispanic, and Women Veterans This study compared clinical diagnosis rates of alcohol use disorder (AUD), drug use disorder (DUD), and total SUD (AUD and/or DUD) to survey-based prevalence among a random sample of VA patients from 30 VA healthcare facilities. Findings showed that the survey-based prevalence of AUD, DUD, and SUD was generally higher than clinical diagnosis rates among all Veterans: 10% vs 6% for AUD, 4.7% vs 4.6% for DUD, and 13% vs 9% for SUD. The survey-based prevalence of AUD and SUD exceeded clinical diagnosis rates in every demographic subgroup. For DUD, the greatest levels of clinical underdiagnosis/under-recognition were seen in the youngest age group and among those reporting White race/ethnicity. For SUD overall, the greatest levels of under-recognition were for women, youngest and oldest age groups, and those reporting Hispanic ethnicity. For AUD, the greatest levels of under-recognition were among women, youngest and oldest age groups, persons of “other” race/ethnicity, and White persons. Documented clinical diagnoses are insufficient to capture the prevalence of SUD, particularly for women, younger, and Hispanic/Latinx patients, the latter of whom may often experience the greatest consequences of SUD. Date: June 30, 2022 Black Veterans with Chronic Kidney Disease Experience Racism in the Healthcare Setting, Resulting in Stress and Distrust This study investigated the healthcare experiences of Black Veterans with chronic kidney disease to assess any discrimination faced by this vulnerable population. Findings showed that these Veterans experienced racism in the healthcare setting resulting in physical and emotional stress and distrust in the healthcare system. Some Veterans also expressed a need to be hypervigilant during the clinical encounter. Veteran comments included: “…it seemed like everything I asked her about, ‘Oh, don’t worry about that. Don’t worry.’ I said, “What do you mean don’t worry about that? I’m concerned about it.” ‘But I tell you when you need to worry.’ “So, I got rid of her.” (patient switched to a different provider) “I just watch how… the interaction with other patients that are White. They may spend time with them, talking with them, this or that… less time with me or the other African Americans that are in the clinic.” When encountering racism, Veterans described both negative (e.g., hypervigilance) and positive (e.g., faith) coping strategies. Talking and sharing stressful events with family was also a major source of support for respondents. Date: May 12, 2022 Genetic Consultation Provided by VA Facilities or Centralized VA Virtual Care More Timely and Better Coordinated than Community Care Options This study assessed care coordination and equity in the delivery of genetic care for the care models available to VA patients (i.e., VA-traditional, centralized VA-telehealth, and non-VA care). Findings showed that VA genetic care models – both traditional and centralized telehealth – had better care coordination than non-VA care. Veterans referred to non-VA care completed their consult only 57% of the time compared with 75% if referred to the VA-traditional model and 73% with the centralized VA-telehealth model. Completion of a genetic consultation if referred to non-VA care was almost 3 times longer than with either VA model (140 days vs 55 days for VA-traditional and 45 days for VA-telehealth). The centralized VA-telehealth model was associated with exacerbated healthcare disparities based on self-reported race or ethnicity and gender compared with the VA traditional model. Veterans reporting their race as Asian, American Indian, Alaskan Native, Hawaiian and other Pacific Islander, and unknown were 46% less likely to be referred to the centralized VA-telehealth model compared to the VA-traditional model. Black Veterans were significantly less likely to complete a consultation compared to White Veterans, but only if referred to the centralized VA-telehealth model. Women Veterans were 50% more likely to be referred to the centralized VA-telehealth model than the VA traditional model. VA should assess structural barriers to using centralized telehealth services and the needs and preferences of vulnerable subpopulations in order to find solutions that mitigate health disparities and improve access. Date: April 11, 2022 Changes in the Association between Race and Urban Residence with COVID-19 Outcomes among Veterans This study examined whether key sociodemographic and clinical risk factors for COVID-19 infection and mortality changed between February 2020 and March 2021 among more than 9 million Veterans enrolled in VA healthcare. Findings showed that strongly positive associations of Black race, American Indian/Alaska Native (AI/AN) race, and urban residence with COVID-19 infection, mortality, and case fatality that were observed early in the pandemic attenuated over time. The magnitude of the association between Black (vs. White) race and COVID-19 infection or mortality declined steadily from February/March 2020 to November 2020, when it was no longer significant. The association between AI/AN (vs. White) race and COVID-19 infection declined steadily over time to a negative association in March 2021. Similarly, the association between urban vs. rural location and COVID-19 infection or mortality also declined steadily over time, shifting from a positive association in February/March 2020 to a negative association in September/October 2020 and to a non-significant association in March 2021. Throughout the study period, high comorbidity burden, younger age, Hispanic ethnicity, and obesity were consistently associated with COVID-19 infection, while high comorbidity burden, older age, Hispanic ethnicity, obesity, and male sex were consistently associated with mortality. Understanding changing patterns of risk factors could be important in informing population-based approaches to prevent infection and reduce mortality by targeting those at highest risk at any given time during the course of an evolving pandemic. Date: October 21, 2021 Receipt of COVID-19 Vaccine is Higher among Racial/Ethnic Minorities than Whites within VA Healthcare System VA began administering COVID-19 vaccinations shortly after the US rollout began, allowing for an examination of vaccination rates among racial/ethnic minorities in an integrated healthcare system with few barriers to access. Findings showed that in contrast to disparities reported in the general population, COVID-19 vaccine receipt in the VA healthcare system was higher among most racial/ethnic minority groups than in Whites, suggesting reduced vaccination barriers compared with non-VA care. Overall, 24% of the cohort received at least one vaccine dose as of 2/23/21. Black (29%), Hispanic (27%), and Asian (27%) Veterans were significantly more likely than White (24%) Veterans to receive a vaccination through VA, while American Indian and Alaska Native (AI/AN) Veterans were less likely. Only AI/ANs in Contract Health Service Delivery Area counties, which indicates residence in/adjacent to federally reserved tribal lands were less likely than Whites to be vaccinated. Since AI/AN Veterans were less likely to obtain COVID-19 vaccinations through VA when close to a tribal area, the Indian Health Service may provide a safety net that is effective at reaching this population despite disparities in other contexts. Influenza vaccination history was positively associated with COVID-19 vaccine uptake. Date: October 21, 2021 Racial and Ethnic Disparities Persist in the Management of VA Patients with Atrial Fibrillation This study compared the initiation of any anticoagulant therapy by race/ethnicity for Veterans with atrial fibrillation (AF). Findings showed that 62% of Veterans in this study initiated any anticoagulant therapy (OAC), varying 10.5 percentage points by race/ethnicity; initiation was lowest in Asian (52%) and Black (60%) patients and highest in White patients (63%). After adjusting for clinical, sociodemographic, provider, and facility factors, Black and Asian patients were significantly less likely than White patients to initiate OAC, with 10-18% lower odds of such therapy. Also, among those who initiated OAC, Black, Hispanic, and American Indian/Alaska Native patients were significantly less likely to initiate direct oral anticoagulants (DOACs), with 21-26% lower odds of such therapy. While overall OAC initiation and DOAC use increased significantly over time, there were no significant differences by race/ethnicity in the initiation of these treatments. Understanding the reasons for these treatment disparities is essential to improving equitable atrial fibrillation management and outcomes among racial/ethnic minority patients managed in VA. Date: July 28, 2021 Fewer than Two-Thirds of Veterans Receive Timely Lung Cancer Screening Follow-Up This retrospective cohort study sought to determine adherence to recommended next steps (i.e., annual screening or evaluation of screen-detected findings) in a national cohort of Veterans screened for lung cancer – and to identify factors associated with delayed or absent follow-up. Findings showed that less than two-thirds of Veterans received timely recommended follow-up after an initial lung cancer screening, with higher risk of delayed or absent follow-up among marginalized populations