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To better understand the causes of racial disparities in health care, we reviewed and synthesized existing evidence related to disparities in the “equal access” Veterans Affairs (VA) health care system.
We systematically reviewed and synthesized evidence from studies comparing health care utilization and quality by race within the VA.
Racial disparities in the VA exist across a wide range of clinical areas and service types. Disparities appear most prevalent for medication adherence and surgery and other invasive procedures, processes that are likely to be affected by the quantity and quality of patient–provider communication, shared decision making, and patient participation. Studies indicate a variety of likely root causes of disparities including: racial differences in patients’ medical knowledge and information sources, trust and skepticism, levels of participation in health care interactions and decisions, and social support and resources; clinician judgment/bias; the racial/cultural milieu of health care settings; and differences in the quality of care at facilities attended by different racial groups.
Existing evidence from the VA indicates several promising targets for interventions to reduce racial disparities in the quality of health care.
Numerous studies have demonstrated racial and ethnic disparities in health care in the United States.1 The Institute of Medicine defines disparities as “racial or ethnic differences in the quality of health care that are not caused by access-related factors or clinical needs, preferences, and appropriateness of intervention.”1 Although studies have clearly documented that both the quantity and quality of health care are lower for minority Americans—African Americans and Latinos in particular—compared to the white majority, the root causes of these disparities are not well understood.1
Disparities in health care have been demonstrated in the Veterans Affairs (VA) health care system. The VA is a national network of health care facilities administered by the federal government, that provides care to over 5 million veterans of U.S. military service, approximately 21% of whom are from racial or ethnic minorities (including 13% African American).2 The VA offers a comprehensive set of physical and mental health services including ambulatory and inpatient care, pharmaceuticals, and medical equipment. Eligible veterans have access to the same set of services and pay no premiums. Most veterans are subject to copayments for medications, and some with financial means surpassing a specified threshold also pay copayments for other services. The VA uses a state-of-the-art electonic medical record system and continously collects data on cost, quality, and utilization. These features of the VA make it an ideal “laboratory” for studying the root causes of disparities in health care use and quality. Specifically, it is a system that provides a wide spectrum of health services to a racially diverse population and collects data on utilization and quality. Moreoever, because most financial barriers present in private-sector U.S. health care are removed, VA studies are able to examine racial disparities without confounding by racial differences in insurance coverage, income, or other factors influencing patients’ ability to pay for care. Studies from the VA are therefore likely to be particularly informative in helping understand racial disparities in health care.
We reviewed and synthesized the existing knowledge base related to racial and ethnic disparities in the VA, to:
We used a conceptual framework to guide our review and synthesis in which studies were considered to be first generation (descriptive studies examining the extent of disparities), second generation (analytical studies examining factors that might explain disparities), or third generation (interventional studies to reduce disparities). Some studies are simultaneously first and second generation, demonstrating racial or ethnic disparities and examining mediating factors that might explain those disparities. However, most second-generation studies examine only the association between race and potential mediating factors, without determining whether those factors truly mediate disparities by race or ethnicity. For example, a study might examine whether race is associated with trust in health care providers, without explicitly examining whether trust is a mediator of actual disparities. The potential for mediation in these cases is theoretical.
There are relatively few third-generation studies; interventional disparities research is still nascent. We therefore used our conceptual framework to propose interventions that might reduce racial disparities by targeting likely mediating factors identified by second-generation studies.
We conducted a search in Medline and HealthSTAR of literature published from 1966 to October 9, 2006. We entered the following string of terms, using the PubMed search engine: ((VA [tw] OR veteran* [tw]) OR (United States Department of Veterans Affairs OR veterans OR veterans hospitals)) AND ((ethnic* [tw] OR race [tw] OR racial [tw] OR disparity [tw] OR disparities [tw] OR blacks [tw] OR black [tw] OR Hispanic* [tw]) OR (population groups OR race relations)).
The search strategy was saved in PubMed to provide weekly automatic updates on new publications until February 28, 2007. We obtained additional articles from reference lists of pertinent studies and consulted authors of retrieved studies and other known experts on disparities within the VA.
Two reviewers assessed abstracts using the criteria described in Table 1. Full-text articles of potentially relevant abstracts were retrieved, and a second review for inclusion was conducted by reapplying the inclusion and exclusion criteria.
We abstracted detailed data from the studies meeting inclusion criteria and critically analyzed them to compare study characteristics, methods, and findings. We compiled a summary of findings by clinical topic and drew conclusions based on qualitative synthesis of the findings. Because the studies were heterogeneous in design, objectives, and outcomes, we did not systematically rate the validity of individual studies. We assessed the level of adjustment for potential confounders and whether race/ethnicity data were gathered by self-report and considered these indicators in our qualitative synthesis of evidence.
