Disparities in Wait Times for Care Among US Veterans by Race and Ethnicity

Gurewich, Deborah; Beilstein‐Wedel, Erin; Shwartz, Michael; Davila, Heather; Rosen, Amy K.

doi:10.1001/jamanetworkopen.2022.52061

Cited by 10 publications

(20 citation statements)

References 64 publications

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“…However, Black and Hispanic Veterans had, on average, longer wait times for all services 16. In a recently published paper using more current data, we found that wait time for Black and Hispanic Veterans increased more than White Veterans’ wait time during the COVID pandemic 17…”

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confidence: 54%

“…16 In a recently published paper using more current data, we found that wait time for Black and Hispanic Veterans increased more than White Veterans' wait time during the COVID pandemic. 17 Our overall goal in this study was to illustrate the use and value of the 2-stage Kitagawa decomposition to partition disparities in outcomes into within-facility and between-facility differences and to identify those facilities that contribute the most to each component. This study received a nonhuman subject research determination from the VA Boston Institutional Review Board.…”

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confidence: 99%

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Using the Kitagawa Decomposition to Measure Overall—and Individual Facility Contributions to—Within-facility and Between-facility Differences

et al. 2023

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Background: Identifying whether differences in health care disparities are due to within-facility or between-facility differences is key to disparity reductions. The Kitagawa decomposition divides the difference between 2 means into within-facility differences and between-facility differences that are measured on the same scale as the original disparity. It also enables the identification of facilities that contribute most to within-facility differences (based on facility-level disparities and the proportion of patient population served) and between-facility differences.Objectives: Illustrate the value of a 2-stage Kitagawa decomposition to partition a disparity into within-facility and between-facility differences and to measure the contribution of individual facilities to each type of difference.Subjects: Veterans receiving a new outpatient consult for cardiology or orthopedic services during fiscal years 2019-2021. Measures: Wait time for a new-patient consultMethods: In stage 1, we predicted wait time for each Veteran from a multivariable model; in stage 2, we aggregated individual predictions to determine mean adjusted wait times for Hispanic, Black, and White Veterans and then decomposed differences in wait times between White Veterans and each of the other groups.Results: Noticeably longer wait times were experienced by Hispanic Veterans for cardiology (2.32 d, 6.8% longer) and Black Veterans for orthopedics (3.49 d, 10.3% longer) in both cases due entirely to within-facility differences. The results for Hispanic Veterans using orthopedics illustrate how positive within-facility differences (0.57 d) can be offset by negative between-facility differences (−0.34 d), resulting in a smaller overall disparity (0.23 d). Selecting 10 facilities for interventions in orthopedics based on the largest contributions to within-in facility differences instead of the largest disparities resulted in a higher percentage of Veterans impacted (31% and 12% of Black and White Veterans, respectively, versus 9% and 10% of Black and White Veterans, respectively) and explained 21% of the overall within-facility difference versus 11%. Conclusions:The Kitagawa approach allows the identification of disparities that might otherwise be undetected. It also allows the targeting of interventions at those facilities where improvements will have the largest impact on the overall disparity.

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confidence: 54%

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confidence: 99%

Using the Kitagawa Decomposition to Measure Overall—and Individual Facility Contributions to—Within-facility and Between-facility Differences

et al. 2023

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“…41,43 We used insurance type as a proxy for health care access. In addition to insurance type, other financial and physical barriers exist, such as the availability of appointments with primary and specialty care providers, 57 the distance between minority populations and needed care-as may occur with residential segregation, 58,59 and inequities in paid family medical leave. 60 Veterans receiving care within the Veterans Health Administration have reduced mortality for patients identifying as Black versus White.…”

Section: Discussionmentioning

confidence: 99%

A Surgical Desirability of Outcome Ranking (DOOR) Reveals Complex Relationships between Race/Ethnicity, Insurance Type and Neighborhood Deprivation

