The Veterans Health Administration’s Promotion of Health Equity for Racial and Ethnic Minorities

The Department of Veterans Affairs (VA) Health Services Research and Development Service (HSRD) is proud to collaborate with the Journal to publish this special edition highlighting the Third Annual National Minority Health Leadership Summit. The summit, held in Pittsburgh, Pa, in January 2003, was titled “Eliminating Racial and Ethnic Health Disparities: The Role of Community-Based Participatory Research.” It was organized by the Center for Minority Health at the University of Pittsburgh Graduate School of Public Health and was cosponsored by the US Department of Health and Human Services Office for Civil Rights (Region III) and the VA Center for Health Equity Research and Promotion.

During a special VA panel session at the summit, we described the VA’s comprehensive response to the national initiative to eliminate disparities in health and health care among racial and ethnic minorities. The audience, a diverse group of health professionals, public health workers, and community service providers, was largely unaware of the leading role the VA has played in promoting equality in health and health care among these traditionally underserved populations.

A LEADER IN THE EFFORT TO ELIMINATE HEALTH DISPARITIES

With its overlapping medical, educational, social, and research missions, the Veterans Health Administration (VHA) is uniquely positioned to respond to the congressionally endorsed national mandate to eliminate disparities in health and health care by 2010. First, it is the largest integrated health care delivery system in the nation, and it continues to grow. Its 163 hospitals, more than 850 ambulatory care and community-based outpatient clinics, 137 nursing homes, 43 domiciliary units, and 73 comprehensive home-care programs provide state-of-the-art health care. In 2002 more than 4.5 million people were treated in VA health care facilities. The VA’s outpatient clinics alone registered approximately 46.5 million visits in 2002. The number of patients cared for by the VHA increased by more than 9.5% from 2001 to 2002.

Second, the VHA provides medical care for an ethnically and racially diverse patient population. In the post-Vietnam era, African American and Hispanic patients represented 17.1% and 5.1%, respectively, of all veterans.1 These proportions are likely to increase in the future owing to the ever increasing diversity of the US military workforce.

Third, the VHA is committed to ensuring the highest quality of health care for all veterans. One example of a salient contribution to quality care is the Quality Enhancement Research Initiatives (QUERIs) program created by the HSRD to rapidly translate research findings into improved patient care.2 At the present time, QUERIs have been established for 8 medical conditions prevalent among veterans (e.g., diabetes mellitus, congestive heart failure), and several more are in the planning stages. In addition, past investments in systemwide computerized clinical and administrative databases such as the national Patient Treatment File, have made it possible to measure quality of medical care and health outcomes throughout the VHA health care delivery system and to prospectively track the success of ongoing national quality improvement programs.

Fourth, embedded within the VHA’s medical mission, to provide quality health care to all veterans, is a social mission—to achieve equity in health care for all veterans. It is well documented that veterans who seek care within the VHA are more likely to be impoverished and less likely to have access to supplemental forms of health insurance than veterans who seek care elsewhere.3,4 The standards used to determine veterans’ eligibility for health care benefits include personal income. This system of unrestricted access and eligibility for services based on need lessens the influence of income and access to health care as potential confounders of the associations between race/ethnicity and disparities in health and health care. Thus, research that addresses the pressing issues of health disparities within the VHA can more easily focus on identifying other possible mediators of observed disparities.

Fifth, the VHA manages the largest medical education and health professional training program in the United States. VA facilities are affiliated with 107 medical schools, 55 dental schools, and more than 1200 other schools across the country. Each year, about 81 000 health professionals are trained in VA medical centers. More than half of the physicians practicing in the United States have had part of their professional education in the VHA system. These training programs help promote the tenet that the education of health care providers must be relevant and culturally sensitive to the priorities of the racial and ethnic minority communities they serve. Thus, VA training programs have tremendous potential to imprint and reinforce these important values in the nation’s medical workforce.

Finally, the VHA has a strong commitment to research that reinforces its medical mission to provide high-quality health care to veterans, supports its social mission to provide a safety net for vulnerable veterans, and demonstrates its value to the nation as a whole. In 2002, VA funding for research was $371 million, with an additional $377 million in support from the VA’s medical care account and $624 million from the National Institutes of Health, research foundations, and pharmaceutical companies. The VHA currently conducts more than 15 000 research projects at 115 VA medical centers, many focused on issues of health care disparities among racial/ethnic minorities.

VA RESEARCH ADVANCES THE NATIONAL INITIATIVE TO ELIMINATE HEALTH DISPARITIES

The VA’s commitment to identify, understand, and eliminate racial, ethnic, and cultural disparities in health and health care is demonstrated in its increasing support of research related to minority health and health disparities over the last 5 years. In fiscal year 2002, VA investigators received almost $28 million in funding for 203 minority health and health-disparities research projects. Of this total, the VA provided $7.8 million for 59 relevant studies, increasing its funding in this area by 44% between 2001 and 2002.

