Search

Patient assessment surveys have established a primary role in health care quality measurement as evidence has shown that information from patients can affect quality improvement for practitioners and lead to positive marketwide changes. This article presents findings from the recently released National Healthcare Disparities Report revealing that although most clinical quality and access indicators show superior health care for non-Hispanic whites compared with blacks and Hispanics, blacks and Hispanics assess their interactions with providers more positively than non-Hispanic whites do. The article explores possible explanations for these racial/ethnic differences, including potential pitfalls in survey design that draw biased responses by race/ethnicity. The article then suggests strategies for refining future research on racial/ethnic disparities based on patient assessment of health care. [ABSTRACT FROM AUTHOR]

Context: Previous studies have suggested that minority medical school faculty are at a disadvantage in promotion opportunities compared with white faculty.Objective: To compare promotion rates of minority and white medical school faculty in the United States.Design and Setting: Analysis of data from the Association of American Medical Colleges' Faculty Roster System, the official data system for tracking US medical school faculty.Participants: A total of 50,145 full-time US medical school faculty who became assistant professors or associate professors between 1980 and 1989. Faculty of historically black and Puerto Rican medical schools were excluded.Main Outcome Measures: Attainment of associate or full professorship among assistant professors and full professorship among associate professors by 1997, among white, Asian or Pacific Islander (API), underrepresented minority (URM; including black, Mexican American, Puerto Rican, Native American, and Native Alaskan), and other Hispanic faculty.Results: By 1997, 46% of white assistant professors (13,479/28,953) had been promoted, whereas 37% of API (1123/2997; P<.001), 30% of URM (311/1053, P<.001), and 43% of other Hispanic assistant professors (256/598; P =.07) had been promoted. Similarly, by 1997, 50% of white associate professors (7234/14,559) had been promoted, whereas 44% of API (629/1419; P<.001), 36% of URM (101/280; P<.001), and 43% of other Hispanic (122/286; P =.02) associate professors had been promoted. Racial/ethnic disparities in promotion were evident among tenure and nontenure faculty and among faculty who received and did not receive National Institutes of Health research awards. After adjusting for cohort, sex, tenure status, degree, department, medical school type, and receipt of NIH awards, URM faculty remained less likely to be promoted compared with white faculty (relative risk [RR], 0.68 [99% confidence interval CI, 0.59-0.77] for assistant professors and 0.81 [99% CI, 0.65-0.99] for associate professors). API assistant professors also were less likely to be promoted (RR, 0.91 [99% CI, 0.84-0.98]), whereas API associate professors and other Hispanic assistant and associate professors were promoted at comparable rates.Conclusion: Our data indicate that minority faculty are promoted at lower rates compared with white faculty. JAMA. 2000;284:1085-1092 [ABSTRACT FROM AUTHOR]

Background: Managed care reduces the demand for internal medicine subspecialists, but little empirical information is available on how increasing managed care may be affecting residents' training choices.Objective: To determine whether increased managed care penetration into an area where residents train was associated with a decreased likelihood that residents who completed general internal medicine training pursued subspecialty training.Design: Secondary logistic regression analysis of data from the 1993 cohort of general internal medicine residents.Setting: U.S. residency training sites.Participants: 2263 U.S. medical school graduates who completed general internal medicine residency training in 1993.Measurements: The outcome variable (enrollment in subspecialty training) was derived from the Graduate Medical Education Tracking Census of the Association of American Medical Colleges (AAMC). Health maintenance organization (HMO) penetration (possible range, 0.0 to 1.0; higher values indicate greater penetration) was taken from the Interstudy Competitive Edge Database. Individual and medical school covariates were taken from the AAMC's Student and Applicant Information Management System database and the National Institutes of Health Information for Management Planning, Analysis, and Coordination system. The U.S. Census division was included as a control covariate.Results: 980 participants (43%) enrolled in subspecialty training. Logistic regression analyses indicated a nonlinear association between managed care penetration into a training area and the odds of subspecialization. Increasing managed care penetration was associated with decreasing odds of subspecialization when penetration exceeded 0.15. The choice of subspecialty training increased as HMO penetration increased from 0 to 0.15.Conclusions: Local market forces locally influenced the career decisions of internal medicine residents, but the influence was small compared with the effects of age and sex. These results suggest that market forces help to achieve more desirable generalist-to-specialist physician ratios in internal medicine. [ABSTRACT FROM AUTHOR]

Background: Until recently, minority and poor men have been characterized as "an invisible population," overlooked by public and private efforts to improve the health status of women, children, and the elderly.Objective: This study compares the health care experiences of racial and ethnic minority men with that of white men, and low socioeconomic status with those of higher status. MEASURES/SUBJECTS: Quality-of-care measures in multiple clinical domains are evaluated. The authors use data from several databases, including the National Health Interview Survey, Medical Expenditure Panel Survey, and Health Care Cost and Utilization Project State Inpatient Database. The relative difference between each racial/ethnic and socioeconomic group and a fixed reference group is used to assess differences in use of services. Statistical significance is assessed using z tests.Results: Hispanic men were much less likely to receive colorectal cancer screening (relative risk [RR] range, 0.61-0.69), cardiovascular risk factor screening and management (RR, 0.84-0.88), and vaccinations (RR, 0.47-0.94). Black and Asian men were significantly less likely to have received selected preventive services (adult immunization and colorectal cancer screening). The differences in end-stage renal disease care that black and white men received were statistically significant (RR, 0.39-0.97), with black men consistently receiving worse care. For some measures of management of end-stage renal disease, Asian men received care that was similar to or better than that received by non-Hispanic whites.Conclusion: Minority men are at a markedly elevated risk for the receipt of poor health care quality. However, generalizations about "minority" men are likely to be misleading and incomplete. There is a considerable variation in the magnitude, direction, and significance of these risks. [ABSTRACT FROM AUTHOR]

