Racial gaps persist in VA health care

BROWN (US) — Despite dramatic overall improvements at Veterans Affairs medical centers, health outcomes of African-Americans remains at a level below that of whites.

Disparities are not found in just a few VA medical centers, but can be found widely throughout the system that cares for more than 5 million patients.

While VA doctors became significantly more likely to provide better care to members of each racial group, both for process (ordering appropriate tests) and outcomes (obtaining improved results),  because care for black veterans did not increase in quality faster than it did for white veterans, the disparity that existed before remains stubbornly in place.

“The disparities that we saw were for outcomes measures, or getting the right result, as opposed to the provider doing the correct thing,” says Amal Trivedi, assistant professor of community medicine at Brown University.

Details are published in the journal Health Affairs.

For example, in 2009, 63 percent of black veterans with diabetes had controlled cholesterol compared to 71 percent of white veterans, a disparity of 8 percentage points. In 2005, the disparity was 9 percentage
points.

While the disparity didn’t change, the quality of care did. Among patients with diabetes, only 52 percent of black veterans and only 61 percent of white veterans had controlled cholesterol in 2005. Between 2005
and 2009, whites and blacks saw 10 and 11 percentage-point jumps in better outcomes respectively.

Trivedi can’t account for why the gap has remained even though the VA has improved quality overall, but says the data present the VA with the opportunity to recognize the disparity and focus on it. “It’s important for all health systems, not just the VA, to track performance for vulnerable groups,” he says.

Other research, he says, has shown that racial disparities on similar measures is 1.3 to 2 times higher in the Medicare system than at the VA.

Better than Medicare

Overall, the Veterans Affairs system trumps private Medicare plans for patients 65 and older, according toa separate study published in the journal Medical Care.

Trivedi and co-author Regina Grebla, looked at comparable quality indicators in 293,000 VA records from 142 VA medical centers and more than 5.7 million from 305 Medicare Advantage plans between 2000 and 2007.

“On these indicators the VA outperformed private sector Medicare Advantage plans by a wide and increasing margin,” Trivedi says. “Quality is going to be a function of incentives and capabilities, and in the VA the incentives may be better aligned for providing high-quality care.”

In the study’s first year, the VA system scored higher in 10 of 11 quality measures, missing the mark only on providing eye exams to diabetic patients, by 2.6 percentage points.

After the first year, the VA’s quality improved faster than the private plans in a majority of indicators.

By the final year in the study, the VA surpassed Medicare Advantage providers in all 12 measures he studied.

The VA’s higher quality margin in 2007 ranged from 4.3 percentage points in the case of testing LDL cholesterol among patients with coronary artery disease to 30.8 percentage points in providing colorectal cancer screening.

In all 12 measures, the VA also had lower quality disparities than private plans between patients living in areas with the highest and lowest incomes and education levels. For example, for diabetic patients, the quality difference in controlling blood sugar between patients living in the richest and poorest areas was 0.6 percentage points in the VA system, compared to 8.1 percentage points in Medicare Advantage plans.

“The VA holds clinicians and managers accountable for quality, and emphasizes primary care and health information technology,” Trivedi says. “These practices can also be used by private-sector systems to improve care.”

The study was funded in part by the Robert Wood Johnson Foundation.

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