Skip to main content

Racial and Ethnic Disparities in the VA Health Care System: A Systematic Review

Abstract

Objectives

To better understand the causes of racial disparities in health care, we reviewed and synthesized existing evidence related to disparities in the “equal access” Veterans Affairs (VA) health care system.

Methods

We systematically reviewed and synthesized evidence from studies comparing health care utilization and quality by race within the VA.

Results

Racial disparities in the VA exist across a wide range of clinical areas and service types. Disparities appear most prevalent for medication adherence and surgery and other invasive procedures, processes that are likely to be affected by the quantity and quality of patient–provider communication, shared decision making, and patient participation. Studies indicate a variety of likely root causes of disparities including: racial differences in patients’ medical knowledge and information sources, trust and skepticism, levels of participation in health care interactions and decisions, and social support and resources; clinician judgment/bias; the racial/cultural milieu of health care settings; and differences in the quality of care at facilities attended by different racial groups.

Conclusions

Existing evidence from the VA indicates several promising targets for interventions to reduce racial disparities in the quality of health care.

This is a preview of subscription content, access via your institution.

Figure 1

References

  1. 1.

    Smedley BD, Stith AY, Nelson AR. Institute of Medicine Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health CareUnequal treatment: confronting racial and ethnic disparities in health care. Washington, D.C.: National Academies Press; 2003.

    Google Scholar 

  2. 2.

    Department of Veterans Affairs. 2001 National Survey of Veterans. Final Report. Available at http://www1.va.gov/vetdata/docs/NSV%20Final%20Report.pdf (accessed November 25, 2007).

  3. 3.

    Halanych JH, Wang F, Miller DR, Pogach LM, Lin H, Berlowitz DR, et al. Racial/ethnic differences in diabetes care for older veterans: accounting for dual health system use changes conclusions. Medical Care. 2006;44(5):439–45.

    PubMed  Google Scholar 

  4. 4.

    Gurmankin AD, Polsky D, Volpp KG. Accounting for apparent “reverse” racial disparities in Department of Veterans Affairs (VA)-based medical care: influence of out-of-VA care. Am J Public Health. 2004;94(12):2076–8.

    PubMed  Google Scholar 

  5. 5.

    Dominick KL, Bosworth HB, Jeffreys AS, Grambow SC, Oddone EZ, Horner RD. Racial/ethnic variations in non-steroidal anti-inflammatory drug (NSAID) use among patients with osteoarthritis. Pharmacoepidemiol Drug Saf. 2004;13(10):683–94.

    PubMed  Google Scholar 

  6. 6.

    Dominick KL, Bosworth HB, Dudley TK, Waters SJ, Campbell LC, Keefe FJ. Patterns of opioid analgesic prescription among patients with osteoarthritis. J Pain Palliat Care Pharmacother. 2004;18(1):31–46.

    PubMed  Google Scholar 

  7. 7.

    Dominick KL, Dudley TK, Grambow SC, Oddone EZ, Bosworth HB. Racial differences in health care utilization among patients with osteoarthritis. J Rheumatol. 2003;30(10):2201–6.

    PubMed  Google Scholar 

  8. 8.

    Dominick KL, Bosworth HB, Hsieh JB, Moser BK. Racial differences in analgesic/anti-inflammatory medication use and perceptions of efficacy. J Natl Med Assoc. 2004;96(7):928–32.

    PubMed  Google Scholar 

  9. 9.

    Golightly YM, Dominick KL. Racial variations in self-reported osteoarthritis symptom severity among veterans. Aging Clin Exp Res. 2005;17(4):264–9.

    PubMed  Google Scholar 

  10. 10.

    Ang DC, Ibrahim SA, Burant CJ, Kwoh CK. Is there a difference in the perception of symptoms between African Americans and whites with osteoarthritis? J Rheumatol. 2003;30(6):1305–10.

    PubMed  Google Scholar 

  11. 11.

    Ibrahim SA, Siminoff LA, Burant CJ, Kwoh CK. Understanding ethnic differences in the utilization of joint replacement for osteoarthritis: the role of patient-level factors. Med Care. 2002;40(1 Suppl):I44–51.

    PubMed  Google Scholar 

  12. 12.

    Ibrahim SA, Siminoff LA, Burant CJ, Kwoh CK. Differences in expectations of outcome mediate African American/white patient differences in “willingness” to consider joint replacement. Arthritis Rheum. 2002;46(9):2429–35.

    PubMed  Google Scholar 

  13. 13.

    Tan G, Jensen MP, Thornby J, Anderson KO. Ethnicity, control appraisal, coping, and adjustment to chronic pain among black and white Americans. Pain Med. 2005;6(1):18–28.