After summarizing the findings for each clinical topic, we synthesized the descriptions and summaries of the literature for each clinical topic to derive a set of “cross-cutting” themes related to the underlying causes of disparities. We also sorted findings by categories of health care utilization and quality (e.g., use of surgery and invasive procedures, patient satisfaction, etc.), to provide additional insight.
The initial electronic literature search generated 1,098 titles and abstracts. An additional 7 titles were added through manual and automated update searches. After applying inclusion and exclusion criteria at the abstract level, 171 full-text articles were reviewed and sorted by clinical content area, as shown in Figure Figure1.1. Details of these studies including sample sizes and other study characteristics are available in the Appendix.
In Table 2, we present numbers of studies in which disparities were found, and not found, by clinical content area. In the table, a single study might contribute to both columns if the study found disparities in 1 measure of quality or utilization and no disparities in another measure. Most second-generation studies in our review examined potential sources of disparities (e.g., patient trust) without examining actual disparities in quality or utilization. These studies did not contribute data to either column of the table. Table 3 presents similar data stratified by categories of utilization and quality measures.
Tables 2 and and33 are intended not for statistical comparisons but as qualitative “balance sheets” to provide a broad overview of first-generation disparities studies in the VA. There are several points worth noting. First, there is no indication that disparities are more prevalent in some clinical content areas than others. Second, disparities appear most prevalent for surgery and other invasive procedures and medication adherence, processes that are likely to be affected by the quantity and quality of patient–provider communication, shared decision making, and patient participation. Third, in studies examining quality indicators that represent intermediate health outcomes, non-white patients generally fared worse than whites. This potentially indicates that disparities in service intensity are contributing to real disparities in health outcomes, or that minorities are receiving fewer and lower quality services despite greater need, as reflected by less adequate chronic illness management, or both. Finally, because white patients tend to use non-VA care more often than non-white patients do, studies that do not capture non-VA utilization, particularly those using administrative data, may underestimate the degree of disparities, find disparities to be absent when they in fact exist,3 or find “reverse” disparities (non-whites receive more/better care) when in fact no disparities exist.4 Two studies demonstrated this misleading effect of not capturing non-VA utilization.3,4
In the sections below, we provide findings from our review on selected clinical topics that illustrate many of the principal themes of our analysis (for a complete review of all clinical topics, our full report is available at http://www.hsrd.research.va.gov/publications/esp/RacialDisparities-2007.pdf).
Arthritis and pain management Studies of osteoarthritis and pain management reported racial differences in joint replacement surgery and analgesic medication use that generally indicate less aggressive management of osteoarthritis in African Americans and Latinos compared to whites.5–7 These differences do not appear to be explained by differences in symptom severity, as African Americans tend to report similar if not greater levels of pain compared to whites.8–10
African Americans were generally less willing than whites to undergo joint replacement surgery.11 This greater reluctance appears to be caused by less familiarity with the procedure and worse expectations of surgical outcomes, including postoperative recovery, chronic pain, and functioning.12 African Americans also appear to place greater value than whites on non-medical options for managing arthritis, particularly prayer.13–15 However, the degree to which lower willingness among African-American patients explains observed disparities in joint replacement surgery is unknown.
Cancer For some cancers, African Americans are less likely to undergo potentially curative surgical resection, but equally likely to undergo non-surgical interventions, such as chemotherapy and radiation.16–19 Studies exploring possible reasons for this disparity suggest that physicians engage in less effective partnerships with African-American patients and provide them with less information as compared to white patients.20–22 Part of this communication disparity appears to be related to African-American patients’ being less assertive or active in their conversations with physicians. As a result of less effective partnerships and less information exchange between physicians and African-American patients, physicians engender less trust among African American as compared to white patients.20 The degree to which these differences in communication, partnership, and trust actually explain disparities in cancer surgery is unknown.
Cardiovascular diseases There were mixed findings across studies on racial disparities in the use of invasive procedures in patients with cardiovascular diseases, but the majority of studies found that non-whites undergo fewer procedures than whites.23–43 In 1 study, an observed disparity in the use of cardiac catheterization was partly caused by greater overuse of the procedure among whites than African Americans.27
Studies found greater aversion to invasive procedures among African Americans compared with whites,26,44–46 as well as lower trust among African Americans and greater emphasis on religion as an alternative to medical care.41,47 Notably, African Americans were less familiar with cardiovascular procedures, and this lack of familiarity helped explain racial differences in willingness to undergo procedures in 1 study.46
Patient–physician communication behaviors differed between African American and white patients. One study identified a cycle of passivity in which African American patients, and patients interacting with race discordant physicians, received less information overall because they engaged less often in communication behaviors (e.g., questions, assertions) that typically elicit more information from doctors.48 In focus groups, African-American patients placed greater emphasis on the need for trust in their physicians in deciding about invasive procedures, whereas white patients placed greater emphasis on clinical indications.49
Whereas racial differences were apparent in factors that might influence the use of cardiac care—e.g., aversion to surgery, trust, communication—studies that were able to examine the influence of these factors on the actual use of invasive procedures generally found that they did not explain observed disparities. Physician decision making was more influential, and in 1 study physician recommendations helped explain racial disparities in cardiac procedure use, even after accounting for clinical variables and severity of coronary disease.41
African Americans were more likely to delay seeking treatment for heart failure symptoms and were less adherent (both intentionally and unintentionally) to medication regimens.50 Among patients with peripheral arterial disease, African Americans and Latinos had higher rates of limb amputation.43 The reasons underlying these findings of lower adherence and later presentation were not investigated.
