Third-generation studies evaluate strategies or interventions aimed at reducing or eliminating disparities. “So what can we do,” said Fine, “once we’ve detected a disparity and understand its root causes, to eliminate a disparity between a vulnerable and a non-vulnerable population? The goal of our center – and the goal of most people invested in health equity research – is to move the continuum from first- to second- to third-generation work, to ultimately make a difference and reduce health disparities.”
The Conceptual Model in Action
A good example of one who has moved the continuum of research in this way is Said Ibrahim, MD, co-director of CHERP and a physician at the Corporal Michael J. Crescenz VA Medical Center in Philadelphia. Ibrahim’s research, funded continuously by the VA and the National Institutes of Health for the past 15 years, has focused particularly on racial disparities in the use of knee and hip replacement surgery in the management of advanced osteoarthritis – procedures that are on the rise nationally as the American population ages and the incidence of osteoarthritis increases.
When Ibrahim’s team examined knee and hip replacement utilization nationwide, they found that minority patients, and particularly African-American veterans, were significantly less likely than non-minority veterans to undergo the procedures when they needed them.
CHERP co-director Said Ibrahim, MD, MPH, right, a staff physician at the Cpl. Michael J. Crescenz VA Medical Center (CMC VAMC) in Philadelphia, Pennsylvania, and professor of medicine at the University of Pennsylvania’s Perelman School of Medicine, shown here with Daniel Hendee, CMC VAMC medical center director, has long focused his research on health equity and disparities, particularly in the area of osteoarthritis care. One of Ibrahim’s studies is the first-ever third-generation intervention trial to reduce a well-documented disparity.
The team’s second-generation studies were designed to discover why this disparity existed. They yielded a surprising result. Ibrahim examined several issues and was able to eliminate them one by one: Though joint replacements are elective procedures, among the most expensive funded through U.S. health care plans, the motivations weren’t financial. “Obviously insurance is not a problem in the VA, because everybody is insured,” Ibrahim said, “and in fact, outside of the VA, the majority of these procedures are paid for by Medicare.”
Ibrahim also looked into whether there was a difference in how orthopedic surgeons treated African-American patients, and discovered that this wasn’t a significant issue, either; VA surgeons would generally operate on anyone who elected to undergo the procedure. “We didn’t find any bias on the part of physicians in terms of the treatment recommendation,” Ibrahim said.
What remained to be studied were the patients. “We found that minority patients, both at the VA as well as outside of the VA, are significantly less willing to try knee or hip replacement, compared to non-minority patients,” said Ibrahim, “and we found out that part of the reason is that there is actually a lot of misinformation about the risks and the benefits of the treatment. Minority patients don’t have enough information about the complications from the treatment. They tend to exaggerate it, and they don’t actually have a whole lot of family or friends who have had the procedure, compared to white patients.”
Ibrahim’s next study was the first-ever third-generation intervention trial to reduce a well-documented disparity. “We educated minority patients, before they actually saw the orthopedic surgeon about knee or hip problems,” Ibrahim said. “And what we found, to our surprise, was that educating minority patients about the risks and benefits of hip or knee replacement increases their likelihood of undergoing the surgery by almost 85 percent.” Ibrahim’s findings are to be published soon in the journal JAMA Surgery.
It’s worth asking why, given the time, attention, and resources paid to health disparities by researchers from the VA and other agencies, it’s taken so long for a third-generation trial to succeed in reducing a health care disparity. The answer lies in the complexity of the problems investigated. Ibrahim’s findings, for example, raised several more questions that could have been investigated. Why, for example, did minority patients tend to exaggerate the negative complications of joint replacement surgery? Where did the misinformation come from? But Ibrahim was able to apply Occam’s razor, designing an intervention aimed at the most easily addressed problem – the information gap that seemed to be the primary reason for minority patients’ unwillingness to undergo joint replacement.
Teasing apart the variables contributing to health disparities among racial and ethnic minorities isn’t easy, particularly when they deal with patient-provider relationships or institutional practices and policies. Somnath Saha, MD, a researcher and physician at the Portland VA Medical Center, has spent the past 10 years studying the issue of “cultural competence,” which has become a catchall term describing one’s ability to interact effectively with people of different backgrounds. In order to determine whether interventions – training programs to develop cultural competence – could be designed to reduce disparities, Saha first had to do two things: come up with a useful and distinct definition of the term, and develop a valid means of measuring it.
Saha’s research team surveyed 800 primary care doctors across the country and, after analyzing the responses, developed six distinct scales that could be used to measure cultural competence. The team used those scales to examine differences among HIV care providers and, in 2013, reported that providers who scored higher in cultural competence delivered more equitable care among white and nonwhite patients – most of whom were African-American.
Another issue that’s been studied by VA researchers is perceived and unconscious biases in the health care system. Leslie Hausmann, Ph.D., a core investigator at CHERP in Pittsburgh, investigates how different types of discrimination and bias can affect a VA patient’s health care experience and his or her health status. Her research has demonstrated that perceived discrimination is negatively associated with outcomes such as patient-provider communication, trust in physicians, health status, and utilization of preventive health care services in patients with common medical conditions, including osteoarthritis, diabetes, heart disease, and hypertension. In a 2015 study, she also reported that unconscious racial bias among providers is associated with poorer psychosocial outcomes for individuals with spinal cord injury.
A second study, among VA patients with diabetes, found that among the six concepts evaluated, the one that had the greatest impact on racial disparities was “valuing diverse perspectives,” a scale that Saha said measured a provider’s openness to hearing about a patient’s values and health beliefs. “Among people who scored high on that scale,” Saha said, “their white and black patients basically did the same. But black patients rated them much lower than white patients when they scored low on that scale.”
For Saha’s team, the next question that needs to be answered is: What do providers who score high on this scale actually do differently when they’re with patients? What does open-mindedness look like? They recently launched a study in which they’ll observe VA physicians who score high and low on that scale, and compare what they actually do and say when they’re with patients. “The study is called ‘Opening the Black Box of Cultural Competence,’” Saha said. “We want to find out what’s in the box that translates into better care.”
Another issue that’s been studied by VA researchers is perceived and unconscious biases in the health care system. Leslie Hausmann, Ph.D., a core investigator at CHERP in Pittsburgh, investigates how different types of discrimination and bias can affect a VA patient’s health care experience and his or her health status. Her research has demonstrated that perceived discrimination is negatively associated with outcomes such as patient-provider communication, trust in physicians, health status, and utilization of preventive health care services in patients with common medical conditions, including osteoarthritis, diabetes, heart disease, and hypertension. In a 2015 study, she also reported that unconscious racial bias among providers is associated with poorer psychosocial outcomes for individuals with spinal cord injury.
In 2014, Hausmann, in partnership with the VA’s Office of Health Equity (OHE), piloted a curriculum for a training program aimed at raising awareness of unconscious bias among providers. The curriculum was pilot-tested at three different VA facilities. “It was an innovative project,” Hausmann said, “that brought a lot of people across the VA together to focus [on] how unconscious biases permeate our interactions with each other and with patients – and strategies to try to make patient care experience as positive as possible, no matter who the patients are.”