    PubMed  Google Scholar 

  14. 14.

    Ang DC, Ibrahim SA, Burant CJ, Siminoff LA, Kwoh CK. Ethnic differences in the perception of prayer and consideration of joint arthroplasty. Med Care. 2002;40(6):471–6.

    PubMed  Google Scholar 

  15. 15.

    Ibrahim SA, Siminoff LA, Burant CJ, Kwoh CK. Variation in perceptions of treatment and self-care practices in elderly with osteoarthritis: a comparison between African American and white patients. Arthritis & Rheumatism. 2001;45(4):340–5.

    CAS  Google Scholar 

  16. 16.

    Knight SJ, Siston AK, Chmiel JS, Slimack N, Elstein AS, Chapman GB, et al. Ethnic variation in localized prostate cancer: a pilot study of preferences, optimism, and quality of life among black and white veterans. Clin Prostate Cancer. 2004;3(1):31–7.

    PubMed  Google Scholar 

  17. 17.

    Dominitz JA, Samsa GP, Landsman P, Provenzale D. Race, treatment, and survival among colorectal carcinoma patients in an equal-access medical system. Cancer. 1998;82(12):2312–20.

    PubMed  CAS  Google Scholar 

  18. 18.

    Dominitz JA, Maynard C, Billingsley KG, Boyko EJ. Race, treatment, and survival of veterans with cancer of the distal esophagus and gastric cardia. Med Care. 2002;40(1 Suppl):I14–26.

    PubMed  Google Scholar 

  19. 19.

    Akerley WL 3rd, Moritz TE, Ryan LS, Henderson WG, Zacharski LR. Racial comparison of outcomes of male Department of Veterans Affairs patients with lung and colon cancer. Arch Intern Med. 1993;153(14):1681–8.

    PubMed  Google Scholar 

  20. 20.

    Gordon HS, Street RL Jr., Sharf BF, Kelly PA, Souchek J. Racial differences in trust and lung cancer patients’ perceptions of physician communication. J Clin Oncol. 2006;24(6):904–9.

    PubMed  Google Scholar 

  21. 21.

    Gordon HS, Street RL Jr., Sharf BF, Souchek J. Racial differences in doctors’ information-giving and patients’ participation. Cancer. 2006;107(6):1313–20.

    PubMed  Google Scholar 

  22. 22.

    Street RL Jr., Gordon HS. The clinical context and patient participation in post-diagnostic consultations. Patient Educ Couns 2006;(in press).

  23. 23.

    Oddone EZ, Horner RD, Monger ME, Matchar DB. Racial variations in the rates of carotid angiography and endarterectomy in patients with stroke and transient ischemic attack. Arch Intern Med. 1993;153(24):2781–6.

    PubMed  CAS  Google Scholar 

  24. 24.

    Oddone EZ, Horner RD, Sloane R, McIntyre L, Ward A, Whittle J, et al. Race, presenting signs and symptoms, use of carotid artery imaging, and appropriateness of carotid endarterectomy. Stroke. 1999;30(7):1350–6.

    PubMed  CAS  Google Scholar 

  25. 25.

    Goldstein LB, Matchar DB, Hoff-Lindquist J, Samsa GP, Horner RD. Veterans Administration Acute Stroke (VASt) Study: lack of race/ethnic-based differences in utilization of stroke-related procedures or services. Stroke. 2003;34(4):999–1004.

    PubMed  Google Scholar 

  26. 26.

    Oddone EZ, Horner RD, Johnston DC, Stechuchak K, McIntyre L, Ward A, et al. Carotid endarterectomy and race: do clinical indications and patient preferences account for differences? Stroke. 2002;33(12):2936–43.

    PubMed  Google Scholar 

  27. 27.

    Ferguson JA, Adams TA, Weinberger M. Racial differences in cardiac catheterization use and appropriateness. Am J Med Sci. 1998;315(5):302–6.

    PubMed  CAS  Google Scholar 

  28. 28.

    Hassapoyannes CA, Giurgiutiu DV, Eaves G, Movahed MR. Apparent racial disparity in the utilization of invasive testing for risk assessment of cardiac patients undergoing noncardiac surgery. Cardiovasc Revasc Med. 2006;7(2):64–9.

    PubMed  Google Scholar 

  29. 29.

    Mirvis DM, Burns R, Gaschen L, Cloar FT, Graney M. Variation in utilization of cardiac procedures in the Department of Veterans Affairs health care system: effect of race. J Am Coll Cardiol. 1994;24(5):1297–304.

    PubMed  CAS  Google Scholar 

  30. 30.

