Heart Disease Toll Varies In Black And White Vets

BETHESDA, MD—In the past decade, the Veterans Affairs (VA) Health Care System has made great progress in providing screenings and treating high-risk conditions for all its patients, thus substantially closing the gaps in care provided white and African American enrollees.  However, a new study shows that big differences still persist between black and white veterans when it comes to outcomes in heart disease, diabetes, and hypertension.  The research appears in the April 2011 edition of the monthly journal Health Affairs.  The Robert Wood Johnson Foundation, the nation’s largest philanthropy focused solely on health and health care, sponsored the issue.

The study examined a national sample of more than 1.2 million VA enrollees between 2000 and 2009 for 10 clinical performance measures related to cancer screening and cardiovascular and diabetes care.  The authors of the study say that, while the VA greatly improved the quality of care for white and black veterans over that period, those efforts have not narrowed racial gaps in clinical outcomes.

“The VA has narrowed care gaps that are directly under the control of the providers - ordering tests, referring to the appropriate specialist, and conducting screenings,” says Amal Trivedi, research investigator at the Providence VA Medical Center and an assistant professor at the Warren Alpert Medical School of Brown University. However, among all VA medical centers, there was as much as a nine percentage point difference between black and white veterans in measures indicating whether cholesterol, diabetes, and blood pressure were under control. Thus, improvements in clinical performance were not accompanied by meaningful reductions in racial disparities for outcomes that not only affect how healthy people are and how long they live, but also significantly drive up health costs. 

The bottom line, says Trivedi, is that “Even in a system with all the quality improvement strengths of the VA, important gaps remain,” he says.   The reasons are unknown, he says, and more research is needed to understand the drivers of these differences in clinical outcomes. 

Trivedi and his colleagues also examined whether racial disparities in care were driven primarily by a concentration of black enrollees in lower performing VA facilities or differential quality for white and black veterans receiving care in the same VA facility.  With the exception of mammography screening, performance rates improved for white and black veterans on each quality indicator for processes and outcomes of care, most particularly for eye exams for diabetes. 

Although the VA is a universal health system that has spent a decade working on quality improvement, Trivedi says the study has broad implications.  The findings underscore the urgency of “focused efforts” to improve intermediate clinical outcomes among black Americans in both the VA and other health care settings.  “We not only have to measure whether someone got a test but also whether anything happened as a result of that test,” he says. “In other words, whether the test showed that treatment was indicated; whether the treatment was received; and whether the treatment translated into improvements in measurements like blood pressure or cholesterol control.” 

The study’s coauthors were Regina Grebla of the Warren Alpert Medical School of Brown University, Steven Wright of the VA’s Office of Quality and Performance, and Donna Washington of the Greater Los Angeles VA Medical Center and UCLA. 

The findings come at the heels of a growing number of studies, most recently from the Agency for Healthcare Research and Quality (AHRQ)’s 2010 National Healthcare Quality Report and National Healthcare Disparity Report.  The AHRQ and other studies show that racial and ethnic disparities continue at persistently high levels.