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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).
Research on racial and ethnic disparities has been a priority area at HSR&D, and its importance was reiterated in the FY 2008 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:
- understanding the reasons for disparities in care,
- developing interventions to reduce disparities,
- and the development of better implementation strategies to translate disparities research findings into practice.
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: ECV 02-254
Principal Investigator: Howard S. Gordon, MD, SB
Location: Jesse Brown VAMC (WestSide Division, Chicago, IL
Title: Physician-Patient Communication in Patients with Chronic Heart Failure
Objective: The specific aim is to assess the relationship of communication to outcomes in patients with chronic heart failure (CHF). We hypothesize that interactions characterized by more effective communication are associated with (a) better CHF outcomes (e.g., higher functional status, and lower emergency room and hospital utilization) than interactions with less effective communication; and with (b) improved patient perceptions (e.g., increased trust, satisfaction, communication) and improved behaviors (e.g., adherence). We also hypothesize that (for a number of reasons) black patients have more difficulty communicating with physicians than white patients.
Funding Period: July 2004 - March 2010
- Project ID: IAA 06-214
Principal Investigator: Guoqing John Chen, PhD, MD, MPH
Location: Michael E. DeBakey VA Medical Center, Houston, TX
Title: Treatment Cost for Veterans with Chronic Kidney Disease
Objective: The overall goals of this study are to determine racial/ethnic variations in receipt of guideline concordant care and examine the effect of guideline concordant care for CKD on treatment cost. The specific aims of the proposed project are as follows:
Specific Aim 1: To determine racial/ethnic differences in receipt of optimal care for CKD within 12 months from the date of initial CKD diagnosis as defined by the K/DOQI and VHA-DoD clinical practice guideline for CKD.
Specific Aim 2: To examine impact of provision of overall recommended care for patients with CKD within 12 months from the date of initial CKD diagnosis on treatment cost in Veterans with CKD.
Funding Period: March 2008 - February 2010
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Project ID: IAA 07-069
Principal Investigator:Stefan G. Kertesz MSc MD
Title: Primary Care Quality and Service Customization for the Homeless
Location: Brimingham VA Medical Center, Birmingham, AL
Objective:
Objective 1: Using the Institute of Medicine (IOM)'s constructs for quality primary care, to operationalize high-quality primary care for the homeless using the perspectives of homeless persons, clinicians, and administrators of programs for the homeless;
Objective 2: Based on Aim 1, to develop a patient-reported instrument (PCQ-H) and establish its validity and reliability;
Objective 3. To compare the quality of primary care among homeless adults who obtain VA primary care services to the quality of care for homeless adults who obtain primary care services in a highly-customized program.
Funding Period: September 2008 - August 2011
- 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: The specific aims of this project are (1) To assess racial differences in the proportion of patients who receive recommendations for joint replacement as a treatment option, who accept treatment recommendations, who are satisfied with the treatment decision, and who undergo joint replacement surgery within 6 months of the recommendation; (2) To examine racial differences in patient-provider communication content and processes (style/pattern) regarding knee/hip OA and joint replacement as a treatment option; and (3) To examine the association between doctor-patient communication, patient race, and study outcomes.
Funding Period: September 2005 - February 2009
- Project ID:IIR 04-436
Principal Investigator: Karin M. Nelson, MD, MSHS
Location: Seattle, WA
Title: The Impact of Neighborhood Environment on Veteran Health and Survival
Objective:The primary aim of this study is to determine the relative contributions of neighborhood social and physical environments, health system factors, and individual characteristics to health status and mortality among veterans. The secondary aims are (1) to determine whether the association between neighborhood characteristics and veteran health status is modified by age or race/ethnicity and (2) to assess potential mediators of the association between neighborhood characteristics and health status, including health behaviors and physiologic endpoints, among veterans with chronic disease.
Funding Period: October 2007 - September 2009
- Project ID: IIR 05-062
Principal Investigator: Barbara G. Bokhour, PhD
Location: VA New England Health Care System, Bedford, MA
Title:
Culture and Communication in Hypertension Management
Objective: In this study we are examining the relationships between patient preferences, patients' health literacy, cultural explanatory models, patient-provider communication and behaviors patients engage in to control their blood pressure, what we call hypertension self-management. The primary objective of the proposed study is to better understand the ways in which cultural factors affect patient-provider communication and behaviors patients engage in to control their hypertension, particularly adherence to medication regimens. This innovative study uses qualitative methods to study the ways in which patients' cultural backgrounds, perspectives and preferences affect communication with providers about hypertension care and patients' health behaviors related to their blood pressure.
Funding Period: October 2006 - September 2009
- 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:This project aims 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. With this in mind, our specific objectives are: 1) to describe key patient, provider and practice-setting factors that influence provider decision-making about the assessment, diagnosis and treatment of nonmalignant pain; 2) to assess the relationships between and relative importance of identified patient, provider and practice-setting factors in shaping provider decision-making in nonmalignant pain management; and 3) to identify key patient, provider and/or practice-setting factors (or sets of factors) as priorities for intervention-targeted work to improve the quality and equity of pain management.
Funding Period: September 2006 - August 2009
- 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: The short-term goals of this randomized, controlled trial are to demonstrate the efficacy of an intervention 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.
Funding Period: September 2006 - August 2009
- Project ID:IIR 05-283
Principal Investigator: Angela Fagerlin, PhD, MA
Location:VA Ann Arbor Healthcare System, Ann Arbor, MI
Title: Impact of a Plain Language Prostate Cancer Decision Aid on Decision Making
Objective: To test the impact of a plain language decision aid (i.e., a low reading level) on prostate cancer patient's decision making experience and in their interactions with their physician and the VA health system. This study will also test if there are differences in receipt of active treatment between men with low vs. high literacy skills.
Funding Period: October 2007 - September 2011
- Project ID: IIR 06-219
Principal Investigator: Patrick D Mauldin, PhD, MA, BS
Location: Ralph H. Johhnson VA Medical Center, Charleston, SC
Title: Ethnic Differences in Medication Adherence and Cost for Elderly Veterans with DM
Objective: The primary objectives of this study are to characterize MNA across racial/ethnic groups of elderly (age 65) diabetic veterans, to determine the longitudinal effect of MNA on health care costs to the VA and Medicare (federal payer) and mortality across racial/ethnic groups, and to determine whether racial/ethnic variations in MNA explain racial/ethnic disparities in health care cost and mortality among elderly veterans with diabetes. We will address these goals through three specific aims: 1) to determine racial/ethnic differences in MNA in elderly veterans with type 2 diabetes after controlling for relevant covariates, 2) to determine the effect of MNA on health care costs across racial/ethnic groups over time, and 3) to determine the effect of MNA on mortality across racial/ethnic groups over time.
Funding Period: February 2008 - January 2010
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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