    Maynard C, Sun H, Lowy E, Sales AE, Fihn SD. The use of percutaneous coronary intervention in black and white veterans with acute myocardial infarction. BMC Health Serv Res. 2006;6:107.

    PubMed  Google Scholar 

  31. 31.

    Ferguson JA, Tierney WM, Westmoreland GR, Mamlin LA, Segar DS, Eckert GJ, et al. Examination of racial differences in management of cardiovascular disease. J Am Coll Cardiol. 1997;30(7):1707–13.

    PubMed  CAS  Google Scholar 

  32. 32.

    Peterson ED, Wright SM, Daley J, Thibault GE. Racial variation in cardiac procedure use and survival following acute myocardial infarction in the Department of Veterans Affairs. Jama. 1994;271(15):1175–80.

    PubMed  CAS  Google Scholar 

  33. 33.

    Whittle J, Conigliaro J, Good CB, Lofgren RP. Racial differences in the use of invasive cardiovascular procedures in the Department of Veterans Affairs medical system. N Engl J Med. 1993;329(9):621–7.

    PubMed  CAS  Google Scholar 

  34. 34.

    Peniston RL, Lu DY, Papademetriou V, Fletcher RD. Severity of coronary artery disease in black and white male veterans and likelihood of revascularization. Am Heart J. 2000;139(5):840–7.

    PubMed  CAS  Google Scholar 

  35. 35.

    Conigliaro J, Whittle J, Good CB, Hanusa BH, Passman LJ, Lofgren RP, et al. Understanding racial variation in the use of coronary revascularization procedures: the role of clinical factors. Arch Intern Med. 2000;160(9):1329–35.

    PubMed  CAS  Google Scholar 

  36. 36.

    Petersen LA, Wright SM, Peterson ED, Daley J. Impact of race on cardiac care and outcomes in veterans with acute myocardial infarction. Medical Care. 2002;40(1 Suppl):I86–96.

    PubMed  Google Scholar 

  37. 37.

    Sedlis SP, Fisher VJ, Tice D, Esposito R, Madmon L, Steinberg EH. Racial differences in performance of invasive cardiac procedures in a Department of Veterans Affairs Medical Center. J Clin Epidemiol. 1997;50(8):899–901.

    PubMed  CAS  Google Scholar 

  38. 38.

    Mickelson JK, Blum CM, Geraci JM. Acute myocardial infarction: clinical characteristics, management and outcome in a metropolitan Veterans Affairs Medical Center teaching hospital. J Am Coll Cardiol. 1997;29(5):915–25.

    PubMed  CAS  Google Scholar 

  39. 39.

    Mirvis DM, Graney MJ. Impact of race and age on the effects of regionalization of cardiac procedures in the Department of Veterans Affairs Health Care System. Am J Cardiol. 1998;81(8):982–7.

    PubMed  CAS  Google Scholar 

  40. 40.

    Gordon HS, Paterniti DA, Wray NP. Race and patient refusal of invasive cardiac procedures. J Gen Intern Med. 2004;19(9):962–6.

    PubMed  Google Scholar 

  41. 41.

    Kressin NR, Chang BH, Whittle J, Peterson ED, Clark JA, Rosen AK, et al. Racial differences in cardiac catheterization as a function of patients’ beliefs. Am J Public Health. 2004;94(12):2091–7.

    PubMed  Article  Google Scholar 

  42. 42.

    Groeneveld PW, Kruse GB, Chen Z, Asch DA. Variation in cardiac procedure use and racial disparity among Veterans Affairs Hospitals. American Heart Journal. 2007;153(2):320–7.

    PubMed  Google Scholar 

  43. 43.

    Collins TC, Johnson M, Henderson W, Khuri SF, Daley J. Lower extremity nontraumatic amputation among veterans with peripheral arterial disease: is race an independent factor? Med Care. 2002;40(1 Suppl):I106–16.

    PubMed  Google Scholar 

  44. 44.

    Bosworth HB, Stechuchak KM, Grambow SC, Oddone EZ. Patient risk perceptions for carotid endarterectomy: which patients are strongly averse to surgery? J Vasc Surg. 2004;40(1):86–91.

    PubMed  Google Scholar 

  45. 45.

    Oddone EZ, Horner RD, Diers T, Lipscomb J, McIntyre L, Cauffman C, et al. Understanding racial variation in the use of carotid endarterectomy: the role of aversion to surgery. J Natl Med Assoc. 1998;90(1):25–33.

    PubMed  CAS  Google Scholar 

  46. 46.

    Whittle J, Conigliaro J, Good CB, Joswiak M. Do patient preferences contribute to racial differences in cardiovascular procedure use? J Gen Intern Med. 1997;12(5):267–73.

    PubMed  CAS  Google Scholar 

  47. 47.

