Evidence Synthesis Pilot Program 

Racial and Ethnic Disparities

in the VA Healthcare System:

A Systematic Review

Department of Veterans Affairs

Health Services Research & Development Service

June 2007

Prepared for: 

Department of Veterans Affairs

Veterans Health Administration

Health Services Research & Development Service

Washington, DC 20420

Portland VA Medical Center 

Investigators:

Somnath Saha, MD, MPH

Michele Freeman, MPH

Joahd Toure, MD

Kimberly M. Tippens, ND

Christine Weeks
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PREFACE 

VA’s Health Services Research and Development Service (HSR&D) works to improve the cost, 

quality, and outcomes of health care for our nation’s veterans. Collaborating with VA leaders, 

managers, and policy makers, HSR&D focuses on important health care topics that are likely to 

have significant impact on quality improvement efforts. One significant collaborative effort is 

HSR&D’s Evidence-based Synthesis Pilot Project (ESP). Through this project, HSR&D 

provides timely and accurate evidence syntheses on targeted health care topics. These products 

will be disseminated broadly throughout VA and will: inform VA clinical policy, develop 

clinical practice guidelines, set directions for future research to address gaps in knowledge, 

identify the evidence to support VA performance measures, and rationalize drug formulary 

decisions. 

HSR&D provided funding for the two Evidence Based Practice Centers (EPCs) supported by the 

Agency for Healthcare Research and Quality (AHRQ) that also had an active and publicly 

acknowledged VA affiliation—Southern California EPC and Portland, OR EPC—so they could 

develop evidence syntheses on requested topics for dissemination to VA policymakers. A 

planning committee with representation from HSR&D, Patient Care Services, Office of Quality 

and Performance, and the VISN Clinical Management Officers, has been established to identify 

priority topics and to insure the quality of final reports. 

Comments on this evidence report are welcome and can be sent to Susan Schiffner, ESP Program 

Manager, at Susan.Schiffner@va.gov. 
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EXECUTIVE SUMMARY 

INTRODUCTION 

Numerous studies have demonstrated racial and ethnic disparities in health care in the United 

States.These disparities have been demonstrated in the Veterans Affairs (VA) healthcare system, 

where financial barriers to receiving care are minimized. The VA is committed to delivering 

high-quality care in an equitable manner, and as such, to eliminating racial and ethnic disparities 

in health care. To inform this effort, we systematically reviewed the existing evidence on 

disparities within the VA, to address the following objectives: 

1) Determine in which clinical areas racial and ethnic disparities are prevalent within the 

VA; 

2) Describe what is known about the sources of those disparities; and 

3) Qualitatively synthesize that knowledge to determine the most promising avenues for 

future research aimed at improving equity in VA health care. 

METHODS 

Our review consisted of two components: a systematic review of the existing literature reporting 

the findings of research on racial disparities within the VA, and an environmental scan of 

ongoing or recently completed studies of racial disparities within the VA. We critically analyzed 

the evidence, compiled a summary of findings by clinical topic area, and drew conclusions based 

on qualitative synthesis of the findings. After summarizing the findings for each clinical topic, 

we synthesized the descriptions and summaries of the literature for each clinical topic to derive a 

set of “cross-cutting” themes related to the underlying causes of healthcare disparities. These 

served as the basis for a proposed set of potential interventions for future research aimed at 

reducing racial disparities in VA health care. 

RESULTS 

Arthritis and Pain Management: Studies of osteoarthritis and pain management reported racial 

differences in joint replacement surgery and analgesic medication use that generally indicate less 

aggressive management of osteoarthritis in blacks compared to whites. These differences are not 

likely explained by differences in symptom severity, as blacks tend to report similar if not greater 

levels of pain compared to whites. 

Blacks appear less willing than whites to undergo joint replacement surgery. This greater 

reluctance appears to be due to less familiarity with the procedure and worse expectations with 

regard to surgical outcomes, including post-operative recovery, chronic pain, and functioning. 