Background: The first National Healthcare Quality Report (NHQR) and National Healthcare Disparities Report (NHDR) are landmark events for children's health care quality and are expected to stimulate local measurement, benchmarking, and quality improvement efforts.Method: The authors select findings from the NHQR and NHDR, focusing on topics reflecting a range of health care and health care settings affecting children. They highlight disparities by race/ethnicity, socioeconomic status, and insurance source. They critique the first NHQR and NHDR from a child health perspective. SELECT NHQR/DR FINDINGS: Quality-of-care issues in the effectiveness domain were identified for black infant mortality, low and very low birth weight rates, antibiotic use for the common cold, and childhood hospitalizations for asthma. Immunization rates have improved. Patient centeredness and timeliness results vary by race, ethnicity and income. The NHDR found that Hispanic and low-income children are most likely to be uninsured for part of the year. Groups of children most likely to have public coverage are American Indian/Alaska native, black, and Hispanic. CRITIQUE OF REPORTS: The structure and criteria used for the first reports limit their usefulness from a child health perspective. A basic problem is that the conceptualizations of health and health care that are driving national initiatives on quality are based largely on an adult chronic care model focused on conditions with high expenditures as treated in the mainstream health care delivery system.Conclusion: NHQR and NHDR provide essential information on children's health care quality. Future reports can be improved by including child-relevant perspectives in priority-setting and data-gathering efforts. [ABSTRACT FROM AUTHOR]

Background: Patient safety events that result from the happenstance of mistakes and errors should not occur systematically across racial, ethnic, or socioeconomic subgroups.Objective: To determine whether racial and ethnic differences in patient safety events disappear when income (a proxy for socioeconomic status) is taken into account.Research Design: This study analyzes administrative data from community hospitals in 16 states with reliable race/ethnicity measures in the 2000 Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality (AHRQ), using the publicly available AHRQ patient safety indicators (PSIs).Results: Different indicators show different results for different racial/ethnic subgroups. Many events with higher rates for non-Hispanic blacks (compared with non-Hispanic whites) remain higher when income is taken into account, although such differences for Hispanics or Asian/Pacific Islanders (APIs) tend to disappear. Many events with lower rates for Hispanics and APIs remain lower than whites when income is taken into account, but for blacks, they disappear.Discussion: The higher rates for minorities that reflect the way health care is delivered raise troubling questions about potential racial/ethnic bias and discrimination in the US health care system, problems with cultural sensitivity and effective communication, and access to high-quality health care providers.Conclusions: The AHRQ PSIs are a broad screen for potential safety events that point to needed improvement in the quality of care for specific populations. [ABSTRACT FROM AUTHOR]

Objective: To evaluate racial and ethnic differences in patient experience among VA primary care users at the Veterans Integrated Service Network (VISN) level., Data Source and Study Setting: We performed a secondary analysis of the VA Survey of Healthcare Experiences of Patients-Patient Centered Medical Home for fiscal years 2016-2019., Study Design: We compared 28 patient experience measures (six each in the domains of access and care coordination, 16 in the domain of person-centered care) between minoritized racial and ethnic groups (American Indian or Alaska Native [AIAN], Asian, Black, Hispanic, Multi-Race, Native Hawaiian or Other Pacific Islander [NHOPI]) and White Veterans. We used weighted logistic regression to test differences between minoritized and White Veterans, controlling for age and gender., Data Collection/extraction Methods: We defined meaningful difference as both statistically significant at two-tailed p < 0.05 with a relative difference ≥10% or ≤-10%. Within VISNs, we included tests of group differences with adequate power to detect meaningful relative differences from a minimum of five comparisons (domain agnostic) per VISN, and separately for a minimum of two for access and care coordination and four for person-centered care domains. We report differences as disparities/large disparities (relative difference ≥10%/≥ 25%), advantages (experience worse or better, respectively, than White patients), or equivalence., Principal Findings: Our analytic sample included 1,038,212 Veterans (0.6% AIAN, 1.4% Asian, 16.9% Black, 7.4% Hispanic, 0.8% Multi-Race, 0.8% NHOPI, 67.7% White). Across VISNs, the greatest proportion of comparisons indicated disparities for three of seven eligible VISNs for AIAN, 6/10 for Asian, 3/4 for Multi-Race, and 2/6 for NHOPI Veterans. The plurality of comparisons indicated advantages or equivalence for 17/18 eligible VISNs for Black and 12/14 for Hispanic Veterans. AIAN, Asian, Multi-Race, and NHOPI groups had more comparisons indicating disparities by VISN in the access domain than person-centered care and care coordination., Conclusions: We found meaningful differences in patient experience measures across VISNs for minoritized compared to White groups, especially for groups with lower population representation., (Published 2024. This article is a U.S. Government work and is in the public domain in the USA. Health Services Research published by Wiley Periodicals LLC on behalf of Health Research and Educational Trust.)