    Kressin NR, Clark JA, Whittle J, East M, Peterson ED, Chang BH, et al. Racial differences in health-related beliefs, attitudes, and experiences of VA cardiac patients: scale development and application. Med Care. 2002;40(1 Suppl):I72–85.

    PubMed  Google Scholar 

  48. 48.

    Gordon HS, Street RL Jr., Kelly PA, Souchek J, Wray NP. Physician–patient communication following invasive procedures: an analysis of post-angiogram consultations. Soc Sci Med. 2005;61(5):1015–25.

    PubMed  Google Scholar 

  49. 49.

    Collins TC, Clark JA, Petersen LA, Kressin NR. Racial differences in how patients perceive physician communication regarding cardiac testing. Med Care. 2002;40(1 Suppl):I27–34.

    PubMed  Google Scholar 

  50. 50.

    Evangelista LS, Dracup K, Doering LV. Racial differences in treatment-seeking delays among heart failure patients. J Card Fail. 2002;8(6):381–6.

    PubMed  Google Scholar 

  51. 51.

    Blow FC, Zeber JE, McCarthy JF, Valenstein M, Gillon L, Bingham CR. Ethnicity and diagnostic patterns in veterans with psychoses. Soc Psychiatry Psychiatr Epidemiol. 2004;39(10):841–51.

    PubMed  Google Scholar 

  52. 52.

    Kales HC, Blow FC, Bingham CR, Copeland LA, Mellow AM. Race and inpatient psychiatric diagnoses among elderly veterans. Psychiatr Serv. 2000;51(6):795–800.

    PubMed  CAS  Google Scholar 

  53. 53.

    Rosenheck R, Fontana A, Cottrol C. Effect of clinician-veteran racial pairing in the treatment of posttraumatic stress disorder. Am J Psychiatry. 1995;152(4):555–63.

    PubMed  CAS  Google Scholar 

  54. 54.

    Rosenheck R, Seibyl CL. Participation and outcome in a residential treatment and work therapy program for addictive disorders: the effects of race. Am J Psychiatry. 1998;155(8):1029–34.

    PubMed  CAS  Google Scholar 

  55. 55.

    Dolan NC, Ferreira MR, Fitzgibbon ML, Davis TC, Rademaker AW, Liu D, et al. Colorectal cancer screening among African-American and white male veterans. Am J Prev Med. 2005;28(5):479–82.

    PubMed  Google Scholar 

  56. 56.

    Fisher DA, Jeffreys A, Coffman CJ, Fasanella K. Barriers to full colon evaluation for a positive fecal occult blood test. Cancer Epidemiol Biomarkers Prev. 2006;15(6):1232–5.

    PubMed  Google Scholar 

  57. 57.

    Etzioni DA, Yano EM, Rubenstein LV, Lee ML, Ko CY, Brook RH, et al. Measuring the quality of colorectal cancer screening: the importance of follow-up. Dis Colon Rectum. 2006;49(7):1002–10.

    PubMed  Google Scholar 

  58. 58.

    Woodard LD, Kressin NR, Petersen LA. Is lipid-lowering therapy underused by African Americans at high risk of coronary heart disease within the VA health care system? Am J Public Health. 2004;94(12):2112–7.

    PubMed  Google Scholar 

  59. 59.

    Williams ML, Morris MT 2nd, Ahmad U, Yousseff M, Li W, Ertel N. Racial differences in compliance with NCEP-II recommendations for secondary prevention at a Veterans Affairs medical center. Ethn Dis. 2002;12(1):S158–S162.

    Google Scholar 

  60. 60.

    Bosworth HB, Dudley T, Olsen MK, Voils CI, Powers B, Goldstein MK, et al. Racial differences in blood pressure control: potential explanatory factors. Am J Med. 2006;119(1):70.e9–15.

    Google Scholar 

  61. 61.

    Lowry KP, Dudley TK, Oddone EZ, Bosworth HB. Intentional and unintentional nonadherence to antihypertensive medication. Ann Pharmacother. 2005;39(7–8):1198–203.

    PubMed  Google Scholar 

  62. 62.

    Woodard LD, Hernandez MT, Lees E, Petersen LA. Racial differences in attitudes regarding cardiovascular disease prevention and treatment: a qualitative study. Patient Educ Couns. 2005;57(2):225–31.

    PubMed  Google Scholar 

  63. 63.

    Straits-Troster KA, Kahwati LC, Kinsinger LS, Orelien J, Burdick MB, Yevich SJ. Racial/Ethnic differences in influenza vaccination in the veterans affairs healthcare system. Am J Prev Med. 2006;315375–82.

    PubMed  Google Scholar 

  64. 64.