that have long experienced disparities in lung cancer outcomes. Of the 28,294 Veterans in this study, 63% underwent recommended follow-up, while 29% received delayed (13%) or no (16%) follow-up. Veterans with higher-risk findings and those in high-volume or academic centers were more likely to receive timely follow-up. Black Veterans, Veterans with mental health disorders or lower income were more likely to have delayed or absent follow-up. Date: July 8, 2021 Women Veterans with Premature Cardiovascular Disease Less Likely than Men to Receive Secondary Prevention Therapy This study sought to evaluate sex-based differences in antiplatelet use, any statin and high-intensity statin (HIS) therapy, and statin adherence among patients with premature and extremely premature atherosclerotic cardiovascular disease (ASCVD). Findings showed that women Veterans with premature (age < 55 years) and extremely premature (age < 40 years) ASCVD were less likely to receive antiplatelet agents or statins than men. Premature ASCVD women, compared with men, were significantly less likely to receive antiplatelets (61% vs. 79%), any statin (58% vs. 75%), or HIS therapy (24% vs. 38%). Women with premature ischemic heart disease were comparatively less statin adherent. Relative to women of other races, Black women were less likely to receive some therapies but also more likely to receive others. There was no heterogeneity observed regarding statin adherence. Overall, both sexes received sub-optimal aspirin and statin therapy and had poor statin adherence. Date: April 21, 2021 Veterans of Color Are More Likely to be Tested for COVID-19 at VA than White Veterans and are More Likely to Test Positive This analysis evaluated the characteristics associated with obtaining a COVID-19 test within the VA healthcare system – and receiving a positive test result from February 8 through December 28, 2020. Findings showed that VA is testing a significantly higher proportion of traditionally disenfranchised patient groups for COVID-19 than other healthcare systems. However, Black and Hispanic/Latino Veterans have an increased risk of receiving a positive test result for COVID-19, despite receiving more tests than White and non-Hispanic/Latino Veterans. Overall, Veterans who were female, Black/African American, Hispanic/Latino, lived in urban settings, had a low income, or had a disability had an increased likelihood of obtaining a COVID-19 test, while Veterans who were Asian had a decreased likelihood. Compared with Veterans who were White, Veterans who were Black/African American were 23% more likely and Native Hawaiian/Other Pacific Islander 13% more likely to receive a positive test result. Hispanic/Latino Veterans had a 43% higher risk of receiving a positive test result than non-Hispanic/Latino Veterans. Veterans with disabilities or who were low-income were more likely to obtain a COVID-19 test but had a lower risk of receiving a positive test. Although disparities are significantly smaller at VA, the test positivity differences suggest that Veterans are not immune to the negative external effects of SDH. Results suggest that other factors (e.g., external social inequities) are driving disparities in COVID-19 prevalence. Date: April 7, 2021 Geographic and Racial/Ethnic Variation in Glycemic Control and Treatment among Veterans with Diabetes Geography is a well-known determinant of health and an improved understanding of the relationships between geographic factors (social and environmental) and diabetes outcomes may lead to targeted interventions. This retrospective cohort study sought to answer the following questions: 1) Do rates of metabolic control exhibit geographic patterning or “hotspots”? and 2) Does patterning vary by race-ethnicity? Findings showed that after adjusting for age, gender, race-ethnic group, service-connected disability, marital status and comorbidities, the prevalence of uncontrolled diabetes varied by VA catchment area, with values ranging from 19% to 29%. These differences persisted after further adjustment for medication use and adherence, as well as use and access metrics. Disparities in sub-optimal control appeared consistent across most but not all catchment areas, with Black and Hispanic Veterans having higher odds of sub-optimal control than White Veterans. Prevalence of uncontrolled diabetes in the VA catchment area with the poorest control rates was estimated as high as 28% for Whites, 30% for Blacks, and 35% for Hispanics. Patterns of uncontrolled diabetes within VA did not mirror patterns of diabetes prevalence across the country. While high diabetes prevalence in the general population overlapped with sub-optimal diabetes control in parts of Appalachia, Georgia, Alabama, Mississippi, and Tennessee, parts of the Diabetes Belt had lower than average rates of uncontrolled diabetes in VA, indicating that areas of high diabetes prevalence can have below average rates of uncontrolled diabetes. Geographic as well as racial-ethnic differences in diabetes control rates were not explained by adjustment for demographics, comorbidity burden, use or type of diabetes medication, healthcare use, access metrics, or medication adherence, suggesting there is a geographic component to diabetes control that needs to be further explored. Date: October 1, 2020 Racial Differences in Conservative Management of Low- to Intermediate-Risk Prostate Cancer among Veterans This study sought to determine whether there are any racial differences in the receipt and duration of conservative management among Veterans treated in the VA healthcare system. Findings showed that African American Veterans were slightly less likely to receive conservative management than White Veterans with localized prostate cancer. Further, among patients receiving conservative management, African American Veterans had a higher risk of receiving definitive therapy within five years of diagnosis than White Veterans. The median time to definitive treatment was 719 days for African American Veterans and 787 days for White Veterans. Compared to White Veterans, African American Veterans were more likely to have intermediate-risk disease (58% vs. 52%). Conservative management for low- and intermediate-risk prostate cancer may be less durable for African American Veterans compared to White Veterans. Date: September 28, 2020 Blacks and Hispanics Twice as Likely as White Veterans to Test Positive for COVID-19 This study examined racial and ethnic disparities in patterns of COVID-19 testing (i.e., who received testing and who tested positive) and subsequent 30-day mortality for Veterans receiving VA healthcare (all testing and services in this study were provided within VA). Findings showed that Black Veterans were more likely to be tested (rate per 1,000 patients, 60.0) than Hispanic (52.7) or White Veterans (38.6). Among those tested, both Black and Hispanic Veterans were twice as likely to test positive than White Veterans, even after accounting for all adjusting variables. The disparity between Black and White Veterans in testing positive slightly decreased over the study period – and was highest in the Midwest compared to other regions. The disparity between Hispanic and White Veterans was consistent across time, geographic region, and outbreak pattern. Among those who tested positive for COVID-19, there were no other observed differences in 30-day mortality by race/ethnicity group. Date: September 22, 2020 Treatment Disparities for Vulnerable VA Patient Populations with Opioid Use Disorder This study examined the association between vulnerable populations, facility characteristics, and receipt of medications for opioid use disorder (OUD). Findings showed that since the last national study of VA patients (using FY2012 data), the prevalence of receipt of medications for OUD increased overall from 33% to 41%; however, vulnerable patient populations – including women, older, Black, rural, homeless, and justice-involved Veterans – had lower odds of receiving medications for OUD than their non-vulnerable counterparts. Veterans had higher odds of receiving medications at facilities with a higher proportion of patients with OUD, and lower odds of receiving medications at facilities in the Southern region of the United States compared to the Northeast. The prevalence of OUD was notably higher among homeless compared to housed Veterans (10% vs 2%), and justice-involved compared to non-justice-involved Veterans (10% vs 2%). Date: August 18, 2020 VA Healthcare Benefits May Reduce Racial/Ethnic Disparities in Seeking Mental Health Treatment among Veterans This study assessed whether racial/ethnic disparities in mental health treatment seeking for psychiatric conditions common in the Veteran population (PTSD, major depressive disorder, alcohol-use disorder or AUD) were attenuated for military Veterans compared to civilians, and whether attenuation was more pronounced among Veterans who had VA healthcare coverage in the past 12 months. Findings showed that unlike civilians, racial/ethnic minority Veterans did not differ from whites in time to initiate treatment for PTSD and depression, and showed a shorter time to initiate treatment for AUD. Racial/ethnic minority Veterans with past year VA healthcare coverage were the most likely to seek treatment for all three disorders, whereas