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Research on Health Disparities and Minority Health
The VA Office of Research & Development has had a Center of Excellence (CoE) devoted to equity research since 2001. This CoE - the Center for Health Equity Research and Promotion (CHERP) - is part of the Health Services R&D Service (HSR&D).
HSR&D also supports a Targeted Research Enhancement Program (TREP), Understanding Racial and Ethnic Variations in Health Outcomes for Chronic Diseases in Charleston, SC. The purposes of this TREP are:
- To advance knowledge on racial and ethnic variations in care by focusing on two patient level factors - patient trust and patient preferences for care
- To evaluate the incremental effect of these patient level factors on racial and ethnic disparities in health outcomes for chronic medical conditions such as diabetes, hypertension, and osteoarthritis of the knee that are highly prevalent in the veteran population.
Research on racial and ethnic disparities has been a priority area at HSR&D, and its importance was reiterated in the FY 2006 Priority Research Solicitation. Additionally, HSR&D also funds Career Development Awards concentrated on equity and racial and ethnic variations.
The current equity research portfolio focuses on
- identifying disparities in care related to a number of health conditions,
- understanding possible reasons for disparities in care,
- and, most recently, developing interventions to reduce disparities.
Research studies are examining disparities in care related to joint replacement, end of life care, care mood disorders, diabetes, and health literacy. More system level disparities are also being investigated, with one study comparing VA health disparities to those in the non-VA health care system.
Studies exploring possible reasons for disparities are focused on communication, decision making, health literacy, and the role of culture as possible factors explaining variations in treatment for chronic heart failure, cancer, joint replacement, hypertension management and pain management. Other research is aimed at developing more culturally sensitive models of care and decision making aids for care giving, stroke recovery and end of life care.
HSR&D is also supporting the next generation of disparities research targeting interventions to reduce disparities, in this case regarding knee replacements, as well as the development of better implementation strategies to translate disparities research findings into practice.
These varied research studies address disparities among multiple ethnic and racial groups, most prominently between African Americans and whites, but also among different Hispanic groups as well as American Indians.
Publications
Racial and Ethnic Disparities in the VA Healthcare System (June 2007) (868 KB, PDF)
Numerous studies have demonstrated racial and ethnic disparities in health care in the United States. These disparities have been demonstrated in the Veterans Affairs (VA) healthcare system, where financial barriers to receiving care are minimized. The VA is committed to delivering high-quality care in an equitable manner, and as such, to eliminating racial and ethnic disparities in health care. To inform this effort, the existing evidence on disparities within the VA was systematically reviewed, to address the following objectives:
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Determine in which clinical areas racial and ethnic disparities are prevalent within the VA;
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Describe what is known about the sources of those disparities; and
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Qualitatively synthesize that knowledge to determine the most promising avenues for future research aimed at improving equity in VA health care.
This report was published by the VA HSR&D Evidence-based Synthesis Program (ESP). The program was established to provide timely and accurate synthesis of targeted health care topics of particular importance to VA managers and policy makers and to disseminate these reports broadly throughout VA. Available reports are listed and linked below.
Current Projects
The following are examples of specific studies. More detail about these studies is available by using the search function at http://www.hsrd.research.va.gov/research/.
- Project ID: ACC 03-304
Principal Investigator: B. Josea Kramer, PhD, MA
Location: VA Greater Los Angeles Health Care System
Title: VA and Indian Health Services (IHS): Access for American Indian Veterans
Objective: To assess access to VA by American Indian and Alaska Native veterans and to analyze how VA and Indian Health Service work together.
- Project ID: IIR 03-070
Principal Investigator: Kevin G. Volpp, MD, PhD
Location: VA Medical Center, Philadelphia
Title: Comparing VA Health Disparities to Health Disparities Outside the VA
Objective: To estimate racial disparities in 30-day mortality among patients treated in VA hospitals and compare these estimates with disparities among similar patients treated in non-VA hospitals.
- Project ID: IIR 05-234
Principal Investigator: Said A. Ibrahim, MD, MPH
Location: Center for Health Equity Research and Promotion Pittsburgh, PA
Title: Knee Replacement Disparity: A Randomized, Controlled Intervention
Objective: To improve understanding of knee joint replacement risks, benefits, and expected outcomes among AA primary care patients, increase willingness to consider knee joint replacement among AA primary care patients, and increase primary care referral rates for surgical consideration for AA patients who meet the indications for knee joint replacement.
- Project ID: ECV 03-201
Principal Investigator: C. Kent Kwoh, MD
Location: Center for Health Equity Research and Promotion Pittsburgh, PA
Title: Reasons for Disparities in Joint Replacement Utilization
Objective: To examine cultural and clinical context factors in African-American veterans and white veterans with knee or hip OA with a focus on how these factors may be potentially modifiable determinants of willingness to consider joint replacement.
