Spotlight on Health Equity & Disparities Research

April 2018

Health disparities are defined as significant differences in healthcare or health status between distinct, vulnerable populations linked with social, economic, and/or environmental disadvantage—and an elevated burden of ill health or premature mortality. Within the VA healthcare system, health equity and disparity research focuses on concerns specific to unique groups of Veterans (such as veterans living in rural areas, women, and minorities) and those who have served in specific deployment periods (such as Iraq and Afghanistan, or Viet Nam).

VA is committed to ensuring that all Veterans have barrier-free access to the same high-quality, evidence-based care. Understanding and eliminating disparities in care is a key component of that goal. To support these efforts, VA’s Health Services Research & Development Service  (VA HSR&D) investigators conduct a variety of studies to help improve healthcare equity among Veterans. In addition to individually funded studies, VA HSR&D supports two Centers of Innovation that focus specifically on issues related to health equity: the Charleston Health Equity and Rural Outreach Innovation Center (HEROIC) and the Center for Health Equity Research & Promotion (CHERP). In addition, VA’s Quality Enhancement Research Initiative has several programs that focus on aspects of healthcare disparities including those faced by rural-dwelling Veterans, and Veterans dealing with social justice issues and housing challenges. The following studies represent just a few examples of the impactful research being conducted by HSR&D investigators.

Special Supplement to Medical Care, September 2017

In September 2016, two HSR&D Centers for Innovation focused on health equity—CHERP and HEROIC—hosted a state-of-the-science conference, “Field-based Meeting to Engage Diverse Stakeholders and Operational Partners in Advancing Health Equity in the VA Healthcare System.” This meeting brought together health equity investigators, representatives of vulnerable Veteran populations, and operational leaders to identify strategies to advance implementation of evidence-based interventions to improve the quality and equity of health and healthcare. The journal Medical Care produced a special supplement featuring commentary, discussion, and several original research studies resulting from this conference. Three of those studies are described here.  

• Using Stories to Address Disparities in Hypertension. Control rates for hypertension (HTN) among minority Veterans, in particular African American Veterans, are significantly lower compared to white Veterans. Poor HTN control leads to higher rates of organ damage, stroke, and cardiovascular complications. Few strategies to improve HTN control have focused on culturally-sensitive interventions to improve control among African American Veterans. Moreover, providing information in a narrative, or story, form has been found to be an effective mode of delivering health information. This HSR&D study builds on the investigators’ prior work to evaluate the effectiveness of a "Stories" intervention among African American patients at three VA medical centers with a high prevalence of African American Veterans. Investigators recruited more than 600 African American Veterans and videotaped them telling their stories about managing their blood pressure. With these stories, they developed an interactive multimedia intervention targeted to African American patients, "Stories to Communicate about Managing Hypertension," and delivered it as an easy-to-use DVD resource.
  
  Study participants were then randomized to the Stories intervention or the control group. After watching the DVD, Veterans in the intervention group reported the content more emotionally engaging compared to those in the control group. At follow-up, 87% of African American Veterans in the intervention group strongly agreed/agreed that they were confident they could maintain lifestyle change compared with 77% of Veterans in the control group. Looking at physiologic outcomes, at baseline the mean systolic blood pressure was 138.4 with no significant difference by group. However, at follow-up there was a 3.3mmHg difference in blood pressure, favoring Veterans in the intervention group.
  
  Implications: In this population of at-risk African American Veterans, adding personal stories of Veterans resulted in increased emotional engagement and downstream positive effects on self-reported behavior and objectively measured blood pressure.

• Creating a Toolkit to Reduce Disparities in Patient Engagement. In 2010, VA began implementing the Patient Aligned Care Teams (PACT) model, which uses a team-based approach to care and has patient engagement at its core. To support VA’s successful implementation of PACT, investigators in this study focused on developing a toolkit to help providers increase, and reduce disparities in, patient engagement. Using interviews and observations with staff at VA primary care sites nationwide, investigators identified effective patient engagement practices and resources. Then, through a series of conference calls and surveys, stakeholders cultivated lists of engagement practices based on perceived feasibility and importance.
  
  Resulting data were used to create a toolkit consisting of patient engagement practices and resources to support patient engagement. Results also described general environments that were either conducive to or limiting to patient engagement, including: No identified practices or resources that specifically targeted patient engagement of minorities or addressed disparities; high-performing, high–minority-serving sites tended to describe more staff training opportunities and staff feedback mechanisms; and low-performing and high-minority-serving sites more often reported barriers to implementation of patient engagement practices.
  
  Implications: Both patient engagement and reducing disparities in care in VA are priorities. These goals will be supported by implementation of the toolkit and through close follow-up and evaluation of toolkit implementation and efficacy.
  