Jacobs

Schmidt²,

Hall

et al. 2023

Annals of Surgery

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Objective: Develop an ordinal Desirability of Outcome Ranking (DOOR) for surgical outcomes to examine complex associations of Social Determinants of Health (SDoH). Summary background data: Studies focused on single or binary composite outcome may not detect health disparities. Methods: Three healthcare system cohort study using NSQIP (2013-2019) linked with EHR and risk-adjusted for frailty, Preoperative Acute Serious Conditions (PASC), case status and operative stress assessing associations of multi-level SDoH of race/ethnicity, insurance type (Private 13,957; Medicare 15,198; Medicaid 2,835; Uninsured 2,963) and Area Deprivation Index (ADI) on DOOR and the binary Textbook Outcomes (TO). Results: Patients living in highly deprived neighborhoods (ADI>85) had higher odds of PASC (aOR=1.13, CI=1.02-1.25, P<0.001) and urgent/emergent cases (aOR=1.23, CI=1.16-1.31, P<0.001). Increased odds of higher/less desirable DOOR scores were associated with patients identifying as Black versus White, and on Medicare, Medicaid or Uninsured versus Private insurance. Patients with ADI>85 had lower odds of TO (aOR=0.91, CI=0.85-0.97, P=0.006) until adjusting for insurance but increased odds of higher DOOR (aOR=1.07, CI=1.01-1.14, P<0.021) after adjusting for insurance but similar odds after adjusting for PASC and urgent/emergent cases. Conclusions: DOOR revealed complex interactions between race/ethnicity, insurance type and neighborhood deprivation. ADI>85 was associated with higher odds of worse DOOR outcomes while TO failed to capture the effect of ADI. Our results suggest that presentation acuity is a critical determinant of worse outcomes in patients in highly deprived neighborhoods and without insurance. Including risk adjustment for living in deprived neighborhoods and urgent/emergent surgeries could improve the accuracy of quality metrics.

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“…1 However, disparities persist in health and health care due to nonclinical differences such as race and sex. [2][3][4][5][6] Understanding veteran experiences is an essential part of the VHA action plan for advancing health equity. 7 Veteran experiences must be contextualized within the realities of the contemporary sociopolitical environment.…”

Section: Introductionmentioning

confidence: 99%

“…Equitable care is a major tenet of the Veterans Health Administration (VHA) mission . However, disparities persist in health and health care due to nonclinical differences such as race and sex . Understanding veteran experiences is an essential part of the VHA action plan for advancing health equity…”

Section: Introductionmentioning

confidence: 99%

Health Equity in the Veterans Health Administration From Veterans’ Perspectives by Race and Sex

Lee,

Keddem,

Sorrentino

et al. 2024

JAMA Netw Open

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ImportanceAdvancing equitable patient-centered care in the Veterans Health Administration (VHA) requires understanding the differential experiences of unique patient groups.ObjectiveTo inform a comprehensive strategy for improving VHA health equity through the comparative qualitative analysis of care experiences at the VHA among veterans of Black and White race and male and female sex.Design, Setting, and ParticipantsThis qualitative study used a technique termed freelisting, an anthropologic technique eliciting responses in list form, at an urban academic VHA medical center from August 2, 2021, to February 9, 2022. Participants included veterans with chronic hypertension. The length of individual lists, item order in those lists, and item frequency across lists were used to calculate a salience score for each item, allowing comparison of salient words and topics within and across different groups. Participants were asked about current perceptions of VHA care, challenges in the past year, virtual care, suggestions for change, and experiences of racism. Data were analyzed from February 10 through September 30, 2022.Main Outcomes and MeasuresThe Smith salience index, which measures the frequency and rank of each word or phrase, was calculated for each group.ResultsResponses from 49 veterans (12 Black men, 12 Black women, 12 White men, and 13 White women) were compared by race (24 Black and 25 White) and sex (24 men and 25 women). The mean (SD) age was 64.5 (9.2) years. Some positive items were salient across race and sex, including “good medical care” and telehealth as a “comfortable/great option,” as were some negative items, including “long waits/delays in getting care,” “transportation/traffic challenges,” and “anxiety/stress/fear.” Reporting “no impact” of racism on experiences of VHA health care was salient across race and sex; however, reports of race-related unprofessional treatment and active avoidance of race-related conflict differed by race (present among Black and not White participants). Experiences of interpersonal interactions also diverged. “Impersonal/cursory” telehealth experiences and the need for “more personal/attentive” care were salient among women and Black participants, but not men or White participants, who associated VHA care with courtesy and respect.Conclusions and RelevanceIn this qualitative freelist study of veteran experiences, divergent experiences of interpersonal care by race and sex provided insights for improving equitable, patient-centered VHA care. Future research and interventions could focus on identifying differences across broader categories both within and beyond race and sex and bolstering efforts to improve respect and personalized care to diverse veteran populations.

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Disparities in Wait Times for Care Among US Veterans by Race and Ethnicity

Cited by 10 publications

References 64 publications

Using the Kitagawa Decomposition to Measure Overall—and Individual Facility Contributions to—Within-facility and Between-facility Differences

Using the Kitagawa Decomposition to Measure Overall—and Individual Facility Contributions to—Within-facility and Between-facility Differences

A Surgical Desirability of Outcome Ranking (DOOR) Reveals Complex Relationships between Race/Ethnicity, Insurance Type and Neighborhood Deprivation

Health Equity in the Veterans Health Administration From Veterans’ Perspectives by Race and Sex

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