Gurmankin AD (Dana-Farber Cancer Institute/Harvard School of Public Health)
Polsky D (University of Pennsylvania School of Medicine)
Volpp KG (Center for Health Equity Research and Promotion, Philadelphia VA)
Studies within the VA have generally shown that Black patients receive more health care services and have better outcomes than White patients, but the reverse has been found in studies of care outside the VA. The objective of this study is to explain this discrepancy by examining how the racial disparity measured by care obtained within the VA differs from the disparity measured by care obtained both within and outside of the VA.
Consecutive Philadelphia VA patients with a newly elevated PSA test (N=143) were interviewed one year following the newly elevated PSA test to assess follow-up care received within and outside of the VA. Medical chart abstractions were conducted to validate patient self-report of care obtained inside the VA.
Significantly more Whites than Blacks obtain health care outside of the VA (65% vs. 17%, p<.0001). Among subjects who just use the VA, Blacks were just as likely as Whites to know of their elevated PSA test (B:55%, W:56% p=.94), and significantly more likely to have seen a urologist (B:73%, W:44% p=.05) and to have had a prostate biopsy (B:67%, W:28% p-value =.008). Among subjects who also obtain care outside of the VA, the magnitude of the race difference was smaller or reversed for all outcome variables (knowledge B:31%, W:43% p=.41; urologist appointment B:50%, W:58% p=.55; biopsy B:36%, W:31% p=.71).
More Whites than Blacks utilize care outside the VA, and these White patients may therefore receive less care within the VA. As a result, in assessments of racial differences in care received within the VA, it may appear that Blacks obtain more care than Whites. Including information on the care received by VA patients outside the VA may markedly affect the conclusion of whether there are racial disparities in the utilization of health care services among VA patients.
Understanding whether racial disparities in utilization of health care services exist within the VA requires consideration of services that patients receive outside the VA.