racial/ethnic minority civilians were the least likely to seek treatment for all three disorders. Among racial/ethnic minority patients, shortened time to treatment initiation for Veterans relative to civilians remained significant after adjusting for additional demographic and clinical covariates for PTSD and major depressive disorder, but not alcohol use disorder. Findings suggest that military service and benefits available to Veterans may reduce racial/ethnic disparities in seeking mental health treatment seen in the civilian population. Date: January 27, 2020 Few Disparities in Medical Treatment for Opioid Use Disorder after Non-Fatal Overdose This study assessed the association between race and ethnicity and patterns of opioid prescribing before and after a non-fatal opioid overdose – and also assessed the receipt of medications for opioid use disorder (MOUD: buprenorphine, methadone, and naltrexone) following such events among VA patients. Findings showed that receipt of an opioid prescription decreased by 16-21 percentage points in the 30 days after overdose, but remained high, with no significant differences across racial and ethnic groups. After overdose, the frequency of receiving opioids was reduced by 18.3, 16.4, and 20.6 percentage points in whites, blacks, and Hispanics, respectively. Overall, MOUD prescribing in VA was very low in all racial groups in the 30 days after overdose, though statistically significantly higher in black and Hispanic patients. After overdose, 3% of patients received MOUDs (3% white, 5% black, and 6% Hispanic). Blacks and Hispanics had significantly larger odds of receiving MOUDs than whites. Findings demonstrate an opportunity to improve the quality of care for all patients with opioid use disorder, particularly in the vulnerable period around a non-fatal overdose event. Date: January 21, 2020 Women Veterans with Pain More Likely to Use Complementary and Integrative Therapies This study sought to examine complementary and integrative health (CIH) therapy use by gender among Veterans with chronic musculoskeletal pain, and variations in gender differences by race/ethnicity and age. Findings showed that of Veterans with chronic musculoskeletal pain, more women than men used CIH therapies (36% vs. 26%). Black women, regardless of age, were least likely to use CIH therapies compared to other women. Among men, White and Black Veterans were less likely to use CIH therapies, irrespective of age, than men of Hispanic or other race/ethnicities. Among both women and men, CIH therapies were least likely to be used by younger Black or White Veterans. Given the disparities in CIH therapy use, tailoring CIH therapy engagement to gender, race/ethnicity, and age may increase CIH therapy use among Veterans. Date: September 1, 2018 VA Successfully Implements Interferon-free Treatment for Hepatitis C Virus in Previously Undertreated Patient Populations This study examined the adoption of interferon-free treatment for hepatitis C virus (HCV) in VA to learn who received this therapy and whether the limitations of interferon-containing treatments have been overcome, including low rates of use among VA healthcare users who are African American or Hispanic, and among those with HCV-HIV co-infection. Findings showed that with the advent of interferon-free regimens, the percentage of VA patients with HCV infection that was treated increased from 2% in 2010 to 18% in 2015, an absolute increase of 16%. There were large treatment gains realized by groups of patients that had been less likely to be treated in 2010. Large absolute increases in the percentage treated were achieved in Veterans with HIV co-infection (19%), alcohol use disorder (12%), and drug use disorder (13%), and in Veterans who were African-American (14%) or Hispanic (14%). Veterans with mental illnesses exacerbated by interferon, depression, PTSD, and bipolar disorder, had absolute increases in treatment that were larger than the overall increase. Date: March 7, 2018 Evidence Review Identifies Modest Mortality Disparities among Racial and Ethnic Minority Groups in VA Healthcare To support VA’s efforts to better understand the scale and determinants of disparities in racial and ethnic mortality – and to develop interventions to reduce disparities, investigators from the VA Evidence-based Synthesis Program (ESP) Coordinating Center in Portland, OR conducted an evidence review of mortality disparities specific to VA. Findings showed that although VA’s equal access healthcare system has reduced many racial/ethnic mortality disparities still present in the private sector, modest mortality disparities persist mainly for black Veterans with conditions that include: stage 4 chronic kidney disease, colon cancer, diabetes, HIV, rectal cancer, and stroke. There also were modest disparities in mortality for American Indian and Alaska Native Veterans undergoing major non-cardiac surgery, and for Hispanic Veterans with HIV or traumatic brain injury. Date: March 1, 2018 Racial/Ethnic and Gender Variations in Veteran Satisfaction with VA Healthcare This study of Veterans’ satisfaction with outpatient, inpatient, and specialist care in a diverse sample of Veterans from predominantly minority-serving VAMCs sought to better understand racial/ethnic and gender variations in healthcare satisfaction. Findings showed generally high levels of healthcare satisfaction across 16 domains, with 83% of respondents somewhat or very satisfied with VA healthcare overall. The highest satisfaction ratings were reported for costs, outpatient facilities, and pharmacy services (74% to 76% were very satisfied); the lowest ratings were reported for access to care, pain management, and mental healthcare (21% to 24% were less than satisfied). Contrary to previous studies, there was little evidence of racial, ethnic, or gender disparities in satisfaction with care at minority serving VAMCs. Date: March 1, 2018 Medical Care Supplement Features Articles by VA Researchers on Improving the Quality and Equity of Health and Healthcare In 2016, HSR&D’s Center for Health Equity Research and Promotion (CHERP) and the Health Equity and Rural Outreach Innovation Center (HEROIC) hosted a state-of-the-science conference. This field-based meeting to “Engage Diverse Stakeholders and Operational Partners in Advancing Health Equity in the VA Healthcare System” brought together health equity investigators, representatives of vulnerable Veteran populations, and operational leaders to identify strategies to advance the implementation of evidence-based interventions to improve the quality and equity of health and healthcare. The conference focused on three specific vulnerable Veteran populations: racial and ethnic minorities, homeless Veterans, and Veterans from the LGBT community. This supplement features several articles that emanated from this meeting. Date: September 1, 2017 PACT Initiative Did Not Reduce Most Disparities in Improved Hypertension or Diabetes Control among VA Patients This study sought to determine whether PACTs helped mitigate national racial/ethnic disparities in VA clinical outcomes, after adjusting for variable implementation and social determinants of health. Findings showed that improvements in clinical outcomes for hypertension and diabetes control had not been achieved for whites or most racial/ethnic groups four years into VA’s system-wide roll-out of the PACT initiative. Greater PACT implementation was associated with higher percentages of Veterans who achieved hypertension or diabetes control, but most racial/ethnic disparities in achieving control persisted. Authors suggest that to promote health equity, healthcare innovations such as patient-centered medical homes should incorporate tailored strategies that account for determinants of racial/ethnic variations. Date: June 1, 2017 Racial Disparities in HIV Quality of Care that May Extend to Common Comorbid Conditions To more fully understand patterns of racial disparities in the quality of care for persons with HIV infection, this study examined a national cohort of Veterans in care for HIV in the VA healthcare system during 2013. Findings showed that racial disparities were identified in quality of care specific to HIV infection – and in the care of common comorbid conditions. Blacks were less likely than whites to receive combination antiretroviral therapy (90% vs. 93%) or to experience viral control (85% vs. 91%), hypertension control (62% vs. 68%), diabetes control (86% vs. 90%), or lipid monitoring (82% vs. 85%). Although performance on quality measures was generally high, racial disparities in HIV care for Veterans remain problematic and extend to comorbid conditions. Implementation of interventions to reduce racial disparities in HIV care should comprehensively address and monitor processes and outcomes of care for key comorbidities. Date: September 22, 2016 VA National Transplant System Shows No Racial/Ethnic Disparities in Evaluating Veterans for Kidney Transplant This study examined VA patients of diverse racial/ethnic backgrounds with end-stage kidney disease (ESKD) who underwent the evaluation process for kidney transplantation (KT). Findings showed that in comparing African American Veterans with white Veterans and other minority Veterans, the VA National Transplant System did not exhibit the racial/ethnic