• Racial and Ethnic Variation in Perceptions of VA Mental Health Providers are Associated with Treatment Retention among Veterans With PTSD. Although effective treatments exist for post-traumatic stress disorder (PTSD), a substantial number of patients who enter PTSD treatment discontinue it. Data on racial and ethnic minority Veterans with PTSD indicate that they are less likely than their white counterparts to persist in mental health treatment. In this study, investigators sought to determine whether retention in individual PTSD therapy or pharmacotherapy were associated with patients’ ratings of their mental health providers, and if those associations differ depending on Veteran race or ethnicity.
  
  Investigators used VA data to identify a 2,452 Latino, African American, and white Veterans who initiated pharmacotherapy or individual psychotherapy for PTSD. Results indicated that ratings of mental health providers—more than treatment beliefs—were associated with persistence in individual psychotherapy and pharmacotherapy. Among African American Veterans, retention in pharmacotherapy was reduced if the provider was perceived as not having helped manage medication side-effects. All but one of the Latino Veteran participants who had rated their therapist as not caring discontinued individual psychotherapy.
  
  Implications: Data suggest that interventions focusing on provider contributions to therapeutic interactions may more successfully address treatment retention among racial and ethnic minority Veterans with PTSD than interventions that “culturally tailor” treatments to match belief systems of patient demographic groups. 

Understanding Women's Disparities in Satisfaction with VA Care

Patient satisfaction is an important dimension of healthcare quality, and VA is committed to providing high-quality care to an increasingly diverse patient population. In two contiguous, recently-concluded studies, investigators sought to assess Veteran satisfaction with VA healthcare by race/ethnicity and gender. Using telephone interviews with Black, white, and Hispanic Veterans from 25 predominantly minority-serving VA medical centers from June 2013 to January 2015, researchers assessed satisfaction with VA care across 16 domains, comparing the proportion of Veterans who were very satisfied, somewhat satisfied, or less than satisfied (that is, neither satisfied nor dissatisfied; somewhat dissatisfied; or very dissatisfied) in each domain.

Interviews were completed for 1222 of the 1929 Veteran participants (421 white, 389 Black, and 396 Hispanic Veterans). Of the participating group, 616 were female. Multisite interviews with Veterans at primarily minority-serving sites showed generally high levels of health care satisfaction across 16 domains, with few quantitative differences by race/ethnicity or gender. The highest satisfaction ratings were reported for costs, outpatient facilities, and pharmacy (74-76% very satisfied); the lowest ratings were reported for access, pain management, and mental health care (21-24% less than satisfied). None of the joint tests of racial/ethnic or gender differences showed any statistically significant difference in satisfaction.

Implications. Given VA's commitment to providing high quality care to all patients, capturing evidence about the unique concerns of a diverse group of male and women Veterans is a critical component in supporting health system changes that improve care among minority patient populations.

Citation

Zickmund S, Burkitt K, Gao S, et al. Racial, ethnic, and gender equity in Veteran satisfaction with health care in the Veterans Affairs health care system. Journal of General Internal Medicine. March 2018;33(3):305-331.

Staying Positive: An Intervention to Reduce Osteoarthritis Pain Disparities

Arthritis is a prevalent and disabling source of chronic pain for which African Americans bear a disproportionate burden. This study tested a patient-centered, non-invasive intervention to improve pain outcomes and reduce disparities in African American and white Veterans with knee arthritis. The intervention is designed to help Veterans develop positive psychological skills such as gratitude and kindness, the health benefits of which are well-documented. 

In a pilot test of this intervention, a small group of patients (N = 42) were randomized to a six-week program containing positive skill-building activities or neutral control activities tailored to the patient population. Adherence was assessed by telephone each week. Osteoarthritis symptom severity was assessed, as well as measures of well-being (positive affect, negative affect, and life satisfaction) at baseline and by telephone one, three, and six months after the program ended. 

Results showed that the majority (64%) of patients completed more than 80% of their weekly activities. Patients in the positive (vs neutral) program reported significantly more improvement over time in osteoarthritis symptom severity, negative affect, and life satisfaction. The intervention is now being tested in a larger study to determine whether these benefits generalize to a broader sample of Veterans with arthritis.

Implications. Since Veterans with knee osteoarthritis are open to participating in a six-week non-pharmacological intervention to build positive psychological skills, this approach may have potential, wider application for a diverse group of Veterans with other chronic pain conditions. 

Citations

Hausmann LRM, Youk A, Kwoh CK, et al. Testing a positive psychological intervention for osteoarthritis. Pain Medicine. 2017 Oct 1; 18(10):1908-1920.

Hausmann LRM, Ibrahim SA, Kwoh CK, et al. Rationale and design of the staying positive with arthritis (SPA) study: A randomized controlled trial testing the impact of a positive psychology intervention on racial disparities in pain. Contemporary Clinical Trials. 2017 Sep 8; (64):243-253.

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