Study Suggests Despite Improved Quality of VA Healthcare, Racial Disparity Persists for Important Clinical Outcomes
Since its reorganization in the mid-1990s, studies show that VA has substantially improved the quality of healthcare for Veterans; however, the effect of these efforts on racial disparities in quality is unknown. 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. Performance measures included: LDL cholesterol testing and control, retinal eye exams, and control of glucose among Veterans with diabetes; LDL cholesterol testing and control in Veterans with cardiovascular disease; BP control among Veterans with hypertension; and mammography and colorectal cancer (CRC) screening. This study also examined whether racial disparities were driven primarily by a concentration of African American Veterans in lower-performing VA facilities, or a differential quality for white and African American Veterans receiving care in the same VA facility. Investigators used data from VA’s External Peer Review Program, which collects data annually from a random sample of Veterans enrolled for at least two years in the VA healthcare system. The study cohort included 955,047 whites and 171,207 African Americans.
FINDINGS: 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.
LIMITATIONS: Only 10 performance measures were assessed; therefore, investigators were unable to evaluate many aspects of unmeasured quality. Also, other potential mediators of disparities in intermediate outcomes were not examined, such as prescribed medications and lifestyle modifications.
Investigators did not examine the impact of comorbid medical conditions.
This study was funded by HSR&D. Dr. Trivedi is supported by an HSR&D Career Development Award. Drs. Trivedi and Grebla are part of HSR&D’s Center on Systems, Outcomes & Quality in Chronic Disease & Rehabilitation, Providence, RI. Dr. Washington is part of HSR&D/VA Greater Los Angeles.
Trivedi A, Grebla R, Wright S, Washington D. Despite Improved Quality of Care in the Veterans Affairs Healthcare System, Racial Disparity Persists for Important Clinical Outcomes. Health Affairs April 2011;30(4):707-15.