disparities in evaluation for kidney transplant that have been found in non-VA transplant centers. Moreover, VA kidney transplant centers are successfully bringing ESKD patients through the evaluation process without race disparities at a time when non-VA transplant centers are unable to do so, while achieving a median time to complete evaluation similar to other published rates in non-VA settings. Date: August 1, 2016 Racial and Ethnic Differences in Primary Care Experiences for Veterans with Mental Health and Substance Use Disorders This study examined racial and ethnic differences in positive and negative experiences in VA Patient-Centered Medical Home (PCMH) settings among Veterans with mental health or substance use disorders (MHSUDs) who completed VA’s 2013 PCMH Survey of Healthcare Experiences of Patients. Findings showed that positive experiences were reported least often for access. Negative experiences were reported most often for self-management support and comprehensiveness, defined as provider attention to MHSUD concerns. One or more racial/ethnic minority groups reported more negative and/or fewer positive experiences than Whites in the following 4 domains: access, communication, office staff helpfulness/courtesy, and comprehensiveness. Solutions are needed to improve access to care for all Veterans with MHSUDs, with additional attention on improving access for Black, Hispanic, and AI/AN Veterans. Date: June 20, 2016 Female Veterans with CVD Less Likely to Receive Statin and High-Intensity Statin Therapy Compared to Male Veterans with CVD This study sought to identify the proportion of male and female Veterans with cardiovascular disease (CVD) who received care in any of 130 VA facilities between 10/1/10 and 9/30/11, and who received any statin and high-intensity statin. Findings showed that while evidence-based use of both statin and high-intensity statin therapy remains low in both genders, female Veterans with CVD were less likely to receive evidence-based statins (58% vs. 65%) and high-intensity statins (21% vs. 24%) compared with male Veterans. In fully adjusted analyses, female gender was independently associated with a 32% lower likelihood of receiving any statin therapy and a 24% lower likelihood of receiving high-intensity statin therapy. Mean low-density lipoprotein cholesterol levels were higher in female compared with male Veterans (99 vs. 85 mg/dl) with CVD. The use of statin and high-intensity statin therapy among female Veterans with CVD showed substantial facility-level variation. With the “statin dose-based approach” proposed by the recent cholesterol guidelines, these results highlight areas for quality improvement. It is important to note that despite the observed gender disparity noted in this study, statin and high-intensity statin use remain low in both genders. This is concerning, as the patient population studied in these analyses (i.e., those with established CVD) is the one that derives the most benefit from statin and high-intensity statin therapy. Date: January 1, 2015 Improved Performance on Quality Measures is Accompanied by Increased Racial/Ethnic Equity in Care This study examined the quality and equity of hospital care during the six years following initiation of the Centers for Medicare & Medicaid Services (CMS) Inpatient Quality Reporting (IQR) Program (2005 to 2010), focusing on 17 process-of-care quality indicators publicly reported by the program for white, black, and Hispanic patients hospitalized for AMI, HF, and pneumonia in non-VA hospitals. Findings showed that improved performance on quality measures for white, black, and Hispanic adults hospitalized with AMI, HF, and pneumonia was accompanied by increased racial/ethnic equity in performance rates both within and between U.S. hospitals. Over this time period, adjusted performance rates for the 17 quality measures improved by 3.4 to 57.6 percentage points for these patients. In 2010, unadjusted performance rates exceeded 90% for all subgroups for 14 of 17 measures. Declining racial/ethnic differences occurred through more equitable care for white and minority patients treated in the same hospital, as well as greater performance improvements among hospitals that disproportionately serve minority patients. Date: December 11, 2014 Racial/Ethnic Disparities in Treatment Retention for Veterans with PTSD This study of Veterans recently diagnosed with PTSD sought to determine whether the odds of premature mental health treatment termination varied by patient race/ethnicity and, if so, whether such variation is due to differential access to services or beliefs about mental health treatment, or whether there is a disparity in the provision of treatment. Findings showed that compared to White Veterans, African-American and Latino Veterans were less likely to receive a minimal trial of pharmacotherapy and, overall, African-Americans were less likely to receive a minimal trial of any treatment in the six months after being diagnosed with PTSD. Controlling for beliefs about mental health treatments diminished the lower odds of pharmacotherapy retention among Latino Veterans but not African-American Veterans. As expected, positive beliefs about psychotherapy or pharmacotherapy facilitated treatment retention. Access barriers did not contribute to treatment retention disparities. They significantly impacted psychotherapy participation, but equally across the entire sample. To improve treatment equity, clinicians may need to directly address patients’ treatment beliefs and preferences. Date: November 24, 2014 Adverse Childhood Experiences More Common among Men with Military Service Those with a history of military service may be a specific subpopulation of interest regarding adverse childhood experiences (ACE), as some may enlist to escape personal problems, potentially elevating the prevalence of ACE among military populations. This study sought to compare the prevalence of ACE among individuals with and without histories of military service based on service during the draft era (enlisted prior to 1973) or during the all-volunteer era (enlisted on/after 1973). Findings showed that men with military service during the all-volunteer era had a higher prevalence of all 11 ACE items than men without military service in this era. Notably, men with military service during this era had more than twice the odds of men without military service history of reporting household drug or alcohol abuse while growing up, suffering physical abuse or witnessing domestic violence, or some form of sexual abuse (being touched or being forced to touch, or to have sex before age 18). During this era, men with military service had more than twice the prevalence of experiencing 4 or more ACE categories (27% vs. 13%) compared to those without military service. Markedly fewer differences in ACE were found among women with and without military service histories across either era. Women with military service histories from both eras had similar patterns of elevated odds for physical abuse, household alcohol abuse, exposure to domestic violence, and emotional abuse compared with women without military service. Identifying the presence of ACE among military service members and Veterans may aid in better understanding the etiology of trauma-related mental and behavioral health conditions as well as the cumulative impact of trauma. Date: September 1, 2014 Women Veterans, Particularly Black Veterans, Have Worse Risk Factor Control for Cardiovascular Disease than Male Veterans This study compared gender and racial differences in three risk factors that predispose individuals to cardiovascular disease: diabetes, hypertension, and hyperlipidemia. Findings showed that overall, female Veterans had significantly higher LDL cholesterol levels than male Veterans, despite being almost ten years younger, on average. These differences are similar to gender disparities previously reported both within and outside VHA and represent a clinically significant difference. African-American women Veterans had worse blood pressure control than White women Veterans, and among Veterans with diabetes, male African-Americans had worse control of higher blood pressure, LDL, and HbA1c levels than White males. Date: September 1, 2014 Providers’ Endorsement of Stigma Regarding Mental Illness Is Related to Patient Treatment Options This study examined provider response to two treatment options that might be offered to a male patient with schizophrenia who was seeking help for low back pain due to arthritis: 1) referral for specialist consult, or 2) refilling the patient’s prescription for Naproxen. Findings showed that healthcare providers who endorsed more stigmatizing attitudes about mental illness were likely to be more pessimistic about the patient’s adherence to treatment. Stigmatizing attitudes were greater among those providers who were relatively less comfortable with using mental health services themselves. Greater perceived treatment adherence was positively associated with both health decisions: referrals and prescription refill. Thus, poor perceived adherence was partly a proxy for stigmatizing attitudes providers held about people with mental illness, which in turn led to different treatment decisions in patients with serious mental illness. Providers from mental