Background: In-home remote foot temperature monitoring (RTM) holds promise as a method to reduce foot ulceration in high-risk patients with diabetes. Few studies have evaluated adherence to this method or evaluated the factors associated with noncompliance., Objective: The aims of this study were to estimate noncompliance in patients who were enrolled in RTM nationwide across Department of Veterans Affairs (VA) and to evaluate characteristics associated with noncompliance., Methods: We conducted an observational study including 1137 patients in the VA who were enrolled in RTM between January 2019 and June 2021, with follow-up through October 2021. Patient information was obtained from the VA's electronic health record and RTM use was obtained from the company. Noncompliance was defined as using the mat <2 days per week for ≥4 of the 12 months of follow-up. Using a multivariable model, we calculated odds ratios (ORs) and 95% CIs for associations between various factors and noncompliance and compared using Akaike information criterion statistics, a measure of model fit., Results: The sample was predominantly male (n=1125, 98.94%) ; 21.1% (n=230) were Black and 75.7% (n=825) were White. Overall, 37.6% (428/1137) of patients were classified as noncompliant. In the multivariable model, an intermediate area deprivation index was statistically significantly and inversely associated with noncompliance (area deprivation index 50-74 vs 1-24; OR 0.56, 95% CI 0.35-0.89); factors significantly and positively associated with noncompliance included recent history of osteomyelitis (OR 1.44, 95% CI 1.06-1.97), Gagne comorbidity index score ≥4 (vs ≤0; OR 1.81, 95% CI 1.15-2.83), telehealth encounters (28+ vs <6; OR 1.70, 95% CI 1.02-2.84), hemoglobin A1c≥10 (vs <5.7; OR 2.67, 95% CI 1.27-5.58), and current smoking (OR 2.06, 95% CI 1.32-3.20). Based on Akaike information criterion differences, the strongest factors associated with noncompliance were behavioral factors (poor glucose control [as measured by hemoglobin A1c] and smoking), and to a lesser extent, factors such as a recent history of osteomyelitis and an elevated Gagne comorbidity index, indicating a high comorbidity burden., Conclusions: To reduce the risk of ulcer recurrence and amputation, proactively providing additional support for self-monitoring to patients with characteristics identified in this study (poor glucose control, current smoking, high comorbidity burden) may be helpful. Furthermore, research is needed to better understand barriers to use, and whether the addition of design features, reminders, or incentives may reduce noncompliance and the risk of foot ulcers., (© Alyson J Littman, Andrew K Timmons, Anna Korpak, Kwun C G Chan, Kenneth T Jones, Suzanne Shirley, Kyle Nordrum, Jeffrey Robbins, Suhail Masadeh, Ernest Moy. Originally published in JMIR Diabetes (https://diabetes.jmir.org).)

Importance: Telehealth can expand access to care, but digital needs present barriers for some patients., Objective: To investigate sociodemographic and clinical associations of digital needs among veterans., Design, Setting, and Participants: This quality improvement study used data collected between July 2021 and September 2023 from Assessing Circumstances and Offering Resources for Needs (ACORN), a Department of Veterans Affairs (VA) initiative to systematically screen for, comprehensively assess, and address social risks and social needs. Eligible participants were veterans screened for social risks and social needs during routine care at 12 outpatient clinics, 3 emergency departments, and 1 inpatient unit across 14 VA medical centers. Data analysis occurred between October 2023 and January 2024., Exposure: The ACORN screening tool was administered by clinical staff., Main Outcomes and Measures: Veterans were considered positive for a digital need if they reported no smartphone or computer, no access to affordable and reliable internet, running out of minutes and/or data before the end of the month, and/or requested help setting up a video telehealth visit., Results: Among 6419 veterans screened (mean [SD] age, 67.6 [15.9] years; 716 female [11.2%]; 1740 Black or African American [27.1%]; 202 Hispanic or Latino [3.1%]; 4125 White [64.3%]), 2740 (42.7%) reported 1 or more digital needs. Adjusting for sociodemographic and clinical characteristics, the adjusted prevalence (AP) of lacking a device among veterans aged 80 years or older was 30.8% (95% CI, 27.9%-33.7%), 17.9% (95% CI, 16.5%-19.2%) among veterans aged 65 to 79 years, 9.9% (95% CI, 8.2%-11.6%) among veterans aged 50 to 64 years, 3.4% (95% CI, 2.1%-4.6%) among veterans aged 18 to 49 years, 17.6% (95% CI, 16.7%-18.6%) for males, and 7.9% (95% CI, 5.5%-10.3%) for females. AP of lacking affordable or reliable internet was 25.3% (95% CI, 22.6%-27.9%) among veterans aged 80 years or older, 15.0% (95% CI, 12.1%-18.0%) among veterans aged 18 to 49 years, 31.1% (95% CI, 28.9%-33.4%) for Black or African American veterans, 32.1% (95% CI, 25.2%-39.0%) for veterans belonging to other racial groups (ie, American Indian or Alaska Native, Asian, Native Hawaiian or Other Pacific Islander, as well as those with more than 1 race captured in their medical record), and 19.4% (95% CI, 18.2%-20.6%) for White veterans. Veterans with dementia were at higher risk of lacking a device (adjusted relative risk [aRR], 1.21; 95% CI, 1.00-1.48). Veterans with high medical complexity were at higher risk of lacking internet (aRR, 1.26; 95% CI, 1.11-1.42). Veterans with dementia (aRR, 1.58; 95% CI, 1.24-2.01) or substance use disorder (aRR, 1.22; 95% CI, 1.00-1.49) were more likely to want help scheduling a telehealth visit than those without., Conclusions and Relevance: In this quality improvement study of veterans screened for social risks and social needs, there were substantial disparities in digital needs. These findings suggest that routine screening is important to understand patients' digital access barriers and connect patients with telehealth resources to address inequities in health care.

Purpose: This study examined the differences by sexual orientation in patient-centered care outcomes (including health care experiences and health-related screening) of veterans utilizing Veterans Health Administration (VHA) primary care. Methods: VHA's adapted version of the Consumer Assessment of Healthcare Providers and Systems was used to compare the health care experience of primary care services among sexual minority (SM) and heterosexual veterans. Health care experience measures were dichotomized to "always" versus "less" and stratified by SM status. Health-related screening measures were dichotomous. Survey data were weighted using provided sample weights. Descriptive statistics were performed on sociodemographic characteristics. Logistic regression coefficients were represented as adjusted odds ratios (aORs). A total of 66,348 veterans were included in the analytic sample, of which 2.9% ( n  = 1,935) identified as SM. Sexual orientation was ascertained by self-report measures by veterans. Results: SM veterans were significantly younger (56.95 years vs. 63.43 years, p  < 0.001), were less likely to report that their provider showed respect for what they had to say (aOR: 0.76; 95% confidence interval [CI]: 0.61-0.95), that they were asked about difficulties taking care of their health (aOR: 0.81; 95% CI: 0.67-0.96), and their provider listened carefully to them (aOR: 0.71; 95% CI: 0.57-0.87) compared to heterosexual veterans. Conclusion: Health care experiences differed between SM and heterosexual veterans who sought VHA primary care, suggesting the need to increase provider trainings, which may improve cultural competency and promote a more welcoming and inclusive environment.

