The goal of the curriculum wasn’t necessarily to eliminate biases, but to encourage providers’ understanding that biases are real and can affect interactions with patients. “This was one of the first efforts to systematically evaluate a curriculum to train providers to understand the presence of unconscious bias,” said Hausmann, “and how it can play out in their interactions with each other and with their patients.”

In addition to exploring how patient-provider relationships affect disparities, other researchers are examining a multitude of additional factors such as patient preferences, health care beliefs, health care system issues, and social context. This research has informed the development of initiatives to reduce disparities, including novel storytelling models to improve patient engagement and self-management of chronic diseases such as hypertension as well as interventions that target veteran behavior and experience through multifaceted approaches sometimes including family, peers, and social networks.

Some of the most difficult variables to account for in health disparities research, said Fine, involve social determinants of health – factors outside the health care setting. “I think we’re really becoming much more aware of the fact that within the health care system, there are only so many things we can do,” he said. “And unless we get beyond the health care system and understand where patients live and what factors influence them during the 99 percent of the time they’re outside the health care system, it’s going to be very difficult to make meaningful change.”

For example, rural Americans, compared to their urban counterparts, confront several obstacles – long distances to VA facilities, lack of specialty and urgent care within rural VA clinics, and shortages of providers – to quality care. These circumstances can adversely affect the health of rural veterans, who typically report lower health-related quality of life than urban veterans.

Leonard Egede, MD, director of HEROIC in Charleston, recently studied an intervention designed to overcome the difficulty older rural patients often have in accessing mental health care professionals from where they live. “We did eight sessions of behavioral intervention by video phone,” Egede said, “and we found that, compared to a face-to-face visit, it was just as good. That’s the first large study to show you can actually provide care for rural veterans using video teleconferencing.” The study of more than 200 veterans was reported in The Lancet in July 2015.

Egede is now at work on a study to evaluate, among veteran and non-veteran patients alike, the effectiveness of telemedicine in the treatment of Type 2 diabetes.

 

Research into Practice

The establishment of the VA’s OHE in 2012 was intended to invigorate the work of CHERP and HEROIC investigators, and other health care researchers throughout the VA, to measure progress, chart the path forward, and translate research into health care practices and policies. OHE is also charged to champion efforts to address health disparities through education, training, communications, programs, projects, and initiatives that combine efforts and break down silos in the organization. One of the first achievements of the OHE, led by Uchenna Uchendu, MD, was to develop and publish the “Health Equity Action Plan,” a strategic roadmap for reducing health disparities throughout the VA health care system and position VA as a leader in this area.

In 2015, the OHE announced and funded a new initiative and identified a core investigator through the VA’s Quality Enhancement Research Initiative (QUERI). The project is designed to establish a clear link between VA researchers, clinical practice, and operations specific to addressing health care disparities. The Partnered Evaluation Initiative is led jointly by Uchendu and by Donna Washington, MD, MPH, an investigator at the VA’s Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP) in Los Angeles, California.

It should be pointed out that the connection between health disparities research and clinical practice isn’t new at the VA; for one thing, it already exists organically, as many researchers, including Fine, Ibrahim, Saha, Egede, and Washington, are practicing VA physicians who see patients regularly. The idea behind the Partnered Evaluation Initiative is to create a higher-level engagement between research and clinical operations – and ultimately, to bring department-wide change that will provide the same level of high-quality care and improve health for all veterans, regardless of demographics.

While the work done thus far by VA investigators has revealed many disparities among VA patients and done much to advance our understanding of them, Washington said the knowledge base remains incomplete: “So often there may be a lack of information about some of the smaller racial and ethnic groups,” she said, “or there may be particular conditions that haven’t been examined. So what we’re doing here at the Partnered Evaluation Center is systematically using VA data to describe where the disparities are in health and health care for vulnerable populations.”

According to Uchendu, the Partnered Evaluation Initiative’s three basic goals are to:

• assess current gaps in morbidity and mortality for conditions among vulnerable veteran populations;
• examine trends in quality of care across the conditions observed in these populations; and
• assess how new models of care, such as telemedicine, affect health and health care disparities.

The linkage between the Partnered Evaluation Center and the OHE, Washington said, will push data with a clinical orientation to an office well positioned to act on it. Work supported by the initiative can then be used to inform policy, education, resource allocation, operations, and practice. “We hope to produce actionable data that all stakeholders can use to address disparities,” Uchendu said.

It should be pointed out that the connection between health disparities research and clinical practice isn’t new at the VA; for one thing, it already exists organically, as many researchers, including Fine, Ibrahim, Saha, Egede, and Washington, are practicing VA physicians who see patients regularly. The idea behind the Partnered Evaluation Initiative is to create a higher-level engagement between research and clinical operations – and ultimately, to bring department-wide change that will provide the same level of high-quality care and improve health for all veterans, regardless of demographics.

This article was first published in the Veterans Affairs & Military Medicine Outlook magazine.