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Quiñones AR, O'Neil M, Saha S, et al. Interventions to Improve Minority Health Care and Reduce Racial and Ethnic Disparities [Internet]. Washington (DC): Department of Veterans Affairs (US); 2011 Sep.

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Interventions to Improve Minority Health Care and Reduce Racial and Ethnic Disparities [Internet].

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DISCUSSION

STATE OF INTERVENTION RESEARCH

The original intent of this review was to take stock of evidence provided by VA intervention studies designed to reduce race/ethnic disparities among minority Veteran populations. However, very few published interventions in VA settings were found in our systematic searches. As a result, we examined intervention studies not limited to VA populations because many of the interventions studied – outside of those focused on organizational change in non-integrated health systems – could be potentially informative to VA settings. Because of the number of studies and the adequacy of existing systematic reviews, we conducted a review of systematic reviews rather than of original studies. The review of reviews also allowed us to discern lessons through a qualitative “meta-synthesis” of the syntheses offered in the existing reviews. In general, these reviews from disparate clinical and cross-clinical areas find that a good case can be made for interventions based on case manager-led care coordination efforts, culturally tailored patient education, and community health workers. However, most studies included only single-race, minority populations. Very few interventions tested for reductions in disparities between minority and white adults. Thus, much of the evidence in the reviews provided only indirect evidence of the potential for interventions to reduce disparities. Fewer interventions still have been tested with Veteran populations.

Our review provided the opportunity to categorize existing disparities intervention research into a framework that can be used to guide future research. This framework builds on a taxonomic system widely used to sort disparities research into three generational categories.45, 46 First generation research is the term coined for work that identifies race/ethnic disparities in health or health care. In logical sequence, second generation research then attempts to explain and elucidate reasons for these disparities, and third generation work describes efforts to deploy interventions to reduce and eliminate observed disparities. Increased attention to third generation research is seen as a necessary next step in order to continue to make advances in reducing disparities in health and health care. However, little effort has been paid to further categorizing third generation research.

We categorize existing disparities research in order to highlight gaps in the literature and provide a framework for describing future interventions. Based on our review, we categorized disparities intervention research studies according to the populations included. Most studies included single-race or minority-only populations, examining the effect of interventions within a group known to receive lower quality care or have poorer outcomes than the majority white population. Effectiveness documented in such studies provides only indirect evidence that the studied intervention will reduce disparities. Fewer studies were comparative in nature, including both minority and majority populations, and comparing measures in both groups before and after the intervention. Such studies provide direct evidence of an intervention's capacity to reduce disparities. However, studies including minority and majority groups did not always report data stratified by race/ethnicity.

We also categorized interventions, as “generic” or “tailored”. The bulk of included studies described generic interventions, ones that are applied without consideration of group specific needs or preferences. Many of these interventions involved quality improvement efforts, or care standardization, testing the premise that deficits in care for minority groups might be reduced if care was applied similarly for everyone. In contrast, tailored interventions describe efforts to address barriers specific to a minority group. Many of these interventions involved specially designed educational materials crafted with specific minority groups in mind (e.g., lessons that address knowledge and health beliefs of minority populations), or community health workers that addressed the special needs of minority patients within their own communities. Community health workers were typically members of those minority communities and therefore understood the context and culture of the population served.

Only studies that examine intervention effectiveness with a minority population (or several) alongside whites can detail the extent of a disparity and the potential for the intervention to reduce it. Ideally, these studies would report differences between minorities and whites before and after intervention implementation. Instead, the majority of third generation literature is populated with studies that either: (1) do not allow determination of the presence of a disparity because of the lack of a white comparison group, or (2) do not provide pre-post intervention measures for both minority and white population groups. In order to determine whether interventions are effective in reducing disparities in outcomes or care, it is necessary to examine both minority and white populations using a difference-in-difference approach to evaluating intervention effectiveness. However, the methodological challenges (e.g., sample size, ability to receive funding, cost) inherent in designing, testing and implementing interventions to reduce disparities raise questions of feasibility. It is possible that partnering with large projects to investigate multiple research objectives could provide sufficiently large populations of minority Veterans to detect effects in clinically meaningful outcomes.