Failing to consider disparities in quality measures, such as by race and ethnicity, may obscure inequities in care, which could exist in facilities with overall high-quality ratings. We examined the relationship between overall quality and racial and ethnic disparities in diabetes care quality by health care facility-level performance on a diabetes-related quality measure within a national dataset of veterans using Veterans Health Administration (VA) ambulatory care between March 1, 2020 and Feburary 28, 2021, and were eligible for diabetes quality assessment. We found racial and ethnic disparities in diabetes care quality existed in top-performing VA medical centers (VAMCs) among American Indian or Alaska Native (AIAN) (predicted probability = 30%), Black (predicted probability = 29%), and Hispanic VA-users (predicted probability = 30%) vs White VA-users (predicted probability = 26%). While disparities among Black and Hispanic VA-users were similar relative to White VA-users across VAMCs at all performance levels, disparities were exacerbated for AIAN and Native Hawaiian or Other Pacific Islander VA-users in bottom-performing VAMCs. Equity remains an issue even in facilities providing overall high-quality care. Integrating equity as a component of quality measures can incentivize greater focus on equity in quality improvement., Competing Interests: Conflicts of interest Please see ICMJE form(s) for author conflicts of interest. These have been provided as supplementary materials., (Published by Oxford University Press on behalf of Project HOPE - The People-To-People Health Foundation, Inc. 2024.)

Objective: We assessed equity in the uptake of remote foot temperature monitoring (RTM) for amputation prevention throughout a large, integrated US healthcare system between 2019 and 2021, including comparisons across facilities and between patients enrolled and eligible patients not enrolled in RTM focusing on the Reach and Adoption dimensions of the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework., Material and Methods: To assess whether there was equitable use of RTM across facilities, we examined distributions of patient demographic, geographic, and facility characteristics across facility RTM use categories (e.g., no RTM use, and low, moderate, and high RTM use) among all eligible patients (n = 46,294). Second, to understand whether, among facilities using RTM, there was equitable enrollment of patients in RTM, we compared characteristics of patients enrolled in RTM (n = 1066) relative to a group of eligible patients not enrolled in RTM (n = 27,166) using logistic regression and including all covariates., Results: RTM use increased substantially from an average of 11 patients per month to over 40 patients per month between 2019 and 2021. High-use RTM facilities had higher complexity and a lower ratio of patients per podiatrist but did not have consistent evidence of better footcare process measures. Among facilities offering RTM, enrollment varied by age, was inversely associated with Black race (vs. white), low income, living far from specialty care, and being in the highest quartiles of telehealth use prior to enrollment. Enrollment was positively associated with having osteomyelitis, Charcot foot, a partial foot amputation, BMI≥30 kg/m2, and high outpatient utilization., Conclusions: RTM growth was concentrated in a small number of higher-resourced facilities, with evidence of lower enrollment among those who were Black and lived farther from specialty care. Future studies are needed to identify and address barriers to uptake of new interventions like RTM to prevent exacerbating existing ulceration and amputation disparities., Competing Interests: The authors have declared that no competing interests exist., (Copyright: This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.)

Background: The Joint Commission recently named reduction of health care disparities and improvement of health care equity as quality and safety priorities (Leadership [LD] Standard LD.04.03.08 and National Patient Safety Goal [NPSG] Standard NPSG.16.01.01). As the largest integrated health system, the Veterans Health Administration (VHA) sought to leverage these new accreditation standards to further integrate and expand existing tools and initiatives to reduce health care disparities and address health-related social needs (HRSNs)., Initiatives and Tools: A combination of existing data tools (for example, Primary Care Equity Dashboard), resource tools (for example, Assessing Circumstances and Offering Resources for Needs tool), and a care delivery approach (for example, Whole Health) are discussed as quality improvement opportunities to further integrate and expand how VHA addresses health care disparities and HRSNs. The authors detail the development timeline, building, limitations, and future plans for these tools and initiatives., Coordination of Initiatives: Responding to new health care equity Joint Commission standards led to new implementation strategies and deeper partnerships across VHA that facilitated expanded dissemination, technical assistance activities, and additional resources for VHA facilities to meet new standards and improve health care equity for veterans. Health care systems may learn from VHA's experiences, which include building actionable data platforms, employing user-centered design for initiative development and iteration, designing wide-reaching dissemination strategies for tools, and recognizing the importance of providing technical assistance for stakeholders., Future Directions: VHA continues to expand implementation of a diverse set of tools and resources to reduce health care disparities and identify and address unmet individual veteran HRSNs more widely and effectively., (Published by Elsevier Inc.)

Background: Health care organizations, including the Veterans Health Administration (VHA), are increasingly adopting programs to address social determinants of health. As part of a comprehensive social risk screening and referral model, tailored resource guides can support efforts to address unmet social needs. However, limited guidance is available on best practices for the development of resource guides in health care settings., Observations: This article describes the development of geographically tailored resource guides for a national VHA quality improvement initiative, Assessing Circumstances and Offering Resources for Needs (ACORN), which aims to systematically screen for and address social needs among veterans. We outline the rationale for using resource guides as a social needs intervention and provide a pragmatic framework for resource guide development and maintenance. We offer guidance based on lessons learned from the development of ACORN resource guides, emphasizing a collaborative approach with VHA social workers and other frontline clinical staff, as well as with community-based organizations. Our how-to guide provides steps for identifying high-yield resources along with formatting considerations to maximize accessibility and usability among patients., Conclusions: Resource guides can serve as a valuable cross-cutting component of health care organizations' efforts to address social needs. We provide a practical approach to resource guide development that may support successful implementation within the VHA and other clinical settings., Competing Interests: Author disclosures: The authors report no actual or potential conflicts of interest or outside sources of funding with regard to this article., (Copyright © 2024 Frontline Medical Communications Inc., Parsippany, NJ, USA.)