Mental health and substance abuse Clinicians tend to more frequently diagnose and treat African-American patients with mental illness as having psychotic disorders (e.g., schizophrenia) and white patients as having affective disorders (e.g., bipolar disorder, depression).51,52 The underlying causes of these disparities in diagnostic and treatment patterns remain unclear.
Studies investigating the effect of the “racial environment” on mental health and substance abuse outcomes suggest that African-American patients may derive benefit from having a racially concordant clinician, and from being in a racially concordant treatment group.53,54
Preventive and ambulatory care Studies of preventive and ambulatory care use by patient race reveal mixed findings. For some services—e.g., colorectal cancer screening, lipid lowering therapy—racial disparities do not appear prevalent.55–58 Studies did reveal disparities in some primary care outcome measures, including achieving blood pressure and lipid goals, but these findings may have been explained in part by more severe disease among non-whites.59,60 Non-whites with hypertension were less adherent to medications, both unintentionally and intentionally, part of which was related to medication side effects.60,61 Qualitative research suggested that disparities in cardiovascular risk management may be related to low health literacy, less knowledge, and less assertiveness with physicians among African-American patients.62
African Americans were less likely than whites to receive influenza vaccines. In addition, both African Americans and Latinos were less likely than whites to know they needed a vaccination and more likely to rely on physician recommendations and reminders to receive vaccinations.63
Several themes emerged from our qualitative review as likely contributors to racial disparities in VA health care.
Our review reveals that racial disparities in the VA health care system exist across a wide range of clinical areas and service types. The existence of these disparities is noteworthy in a health care system where financial barriers are minimized. Our review also reveals several potential sources of racial disparities in health care. It should be noted, however, that important limitations make it difficult to draw firm conclusions about the sources of racial disparities elucidated in our review. First, studies were highly varied in terms of settings and populations, clinical topics and services, data collection methods, and measures. This variability makes it difficult to generate unifying theories that are generalizable across settings and services. Second, most studies examining potential sources of disparities focused on whether a hypothesized cause (e.g., communication patterns) varied by patient race or ethnicity, but not on the degree to which that cause helped explain the disparity that motivated the study (e.g., differential use of cancer surgery). For example, 1 study found that African-American patients with lung cancer are less likely to undergo surgical tumor resection than white patients.18 In a subsequent study, investigators hypothesized that this disparity might be explained by different patterns of patient–physician communication and patient trust in physicians, by race.19,20 They found that communication patterns and trust did indeed differ by race. However, because of the relatively small number of patients in their study, they were not able to examine whether differential communication patterns and trust helped explain differences in lung cancer surgery. This is a pervasive limitation, because the detailed data needed for studies exploring potential causes of disparities—which often involve surveys, chart review, or qualitative research methods—are often difficult to collect in numbers large enough to determine whether those potential causes explain observed disparities, which are often documented using large administrative data sets.
Acknowledging these cautions, we believe the findings of our review suggest some promising areas for future research to further elucidate and reduce racial disparities in health care.
Decision aids and information tools Because disparities may arise from different levels of familiarity with and information about medical interventions, tools that provide accurate information about the rationale, risks, and benefits of interventions have the potential to “even the playing field” among minority and white patients in terms of knowledge. Such tools, many of which use computer technology to help patients better understand not only medical interventions but also their own preferences, also have the potential to make patients more active participants in their medical care, which may improve understanding and adherence. In designing decision aids and information tools for minority patients, investigators should pay attention to issues of literacy, language, and culture.
Adherence support interventions Minority patients appear to be consistently less adherent to treatment plans than whites. Studies suggest that this may in part be caused by less social support and planning among minority patients. Interventions to provide adherence support—e.g., education, assistance with care planning—may help reduce this disparity.
Patient activation interventions Interventions to make patients more active participants in their interactions with health care providers and in the management of their illnesses have been shown to improve health outcomes. They may also reduce disparities by breaking the cycle of passivity that leads to less information exchange between minority patients and their health care providers. More active patient participation has the potential to improve patient adherence and to strengthen patient–provider partnerships and mutual trust.