    Hwang SS, Chang VT, Cogswell J, Srinivas S, Kasimis B. Knowledge and attitudes toward end-of-life care in veterans with symptomatic metastatic cancer. Palliat Support Care. 2003;1(3):221–30.

    PubMed  Article  Google Scholar 

  65. 65.

    Basson MD, Gomez R, Fishman L, Panzini L. Informed consent for screening sigmoidoscopy in a Veterans Administration population. Dis Colon Rectum. 2004;47(11):1939–46.

    PubMed  Google Scholar 

  66. 66.

    Kemppainen JK, Levine RE, Mistal M, Schmidgall D. HAART adherence in culturally diverse patients with HIV/AIDS: a study of male patients from a Veteran’s Administration Hospital in northern California. AIDS Patient Care STDS. 2001;15(3):117–27.

    PubMed  CAS  Google Scholar 

  67. 67.

    Curtis JR, Park DR, Krone MR, Pearlman RA. Use of the medical futility rationale in do-not-attempt-resuscitation orders. JAMA. 1995;273(2):124–8.

    PubMed  CAS  Google Scholar 

  68. 68.

    Heisler M, Smith DM, Hayward RA, Krein SL, Kerr EA. Racial disparities in diabetes care processes, outcomes, and treatment intensity. Med Care. 2003;41(11):1221–32.

    PubMed  Google Scholar 

  69. 69.

    Heisler M, Zemencuk JK, Krein SL, Hayward RA, Piette JD, Kerr EA. Racial disparities in diabetes care processes, outcomes, and treatment intensity. In: HSR&D National Meeting; 2006; Washington, DC; 2006.

  70. 70.

    Jha AK, Stone RA, Lave J, Chen H, Klusartiz H, Volpp KG. Where do black veterans receive hospital care? Variability in disparities within the VA healthcare system. In: HSR&D National Meeting; 2007; Washington, DC; 2007.

  71. 71.

    Walsh ME, Katz MA, Sechrest L. Unpacking cultural factors in adaptation to type 2 diabetes mellitus. Med Care. 2002;40(1 Suppl)I129–39.

    PubMed  Google Scholar 

  72. 72.

    Agha Z, Lofgren RP, VanRuiswyk JV, Layde PM. Are patients at Veterans Affairs Medical Centers sicker? A comparative analysis of health status and medical resource use. Arch Intern Med. 2000;160(27):3252–7.

    PubMed  CAS  Google Scholar 

References

  1. 1.

    Dominitz JA, Maynard C, Billingsley KG, Boyko EJ. Race, treatment, and survival of veterans with cancer of the distal esophagus and gastric cardia. Med Care. Jan 2002;40(1 Suppl):I14–26.

    PubMed  Google Scholar 

  2. 2.

    Akerley WL, 3rd, Moritz TE, Ryan LS, Henderson WG, Zacharski LR. Racial comparison of outcomes of male Department of Veterans Affairs patients with lung and colon cancer. Arch Intern Med. 1993;153(14):1681–1688.

    PubMed  Google Scholar 

  3. 3.

    Dominitz JA, Samsa GP, Landsman P, Provenzale D. Race, treatment, and survival among colorectal carcinoma patients in an equal access medical system. Cancer. 1998;82(12):2312–2320.

    PubMed  CAS  Google Scholar 

  4. 4.

    Knight SJ, Siston AK, Chmiel JS, et al. Ethnic variation in localized prostate cancer: a pilot study of preferences, optimism, and quality of life among black and white veterans. Clin Prostate Cancer. 2004;3(1):31–37.

    PubMed  Google Scholar 

  5. 5.

    Oddone EZ, Horner RD, Monger ME, Matchar DB. Racial variations in the rates of carotid angiography and endarterectomy in patients with stroke and transient ischemic attack. Arch Intern Med. 1993;153(24):2781–2786.

    PubMed  CAS  Google Scholar 

  6. 6.

    Oddone EZ, Horner RD, Sloane R, et al. Race, presenting signs and symptoms, use of carotid artery imaging, and appropriateness of carotid endarterectomy. Stroke. 1999;30(7):1350–1356.

    PubMed  CAS  Google Scholar 

  7. 7.

    Oddone EZ, Horner RD, Johnston DC, et al. Carotid endarterectomy and race: do clinical indications and patient preferences account for differences? Stroke. 2002;33(12):2936–2943.

    PubMed  Google Scholar 

  8. 8.

    Goldstein LB, Matchar DB, Hoff-Lindquist J, Samsa GP, Horner RD. Veterans Administration Acute Stroke (VASt) Study: lack of race/ethnic-based differences in utilization of stroke-related procedures or services. Stroke. 2003;34(4):999–1004

    PubMed  Google Scholar 

  9. 9.