The Veterans Health Administration uses equity- and evidence-based principles to examine, correct, and eliminate use of potentially biased clinical equations and predictive models. We discuss the processes, successes, challenges, and next steps in four examples. We detail elimination of the race modifier for estimated kidney function and discuss steps to achieve more equitable pulmonary function testing measurement. We detail the use of equity lenses in two predictive clinical modeling tools: Stratification Tool for Opioid Risk Mitigation (STORM) and Care Assessment Need (CAN) predictive models. We conclude with consideration of ways to advance racial health equity in clinical decision support algorithms., (© Justin M. List et al., 2023; Published by Mary Ann Liebert, Inc.)

Background: The Department of Veterans Affairs (VA) healthcare system routinely screens Veterans for food insecurity, housing instability, and intimate partner violence, but does not systematically screen for other health-related social needs (HRSNs)., Objectives: To (1) develop a process for systematically identifying and addressing Veterans' HRSNs, (2) determine reported prevalence of HRSNs, and (3) assess the acceptability of HRSN screening among Veterans., Design: "Assessing Circumstances and Offering Resources for Needs" (ACORN) is a Veteran-tailored HRSN screening and referral quality improvement initiative. Veterans were screened via electronic tablet for nine HRSNs (food, housing, utilities, transportation, legal needs, social isolation, interpersonal violence, employment, and education) and provided geographically tailored resource guides for identified needs. Two-week follow-up interviews with a purposive sample of Veterans explored screening experiences., Participants: Convenience sample of Veterans presenting for primary care at a VA urban women's health clinic and suburban community-based outpatient clinic (October 2019-May 2020)., Main Measures: Primary outcomes included prevalence of HRSNs, Veteran-reported acceptability of screening, and use of resources guides. Data were analyzed using descriptive statistics, chi-square tests, and rapid qualitative analysis., Key Results: Of 268 Veterans screened, 50% reported one or more HRSNs. Social isolation was endorsed most frequently (29%), followed by educational needs (19%), interpersonal violence (12%), housing instability (9%), and utility concerns (7%). One in five Veterans reported at least one form of material hardship. In follow-up interviews (n = 15), Veterans found screening acceptable and felt VA should continue screening. No Veterans interviewed had contacted recommended resources at two-week follow-up, although several planned to use resource guides in the future., Conclusion: In a VA HRSN screening and referral program, Veterans frequently reported HRSNs, felt screening was important, and thought VA should continue to screen for these needs. Screening for HRSNs is a critical step towards connecting patients with services, identifying gaps in service delivery, and informing future resource allocation., (© 2023. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Objective: We evaluated the effectiveness of remote foot temperature monitoring (RTM) in the Veterans Affairs health care system., Research Design and Methods: We conducted a retrospective cohort study that included 924 eligible patients enrolled in RTM between 2019 and 2021 who were matched up to 3:1 to 2,757 nonenrolled comparison patients. We used conditional Cox regression to estimate adjusted cause-specific hazard ratios (aHRs) and corresponding 95% CIs for lower-extremity amputation (LEA) as the primary outcome and all-cause hospitalization and death as secondary outcomes., Results: RTM was not associated with LEA incidence (aHR 0.92, 95% CI 0.62-1.37) or all-cause hospitalization (aHR 0.97, 95% CI 0.82-1.14) but was inversely associated (reduced risk) with death (aHR 0.63, 95% CI 0.49-0.82)., Conclusions: This study does not provide support that RTM reduces the risk of LEA or all-cause hospitalization in individuals with a history of diabetic foot ulcer. Randomized controlled trials can overcome important limitations., (© 2023 by the American Diabetes Association.)

Background: The Covid-19 pandemic dramatically changed healthcare delivery, driving rapid expansion of synchronous (i.e., real-time) audio-only and video telehealth, otherwise known as virtual care. Yet evidence describes significant inequities in virtual care utilization, with certain populations more dependent on audio-only virtual care than video-based care. Research is needed to inform virtual care policies and processes to counteract current inequities in access and health outcomes., Objective: Given the importance of incorporating equity into virtual care within the Veterans Health Administration (VHA), we convened a Think Tank to identify priorities for future research and virtual care operations focused on achieving equitable implementation of virtual care within the VHA., Methods: We used participatory activities to engage clinicians, researchers, and operational partners from across the VHA to develop priorities for equitable implementation of virtual care. We refined priorities through group discussion and force-ranked prioritization and outlined next steps for selected priorities., Key Results: Think Tank participants included 43 individuals from the VHA who represented diverse geographical regions, offices, and backgrounds. Attendees self-identified their associations primarily as operations (n = 9), research (n = 28), or both (n = 6). We identified an initial list of 63 potential priorities for future research and virtual care operations. Following discussion, we narrowed the list to four priority areas: (1) measure inequities in virtual care, (2) address emerging inequities in virtual care, (3) deploy virtual care equitably to accommodate differently abled veterans, and (4) measure and address potential adverse consequences of expanded virtual care. We discuss related information, data, key partners, and outline potential next steps., Conclusions: This Think Tank of research and operational partners from across the VHA identified promising opportunities to incorporate equity into the design and implementation of virtual care. Although much work remains, the priorities identified represent important steps toward achieving this vital goal., (© 2023. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Introduction: Uterine fibroids are common, nonmalignant tumors that disproportionately impact Black patients. We aimed to examine Black and White differences in receipt of any treatment and type of first treatment in the Department of Veterans Affairs, including effect modification by severity as approximated by anemia., Methods: We used Department of Veterans Affairs administrative data to identify 5,041 Black and 3,206 White veterans with symptomatic uterine fibroids, identified by International Classification of Diseases, 9th edition, Clinical Modification, codes, between fiscal year 2010 and fiscal year 2012 and followed in the administrative data through fiscal year 2018 for outcomes. Outcomes included receipt of any treatment, hysterectomy as first treatment, and fertility-sparing treatment as first treatment. We stratified all analyses by age (<45, ≥45 years old), used generalized linear models with a log link and Poisson error distribution, included an interaction term between race and anemia, and used recycled predictions to estimate adjusted percentages for outcomes., Results: There was evidence of effect modification by anemia for receipt of any treatment but not for any other outcomes. Across age and anemia sub-groups, Black veterans were less likely to receive any treatment than White veterans. Adjusted racial differences were most pronounced among veterans with anemia (<45 years, Black-White difference = -10.3 percentage points; 95% confidence interval, -15.9 to -4.7; ≥45 years, Black-White difference = -20.3 percentage points; 95% confidence interval, -27.8 to -12.7). Across age groups, Black veterans were less likely than White veterans to have hysterectomy and more likely to have a fertility-sparing treatment as their first treatment., Conclusions: We identified significant Black-White disparities in receipt of treatment for symptomatic uterine fibroids. Additional research that centers the experiences of Black veterans with uterine fibroids is needed to inform strategies to eliminate racial disparities in uterine fibroid care., (Published by Elsevier Inc.)