health backgrounds showed no difference in expectations about treatment response than primary care professionals, suggesting that both primary care and mental health providers should be targets of interventions aimed at decreasing disparities in clinical care. Date: August 15, 2014 Cardiovascular Outcomes after Addition of Insulin Versus Sulfonylureas in Veterans with Diabetes Taking Metformin This study compared time to a combined outcome of acute myocardial infarction (AMI), stroke, or death among Veterans with diabetes that were initially treated with metformin, and subsequently added either insulin or sulfonylurea. Compared to those who added a sulfonylurea, Veterans who added insulin to metformin therapy had a 30% higher risk of the combined outcome of heart attack, stroke, and all-cause mortality. Although new heart attacks and strokes occurred at similar rates in both groups, mortality was higher in patients who added insulin. Although sulfonylurea use predominated as add-on therapy, there was increasing use of insulin intensification over the study years (increasing by an average of 17% per year). Reasons may include a growing prevalence of obesity and insulin resistance, emphasis on metrics such as glycemic targets, increasing comfort with newer analog insulins, and/or the benefit in microvascular outcome prevention. Date: June 11, 2014 Ethnic Differences in Receipt of Depression Care This study sought to characterize differences in treatment for multiple racial/ethnic groups of Veterans with ongoing depression. Findings showed that there were significant differences in the receipt of depression care between multiple racial/ethnic groups of chronically depressed Veterans. Compared to white Veterans, nearly all minority groups had lower odds of adequate antidepressant use; adequate psychotherapy was more common among minority Veterans in initial analyses but differences between Hispanic, AI/AN, and white Veterans were no longer significant in adjusted analyses. Primarily due to lower use of antidepressants, nearly all minority groups had lower rates of guideline-concordant care than white Veterans with depression. Overall, 51% of Veterans received adequate antidepressant care for the 6-month period following their most recent VA healthcare visit for depression; 10% of Veterans attended at least 6 psychotherapy visits within the same time period; and 55% received guideline-concordant care. Further research is needed to determine whether the observed differences in treatment arise from patient-centered preferences for care (for example, lower willingness to take anti-depressant medication among minority patients) or from providers’ failure to adhere to best-care practices. Date: November 1, 2013 Increase in Psychotherapy Since 2004 Corresponds with VA’s Efforts to Improve Access to Mental Health This study examined longitudinal changes in VA psychotherapy use corresponding with widespread programmatic change targeting increased availability and quality of mental healthcare. Findings showed that the number of Veterans newly diagnosed with depression, anxiety, or PTSD increased by nearly 40% between 2004 and 2010. Rates of PTSD grew most substantially, increasing by more than 2-fold. During this time, the proportion of Veterans with depression, anxiety, or PTSD receiving psychotherapy grew from 21% to 27%. In addition, psychotherapy dose increased – a growing proportion of Veterans received eight or more psychotherapy sessions. More Veterans engaged in individual than group psychotherapy across all study years. However, Veterans who engaged in group psychotherapy received more sessions of psychotherapy than those in individual psychotherapy. Treatment delays decreased across study time points. The median time between index diagnosis and psychotherapy dropped from 56 days in 2004 to 47 days in 2010. Although Veterans with PTSD consistently had shorter delays than Veterans with depression or anxiety, diagnostic disparities in time until treatment grew smaller across the study time points. Consistent with VA expansion efforts, more substantial increases in psychotherapy access, dose, and timeliness occurred between 2007 and 2010 relative to 2004 and 2007. Date: October 1, 2013 Significant Disparities among Women Veterans with and without Mental Illness in Delaying or Going without Medical Care This study examined associations of PTSD and depressive symptoms with unmet medical needs and barriers to care among women Veterans. Findings showed that there was a significant degree of disparities reported by women Veterans with and without mental health symptoms in delaying or going without needed medical care. The majority of those who screened positive for both PTSD and depressive symptoms had unmet medical care needs in the prior 12 months (59%) – compared to 30% of women with PTSD symptoms only, 18% of those with depressive symptoms only, and 16% of women with neither set of symptoms. This pattern remained the same after adjustment (e.g., for demographics, insurance, combat exposure). Overall, among women Veterans in this study who reported unmet medical needs (19% of the women surveyed), those with both PTSD and depressive symptoms were more likely than women in the other groups to identify affordability as a reason for going without or delaying care (69%). Being unable to take time off work (31%) was the second most common reason reported among this group. Women with PTSD symptoms (w/ or w/o depression) were less likely than all other groups to have health insurance to cover non-VA care. Date: May 1, 2013 Equitable Rates of Pain Assessment among African American and White Veterans This study sought to determine whether African American Veterans were less likely to be screened for pain than their White counterparts – and to determine the factors associated with differences in screening rates. Findings showed that VA’s mandate for pain screening has resulted in high and relatively equitable rates of pain assessment among both African American and White Veterans. Although rates of pain screening were lower among African Americans compared to Whites (78% vs.82%), this disparity was reduced by half after controlling for prior healthcare use, in which African American Veterans had a greater number of outpatient visits, which was associated with lower rates of pain screening at the index visit. Overall, Veterans were less likely to be screened for pain if they were African American, female, and married; if they had a diagnosis of deficiency anemia; if they had a greater number of outpatient visits; and if they were an established (vs. new) patient. Veterans were more likely to be screened if they had prior diagnoses of chronic joint, neck, or back pain; opioid abuse, anemia, and pulmonary circulation disorders; and if they had a non-opioid analgesic prescription and/or greater number of inpatient admissions in the previous two years. Date: November 21, 2012 Racial Differences in Outcomes of VA Telephone-Delivered Hypertension Disease Management Program A combination of home BP monitoring, remote medication management, and telephone-tailored behavioral self-management appears to be particularly effective for improving BP among African American Veterans. However, the effect was not seen among non-Hispanic white Veterans. Among African Americans, improvement in mean systolic BP was greatest for those receiving the combined intervention: compared to usual care, systolic BP was 6.6 mmHg lower at 12 months and 9.7 mmHg lower at 18 months. These decreases in BP were not seen in non-Hispanic white Veterans. Date: August 3, 2012 Perceived Discrimination Associated with Risk of Severe Coronary Obstruction among African American Veterans Compared to white Veterans, African American Veterans with abnormal cardiac nuclear imaging studies had greater perceptions of racial discrimination that were related to increased risk for severe coronary obstruction – and to angiographic coronary obstruction, after controlling for clinical and psychosocial factors related to cardiovascular health. Based on their nuclear imaging studies, 44% of Veterans (both whites and African Americans) were at high risk for severe coronary obstruction. Among both African American and white Veterans, prior myocardial infarction (MI) and smoking were associated with high (vs. low/moderate) risk for severe coronary obstruction, while optimism was related to a decreased risk of severe obstruction. No significant associations between social support, negative affect, or religiosity and results from nuclear imaging or coronary angiography were found. Date: April 1, 2012 Relationship between Perceived Racial Discrimination and Wait Times for Kidney Transplant Compared to whites, African Americans took significantly longer to get accepted for transplant. There were also significant racial differences on several cultural factors in patients as they began the evaluation process for kidney transplantation. Compared to white patients, African Americans reported experiencing more discrimination in healthcare, more perceptions of racism in healthcare, higher medical mistrust, and more religious objections to living donor kidney transplantation. Comorbidity, dialysis status, and availability of potential living donors were not associated with length of time to be accepted for