    Mirvis DM, Burns R, Gaschen L, Cloar FT, Graney M. Variation in utilization of cardiac procedures in the Department of Veterans Affairs health care system: effect of race. J Am Coll Cardiol. 1994;24(5):1297–1304.

    PubMed  CAS  Article  Google Scholar 

  10. 10.

    Ferguson JA, Tierney WM, Westmoreland GR, et al. Examination of racial differences in management of cardiovascular disease. J Am Coll Cardiol. 1997;30(7):1707–1713.

    PubMed  CAS  Google Scholar 

  11. 11.

    Whittle J, Conigliaro J, Good CB, Lofgren RP. Racial differences in the use of invasive cardiovascular procedures in the Department of Veterans Affairs medical system. N Engl J Med. Aug 26 1993;329(9):621–627.

    PubMed  CAS  Google Scholar 

  12. 12.

    Groeneveld PW, Kruse GB, Chen Z, Asch DA. Variation in cardiac procedure use and racial disparity among Veterans Affairs Hospitals. American Heart Journal. Feb 2007;153(2):320–327.

    PubMed  Google Scholar 

  13. 13.

    Peterson ED, Wright SM, Daley J, Thibault GE. Racial variation in cardiac procedure use and survival following acute myocardial infarction in the Department of Veterans Affairs. Jama. Apr 20 1994;271(15):1175–1180.

    PubMed  CAS  Google Scholar 

  14. 14.

    Kressin NR, Chang BH, Whittle J, et al. Racial differences in cardiac catheterization as a function of patients’ beliefs. Am J Public Health. Dec 2004;94(12):2091–2097.

    PubMed  Google Scholar 

  15. 15.

    Petersen LA, Wright SM, Peterson ED, Daley J. Impact of race on cardiac care and outcomes in veterans with acute myocardial infarction. Medical Care. Jan 2002;40(1 Suppl):I86–96.

    Google Scholar 

  16. 16.

    Sedlis SP, Fisher VJ, Tice D, Esposito R, Madmon L, Steinberg EH. Racial differences in performance of invasive cardiac procedures in a Department of Veterans Affairs Medical Center. J Clin Epidemiol. Aug 1997;50(8):899–901.

    PubMed  CAS  Google Scholar 

  17. 17.

    Maynard C, Sun H, Lowy E, Sales AE, Fihn SD. The use of percutaneous coronary intervention in black and white veterans with acute myocardial infarction. BMC Health Serv Res. 2006;6:107.

    PubMed  Google Scholar 

  18. 18.

    Conigliaro J, Whittle J, Good CB, et al. Understanding racial variation in the use of coronary revascularization procedures: the role of clinical factors. Arch Intern Med. May 8 2000;160(9):1329–1335.

    PubMed  CAS  Google Scholar 

  19. 19.

    Mickelson JK, Blum CM, Geraci JM. Acute myocardial infarction: clinical characteristics, management and outcome in a metropolitan Veterans Affairs Medical Center teaching hospital. J Am Coll Cardiol. Apr 1997;29(5):915–925.

    PubMed  CAS  Google Scholar 

  20. 20.

    Ferguson JA, Adams TA, Weinberger M. Racial differences in cardiac catheterization use and appropriateness. Am J Med Sci. May 1998;315(5):302–306.

    Google Scholar 

  21. 21.

    Hassapoyannes CA, Giurgiutiu DV, Eaves G, Movahed MR. Apparent racial disparity in the utilization of invasive testing for risk assessment of cardiac patients undergoing noncardiac surgery. Cardiovasc Revasc Med. Apr–Jun 2006;7(2):64–69.

    PubMed  Google Scholar 

  22. 22.

    Gordon HS, Paterniti DA, Wray NP. Race and patient refusal of invasive cardiac procedures. J Gen Intern Med. Sep 2004;19(9):962–966.

    Google Scholar 

  23. 23.

    Peniston RL, Lu DY, Papademetriou V, Fletcher RD. Severity of coronary artery disease in black and white male veterans and likelihood of revascularization. Am Heart J. May 2000;139(5):840–847.

    PubMed  CAS  Google Scholar 

  24. 24.

    Mirvis DM, Graney MJ. Impact of race and age on the effects of regionalization of cardiac procedures in the Department of Veterans Affairs Health Care System. Am J Cardiol. Apr 15 1998;81(8):982–987.

    PubMed  CAS  Google Scholar 

  25. 25.

    Ibrahim SA, Whittle J, Bean-Mayberry B, Kelley ME, Good C, Conigliaro J. Racial/ethnic variations in physician recommendations for cardiac revascularization. Am J Public Health. Oct 2003;93(10):1689–1693.