As novel coronavirus 2019 disease (COVID-19) began to spread across the United States in early 2020, health care systems faced extreme demands on resources. As the country's largest single-payer health care system, the U.S. Department of Veterans Affairs (VA) was uniquely positioned to study how the virus impacted different communities and work to improve care provided to all. Early on, a literature review of prior epidemics revealed that occupational exposures and an inability to socially distance could impact some groups more than others. The VA's Office of Health Equity leveraged a general sense of community to create a collaborative research space and a dedicated analytic space to inform pandemic operations. VA researchers and operations staff were able to quickly share information and respond to updates to produce accurate and reliable publications for medical professionals and the general public. Partnerships with VA Medical Centers and Veteran Service Organizations helped to increase communication across the nation and determine the most critical needs. Although COVID-19 was dynamic in nature, VA's intentional examination of social and structural factors was crucial in informing a more equitable approach. Moving forward, these inequities must be intentionally addressed in future pandemic responses., Competing Interests: No competing financial interests exist., (© Sarah C. Leder et al., 2023; Published by Mary Ann Liebert, Inc.)

Objective: Evaluate self-reported electronic screening ( eScreening ) in a VA Transition Care Management Program (TCM) to improve the accuracy and completeness of administrative ethnicity and race data., Materials and Methods: We compared missing, declined, and complete (neither missing nor declined) rates between (1) TCM-eScreening (ethnicity and race entered into electronic tablet directly by patient using eScreening), (2) TCM-EHR (Veteran-completed paper form plus interview, data entered by staff), and (3) Standard-EHR (multiple processes, data entered by staff). The TCM-eScreening ( n  = 7113) and TCM-EHR groups ( n  = 7113) included post-9/11 Veterans. Standard-EHR Veterans included all non-TCM Gulf War and post-9/11 Veterans at VA San Diego ( n  = 92 921)., Results: Ethnicity : TCM-eScreening had lower rates of missingness than TCM-EHR and Standard-EHR (3.0% vs 5.3% and 8.6%, respectively, P  < .05), but higher rates of "decline to answer" (7% vs 0.5% and 1.2%, P  < .05). TCM-EHR had higher data completeness than TCM-eScreening and Standard-EHR (94.2% vs 90% and 90.2%, respectively, P  < .05). Race : No differences between TCM-eScreening and TCM-EHR for missingness (3.5% vs 3.4%, P  > .05) or data completeness (89.9% vs 91%, P  > .05). Both had better data completeness than Standard-EHR ( P  < .05), which despite the lowest rate of "decline to answer" (3%) had the highest missingness (10.3%) and lowest overall completeness (86.6%). There was strong agreement between TCM-eScreening and TCM-EHR for ethnicity (Kappa = .92) and for Asian, Black, and White Veteran race (Kappas = .87 to .97), but lower agreement for American Indian/Alaska Native (Kappa = .59) and Native Hawaiian/Other Pacific Islander (Kappa = .50) Veterans., Conculsions: eScreening is a promising method for improving ethnicity and race data accuracy and completeness in VA., Competing Interests: None declared., (Published by Oxford University Press on behalf of the American Medical Informatics Association 2023.)

Objectives: The Advisory Committee on Immunization Practices recommends persons aged ≥6 months receive an influenza vaccination annually, and certain adults aged ≥19 years receive the 23-valent pneumococcal polysaccharide vaccine alone or in series with the 13-valent pneumococcal conjugate vaccine, depending on age, chronic conditions, and smoking status. This study examines the prevalence of influenza and pneumococcal vaccination relative to Healthy People 2020 goals to understand how vaccination receipt differs by veteran status and sociodemographic subgroups., Methods: We analyzed pooled data from the 2016-2018 National Health Interview Survey (N = 35 094) in 2021 to estimate the prevalence of influenza and pneumococcal vaccination for men aged 25-64 years and for men aged ≥65 years by veteran status and selected sociodemographic subgroups. We used 2-tailed t tests with an α = .05 to identify significant differences., Results: Among men, 44.7% of veterans and 33.5% of nonveterans aged 25-64 years and 71.0% of veterans and 64.9% of nonveterans aged ≥65 years received an influenza vaccine in the past year. Among men aged 25-64 years at high risk for pneumococcal disease, 35.9% of veterans and 20.8% of nonveterans had ever received ≥1 dose of any pneumococcal vaccination. Disparities in the prevalence of vaccination within examined sociodemographic characteristics were often smaller in magnitude among veterans than among nonveterans for both vaccinations., Conclusions: Vaccination rates were below Healthy People 2020 targets for both groups, except influenza vaccination among veterans aged ≥65 years. Understanding differences in vaccine uptake may inform efforts to improve vaccination rates by identifying subgroups who are at high risk of disease and have low vaccination rates.

