Health Equity Research in the Veterans Health Administration: We’ve Come Far but Aren’t There Yet

One hundred and fifty years ago, the Civil War dramatically altered the makeup of the US military. More than 200 000 freemen and former slaves enlisted in black regiments, and an additional 25% of the Union Army were foreign-born Irish, German, and Dutch immigrants. It was another 80 years before President Harry S. Truman signed Executive Order 9881 officially desegregating the US Armed Forces, declaring “there shall be equality of treatment and opportunity for all persons in the armed services without regard to race, color, religion or national origin.” Since then the makeup of the military and, as a result, that of the veteran population has continued to evolve, with notable recent increases in the number of women, Hispanic, and other minority veterans.

The challenge for the Department of Veterans Affairs (VA) in serving this increasingly diverse population is to ensure that we help each veteran achieve the best outcomes possible regardless of who they are, where they live, or what health problems they have. For well over two decades, VA researchers have been helping the Veterans Health Administration (VHA) determine whether we are meeting that challenge.¹ Almost a decade ago, the VA Health Services Research and Development Program established the Center for Health Equity Research and Promotion to foster research to accelerate disparities research, following a roadmap that progressed rapidly from detecting and understanding health disparities to testing interventions that sought to eliminate them in the real world.² In 2012, faced with evidence that we were not yet achieving equal outcomes for all veterans, VHA established the Office of Health Equity under Uchenna S. Uchendu, MD, creating a policy office with a mandate to addressed a wide range of issues to promote health equity.

WHAT WE HAVE LEARNED SO FAR

Now is an opportune time to reflect on what we have learned from research, why it still remains relevant, and where we need new research. The first lesson of VA research was that providing access to health care doesn’t itself guarantee equal health outcomes. The VA generally does well at delivering preventive and primary care services across demographic groups (e.g. testing for high blood pressure and diabetes, cancer screening) and disparities by socioeconomic groups are smaller than in Medicare advantage.^1,3 Nonetheless, VA hasn’t been able to eliminate the racial and ethnic disparities in outcomes (e.g., blood pressure control, cancer mortality) which are also seen outside VA.¹ Disparities in process measures are more marked for services where patient choice plays a larger role (e.g., knee replacement). Second, the causes of health disparities in VA defy simple explanations—the usual suspects of costs or overt bias are likely less important than many other factors that contribute to disparities at multiple levels of the health care system. These factors include gaps in health literacy and health “activation,” lack of cultural competence or unconscious bias among providers, stigma and other obstacles to accessing care (e.g., transportation or time off work), lack of trust in the health care system, and limited access to the community resources, networks, and social capital that support healthy living and appropriate medical care. As a result, the solutions will not be simple. Several studies since the inception of this roadmap have led to effective interventions in reducing disparities in access to care for conditions including hypertension,⁴ diabetes,⁵ and joint replacement.⁶ Third, general quality improvement sometimes but not always reduce disparities.⁷ VA has had more positive results from targeted approaches using peer support, combinations of medical and behavioral interventions, or multipronged approaches that incorporate the patient, provider, and health care system. All of these approaches align with more patient-centered care and with the need for more culturally tailored (gender, rural, racial or ethnic) strategies to reduce disparities.

Despite areas of progress, research on health equity remains as important within VA and outside VA as two decades ago. It is fundamental to our commitment to veterans that we ensure comparable, high quality care regardless of a veteran’s gender, race, or where they live. Moreover, we won’t make the transformation to veteran-centered care unless we understand the unique attitudes, obstacles, and community supports that may affect what care each veteran gets or the health outcomes they achieve. Finally, because having VHA care does largely remove the role of insurance and costs as barriers to care, VHA has been a great laboratory for revealing the significant noneconomic factors that influence the care and health outcomes of different groups.

Several areas deserve more attention from health services researchers. One is how the health care system can optimally partner with community resources to address disparities. In today’s stressed health care environment, it is an uphill struggle to get primary care teams to take on more responsibilities to address equity. Community-based groups have a long history in maternal and child health and in important public health areas such as HIV and diabetes, and they could probably help patients navigate difficult health care decisions in many other areas (e.g., joint replacement, cancer treatment, end-of-life care). A second area is the role of health information technology and smart-phone apps to promote patient engagement and healthy behaviors. The spread of smart phones can overcome some of the digital divide that remains in access to high-speed Internet, and they provide a resource for information, coaching, and data collection that is ever present. But we may need to tailor these apps to different groups to make them truly patient centered and maximally effective.

GETTING EQUITY RESEARCH INTO PRACTICE

As we identify effective strategies for reducing disparities, we need to ensure we effectively transfer that knowledge to the hands of health care providers, patients, and other affected groups. The VA’s Quality Enhancement Research Initiative Program (QUERI) is devoted to improving veteran care by supporting the implementation of effective treatments or programs into clinical practice. A major component of QUERI’s goal is to identify and use the best implementation strategies so that VA can reduce gaps in quality regardless of patient population or treatment setting. Many of these strategies have been applied in VA practice to address health care disparities in vulnerable populations, including Replicating Effective Programs,⁸ Getting to Outcomes,⁹ and the Blended Facilitation¹⁰ frameworks. The common elements of these frameworks include solicitation of input and engagement of the affected populations up front, specific training and coaching models to support providers in delivering the intervention, and ongoing monitoring and quality improvement to measure both uptake of effective treatments and the added value to the health care system.

To successfully implement interventions to reduce disparities, they must be acceptable to diverse veteran populations, and providers need the knowledge and tools to tailor the interventions to their practices and patients. Adoption by frontline providers is more likely if researchers involve implementation experts while developing the intervention. Similarly, involving veterans and other consumers of health care as interventions are rolled out will ensure they can be used, taught to others, and sustained over time. As an example of this approach, the VA Mental Health QUERI established a Stakeholder Council consisting of veteran representatives who review project ideas and make recommendations regarding the strategic direction of QUERI to improve implementation in mental health. Ultimately, researchers have the opportunity to honor our returning veterans by reaching out and involving them as active partners in their work. With the diversity of our armed forces, these partnerships can provide essential new insights into how to eliminate health care disparities and how to transfer new approaches into treatment settings where they are needed the most.