Achieving Health Equity: Federal Perspectives for 21st Century Health System Research Priorities

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The ability to deliver a consistent product and outcome is a defining factor of a “high-reliability” system. The persistence of health care disparities based on race/ethnicity, income, sex or sexual orientation, and residence is a stark reminder that health inequity is pervasive in the United States and that our health care system is far from becoming a highly reliable system. Moreover, there is increasing recognition that factors outside of health care are among the strongest determinants of health disparities. Although health care reforms have narrowed disparities in access, disparities remain for many health outcomes related to chronic disease and mental health as well as for most processes of care.1 It seems timely to reflect from our positions at 2 major funders of disparities research, the US Department of Veterans Affairs (VA) and National Institutes of Health (NIH), on future directions of this field of research. We recognize that a focus on individual interactions at the level of the health care system needs to be matched with attention at the community and societal level.
The experience of the VA provides a window into how much an integrated health care delivery system can do to reduce disparities through a combination of access to care, social supports, integration of behavioral health and primary care, and outreach to vulnerable populations. The good news is that VA has made substantial progress in eliminating some of the racial and ethnic disparities seen outside VA for conditions such as blood pressure control, receipt of mental health care, and cancer outcomes. A recent review of 362 studies examining disparities in quality of care in Veteran populations,2 however, presented a mixed picture depending on whether disparities were measured in terms of utilization, quality/process, or health outcome. Utilization among Veterans cared for by the VA did not vary consistently based on race/ethnicity, sex, mental health conditions, or age but was lower for those living in rural areas. On process measures, important gaps remain in terms of satisfaction with care, adherence with medications, treatment of pain, and use of surgical procedures. Finally, for Veteran health outcomes, low socioeconomic status was a more consistent source of disparate health outcome than race, ethnicity, sex, rural residence or mental health conditions. This is consistent with the recent reports of rising morbidity and mortality seen among lower-income whites in the United States.3
Taken together, these findings reinforce that health disparities have complex roots outside the health system. These include the multiple economic, cultural, and social factors that contribute to inequality and social disadvantage as well as individual behavioral and biological differences. Research conducted by VA and NIH on underlying contributors to the disparities suggests different targets, or mechanisms, for interventions to improve health equity and reduce disparities.
First, at the individual level, disparities may exist because of gaps in knowledge or health literacy that make it harder for disadvantaged patients to navigate the health system. Notably, for joint replacement, VA research has found that low rates of surgery in African Americans with severe arthritis could be improved with a targeted, patient-centered educational intervention.4 Other research has used peer support effectively to help minority patients with poorly controlled diabetes and to help mental health patients who were reluctant to engage with VA care.5 The NIH-sponsored Diabetes Prevention Program showed that a lifestyle modification intervention leading to modest weight loss and increased physical activity reduced progression of prediabetes to diabetes by 58% compared with metformin and placebo over 3 years in 3234 participants of whom 45% were from minority groups.
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