CONCEPTUAL FRAMEWORK

Though the evidence base is overall a limited one, there are common intervention types across clinical areas that suggest promising results. A key theme was that studies that considered patients in their lived environment were often more promising than those confined to health care systems or interactions. This finding, along with emerging thought about the key drivers of disparities in health and health care, indicates that an intervention framework that considers not only medical care but also incorporates social determinants of health and illness could be helpful in guiding future research. In this view, race/ethnic disparities in health are seen as driven in part by a broad array of social factors – including education, poverty, and community infrastructure – as well as a complex interplay between these social and cultural influences, characteristics of communities and environments where individuals reside, and interactions with providers and health care systems.

Disparities in health and disparities in health care have traditionally been viewed as distinct problems with different solutions. Addressing health disparities has accordingly been viewed largely as a social and public health agenda, beyond the purview of health care delivery systems. Disparities in health care, in contrast, reflect the observation that the quantity and quality of health services received by racial and ethnic minority groups are consistently lower than for the majority white population. Initiatives to address health care disparities typically focus on ensuring equity in health care delivery, which is viewed as a responsibility of health systems. The role of health systems in addressing social determinants has been limited, with difficulties in dealing with factors that traditionally lie outside of physician purview often cited as a main obstacle.

However, reducing disparities in the care and outcomes of minority Veterans poses special challenges that will require taking down the partition between medical care and public health, and between health systems and communities. Minority Americans bear a disproportionate burden of morbidity and mortality attributable to chronic illnesses, such as diabetes, hypertension and heart disease.47-49 Despite the fact that the VA provides an integrated health care system with universal access for Veterans, race/ethnic disparities in care and outcomes have been extensively documented in VA settings.50 Reducing disparities in health care and outcomes will require not only improving equity within the health care system, but extending beyond the system and into the communities where patients live and work. VA health care, in other words, may need to incorporate an understanding of the social determinants of health and extend beyond the health care center into patient communities.51-53

There are efforts underway that attempt to bridge social factors with care delivery. Community health worker interventions represent an effort to bridge communities and health care systems. The VA implementation of a network of community based outpatient clinics represents an effort to connect care access for Veterans in less-populated areas. It is important to consider not only disparities that may arise from clinician biases and organizational deficiencies in cultural competence, but also to incorporate an understanding of patient circumstances in their lived environment. Accounting for what transpires for Veterans as they move from clinician offices through their communities and into their homes may expand the possibilities for reducing and eliminating disparities in care and outcomes.

Figure 2 details our conceptual mapping of areas bearing influence on health outcomes for individuals, which span from the patient-provider interaction to the environments where individuals live and work. In addition, figure 2 describe our meta-findings by mapping interventions identified in this review that bridge areas where disparities in health care and outcomes arise. By considering the entire spectrum, we are able to identify potential for intervention strategies to expand the reach of health systems. While specific interventions tackling disparities arising from particular nodes are associated with limited or equivocal evidence (i.e., clinical reminders), more effective interventions reach beyond one limited area to address multiple components simultaneously (i.e., case management, community health workers, tailored health education). Conceptually, these interventions are more successful at addressing disparities that emerge and operate at different levels. This conceptual diagram also demonstrates the importance of incorporating social factors into the discussion of addressing disparities in health outcomes. In the future, studies designed to address race/ethnic disparities in health should be explicit about where interventions fall within these conceptual ellipses. Based on our review, interventions that span across multiple ellipses may prove to be more effective than more limited interventions.

Figure 2. Conceptual Model—Reach of Interventions.

Figure 2

Conceptual Model—Reach of Interventions.

The strength of interventions lies in the connectedness of intervention programs to the individuals they are meant to reach, as well as the consideration of underlying patient health needs and socioeconomic means. The diagram acknowledges that the effectiveness of interventions that span across providers, health care systems, neighborhood environments and individual residences are at least partly dependent on patient demographics (e.g., age, gender, literacy), individual socioeconomic means and neighborhood structural qualities (e.g., safe and abundant places to exercise) and health needs (e.g. severe chronic conditions). Based on this review, interventions that include comprehensive care management efforts, evidence-based health education programs, and consistent, well-trained community health workers show potential for reducing disparities in health and health care for minority Veterans.

FUTURE RESEARCH AND IMPLICATIONS FOR VA HEALTH CARE SETTINGS

There are several key steps that may aid in the development, testing, and implementation of disparities interventions that could help fill some of the many identified evidence gaps. First and foremost, continuing the VA policy to consistently collect race and ethnicity information for all Veterans is to be encouraged. The ongoing concerted effort to populate race/ethnicity in the VA data records is a critical step to chronicling progress in reducing disparities for minority Veterans.