Patient-centered communication training Interventions to make patients more active participants in their interactions with health care providers can also target providers. Clinicians can adopt communication strategies that help elicit patient perspectives and engage patient participation. As with patient activation interventions, patient-centered approaches to health care interactions hold the potential to strengthen patient–provider partnerships and mutual trust.
Determining sources of variation in clinician judgment by patient race As described above, studies have found that clinicians make different judgments based on patient race. However, the degree to which this variation is driven by clinical characteristics versus non-clinical factors, such as racial bias, remains unclear. Studies exploring how and why patient race is associated with different clinical decisions would help determine the need for and inform interventions to reduce adverse consequences of racial bias among clinicians.
Interventions to promote evidence-based decision making by providers Similar to decision aids and information tools for patients, guidelines and decision rules for providers hold the potential to improve equity by standardizing care. Guidelines, decision rules, and other quality improvement tools that promote evidence-based decision making may reduce the influence of provider bias and enhance equity of care among patients of different races and ethnicities.
Determining facility characteristics associated with health care quality and equity Some disparities are explained by differences in the health care facilities where minority versus white patients seek care. Determining the differences in structures and processes across minority- versus majority-serving health care facilities would inform interventions to eliminate system-level sources of disparities. In addition, studies examining facility-level characteristics associated with more equitable care within institutions—including those related to the racial and cultural context, such as the racial composition of clinical staff—would help inform system-level interventions to eliminate disparities.
In exploring these areas of future research on disparities in health care, researchers should explicitly define how race is conceptualized within a given study. A group of investigators has developed a survey/interview tool to assess the ecocultural factors for which patients’ race and ethnicity often serve as proxies.71 “Unpacking” race and ethnicity in studies of disparities will promote understanding and inform future interventions. Researchers should also be mindful that some disparities represent overuse of medical services among white patients rather than underuse among non-whites. Clearly, interventions to promote greater use of services among non-whites in these instances is unwarranted. Most VA studies to date have examined differences between whites and African Americans and have either excluded other groups or not included them in sufficient numbers for meaningful analysis. As the VA patient population becomes more diverse, it will be important to include sufficient numbers of Latinos and other minority groups in future studies. Finally, future studies should attempt to account for non-VA utilization. Because non-VA care is more prevalent among white patients than among non-whites, ignoring non-VA utilization may generate misleading results.
Our review represents a snapshot of research on racial and ethnic disparities within the VA. The VA is a unique health care system within the U.S. with a unique patient population that includes few women and suffers a greater burden of illness compared to the general population.72 As such, our findings may not be entirely relevant to other systems or populations. However, because research in the VA can examine potential sources of racial disparities in an “equal access” setting relatively free of financial incentives and barriers, we believe that the studies reviewed, and our synthesis of them, represent a unique and important contribution to the literature on racial disparities in health care. Periodic efforts such as this one to take stock of what is known about racial disparities in health care are necessary to ensure that the pressing task of reducing and eliminating disparities is carried out in an evidence-based and efficient way.
This study was funded by and conducted for the Evidence Synthesis Activity Pilot (ESP) Program of the U.S. Department of Veterans Affairs Health Services Research and Development Service (ESP 05-225). The authors are responsible for the content of the manuscript and the decision to submit it for publication. We thank the ESP planning committee as well as content experts Judith Long, M.D., Eugene Oddone, M.D., Elizabeth Yano, Ph.D., and Donna Washington, M.D., M.P.H., for providing guidance and feedback on draft versions of the report. We are grateful to Nancy A. Brown, MLS, for designing the search strategy and conducting the literature search. Dr. Saha is supported by awards from the VA Health Services Research & Development Service Advanced Research Career Development Program, and from the Robert Wood Johnson Foundation Generalist Physician Faculty Scholars Program. Dr. Toure is supported by an award from the Robert Wood Johnson Clinical Scholars Program. Dr. Tippens is supported by the Complementary and Alternative Medicine: Expectancy and Outcomes, Project 2. Dr. Ibrahim is a recipient of a career development award from the VA Health Services Research and Development Service and the Robert Wood Johnson Foundation’s Harold Amos Faculty Development Award.
Conflict of Interest None disclosed.
TABLE OF CONTENTS
Table 1. The use of surgery, radiation, and chemotherapy by race and cancer type .................... 2
Table 2. The use of invasive procedures for stroke among veterans, by race .............................. 3
Table 3. The use of invasive procedures for heart disease among veterans, by race..................... 4
Table 4. Potential mediators of disparities in the use of invasive procedures amomg veterans with cardiovascular disease ................ 7
Table 5. The use of colon cancer screening among veterans, by race ........................................... 9
Table 6. Management of hypertension, by race........................................................................... 10
Table 7. Management of cardiovascular risk factors (excluding hypertension), by race ............ 11
Table 8. Access to the VA healthcare system, by race ................................................................ 12