    PubMed  Google Scholar 

  26. 26.

    Kressin NR, Clark JA, Whittle J, et al. Racial differences in health-related beliefs, attitudes, and experiences of VA cardiac patients: scale development and application. Med Care. Jan 2002;40(1 Suppl):I72–85.

    Google Scholar 

  27. 27.

    Charles H, Good CB, Hanusa BH, Chang CC, Whittle J. Racial differences in adherence to cardiac medications. J Natl Med Assoc. Jan 2003;95(1):17–27.

    PubMed  Google Scholar 

  28. 28.

    Evangelista LS, Dracup K, Doering LV. Racial differences in treatment-seeking delays among heart failure patients. J Card Fail. Dec 2002;8(6):381–386.

    PubMed  Google Scholar 

  29. 29.

    Ohldin A, Young B, Derleth A, et al. Ethnic differences in satisfaction and quality of life in veterans with ischemic heart disease. J Natl Med Assoc. Jun 2004;96(6):799–808.

    PubMed  Google Scholar 

  30. 30.

    Collins TC, Clark JA, Petersen LA, Kressin NR. Racial differences in how patients perceive physician communication regarding cardiac testing. Med Care. Jan 2002;40(1 Suppl):I27–34.

    Google Scholar 

  31. 31.

    Gordon HS, Street RL, Jr., Kelly PA, Souchek J, Wray NP. Physician–patient communication following invasive procedures: an analysis of post angiogram consultations. Soc Sci Med. Sep 2005;61(5):1015–1025.

    PubMed  Google Scholar 

  32. 32.

    Bosworth HB, Stechuchak KM, Grambow SC, Oddone EZ. Patient risk perceptions for carotid endarterectomy: which patients are strongly averse to surgery? J Vasc Surg. Jul 2004;40(1):86–91.

    PubMed  Google Scholar 

  33. 33.

    Oddone EZ, Horner RD, Diers T, et al. Understanding racial variation in the use of carotid endarterectomy: the role of aversion to surgery. J Natl Med Assoc. Jan 1998;90(1):25–33.

    PubMed  CAS  Google Scholar 

  34. 34.

    Whittle J, Conigliaro J, Good CB, Joswiak M. Do patient preferences contribute to racial differences in cardiovascular procedure use? J Gen Intern Med. May 1997;12(5):267–273.

    PubMed  CAS  Google Scholar 

  35. 35.

    Fisher DA, Jeffreys A, Coffman CJ, Fasanella K. Barriers to full colon evaluation for a positive fecal occult blood test. Cancer Epidemiol Biomarkers Prev. Jun 2006;15(6):1232–1235.

    PubMed  Google Scholar 

  36. 36.

    Dolan NC, Ferreira MR, Fitzgibbon ML, et al. Colorectal cancer screening among African-American and white male veterans. Am J Prev Med. Jun 2005;28(5):479–482.

    PubMed  Google Scholar 

  37. 37.

    Etzioni DA, Yano EM, Rubenstein LV, et al. Measuring the quality of colorectal cancer screening: the importance of follow-up. Dis Colon Rectum. Jul 2006;49(7):1002–1010.

    PubMed  Google Scholar 

  38. 38.

    Bosworth HB, Dudley T, Olsen MK, et al. Racial differences in blood pressure control: potential explanatory factors. Am J Med. Jan 2006;119(1):70 e79–15.

    Google Scholar 

  39. 39.

    Rehman SU, Hutchison FN, Hendrix K, Okonofua EC, Egan BM. Ethnic differences in blood pressure control among men at Veterans Affairs clinics and other health care sites. Arch Intern Med. May 9 2005;165(9):1041–1047.

    PubMed  Google Scholar 

  40. 40.

    Lowry KP, Dudley TK, Oddone EZ, Bosworth HB. Intentional and unintentional nonadherence to antihypertensive medication. Ann Pharmacother. Jul–Aug 2005;39(7–8):1198–1203.

    PubMed  Google Scholar 

  41. 41.

    Sharkness CM, Snow DA. The patient’s view of hypertension and compliance. Am J Prev Med. May–Jun 1992;8(3):141–146.

    PubMed  CAS  Google Scholar 

  42. 42.

    Williams ML, Morris MT, 2nd, Ahmad U, Yousseff M, Li W, Ertel N. Racial differences in compliance with NCEP-II recommendations for secondary prevention at a Veterans Affairs medical center. Ethn Dis. Winter 2002;12(1):S1–58–62.

    Google Scholar 

  43. 43.