kidney transplant. Thus, medical factors alone did not explain racial disparities. In analyses to identify which factors predicted racial disparities, the authors found that perceived discrimination in healthcare, less transplant knowledge, more religious objection to transplantation, and lower income explained the racial disparities observed in the time it took to be accepted for transplant. Moreover, after adjusting for demographics, psychosocial, and cultural factors, the association of race with longer time for listing for transplant was no longer significant. Authors suggest these findings indicate that perceived discrimination in healthcare can be as much of a risk factor as race, income, or low transplant knowledge. Date: February 27, 2012 Telemedicine-Based Collaborative Care Intervention for Depression has Greater Effect on Minority vs. White Veterans The Telemedicine Enhanced Antidepressant Management (TEAM) study was a randomized trial of telemedicine-based collaborative care tailored for small, rural primary care practices. Investigators in the current study evaluated racial differences in clinical outcomes among 360 Veterans with depression who were randomized to usual care or the TEAM intervention. Findings showed that in the usual care group, minority Veterans had a lower treatment response rate (8%) than Caucasians (18%), but this was not significant. In contrast, minority Veterans in the TEAM intervention group had a significantly higher treatment response rate (42%) than Caucasians (19%) in the intervention group. Veterans in the minority group were significantly less likely to report that antidepressants were an acceptable form of treatment, and were significantly less likely to have had prior or current depression treatment. However, none of these variables were significantly related to treatment outcomes. Thus, the study was not able to determine why minorities responded better to the intervention than Caucasians. Date: November 1, 2011 Depression and Race may Independently Affect Receipt of Some Surgeries This study examined race and ethnicity as factors potentially associated with surgeries experienced by Veterans with and without major depressive disorder (MDD). Findings show that Veterans with pre-existing MDD were less likely to undergo digestive, hip/knee, vascular, or CABG surgeries than Veterans without MDD. Minority Veterans were slightly less likely to receive vascular operations compared to white Veterans, but were more likely to undergo digestive system procedures. The effect of depression was independent of race and ethnicity; thus, depression and race would have an additive but not synergistic effect on the odds of receiving surgery. In addition, a gender effect was noted: women Veterans were more likely to have digestive procedures but were less likely to undergo CABG or vascular operations. Authors note that the lack of information regarding severity of illness makes it difficult to determine whether or not diagnostic differences explain differences in surgery. Date: October 1, 2011 Veterans with COPD Living in Isolated Rural Areas have Elevated Risk of Mortality This study sought to determine if COPD mortality is higher for Veterans living in isolated rural areas, and, if so, to assess whether or not hospital characteristics mediate such associations. Findings showed that Veterans living in the most isolated rural areas of the United States appear to have an elevated risk of COPD-related 30-day mortality. Overall unadjusted mortality was higher for Veterans from isolated rural areas (5.0%) and rural areas (4.0%) compared to Veterans from urban areas (3.8%). Hospital characteristics were not found to account for this effect. Veterans from isolated rural but not rural areas remained at higher risk for death after adjusting for clinical characteristics, the proportion of COPD admissions in hospitals that came from rural areas, and hospital volume. Date: July 19, 2011 Racial and Ethnic Differences in Blood Pressure Control among Veterans with Type 2 Diabetes This study examined racial/ethnic differences in blood pressure control among Veterans with type 2 diabetes and uncontrolled BP at baseline. Findings showed that the adjusted proportion of Veterans with uncontrolled BP (>=140/90 mmHg) decreased in all groups over the study period. However, ethnic minority Veterans had significantly increased odds of poor BP control over a mean follow-up of 5 years compared to non-Hispanic White Veterans, independent of socio-demographic factors and comorbidity patterns. Compared to non-Hispanic Whites (45%), 54% of non-Hispanic Black Veterans, 48% of Hispanic Veterans, and 49% of Veterans with unknown race had poor blood pressure control. In using a more stringent BP cutoff (>=130/80 mmHg) to define poor BP control, 74% of non-Hispanic White Veterans had poor blood pressure control over the 5 years compared to 82% of non-Hispanic Black Veterans, 75% of Hispanic Veterans, and 79% of Veterans with unknown race/ethnicity. The presence of a hypertension diagnosis at the time of study entry appears to be associated with higher odds of achieving BP control over time. Among other comorbidities, cancer, coronary heart disease, congestive heart failure, and substance use disorders were all associated with increased odds of good BP control over time. Date: June 14, 2011 Despite Improved Quality of VA Healthcare, Racial Disparity Persists for Important Clinical Outcome This article reports on trends in the quality of care and racial disparities in relation to 10 VA clinical performance measures that assessed cancer screening, cardiovascular care, and diabetes care from 2000 to 2009. Findings show that in the decade following VA’s organizational transformation, quality of care improved and racial disparities were minimal for most process measures, such as glucose and LDL screening. However, these were not accompanied by meaningful reductions in racial disparity for important clinical outcomes, such as blood pressure, glucose, and cholesterol control. A gap in clinical outcomes of as much as nine percentage points was observed between African-American and white Veterans. Almost all of the disparity in outcomes was explained by within-facility disparity, which suggests that VA medical centers will need to measure and address racial gaps in care for their patient populations. Of the five performance measures with an absolute racial disparity of 5 percentage points or more in the initial year of the study, there were statistically significant reductions in racial disparity for three: glucose control, BP control, and CRC screening. However, the reductions in disparity were modest, and none were reduced by more than 2 percentage points. Date: April 1, 2011 VA Healthcare Outperforms Private-Sector, Medicare-Managed Care among Older Patients This study compared clinical performance between VA and Medicare-managed care plans, known as Medicare Advantage (MA). Findings show that VA outperformed MA health plans on 10 out of 11 widely used clinical performance indicators assessing diabetes, cardiovascular, and cancer screening care among patients ages 65 and older in the initial study year – and on all 12 measures by the final year. Moreover, for 10 of the 12 measures studied, even the best-performing MA plans lagged behind the lowest-performing VAMCs. The performance advantage for VA was substantial. For example, in 2006 and 2007, adjusted differences between VA and MA ranged from 4.3 percentage points for cholesterol testing in coronary heart disease to 30.8 percentage points for colorectal cancer screening. VA delivered care that was less variable by site, geographic region, and socioeconomic status. For 9 of the 12 measures, socioeconomic disparities were lower in VA than in MA. Date: March 18, 2011 No Racial Disparities in Adherence to CRC Screening among Veterans Receiving VA Care This study examined the contribution of demographic/health-related factors, cognitive factors, and environmental factors to racial disparities in colorectal cancer (CRC) screening in a nationally representative survey of Veterans ages 50 to 75. The effect of race on adherence to CRC screening guidelines was non-significant after adjusting for demographic/health-related factors and environmental factors. Adherence in both African American and White groups was substantially higher than the national average. The high rates of CRC screening are likely, in part, a result of various VA efforts initiated over the past decade to increase screening adherence. There were no racial differences in physician recommendations for CRC screening: 84% for African Americans and 85% for Whites. Among those who were adherent to CRC screening, African American Veterans had significantly lower rates of colonoscopy compared with White Veterans (47% vs. 57%) and significantly higher rates of fecal occult blood testing (60% vs. 53%). Date: March 1, 2011 VA Patient-Provider Communication Does Not Contribute to Racial Disparities in Use of Total Joint Replacement This study examined whether there were racial differences in patient-provider communication about treatment of chronic knee/hip osteoarthritis in African American and white Veterans referred to two VA orthopedic clinics over a 3-year period. Findings show that communication between VA orthopedic