Capacity assessment also forms an important precondition with regard to intervention implementation in the VA. Two active war theaters imply changes in the Veteran population that will result in near-term burdens on the VA health care system. Efforts to improve knowledge and expertise of providers (e.g., through cultural competence training) will increase awareness of disparities in care and outcomes among minority Veterans.

In addition, there are practical and operational considerations to implementing promising interventions. For example, the use of community health workers was frequently identified as a strategy that holds promise for reaching minority populations. However there is substantial heterogeneity in the composition, training, monitoring, frequency of contact and setting for peer health workers. Identifying optimal characteristics (e.g., training protocols, forms, software) for these interventions is necessary for effective implementation. Documentation and implementation details (including unanticipated challenges and solutions) should be encouraged.

A recent study of VA health care trends found that, although gaps in process measures between black and white Veterans in the VA health care system narrowed after the implementation of quality improvement efforts, significant differences in clinical outcomes have persisted, most notably in heart disease, diabetes and hypertension.54 Most studies included in our review focused on process of care outcomes and few examine the effects on distal health outcomes. Future studies should sustain longer follow-up periods and include enough patients to examine distal health outcomes.

The vast majority of reviewed interventions also relied on results from small-scale study settings with limited geographic scope. This raises questions of generalizability of results, and VA capacity for scaling these demonstration projects to larger and more geographically representative Veteran populations. Although it is difficult – and risky – to argue for scaling up promising pilot studies of small-scale interventions, there is potential for partnering with already-deployed, large, multicenter programs such as the VA's patient aligned care team (PACT) demonstration projects. In this way, multiple initiatives that require access to a large pool of Veterans can be addressed with a single research investment.

In sum, in order to translate promising directions posed in this review into future research and implementation efforts in the VA, it is necessary to consider the following issues:

  • Interventions need to be described in more detail in order to allow for determination of effective components of interventions. For example, in interventions involving community health workers and care managers, there was poor specification of the training of those personnel.
  • Integrate the use of community health workers into VA settings. This could involve Veteran peer advisors coming from communities where Veterans reside.
  • Examine the potential for ongoing, large VA demonstration projects in care coordination/care management to improve the health of minority Veterans and reduce disparities.
  • Enhance the capacity to tailor patient educational materials to address the specific needs of minority Veterans.
  • Consider funding studies explicitly designed to measure pre-post changes in disparities between minority and white Veterans.
  • Encourage the inclusion of less well studied minority Veteran groups (i.e., Asian/Pacific Islander and American Indian) in the design and implementation of disparities studies.

There are also opportunities for studies conducted in single VAMCs – such as the lessons offered by the five included primary VA research studies – to provide important discussion of how to best reduce disparities for minority Veterans. Future third generation research specific to VAMCs should be encouraged and disseminated in order for VA researchers and implementers to benefit from a robust evidence base. From a practical standpoint, there is room for “disparities teams” at individual VAMCs to learn from collective knowledge gained across various VA sites. Sharing lessons and promising strategies for reducing disparities from ongoing research projects through periodic communication between disparities interest groups may serve to quicken dissemination of actionable results to VA equity stakeholders.

Given the low yield of VA intervention studies identified in our search of published literature, we examined the abstracts of recently funded HSR&D studies to determine whether intervention studies for racial/ethnic disparities are in progress. We reviewed 89 titles and abstracts of projects in the HSR&D Equity Portfolio and found four projects containing race-specific interventions: Improving Dental Decision Making for Root Canal Therapy (Kressin N), Tailoring Coping Skills Training for African Americans with Osteoarthritis (Allen K), Knee Replacement Disparity: A Randomized, Controlled Intervention (Ibrahim S), Proactive Tobacco Treatment for Diverse Veteran Smokers (Fu S). There were three career development awardees with potentially relevant project titles, although the details of study design are not currently available: Understanding & Reducing Racial Disparities in Renal Transplantation (Myaskovsky L), Understanding & Ameliorating Racial/Ethnic Disparities in Healthcare (Burgess D), Identifying Mechanisms Linking Perceived Discrimination & Health (Hausmann, L).

Few disparities interventions have been implemented in the VA, and although a few race-specific intervention studies are underway, much more work is needed in this area. The barriers to implementing disparities intervention research in VA care settings are not entirely clear. Future steps emanating from this review will include conducting a survey and interviews of key VA informants to identify barriers to dissemination of interventions, in an effort to provide a better understanding of the obstructions in the VA disparities research pipeline.

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