- Project ID: IIR 04-137
Principal Investigator: Said A. Ibrahim, MD, MPH
Location: Center for Health Equity Research and Promotion Pittsburgh, PA
Title: Joint Replacement Utilization Disparity: The Role of Communication
Objective: To examine the potential roles of orthopedic surgeon and patient communication and decision-making in observed racial disparities in utilization of joint replacement.
- Project ID: ECV 02-254
Principal Investigator: Howard S. Gordon, MD, SB
Title: Physician-Patient Communication in Patients with Chronic Heart Failure
Location: Michael E. DeBakey VA Medical Center, Houston, TX
Objective: To assess the relationship of communication to outcomes in patients with chronic heart failure (CHF)
- Project ID: IIR 05-210
Principal Investigator: Megan Crowley-Matoka, PhD
Location: Center for Health Equity Research and Promotion, Pittsburgh, PA
Title: Sociocultural Dimensions of Provider Decision-Making in Pain Management
Objective: To advance understanding of the factors critical to improving the quality and equity of pain management for veterans by studying the sociocultural factors involved in provider decision-making about pain management.
Recent HSR&D studies on racial and ethnic disparities include the following findings:
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Older African American veterans treated at 120 VA sites had lower hospital mortality rates than white veterans for six common conditions including: acute myocardial infarction, hip fracture, stroke, congestive heart failure, gastrointestinal bleeding, and pneumonia. Volpp K, Stone R, and Lave J, et al. "Is Thirty-Day Hospital Mortality really Lower for Black Veterans Compared with White Veterans?" Health Services Research, published online January 24, 2007.
- There are ethnic variations in the use of nicotine replacement therapy (NRP) among smokers receiving care from the VA, with African American and Hispanic smokers about half as likely as white smokers to use NRT to quit smoking. These disparities were not explained by social, physiologic, or psychological factors or by facility differences in prescribing policy of tobacco dependence medications. Fu S, Sherman S, Yano E, et al. "Ethnic Disparities in the Use of Nicotine Replacement Therapy for Smoking Cessation in Equal Access and Health Care System," American Journal of Health Promotion, Nov/Dec 2005, 20 (12): 108.
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Low literacy is not a predictor of preventable hospitalizations among veterans; Ahsan Arozullah et al, "The Roles of Low Literacy and Social Support in Predicting the Preventability of Hospital Admission," Journal of General Internal Medicine, March 2006.
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End of life wishes vary among racial and ethnic groups, as a result of divergent views regarding health care, spirituality, family and dying. Sonia Duffy et al, Journal of the American Geriatrics Society, Vol. 54, No. 1, January 2006. Research jointly funded by VA and state of Michigan and Blue Cross/Blue Shield of Michigan. (See http://www.eurekalert.org/pub_releases/2006-01/uomh-ewv012306.php).
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African American patients appear to have lower trust in physicians regarding lung cancer treatment because of poorer physician-patient communication. Physician communication was perceived as less supportive, less partnering, and less informative, accounting for black patients' lower trust in physicians. Gordon HS, Street RL, Sharf BF, Kelly PA, Souchek J, "Racial Differences in Trust and Lung Cancer Patients' Perceptions of Physician Communication," Journal of Clinical Oncology, Vol 24, February 20, 2006: 904.
- Howard Gordon, Richard Street, Barbara Sharf, Julianne Souchek, "Racial Differences in Doctors' Information-Giving and Patients' Participation," Cancer, online publication August 2006.
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While demographics and health experiences vary by race among women veterans, race was not significantly associated with any primary care domain (patient preference for provider, interpersonal communication, accumulated knowledge and coordination) or satisfaction among women receiving care at VA. Bevanne Bean-Mayberry, Chung-Chou Chang, Sarah Hudson-Scholle, "Brief Report: Lack of a Race Effect in Primary Care Ratings Among Women Veterans," Journal of General Internal Medicine, Vol. 21, October 2006: 1105.
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African American veterans had less severe CAD than white veterans, and treating physicians' estimates of the probability of coronary disease were similar for African American and white veterans. Findings suggest that despite less frequent use of coronary angiography among African American veterans, African Americans who undergo the procedure are at lower risk for having coronary obstructive disease than whites who undergo the procedure. Whittle, J, Kressin N, Peterson E, Orner M et al. "Racial Differences in Prevalence of Coronary Obstructions among Men with Positive Nuclear Imaging Studies," Journal of the American College of Cardiology, May 2006.
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No significant racial differences in general innovativeness between black and white veterans were identified, but whites had higher medical technology innovativeness scores. Medical technology innovativeness scores correlated with a greater likelihood that veterans would be favorably oriented to new medical devices and prescription drugs. Both blacks and whites with low innovativeness scores were hesitant to accept a new medical device, but whites were more likely to adopt a new prescription than blacks. More blacks than whites expressed discomfort with taking risks. Groeneveld P, Sonnad S, Lee A, Asch D, Shea J. "Racial Differences in Attitudes Toward Innovative Medical Technology," Journal of General Internal Medicine, June 2006.
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