surgeons and patients regarding the management of chronic knee/hip osteoarthritis did not, for the most part, vary by patient race. No racial differences were observed with regard to length of visit, overall amount of dialogue, discussion of psychosocial issues, Veteran activation/engagement statements, physician verbal dominance, display of positive affect by Veterans or providers, or discussion related to informed decision-making. However, visits with African American Veterans contained less discussion of biomedical topics and more rapport-building statements than visits with white Veterans. These findings diminish the potential role of communication in VA orthopedic settings as an explanation for racial disparities in the use of total joint replacement. Date: January 10, 2011 Using One Classification System for Estimates of Urban/Rural Impact on AMI Outcomes among Veterans May Not Be Adequate This study examined whether: 1) two different rural classification systems identify differential rates of Veterans admitted for AMI; 2) rural-urban disparities exist for risk-adjusted AMI outcomes (measured by mortality and receipt of coronary revascularization); and 3) whether hospital transfer rates differ for patients admitted with AMI. Findings showed no observed differences between rural-dwelling and urban-dwelling Veterans in risk-adjusted 30-day mortality, regardless of the urban-rural classification system used. However, rural-dwelling Veterans were less likely to receive revascularization compared to urban-dwelling Veterans, but risk estimations were dependent upon the urban-rural classification system used. Regardless of classification system, Veterans residing in rural settings were transferred more often and were more likely to be admitted to VA hospitals without revascularization facilities. This study demonstrates that using a single rural classification system for estimating the effects of living in a rural setting on AMI outcomes among Veterans may not be adequate. Date: September 1, 2010 Study Examines the State of Colorectal Cancer and Finds Cause for Optimism, Particularly within the VA Healthcare System In contrast to the health disparities that are evident in the community, when colorectal cancer (CRC) outcomes were studied within an equal-access, integrated healthcare system, such as VA, racial disparities were markedly decreased or absent. The type of screening test used in the US has varied over the last decade, but colonoscopy is becoming the dominant modality. However, VA relies primarily on fecal occult blood tests (FOBT). From 1998 to 2003, the proportion of screened Veterans undergoing FOBT within VA increased from 82% to 90% compared to that of Veterans receiving screening colonoscopies, which decreased from 6% to 5%. From the perspective of population-based screening, VA is actually more successful than the general population at screening, and has CRC screening rates well above the national average. Date: June 1, 2010 Disparities in Healthcare Coverage and Access among American Indian/Alaska Native Veterans American Indian/Alaska Native (AIAN) Veterans have considerable disparities in healthcare coverage and access to care compared to non-Hispanic white Veterans. For example, AIAN Veterans are nearly twice as likely to be uninsured, even after adjusting for sociodemographic and economic characteristics. AIAN Veterans are significantly less likely to report private coverage and significantly more likely to report public coverage, military coverage, and be uninsured. Regarding barriers to healthcare, AIAN Veterans were significantly more likely to delay healthcare due to not getting timely appointments, not getting through on the telephone, and having transportation problems. Date: June 1, 2010 Patient Treatment Preferences Play Important Role in Racial Disparities in Knee/Hip Total Joint Replacement Overall, 10.3% of Veterans treated for knee/hip osteoarthritis at two VA orthopedic clinics underwent total joint replacement (TJR) within six months of study enrollment. TJR was less likely for African-American Veterans compared to white Veterans of similar age and disease severity, but this difference was not significant after adjusting for whether patients had received a recommendation for the procedure from their orthopedic surgeon. African-American Veterans were less likely to receive a recommendation for TJR than white Veterans of similar age and disease severity. However, this difference was not significant after controlling for Veterans’ willingness to undergo TJR, as assessed prior to the visit with their surgeon. This suggests that the observed race differences in recommendations about joint replacement may result from orthopedic surgeons being responsive to patient preferences regarding the procedure. Date: May 28, 2010 Veterans Living in Rural Settings Less Likely to Receive Psychotherapy than Veterans Living in Urban Settings Analyzing VA data collected in FY 2004, the use of specialty mental health care was significantly and substantially lower for Veterans living in rural settings. Veterans living in urban settings were significantly more likely than rural Veterans to receive a specialty mental health visit, any form of psychotherapy, individual psychotherapy, or group psychotherapy in the 12 months following their initial diagnosis of depression, anxiety, or PTSD. Urban Veterans were about twice as likely as rural Veterans to receive four or more and eight or more psychotherapy sessions, even after controlling for travel distance and other demographic and clinical characteristics. This suggests that distance alone is insufficient to account for the differences observed. Length of time between an initial diagnosis of depression, anxiety, or PTSD and receipt of psychotherapy services was longer for rural Veterans compared to urban Veterans, but the difference was not clinically meaningful. The authors suggest that focused efforts are needed to increase access to psychotherapy services provided to rural Veterans with mental health disorders. It may be useful to examine recent VA data to assess whether VA’s emphasis on health care for rural Veterans is associated with improved measures of access and quality. Date: May 11, 2010 Lower Mortality Rates for African American Compared with White Patients Hospitalized for Heart Failure This study examined research reporting mortality by race after hospitalization for heart failure (HF), and combined the results using meta-analyses. Adjusted mortality rates were 32% lower in short-term follow-up (0-30 days) and 16% lower in long-term follow-up (after 30 days) for African American compared with white patients. Authors suggest that differences in mortality imply unmeasured differences by race in clinical severity of illness at hospital admission and may lead to biased hospital mortality profiles. Date: March 1, 2010 Rural-Dwelling VA Patients have Worse Physical Health but Better Mental Health than Urban-Dwelling Counterparts Rural Veterans reported worse physical health but better mental health when compared to their urban counterparts, and these differences persisted across the four survey years. The differences were substantial and statistically significant and persisted after correcting for age, gender, marital and employment status, educational level, and local income level. Date: March 1, 2010 Lower Quality of Care for Cardiometabolic Disease among Veterans with Mental Disorders, Regardless of Rural or Urban Dwelling Mental disorders (MD) were associated with a decreased likelihood of obtaining quality cardiometabolic care. When compared to those without MD, Veterans with MD were less likely to receive diabetes sensory foot exams, retinal exams, and renal tests. Rural residence was not associated with differences in quality measures. Primary care visit volume was associated with a greater likelihood of obtaining diabetic retinal exam and renal testing, but did not explain disparities among patients with MD. Date: January 1, 2010 Veteran Minorities Equally Likely to Receive PTSD Treatment This study sought to determine the rates of mental health use in the six months after Veterans received a PTSD diagnosis – and to examine whether service use varied by race or ethnicity. Findings show that minority Veterans were similar to Whites in the likelihood of receiving VA mental health treatment in the six months following a diagnosis of PTSD. Of the 20,284 Veterans with PTSD in this study, 50% received psychotropics, 39% received counseling, and 64% received at least one of these forms of treatment. However, only 24% who received any counseling had at least eight sessions, and most had only one session. These findings indicate that possible treatment preferences exist. The authors suggest that incorporating preferences into treatment planning may facilitate treatment retention and help to maximize treatment outcomes for all Veterans with PTSD. Date: December 1, 2009 Ethnic Disparities in Treatment for Chronic Pain This study sought to identify racial and ethnic differences in patient-reported rates of treatment for chronic pain and ratings of pain-treatment effectiveness among 255,522 Veterans who were treated at more than 800 VA healthcare facilities in FY05. Findings show that 35% of male Veterans and 44% of female Veterans reported receiving