Blacks also appear to place greater value than whites on non-medical options for managing 

arthritis, particularly prayer. However, the degree to which lower willingness among black 

veterans explains observed disparities in joint replacement surgery is unknown. 
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Cancer: Studies comparing blacks and whites with cancer suggest that for some cancers, blacks 

are less likely to undergo potentially curative surgical resection but equally likely to undergo 

non-surgical interventions, such as chemotherapy and radiation. Studies exploring possible 

reasons for this disparity suggest that physicians engage in less effective partnerships with black 

veterans and provide them with less information as compared to white veterans. Part of this 

communication disparity appears to be related to black veterans’ being less assertive or active in 

their conversations with physicians. As a result of less effective partnerships and less 

information exchange between physicians and black veterans, physicians engender less trust 

among black as compared to white veterans. The degree to which these differences in 

communication, partnership, and trust actually explain disparities in cancer surgery is unknown. 

Cardiovascular Diseases: There were mixed findings across studies on racial disparities in the 

use of invasive procedures in veterans with cardiovascular diseases, but the majority of studies 

exploring this association found that non-whites undergo fewer procedures than whites. In one 

study an observed disparity in the use of cardiac catheterization was partly explained by greater 

overuse of the procedure among whites than blacks. 

Studies found greater aversion to invasive procedures among blacks compared with whites, as 

well as lower trust among blacks and greater emphasis on religion as an alternative to medical 

care. Notably, blacks were less familiar with cardiovascular procedures, and this lack of 

familiarity helped explain racial differences in willingness to undergo procedures in at least one 

study. 

Patient-physician communication behaviors differed between black and white veterans. One 

study identified a potential cycle of passivity in which black veterans, and veterans interacting 

with race discordant physicians, received less information overall because they less often 

engaged in communication behaviors (e.g. questions, assertions) that typically elicit more 

information from doctors. In focus groups, black veterans placed greater emphasis on the need 

for trust in their physicians in deciding about invasive procedures, while white veterans placed 

greater emphasis on clinical indications. 

While racial differences were apparent in factors that might influence the use of cardiac care—

e.g., aversion to surgery, trust, communication—studies that were able to examine the influence 

of these factors on actual use of invasive procedures generally found that they did not explain 

observed disparities. Physician decision making was more influential, and in one study 

physician recommendations helped explain racial disparities in cardiac procedure use, even after 

accounting for clinical variables and severity of coronary disease. The degree to which this 

difference in physician recommendations for black vs. white veterans was driven by clinical 

factors not captured by the studies, by the influence of patient preferences on physician decision 

making, or by physician bias, was not determined. 

Blacks were more likely to delay seeking treatment for heart failure symptoms and were less 

adherent (both intentionally and unintentionally) to medication regimens. Among veterans with 

peripheral arterial disease, blacks had higher rates of limb amputation. The reasons underlying 

these findings of lower adherence and later presentation were not investigated. 
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The impact of regionalization of services was greater among blacks than whites in one study. 

The presence of a local cardiac surgical program increased the likelihood of invasive procedure 

use to a significantly greater degree among blacks than among whites, suggesting that 

regionalization of cardiac care may have a greater impact on blacks than whites, exacerbating 

existing disparities. 

Diabetes: Existing studies reveal mixed results regarding racial disparities in diabetes care, but 

overall, the quality of care—as measured by process measures (appropriate test ordering) and 

outcome measures (control of blood pressure, glucose, and lipids)—appears to be worse for nonwhite veterans compared to whites. Some of the difference in outcomes may be explained in 

part by lower adherence among non-white veterans. 

Importantly, one study found no disparities in quality measures when examining VA data alone. 

However, when non-VA health care use was included, the study revealed poorer chronic disease 

monitoring for black and Hispanic as compared to white veterans with diabetes, since white 

veterans were more likely to receive care outside the VA. 

HIV and Hepatitis C: Clinical management of veterans with HIV was generally similar across 

racial groups. Self-reported medication adherence was similar for black and white veterans, 

though objective data based on computerized pharmacy refill records revealed lower adherence 

among blacks. Non-white veterans with HIV suggested ways to improve adherence, including 

use of a medication plan and more supportive health care and social interactions. Despite 

inconsistent findings on medication adherence and racially similar clinical management, ageadjusted mortality is higher among non-white veterans with HIV. Minority veterans appear to be 

diagnosed with HIV at a later stage and have more severe illness at the time of diagnosis, which 

may contribute to survival disparities. 

