When the Department of Veterans Affairs (VA) released its Strategic Plan for FY 2014-2020, it noted that the veteran population overall – 21.8 million, according to the 2014 U.S. Census – was undergoing dramatic demographic changes.

American veterans, then, are increasingly from populations the federal government – including the VA, the Department of Health and Human Services, and other health-related agencies – considers to be “potentially vulnerable patient populations.” Veterans from these groups are at risk for receiving lower-quality medical care, or for having worse medical outcomes, than patients from the majority. A higher percentage of nonwhite adults, for example, suffers from at least one of seven chronic conditions – asthma, cancer, heart disease, diabetes, high blood pressure, obesity, or depression.

The majority of veterans today is predominantly male and white, with the largest cohort having served during the Vietnam War. But over the next 25 years, as Gulf War veterans overtake Vietnam veterans as the largest group, the percentage of white male veterans is set to decline by nearly 48 percent. Meanwhile, the percentage of several other groups – women, African-Americans, Hispanics, and other nonwhite veterans – will increase. By 2040, women will be nearly 20 percent of the veteran population, and 34 percent of all veterans will be nonwhite.

American veterans, then, are increasingly from populations the federal government – including the VA, the Department of Health and Human Services, and other health-related agencies – considers to be “potentially vulnerable patient populations.” Veterans from these groups are at risk for receiving lower-quality medical care, or for having worse medical outcomes, than patients from the majority. A higher percentage of nonwhite adults, for example, suffers from at least one of seven chronic conditions – asthma, cancer, heart disease, diabetes, high blood pressure, obesity, or depression.

In 2001, the Institute of Medicine (now the National Academy of Medicine) released a framework outlining six aims for the nation’s 21st century health care system: Medical care, the report stated, should be safe, effective, patient-centered, timely, efficient, and equitable, meaning “Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.”

The VA aims to minimize disparities – significant differences, either in health status or in the quality of health care – among vulnerable patient populations, both in the delivery of care and in a robust research program conducted on a vast number of fronts:

• The Cooperative Studies Program Epidemiology Center, founded in 1997 on the campus of the Durham, North Carolina VA Medical Center, conducts population studies investigating sources of disparities in health care and health outcomes among veterans.
• The Center for Health Equity Research and Promotion (CHERP) was established in 2001 as a national Center of Excellence focused on detecting, understanding, and reducing disparities in health and health care in vulnerable populations. Co-located at the VA Pittsburgh Healthcare System and the Philadelphia VA Medical Center, CHERP promotes equity by conducting research, partnering with VA clinicians and policy stakeholders, and training and mentoring beginning researchers – fellows, medical students, and residents.
• The Health Equity and Rural Outreach Innovation Center (HEROIC) in Charleston, South Carolina, began in 2004 as a targeted research initiative, focused on rural health outcomes, equity, and obstacles to care. In 2013, HEROIC became a VA Center of Innovation (COIN), focused on advancing the implementation of evidence-based interventions and developing innovative research methodologies for health equity data.
• VA has a long-standing and extensive research portfolio and network of investigators nationwide, focused on addressing health disparities among veterans.

There are no simple explanations for differences in health or the quality of care between groups, but the good news is that, as the nation’s largest health care system, the VA offers a unique opportunity to study the many applicable variables and to develop and evaluate patient-centered and culturally sensitive ways to deliver care.

In 2006, a group of VA researchers led by Amy Kilbourne, Ph.D., and including CHERP’s director, Michael Fine, MD, MSc, published a conceptual framework in which it outlined three phases of health disparities research: detection, understanding, and reduction/elimination.

Detection means acquiring the knowledge that disparities exist – knowledge typically discovered through epidemiological studies of large patient populations.

The second phase of research, aimed at understanding why these disparities exist, is more complex. “The explanation,” said Fine, who is also an attending physician in the VA Pittsburgh Healthcare System, “is usually multifactorial. Some factors can be at the patient level – based on patient beliefs, or patient biology, or on differences in demographic characteristics.” Other factors, Fine said, may be provider related: “Do they harbor some type of implicit or explicit bias? How do they communicate with one group of patients versus another group of patients?” A third category of institutional factors could exist at the level of the medical center, or the health care system itself, ingrained in policies or practices. And finally, a host of social and environmental factors, existing completely outside of the health care system, may be at work.