treatment for chronic pain. Male and female Veterans who were Hispanic or non-Hispanic black were more likely to report receiving treatment for chronic pain compared to non-Hispanic white Veterans. Among the Veterans who received treatment for chronic pain, non-Hispanic black men were one-fifth less likely to rate pain treatment effectiveness as very good or excellent compared to non-Hispanic white male Veterans. Date: October 1, 2009 Ethnic Disparities in the Treatment of Veterans with Dementia This study sought to determine if there were ethnic disparities in the evaluation and treatment of dementia among 410 Veterans treated at one VAMC between 4/05 and 6/05. Findings show that while laboratory and imaging workup (i.e., CT, MRI) did not differ between ethnic groups, there were significant differences in the treatment of dementia. For example, African American Veterans with dementia were 40% less likely than all other patients to receive acetylcholinesterase inhibitors. This treatment disparity did not appear to be due to differences in the evaluation of dementia, which was similar across groups, although significantly more Caucasian Veterans (43.8%) underwent neuropsychological testing compared to African American (24.8%) or Hispanic Veterans (32.4%). Date: September 1, 2009 African Americans and Whites Equally Appropriate Candidates for Total Joint Arthroplasty This study sought to determine if racial differences in clinical appropriateness for surgery existed among a sample of primary care patients (425 whites and 260 African Americans) with moderate to severe symptomatic knee or hip osteoarthritis (OA) treated at one VA hospital and one county hospital between 3/03 and 9/06. Findings show that African Americans and whites were equally appropriate candidates for total joint arthroplasty (TJA). There were no significant ethnic differences found between the proportion of those deemed appropriate for TJA and those deemed inappropriate. Date: September 1, 2009 Lower Mortality for African American Veterans with COPD Exacerbation not Explained by More Aggressive Care This study sought to determine the potential impact of racial differences in ICU admission and the use of ventilator support on mortality among African American and white Veterans admitted to VA hospitals with COPD (chronic obstructive pulmonary disease) exacerbation. Findings show that mortality was lower in African American Veterans compared to white Veterans, even after adjusting for differences in ICU admission rates and ventilator support. However, mortality was similar for African Americans and whites receiving mechanical ventilation (28.8% vs. 31.4%), thus the lower risk-adjusted mortality among African Americans was not explained by more aggressive care. Date: July 1, 2009 Perceived Racial Discrimination in Health Care Found to be Low and Similar among Veterans and Non-Veterans This study examined rates of perceived discrimination in healthcare settings for Veterans and non-Veterans, as well as for Veterans who used the VA healthcare system and those who did not. Overall, rates of perceived racial discrimination in healthcare were low and barely differed between Veterans (3.4%) and non-Veterans (3.5%). Rates of perceived racial discrimination were equally prevalent among Veterans who used the VA healthcare system and those who did not. Date: May 14, 2009 Alcohol Misuse and Counseling among Minority Veterans This study sought to describe alcohol consumption across race and ethnicity groups among Veterans treated in VA during FY05, and examine associations between race and ethnicity and receipt of alcohol-related advice by clinicians. Findings show that overall, less than one-third of patients who drank at all and one-third of patients with positive alcohol misuse screens reported receiving alcohol-related advice. After adjusting for demographics, health status, and alcohol consumption, Veterans who self-identified as black, Hispanic, or American Indian/Alaska Native were more likely to report receiving alcohol-related advice from their VA healthcare providers compared to non-Hispanic whites. In addition, women and older Veterans were less likely to receive alcohol-related advice than their male and younger counterparts, respectively. Date: May 1, 2009 Ethnic Differences in Self-Reported Cancer Screening Several studies suggest that non-whites may be more likely than whites to over-report screening behavior, which may have considerable implications for research on racial and ethnic disparities in cancer screening. Findings from this study show that racial and ethnic minorities may be less likely to provide accurate reports of their cancer screening behavior and that over-reporting may be particularly problematic. Research suggests that this might be rectified by changing how screening questions are worded and developing different methods for data collection. A conceptual framework offered by study investigators has the potential to guide exploration of where and why possible bias may be occurring and suggests ways in which these biases might be reduced. Date: February 1, 2009 African-American Veterans More Likely than White Veterans to Receive Mechanical Ventilation for COPD African-American Veterans with COPD exacerbation in VA hospitals are more likely than white Veterans to receive mechanical ventilation, and this difference is not explained by available clinical or demographic variables. By contrast, African-American and white Veterans are equally likely to receive non-invasive ventilation (NIV) when being treated for COPD exacerbation. Authors suggest that there is no underuse of mechanical ventilation and NIV in the treatment of racial minorities in this patient population; however, unmeasured factors, such as patient preferences or disease severity may be affecting the use of mechanical ventilation, and thus warrant further investigation. Date: January 1, 2009 Need for Better Self-Management Education to Address Cultural Differences among Veterans with Diabetes Although non-white Veterans have documented disparities in the quality of some diabetes care processes and intermediate outcome measures, racial disparities in foot care examinations have not been widely explored. Findings from this study show that there are significant differences in self-reported foot care and education across racial and ethnic groups among Veterans with diabetes. Authors suggest the need for better self-management education to address culture, knowledge, preferences, and unique barriers to care. Date: January 1, 2009 Racial Differences in Coping with Chronic Osteoarthritis Pain Compared to white veterans, African American veterans were much more likely to perceive prayer as helpful (85% vs. 66%) and were more likely to have tried it for hip or knee pain (73% vs. 55%). Race was not associated with arthritis pain self-efficacy, arthritis function self-efficacy, or any other coping strategies. Date: December 1, 2008 Students Attending Racially and Ethnically Diverse Medical Schools Report Being Better Prepared to Care for Patients in Diverse Society White students who attend racially diverse medical schools report feeling better prepared than students at less diverse schools to care for racial and ethnic minority patients. They also are more likely to endorse access to adequate health care as a right. However, investigators found no association between the diversity of a medical school and whether white students intended to provide care in underserved areas. Date: September 10, 2008 Variation in Care for Recurrent Non-Melanoma Skin Cancer in a University-Based vs. VA Practice Treatment choices differed significantly between the two sites: after adjusting for patient, tumor, and clinician characteristics that may have affected treatment choice, tumors treated at the university-based site remained significantly more likely to be treated with Mohs surgery. There was no evidence that the quality of care varied at the two sites. Date: September 1, 2008 Disease-Specific Differences in End-of-Life Treatment of Seriously Ill Veterans of Different Ethnic and Racial Backgrounds Differences in the level of end-of-life treatments were disease-specific and not based on race and/or ethnicity. In addition, increased end-of-life care for minorities was most pronounced in veterans with dementia, and non-cancer patients received more invasive care than patients with cancer or dementia, independent of their race or ethnicity. Date: September 1, 2008 Perceived Racial Discrimination in U.S Healthcare More Prevalent among African Americans and Associated with Worse Health Outcomes The prevalence of perceived discrimination in U.S. healthcare is considerably higher for African Americans compared to Whites and Hispanics. [These results were not based on VA data.] Perceived discrimination was associated with worse health for both African Americans and Whites. Health care coverage was not significantly related to perceived discrimination for any of the racial/ethnic groups. However, not obtaining medical care due to cost was associated with a greater likelihood of perceiving discrimination for all groups. Date: September 1, 2008
What is included in Publication Briefs? HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations. ^ top

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