In 2001, the HSRD established the Center for Health Equity Research and Promotion (CHERP) at the VA Pittsburgh Healthcare System and Philadelphia VA Medical Center. CHERP’s vision—“Excellence in health services research forging the path for equity in health and health care quality”—guides its approach to achieving its strategic goals, which include (1) advancing the science of health equity research, (2) increasing the impact of health equity research through effective collaborations and dissemination of research results, (3) translating research into practice (i.e., reducing health and health care disparities in the VHA), and (4) supporting and advancing health equity and health services research training and mentoring within the VHA. Accomplishment of these goals will enable CHERP and the VHA to advance their mission to reduce disparities and promote equity in health and health care in vulnerable veterans, including ethnic and racial minorities.

In addition, in 2002, the HSRD renewed a special solicitation for health services research on ethnic and cultural variation and also funded publication of a special supplement of the journal Medical Care on racial disparities research in the VHA.5 Most recently, in 2003, the HSRD cosponsored the Third Annual National Minority Health Leadership Summit and funded publication of this special theme issue of the American Journal of Public Health.

The breadth of the VA health disparities research portfolio is reflected in the original VA research published in this issue of the Journal. Four of the five VA studies published herein advance the field of health disparities research beyond the identification of disparities in health and health care by clarifying the reasons for disparities and elucidating potential points of intervention to eliminate them. McGinnis et al. not only demonstrate that mortality for veterans with HIV varies by race but explore possible reasons for this variation.6 Ibrahim et al. examine the role of physician decisionmaking in the previously observed racial disparities in cardiac revascularization rates.7 Freeman et al. focus on understanding mediators of the previously documented racial disparities in prostate cancer mortality in VA and non-VA settings.8 Saha et al. examine whether racial differences in satisfaction with health care and use of basic health services are explained by differences in the quality of patient–physician interactions, physician cultural sensitivity, or patient–physician race concordance.9

In the fifth VA study, Kressin et al. advance the methodology of VA health disparities research by quantifying the rates of agreement between VA administrative and self-reported race/ethnicity data.10 This important piece suggests that previous studies using VA administrative data may have underestimated the magnitude of racial disparities observed within the VHA.

THE VHA’S FUTURE PLANS TO PROMOTE HEALTH EQUITY

The recently appointed VA Chief Research and Development Officer, Nelda Wray, MD, MPH, is committed to achieving her vision for VA research: “Today’s VA research leading tomorrow’s health care.” Guided by this vision, the VA Office of Research and Development (ORD) will increase support for research directly affecting clinical practice, translational research to ensure that new evidence is rapidly applied to patient care, and quality measurement efforts to ensure that VA research improves the quality and equity of health care delivery.

Immediately upon assuming this new VA leadership role, Dr Wray appointed 6 blue-ribbon committees to chart the future course of VA research, including the Committee on Building Scientific Career Paths for Underrepresented Minorities in VA Research. This committee was formed in recognition of the fact that the education of clinical investigators must be relevant and culturally sensitive to the priorities of the racial and ethnic minorities served by the VHA. To achieve this goal, it is crucial that faculty from racial/ethnic minoritiy communities play a prominent role in educating health professionals and clinical investigators. Unfortunately, minorities constitute less than 5% of the nation’s medical faculty members, and a significantly smaller percentage of those are engaged in research. In an effort to address this problem, the VA established the Research Experience Program in 1994 to encourage students and faculty from historically Black colleges and universities, Hispanic-serving institutions, and Native American–serving colleges to participate in research with the VA. While this program has provided valuable academic experience for talented faculty and students associated with these important minority-serving institutions, the Committee on Building Scientific Career Paths for Underrepresented Minorities in VA Research has far more ambitious recommendations.

This committee, composed of leading minority researchers and faculty from minority-serving institutions, was charged with (1) developing innovative and productive programs and supporting organizational structures to recruit, mentor, and advance clinical investigators from underrepresented minorities in the VA and (2) developing explicit requests for applications designed to recruit and retain minority applicants for careers in VA biomedical and clinical research. On the basis of recommendations from this committee, the ORD will introduce several additional strategies to foster the development of minority investigators through the establishment of research training opportunities for minorities from the high school level to the midcareer faculty level.

The new programs currently being introduced include (1) the Minority Research Enhancement Centers, which will support institutional collaborations between the VA, minority-serving institutions, and VA affiliate universities; (2) the Mentored-Minority Supplemental Award Program, which will provide individual, one-on-one applied training in research on VA-funded research projects for underrepresented minorities; and (3) the Mentored-Minority Career Enhancement Program, which will provide individual, one-on-one training and a supportive VA research career path for mentored-minority physicians and other clinicians, as well as nonclinical PhD students and recent PhD graduates. The ORD has allocated $6 million annually to establish these programs and is also working to develop targeted outreach strategies to engage the leadership of minority-serving institutions, foundations, professional societies, and the national VA research community in these programs.

In summary, the VHA’s overlapping missions have been pivotal in positioning us to acquire crucial knowledge concerning health disparities and transform that knowledge into high-quality equitable health care for veterans. The new programs proposed by the ORD will reaffirm the VA’s commitment to continue playing a key role in the battle to eliminate disparities in health and health care for veterans and for all US citizens.