Response to Commentary
Partnered Research Supports the Use of Equity-Guided Improvement to Reduce Disparities Among Veterans
In this issue’s lead commentary, Dr. Ernest Moy and Dr. Carolyn Clancy make an excellent case for integrating equity into quality improvement (QI) strategies throughout VA medical facilities. Not only does viewing QI through an equity lens ensure that evidence-based care is reaching Veteran populations who need it the most, but it also provides VA healthcare staff with a strategy to focus resources and QI initiatives where they will potentially have the greatest benefit.
At its core, the equity-guided improvement strategy described by Dr. Moy and Dr. Clancy is aligned with a conceptual framework to advance health equity research that was originally developed by researchers from the HSR&D Center for Health Equity Research and Promotion (CHERP).1 The framework laid out three generations of research to improve equity within healthcare organizations. First generation research seeks to identify specific healthcare disparities that affect historically marginalized or disadvantaged populations. Second generation research seeks to understand causes of disparities at patient, provider, and system levels. Third generation research seeks to address healthcare disparities through interventions designed to address underlying causes. We have updated the original framework to call for health equity researchers to incorporate factors that impede or facilitate implementation of evidence-based treatments as potential causes of disparities.2
The first step of equity-guided improvement is identifying disparities in a specific patient population. If disparities in delivery of evidence-based care are identified within a given VA medical facility, for example, then QI that focuses on the unique needs or barriers to care experienced by an underserved population may be warranted. In such cases, equity-guided improvement would call for healthcare staff to maintain an equity focus as they seek to understand and address causes of their local disparities. Given that disparities are often rooted in structural biases that put Black, Indigenous People of Color, and women Veterans at higher risk for worse health and healthcare, healthcare staff using an equity-guided improvement strategy should pay special attention to identifying aspects of standard processes that may contribute to members of a certain demographic group being systematically left behind.
Using equity to guide QI has been shown to work. A recently published study led by HSR&D researchers at CHERP supports the use of an equity-guided improvement strategy to identify, understand, and reduce healthcare disparities in VA.3 VISN 4 first worked with CHERP investigators to develop a VISN 4 disparities dashboard to identify racial disparities among Veterans receiving recommended care for management of chronic diseases (e.g., diabetes and hypertension) and preventive screenings (e.g., mammograms and colorectal cancer screening). The VISN 4 disparities dashboard revealed that recommended levels of blood pressure control among Black Veterans with hypertension were achieved less often than among white Veterans at nearly every facility in VISN 4. VISN 4 then conducted a year-long VISN-wide QI initiative that specifically focused on improving blood pressure control among Black Veterans with severe hypertension (systolic BP ≥ 160 or diastolic BP ≥ 100 mmHg). In keeping with an equity-guided improvement strategy, the rationale for focusing the initiative on Black Veterans with severe hypertension was that Veterans in this subpopulation had both the highest rates of uncontrolled hypertension and were at substantial risk for developing complications if their blood pressure remained uncontrolled. Also, in keeping with equity-guided improvement, VISN 4 facilities each conducted their own investigation of factors that contributed to disparities in blood pressure control in their local Veteran populations. Although the VISN provided guidance and centralized support throughout the initiative, facilities were encouraged to develop and implement interventions that were tailored to their local conditions.
Health equity researchers from CHERP were embedded in VISN 4’s equity-guided QI initiative to provide subject matter expertise, conduct a process evaluation of the strategies that VISN 4 facilities used to reduce disparities in blood pressure control, and assess the effect of the initiative on clinical outcomes.3 The results of the evaluation not only showed a reduction of disparities in the percentage of Black vs. white Veterans with severe hypertension over time, but it also offered an in-depth account of 21 different strategies that were used across VISN 4 facilities to improve blood pressure control and reduce disparities. Most facilities implemented multiple strategies, with the most common strategies being provider education, audit and feedback, and structural changes to delivering care (e.g., establishing hypertension-related appointments with pharmacists).
The project in VISN 4 offers a successful model for implementing the equity-guided improvement strategy proposed by Dr. Moy and Dr. Clancy. With support from the VHA Innovator’s Network and HSR&D’s Research to Impact for Veterans Program, researchers at CHERP have developed a multifaceted Primary Care Equity Dashboard to support the nationwide spread of equity-guided improvement in primary care throughout VA medical facilities. Built using human-centered design principles and refined through iterative testing with clinical stakeholders, the Primary Care Equity Dashboard is designed to meet the needs of QI champions as they plan, design, implement, and evaluate equity-guided QI projects in VA primary care settings. With its user-friendly layout, the Primary Care Equity Dashboard makes it easy to identify disparities in select outpatient VA Electronic Quality Measures by Veteran race and ethnicity, gender, and urban/rural residence. Because identifying disparities is only the first step towards eliminating them, the Primary Care Equity Dashboard also provides users with resources to help them understand causes of disparities and evidence-based strategies to reduce them. The tool also provides elements that are commonly used in QI initiatives, including patient outlier data that can be used to inform tailoring of interventions for at-risk groups. The tool also provides basic run charts that allow users to examine changes in disparities over time.
Officially introduced on a national scale in February 2021, the Primary Care Equity Dashboard is now accessible to all VA healthcare staff and is being used by at least 200 unique VA staff members located throughout all 18 VISNs and VA Central Office. To guide future enhancements of the tool, members of our CHERP research team are embedded in two demonstration projects being led by QI champions within and outside of VISN 4. The project within VISN 4 is focused on improving statin adherence among Black Veterans with cardiovascular disease. The project outside of VISN 4 is exploring barriers to diabetes management and use of Whole Health among minority Veterans. Our close observation of how the Primary Care Equity Dashboard is utilized in real-world applications will allow us to continue adapting the tool and to develop training materials that can support a variety of use cases.
Although the early adoption of the Primary Care Equity Dashboard is encouraging, equity dashboards are not a panacea for eliminating health inequities. Additional research and engagement will be needed to facilitate the immense organizational and individual changes necessary to weave a culture of equity throughout VA. Drawing from the social and behavioral sciences to develop strategies to support and sustain changes at multiple levels will be paramount. Research that examines how biases in policies, practices, and clinical algorithms cause or exacerbate disparities will also be essential. Engaging Veterans from historically marginalized or disadvantaged groups as partners in our research and equity- guided QI initiatives will be crucial. Finally, we will need strong clinical and operations partners to use such research to guide future changes in policy and practice. Putting equity at the center of our mission, thereby making equity-guided improvement the new status quo, will only improve our ability to provide every Veteran with the care and support they deserve.