Identifying and addressing social risks and social needs in healthcare settings is an important step towards achieving health equity. Assessing Circumstances and Offering Resources for Needs (ACORN) is a Department of Veterans Affairs (VA) social risk screening and referral model that aims to systematically identify and address social needs. Since initial piloting in 2018, our team has collaborated with clinical and operations partners to implement ACORN across multiple VA clinical settings while adapting and tailoring the initiative to meet the needs of different populations, specialties, and individuals administering screening. Given ACORN's complexity as a growing initiative with multiple partners and frequent real-time modifications within a large national healthcare system, we recognized a need to systematically document the rationale and process of adaptations over time. We looked to three implementation frameworks-RE-AIM, the Adaptome, and FRAME-to describe the rationale for adaptations, the nature of and context within which adaptations were made, and the details of each adaptation. In this manuscript, we uniquely interweave these three frameworks to document adaptations to ACORN across diverse VA clinical settings, with a focus on how adaptations support the promotion of heath equity in the Veteran population., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Cohen, Russell, Elwy, Mitchell, Cornell, Silva, Moy and Kennedy.)

Purpose: Marginalized communities have been disproportionally impacted by SARS-CoV-2. How the associations between social determinants of health and the risk of SARS-CoV-2 infection shifted across time is unknown. In this evaluation, we examine individual-level social determinants of health as social risk factors for SARS-CoV-2 infection across the first 12 months of the pandemic among US Veterans., Methods: We conducted a retrospective cohort analysis of 946,358 Veterans who sought testing or treatment for SARS-CoV-2 infection in U.S. Department of Veterans Affairs medical facilities. We estimated risk ratios for testing positive by social risk factors, adjusting for demographics, comorbidities, and time. Adjusted models were stratified by pandemic phase to assess temporal fluctuations in social risks., Results: Approximately 19% of Veterans tested positive for SARS-CoV-2. Larger household size was a persistent risk factor and this association increased over time. Early in the pandemic, lower county-level population density was associated with lower SARS-CoV-2 infection risk, but between June 1 and August 31, 2020, this trend reversed., Conclusions: Temporal fluctuations in social risks associated with Veterans' SARS-CoV-2 infection suggest the need for ongoing, real-time tracking as the social and medical environment continues to evolve., (Published by Elsevier Inc.)

As many health systems have been working to become high-reliability organizations (HROs), health equity has been largely absent from discussions and applications of HRO principles. This is a serious oversight. Disparities in health and health care represent systematic failures to achieve reliable outcomes for certain groups. Acceptance of disparities is antithetical to the essential HRO goal of "zero harm." We propose adding Equity to HROs in the most literal sense by designating it as a key component and achieving High Equity Reliability Organizations. We describe how equity should be a crucial element of all 5 HRO core concepts: sensitivity to operations, preoccupation with failure, deference to expertise, resilience, and reluctance to simplify., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Competing Interests: Conflict-of-Interest Disclosures: None to disclose.

Whether requiring Graduate Record Examinations (GRE) results for doctoral applicants affects the diversity of admitted cohorts remains uncertain. This study randomized applications to 2 population-health doctoral programs at the University of California San Francisco to assess whether masking reviewers to applicant GRE results differentially affects reviewers' scores for underrepresented minority (URM) applicants from 2018-2020. Applications with GRE results and those without were randomly assigned to reviewers to designate scores for each copy (1-10, 1 being best). URM was defined as self-identification as African American/Black, Filipino, Hmong, Vietnamese, Hispanic/Latinx, Native American/Alaska Native, or Native Hawaiian/Other Pacific Islander. We used linear mixed models with random effects for the applicant and fixed effects for each reviewer to evaluate the effect of masking the GRE results on the overall application score and whether this effect differed by URM status. Reviewer scores did not significantly differ for unmasked versus masked applications among non-URM applicants (β = 0.15; 95% CI: -0.03, 0.33) or URM applicants (β = 0.02, 95% CI: -0.49, 0.54). We did not find evidence that removing GREs differentially affected URM compared with non-URM students (β for interaction = -0.13, 95% CI: -0.55, 0.29). Within these doctoral programs, results indicate that GRE scores neither harm nor help URM applicants., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health.)

Studies documenting coronavirus disease 2019 (COVID-19) racial/ethnic disparities in the United States were limited to data from the initial few months of the pandemic, did not account for changes over time, and focused primarily on Black and Hispanic minority groups. To fill these gaps, we examined time trends in racial/ethnic disparities in COVID-19 infection and mortality. We used the Veteran Health Administration's (VHA) national database of veteran COVID-19 infections over three time periods: 3/1/2020-5/31/2020 (spring); 6/1/2020-8/31/2020 (summer); and 9/1/2020-11/25/2020 (fall). We calculated COVID-19 infection and mortality predicted probabilities from logistic regression models that included time period-by-race/ethnicity interaction terms, and controlled for age, gender, and prior diagnosis of CDC risk factors. Racial/ethnic groups at higher risk for COVID-19 infection and mortality changed over time. American Indian/Alaskan Natives (AI/AN), Blacks, Hispanics, and Native Hawaiians/Other Pacific Islanders experienced higher COVID-19 infections compared to Whites during the summertime. There were mortality disparities for Blacks in springtime, and AI/ANs, Asians, and Hispanics in summertime. Policy makers should consider the dynamic nature of racial/ethnic disparities as the pandemic evolves, and potential effects of risk mitigation and other (e.g., economic) policies on these disparities. Researchers should consider how trends in disparities change over time in other samples.

Objectives-This report describes the prevalence of multiple (two or more) chronic conditions (MCC) among veterans and nonveterans and examines whether differences by veteran status may be explained by differences in sociodemographic composition, smoking behavior, and weight status based on body mass index. Methods-Data from the 2015-2018 National Health Interview Survey were used to estimate the prevalence of MCC among adults aged 25 and over by veteran status and sex. Estimates (age-stratified and age-adjusted) were also presented by race and Hispanic origin, educational attainment, poverty status, smoking status, and weight status. Multivariate logistic regression models examined the odds of MCC by veteran status after age stratification (65 and over or under 65) and further adjustment for age and other covariates. Results-Among adults aged 25 and over, age-adjusted prevalence of MCC was higher among veterans compared with nonveterans for both men and women (22.2% compared with 17.0% for men aged 25-64, 66.9% compared with 61.9% for men aged 65 and over, 25.4% compared with 19.6% among women aged 25-64, and 74.1% compared with 61.8% among women aged 65 and over). Following stratification by age and adjustment for selected sociodemographic characteristics, the prevalence of MCC remained higher among veterans compared with nonveterans for both men and women. After further adjustment for smoking status and weight status, differences in the prevalence of MCC by veteran status were reduced but remained statistically significant, with the exception of men aged 65 and over., (All material appearing in this report is in the public domain and may be reproduced or copied without permission; citation as to source, however, is appreciated.)

