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Do gender and race affect quality of care in the VA healthcare system?

Bean-Mayberry B, Yano E, Wang M, Mor MK, Fine MJ. Do gender and race affect quality of care in the VA healthcare system? Paper presented at: Society of General Internal Medicine Annual Meeting; 2007 Apr 28; Toronto, Canada.


BACKGROUND: In the past decade, VA has achieved better quality of care for patients with diabetes and has surpassed the non-VA health care sector in many diabetes performance measures. Given the vulnerable populations served by the VA, we assessed the degree to which gender and race mediate the performance of recommended processes of care and key intermediate outcomes for patients with this illness. METHODS: We performed secondary analyses using a national dataset of outpatient veterans identified by the VA External Peer Review Program (2001-2003). We linked this cohort to the National Patient Care Database to obtain clinical and demographic information and to VA Medicare files to obtain race. We performed bivariate analyses and multiple logistic regression for 4 separate diabetic quality measures, consisting of processes of care and intermediate outcomes, while adjusting for patient demographics, outpatient utilization and geographical region. RESULTS: Our cohort of 56,632 veterans with diabetes included 20% women and 15% black veterans. Compared to men, women had lower performance rates for receipt of pneumonia vaccine (72.3% vs. 80.9%), receipt of influenza vaccine (61.3% vs. 68.2%), and fasting lipids within 2 years (90.1% vs. 92.1%), while presence of uncontrolled blood pressure (BP) > / = 140/90 (11.2% vs. 11.2%) was similar. Compared to whites, blacks had lower performance rates on all measures: receipt of pneumonia vaccine (73.0% vs. 81.7%) or influenza vaccine (60.2% vs. 69.1%); fasting lipids (91.1% vs. 91.9%); and uncontrolled BP (18.7% vs. 9.4%). In multivariate comparisons, compared to men, women had a significantly lower odds of receipt of pneumonia vaccine (OR 0.87, 95%CI 0.82,0.92) or influenza vaccine (OR 0.93, 95%CI 0.88,0.98) and fasting lipids (OR 0.85, 95%CI 0.78,0.92), but were less likely to have uncontrolled BP (OR 0.83, 95%CI 0.76,0.92). While compared to whites, blacks showed significantly lower performance for all measures: receipt of pneumonia vaccine (OR 0.79, 95%CI 0.75,0.84) or influenza vaccine (OR 0.78, 95%CI 0.74,0.82); fasting lipids (0.90, 95%CI 0.82, 0.98) and uncontrolled BP (OR 1.99, 95%CI 1.83,2.16). CONCLUSIONS: While blood pressure control for women in VA appears better than men, women and blacks display consistently poorer levels of quality. These lower levels may stem from lack of knowledge about how vulnerable populations use the VA and obtain chronic disease care, knowledge deficits among patient or providers, or unrecognized gaps in delivering care. Both women and black veterans require interventional efforts to reduce chronic disease care disparities. Planning appropriate interventions will require research that describes gender and racial utilization patterns and informs care delivery models by showing patient or practice determinants associated with improved outcomes in diabetes care.

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