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Equity Research Among Veterans Provides Unique Insights

Kim Krisberg , special to AAMCNews
September 27, 2016

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Editor’s Note: Throughout 2015, an AAMCNews series explored how medical schools and teaching hospitals are addressing social determinants of health in their communities through research, clinical care, and education.

Compared with their urban counterparts, rural Americans often face more barriers to good health and quality health care. Unfortunately, rural veterans are no exception.

For veterans living in rural communities, access to medical care—particularly mental health care—can be a challenge. The Veterans Health Administration (VHA) Office of Rural Health reports a number of “important barriers” that rural veterans face, including long distances to Department of Veterans Affairs (VA) facilities, lack of specialty and urgent care within rural VA facilities, and shortages of health care providers. Such barriers can adversely affect the health of rural veterans, who typically report lower health-related quality of life than veterans living in urban areas.

To help overcome one barrier, Leonard Egede, MD, MS, director of the VA’s Health Equity and Rural Outreach Innovation Center in Charleston, S.C., led a study on the use of videoconferencing to deliver psychotherapy to older veterans with major depression. The study of more than 200 veterans found the telemedicine technique was just as effective as face-to-face therapy. Egede said the results, published in the Lancet in 2015, could help “change the landscape for mental health care for veterans.”

“Right now … it’s not feasible to have enough slots to see patients in the office on a regular basis,” he said. “Having a system that allows you to reach into [people’s] homes will make a huge difference. It will transform the way we deal with access issues.”

Egede’s study is only one example of the wealth of research that the VA is spearheading on equity, disparities, and the social determinants of health. In fact, Uche Uchendu, MD, executive director of the VHA Office of Health Equity, said one of her goals is to leverage the reach and influence of the VHA—the country’s largest integrated health care system—to become a national leader in health equity.

Even though veteran subpopulations tend to experience similar health disparities as those in the general population, they do face some unique health issues. For example, veterans tend to experience high rates of depression and post-traumatic stress disorder, are more likely to use tobacco, and may be at higher risk of homelessness. Uchendu’s office led efforts to highlight such issues in a September 2014 edition of the American Journal of Public Health, which was dedicated to exploring health equity among veterans.

“Having a system that allows you to reach into [people’s] homes will make a huge difference.”

While the VA has been zeroing in on disparities and equity research for more than a decade, most notably through its Center for Health Equity Research and Promotion (CHERP), the 2012 launch of the Office of Health Equity was intended to galvanize efforts across the agency, measure progress, and map the path forward. Perhaps most important, Uchendu said her office sees veteran health outcomes and disparities through a health equity lens, which continually prompts her and her colleagues to ask why certain veteran populations experience poorer outcomes despite having access to care through the VA.

“In order to achieve health equity, we need all hands on deck,” she said. “Everybody owns a piece of the action.”

Michael Fine, MD, MSc, director of CHERP, a joint effort of the VA Pittsburgh Healthcare System and Philadelphia VA Medical Center, noted that the center has a three-generation conceptual model of health disparities research: the first focuses on detection of disparities, the second on understanding the causes of disparities, and the third on creating interventions to eliminate disparities. The model can be applied outside the VA system as well, he added.

“Issues of equity should be thoroughly covered in medical schools,” said Fine, who is also a professor of medicine at the University of Pittsburgh School of Medicine. “We have medical students rotating through (VA) clinical services all the time … and we train fellows, medical students, and residents to do this research.”

Among the underlying issues that CHERP researchers have identified are perceived and unconscious biases. Leslie Hausmann, PhD, a core investigator at CHERP in Pittsburgh, studies how various types of discrimination and bias can affect a veteran’s interaction with the health system and, ultimately, his or her health status. She coauthored a study published in 2012 in the American Heart Journal that found perceived discrimination was associated with a risk of severe coronary artery obstruction among black male veterans.

“We’ve done a lot of work to build that base of evidence to say that this is a worthy target to reduce disparities because there’s such a strong correlation between issues of discrimination and health outcomes,” said Hausmann, who also is an assistant professor of medicine at Pittsburgh.

In an example of translating research into practice, Hausmann partnered with the VA Office of Health Equity to create a training program that raises awareness of unconscious bias among providers. The curriculum, piloted at three VA facilities in 2014, engages primary care teams and creates a safe space in which team members can talk about bias and discrimination. The goal, Hausmann said, is not necessarily to eliminate biases, which can be “very stubborn and ingrained because of the broader society we live in,” but to teach techniques to slow down and recognize that biases exist and can affect patient interactions.

As minorities and people from socioeconomically disadvantaged backgrounds increasingly join the military and ultimately become veterans, tackling disparities and their contributors will remain important, explained Said Ibrahim, MD, MPH, codirector of CHERP and a professor of medicine at the University of Pennsylvania Perelman School of Medicine. Moreover, the VA recognizes that confronting health disparities and their social determinants requires more than good care inside the clinic walls, he noted.

“What we have to do is follow patients into the community to help them there so they don’t have to come back into the hospital,” Ibrahim said. “And the VA is starting to see itself at the forefront of that movement.”

This article originally appeared in print in the November 2015 issue of the AAMC Reporter.

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