Health Policy$ense

State of the Science in VA Health Equity Research

A Supplement in Medical Care

A recent supplement to the journal Medical Care highlighted the importance of the US Department of Veteran Affairs (VA) in addressing health disparities among increasing numbers of women, people of color, and residents of rural communities in the Veteran population. Deputy Under Secretary for Health for Community Care Baligh Yehia (a former LDI fellow and MSHP alumnus) and colleagues write: “As the largest integrated health care system in the nation, VA has an opportunity to lead the rest of the country in reducing health and health care disparities.”

The supplement, “Advancing Health Equity in the VA Healthcare System: State of the Science” was produced by the Center for Health Equity Research and Promotion (CHERP) and the Health Equity and Rural Outreach Innovation Center (HEROIC) of the VA’s Health Services Research and Development Service. This issue was co-edited by LDI Senior Fellow and CHERP Co-Director Said Ibrahim, CHERP Co-Director Michael Fine, and former Director of HEROIC Leonard Egede.

As the editors discuss in the introduction, the articles focus on disparities among three vulnerable populations: homeless Veterans; Veterans identifying as lesbian, gay, bisexual, and transgender; and Veterans of racial/ethnic minority backgrounds. The research emerged from a state-of-the-science conference by CHERP and HEROIC that was a unique opportunity for researchers, operations leaders, and Veterans from these populations to convene.

The supplement sheds light on how different vulnerabilities intersect. In one study, Gawron and colleagues found that ever-homeless women Veterans, in comparison to their housed counterparts, were more likely to suffer from substance abuse and other health conditions. In another study, Bukowski and colleagues found that transgender Veterans living in rural towns were more likely to suffer from tobacco abuse and post-traumatic stress syndrome than their counterparts living in urban areas.

Another study, by Shrimrit Keddem and LDI Senior Fellows Judith Long, Rachel Werner, and Judy Shea assessed barriers to patient engagement in VA sites that serve high proportions of nonwhite patients. They found that “high-performing, high-minority-serving sites tended to describe more staff training opportunities and staff feedback mechanisms, [while] low-performing and high-minority-serving sites more often reported barriers to implementation of patient engagement practices.” Even though all sites experienced the same barriers, high-performing sites more often reported measures for quality improvement and feedback mechanisms.

The authors then developed a toolkit to reduce disparities in patient engagement, using qualitative interviews and observations from more than 30 primary care sites nationally. Through a consensus process that included conference calls and surveys, they pared down an initial list of more than 200 practices and resources. The final toolkit, now available online, comprises 36 practices that engage patients directly in their care and 19 resources that help facilitate patient engagement.

The individual toolkit items already have shown promise in increasing patient engagement  among local facilities; the authors intend to refine the toolkit on a smaller scale before disseminating it further, and then evaluate its effect on measures of patient-centeredness and shared decision-making.The study thus advanced a primary goal of the conference: to drive forward “the implementation of evidence-based interventions to improve the quality and equity of health and healthcare”—perhaps not only of the vulnerable Veteran populations featured in the supplement, but also of the broader American population of which they are a part.

Claire Dinh is a Master of Bioethics student at the University of Pennsylvania.