- 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
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
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
- 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
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
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
- 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
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
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
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