    Woodard LD, Kressin NR, Petersen LA. Is lipid-lowering therapy underused by African Americans at high risk of coronary heart disease within the VA health care system? Am J Public Health. Dec 2004;94(12):2112–2117.

    PubMed  Article  Google Scholar 

  44. 44.

    Fu SS, Sherman SE, Yano EM, van Ryn M, Lanto AB, Joseph AM. Ethnic disparities in the use of nicotine replacement therapy for smoking cessation in an equal access health care system. Am J Health Promot. Nov–Dec 2005;20(2):108–116.

    Google Scholar 

  45. 45.

    Ambriz EH, Woodard LD, Kressin NR, Petersen LA. Use of smoking cessation interventions and aspirin for secondary prevention: are there racial disparities? Am J Med Qual. Jul–Aug 2004;19(4):166–171.

    PubMed  Google Scholar 

  46. 46.

    Woodard LD, Hernandez MT, Lees E, Petersen LA. Racial differences in attitudes regarding cardiovascular disease prevention and treatment: a qualitative study. Patient Educ Couns. May 2005;57(2):225–231.

    PubMed  Google Scholar 

  47. 47.

    Washington DL, Villa V, Brown A, Damron-Rodriguez J, Harada N. Racial/ethnic variations in veterans’ ambulatory care use. American Journal of Public Health. Dec 2005;95(12):2231–2237.

    PubMed  Google Scholar 

  48. 48.

    Washington DL, Harada ND, Villa VM, et al. Racial variations in Department of Veterans Affairs ambulatory care use and unmet health care needs. Military Medicine. Mar 2002;167(3):235–241.

    PubMed  Google Scholar 

Download references

Acknowledgments

This study was funded by and conducted for the Evidence Synthesis Activity Pilot (ESP) Program of the U.S. Department of Veterans Affairs Health Services Research and Development Service (ESP 05-225). The authors are responsible for the content of the manuscript and the decision to submit it for publication. We thank the ESP planning committee as well as content experts Judith Long, M.D., Eugene Oddone, M.D., Elizabeth Yano, Ph.D., and Donna Washington, M.D., M.P.H., for providing guidance and feedback on draft versions of the report. We are grateful to Nancy A. Brown, MLS, for designing the search strategy and conducting the literature search. Dr. Saha is supported by awards from the VA Health Services Research & Development Service Advanced Research Career Development Program, and from the Robert Wood Johnson Foundation Generalist Physician Faculty Scholars Program. Dr. Toure is supported by an award from the Robert Wood Johnson Clinical Scholars Program. Dr. Tippens is supported by the Complementary and Alternative Medicine: Expectancy and Outcomes, Project 2. Dr. Ibrahim is a recipient of a career development award from the VA Health Services Research and Development Service and the Robert Wood Johnson Foundation’s Harold Amos Faculty Development Award.

Conflict of Interest

None disclosed.

Author information

Affiliations

Authors

Corresponding author

Correspondence to Somnath Saha MD, MPH.

Appendix

Appendix

Evidence Summary Tables

TABLE OF CONTENTS

Table 1. The use of surgery, radiation, and chemotherapy by race and cancer type .................... 2

Table 2. The use of invasive procedures for stroke among veterans, by race .............................. 3

Table 3. The use of invasive procedures for heart disease among veterans, by race..................... 4

Table 4. Potential mediators of disparities in the use of invasive procedures amomg veterans with cardiovascular disease ................ 7

Table 5. The use of colon cancer screening among veterans, by race ........................................... 9

Table 6. Management of hypertension, by race........................................................................... 10

Table 7. Management of cardiovascular risk factors (excluding hypertension), by race ............ 11

Table 8. Access to the VA healthcare system, by race ................................................................ 12

References ....................................................................................................................................13

Table 1 The Use of Surgery, Radiation, and Chemotherapy Among Veterans by Race and Cancer Type
Table 2 The Use of Invasive Procedures for Stroke Among Veterans by Race
Table 3 The Use of Invasive Procedures for Heart Disease Among Veterans by Race
Table 4 Potential Mediators of Racial Disparities in the Use of Invasive Procedures Among Veterans with Cardiovascular Disease
Table 5 The Use of Colon Cancer Screening Among Veterans, by Race
Table 6 Management of Hypertension, by Race
Table 7 Management of Cardiovascular Risk Factors (excluding hypertension), by Race
Table 8 Access to the VA Healthcare System, by Race

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Saha, S., Freeman, M., Toure, J. et al. Racial and Ethnic Disparities in the VA Health Care System: A Systematic Review. J GEN INTERN MED 23, 654–671 (2008). https://doi.org/10.1007/s11606-008-0521-4

Download citation

KEY WORDS

  • racial and ethnic disparities
  • medication adherence
  • health care utilization