Objective: Geographic and racial/ethnic disparities related to diabetes control and treatment have not previously been examined at the national level., Research Design and Methods: A retrospective cohort study was conducted in a national cohort of 1,140,634 veterans with diabetes, defined as two or more diabetes ICD-9 codes (250.xx) across inpatient and outpatient records. Main exposures of interest included 125 Veterans Administration Medical Center (VAMC) catchment areas as well as racial/ethnic group. The main outcome measure was HbA 1c level dichotomized at ≥8.0% (≥64 mmol/mol)., Results: After adjustment for age, sex, racial/ethnic group, service-connected disability, marital status, and the van Walraven Elixhauser comorbidity score, the prevalence of uncontrolled diabetes varied by VAMC catchment area, with values ranging from 19.1% to 29.2%. Moreover, these differences largely persisted after further adjusting for medication use and adherence as well as utilization and access metrics. Racial/ethnic differences in diabetes control were also noted. In our final models, compared with non-Hispanic Whites, non-Hispanic Blacks (odds ratio 1.11 [95% credible interval 1.09-1.14]) and Hispanics (1.36 [1.09-1.14]) had a higher odds of uncontrolled HBA 1c level., Conclusions: In a national cohort of veterans with diabetes, we found geographic as well as racial/ethnic differences in diabetes control rates that were not explained by adjustment for demographics, comorbidity burden, use or type of diabetes medication, health care utilization, access metrics, or medication adherence. Moreover, disparities in suboptimal control appeared consistent across most, but not all, VAMC catchment areas, with non-Hispanic Black and Hispanic veterans having a higher odds of suboptimal diabetes control than non-Hispanic White veterans., (© 2020 by the American Diabetes Association.)

For the period 2007-17 rural death rates were higher than urban rates for the seven major causes of death analyzed, and disparities widened for five of the seven. In 2017 urban areas had met national targets for three of the seven causes, while rural areas had met none of the targets.

Introduction: Established by the Affordable Care Act, the National Quality Strategy (NQS) is the national policy goals aimed at improving the quality of health care for all Americans. The NQS established six priorities to provide better, more affordable care for individuals and communities. This is the first analysis of data on the NQS and access measures that focus on sex differences, health conditions, trends, and disparities., Methods: Measures from the 2015 National Healthcare Quality and Disparities Report (QDR) for the four National Quality Strategy priorities (Patient Safety, Person Centered Care, Effective Treatment, and Healthy Living), access to care, and health conditions for women were compared to measures for men. Trends were analyzed for women by health condition and the four NQS priorities and access to care. Baseline year (2000-2002) and most current year (2012-2013) were compared to assess disparity trends. All non-institutionalized women and men in the U.S. over the age of 18 were included in the sample., Results: Disparities between males and females for the four NQS priority and access measures did not change for 83 percent of measures (n=81); disparities remained constant. The greatest improvement over time for females from the baseline year was in the patient safety measures (3.66 percent increase per year). Access of care measures showed the least amount of improvement with a median change of -1.20 percent per year. The greatest improvement in quality of care by health condition was amongst chronic kidney disease (11.95 median percent change) and HIV/AIDS (6.63 median percent change) measures. Behavioral health measures showed the least amount of improvement with a median change of -0.33 percent per year., Conclusions: This analysis highlights cardiovascular disease, behavioral health, and access to care as problem areas for women that require immediate attention. It is of concern that 83% of the measures showed a persistent disparity over time between men and women. These results indicate that there is room for improving the quality of healthcare received by women and reducing sex-based disparities experienced by women in the healthcare delivery system., (Copyright © 2017 Jacobs Institute of Women's Health. All rights reserved.)

Objectives: As sepsis hospitalizations have increased, in-hospital sepsis deaths have declined. However, reported rates may remain higher among racial/ethnic minorities. Most previous studies have adjusted primarily for age and sex. The effect of other patient and hospital characteristics on disparities in sepsis mortality is not yet well-known. Furthermore, coding practices in claims data may influence findings. The objective of this study was to use a broad method of capturing sepsis cases to estimate 2004-2013 trends in risk-adjusted in-hospital sepsis mortality rates by race/ethnicity to inform efforts to reduce disparities in sepsis deaths., Design: Retrospective, repeated cross-sectional study., Setting: Acute care hospitals in the Healthcare Cost and Utilization Project State Inpatient Databases for 18 states with consistent race/ethnicity reporting., Patients: Patients diagnosed with septicemia, sepsis, organ dysfunction plus infection, severe sepsis, or septic shock., Measurements and Main Results: In-hospital sepsis mortality rates adjusted for patient and hospital factors by race/ethnicity were calculated. From 2004 to 2013, sepsis hospitalizations for all racial/ethnic groups increased, and mortality rates decreased by 5-7% annually. Mortality rates adjusted for patient characteristics were higher for all minority groups than for white patients. After adjusting for hospital characteristics, sepsis mortality rates in 2013 were similar for white (92.0 per 1,000 sepsis hospitalizations), black (94.0), and Hispanic (93.5) patients but remained elevated for Asian/Pacific Islander (106.4) and "other" (104.7; p < 0.001) racial/ethnic patients., Conclusions: Our results indicate that hospital characteristics contribute to higher rates of sepsis mortality for blacks and Hispanics. These findings underscore the importance of ensuring that improved sepsis identification and management is implemented across all hospitals, especially those serving diverse populations.