Black and Hispanic veterans with hepatitis C appear less likely than whites to receive antiviral 

treatment, and Hispanic veterans in one study were more likely than whites to discontinue 

treatment. The reasons underlying these disparities were not explored. 

Mental Health and Substance Abuse: Studies comparing utilization and outcomes of mental 

health care by veteran race do not reveal consistent patterns. In general, the quality of inpatient 

and residential treatment for substance abuse and mental illness was similar across racial groups; 

disparities were observed more often in outpatient settings. 

Clinicians tend to more frequently diagnose and treat black veterans with mental illness as 

having psychotic disorders (e.g., schizophrenia) and white veterans as having affective disorders 

(e.g., bipolar disorder, depression). The underlying causes of these disparities in diagnostic and 

treatment patterns remains unclear. 

Studies investigating the effect of the “racial environment” on mental health and substance abuse 

outcomes suggest that black veterans may derive benefit from having a racially concordant 

clinician, and from being in a racially concordant treatment group. These findings are 

considered preliminary and warrant validation in future studies. 
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Preventive and Ambulatory Care: Studies of preventive and ambulatory care use by veteran 

race reveal mixed findings. For some services—e.g., colorectal cancer screening, lipid lowering 

therapy—racial disparities do not appear prevalent. Studies did reveal disparities in some 

primary care outcome measures, including achieving blood pressure and lipid goals, but these 

findings may have explained in part by more severe disease among non-whites. Non-whites with 

hypertension were less adherent to medications, both unintentionally and intentionally, part of 

which was related to medication side effects. Qualitative research findings suggested that 

disparities in cardiovascular risk management may be related to low health literacy, less 

knowledge, and less assertiveness with physicians among black, as compared to white, veterans. 

Blacks were less likely than whites to receive influenza vaccines. Additionally, both blacks and 

Hispanics were less likely than whites to know they needed a vaccination and more likely to rely 

on physician recommendations and reminders to receive vaccinations. 

Non-white veterans are generally more likely than white veterans to use the VA healthcare 

system. American Indian/Alaska Natives and Hispanics were more likely than whites to have 

unmet health needs, while blacks and Asian/Pacific Islanders were similar to whites on this 

outcome measure. Non-white veterans identified interpersonal care, knowledge about VA 

services and eligibility, and dissatisfaction with the VA as barriers to obtaining VA care, though 

a study of women veterans found no racial differences in satisfaction among women using VA 

primary care. 

Rehabilitative and Palliative Care: Studies of end-of-life care were mixed but suggest that in 

some cases, black veterans are less likely than whites to have advanced directives or to engage in 

hospice care. Black veterans in one study were more likely to die in the hospital and in another 

study were more likely to undergo gastrostomy tube placement. Together, these studies suggest 

that black veterans receive a less palliative approach to care at the end of life. Reasons for these 

findings have not been explored. 

Other Clinical Topics: Studies across a range of clinical topics not covered above collectively 

suggest that black and other non-white veterans tend to receive less aggressive medical care than 

whites. Part of this may relate to greater skepticism among black veterans towards new 

medications and medical technology. Some of the variation seen in large national database 

studies may also be related to regional or facility-level practice variation, but findings of racial 

variation in single-center studies indicate that this explanation cannot account for many of the 

observed disparities. The degree to which racial bias among healthcare providers is responsible 

for racial disparities in care remains unclear but is suggested by the finding in one study that 

physicians were more likely to write do-not-resuscitate orders based on medical futility among 

non-white compared to white patients, independent of the same physicians’ predictions of the 

likelihood that the patients would survive resuscitation efforts. 

SUMMARY AND SYNTHESIS 

Prevalence of Disparities 

• There is no clear indication that disparities are more prevalent in some clinical areas than 

others. Although there have been more studies in the area of cardiovascular disease than 
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in other realms (as is also true in the non-VA literature), disparities appear to exist in all 

clinical arenas. 

• Disparities appear to be more consistently observed for processes that entail more risk or 

require more intensive decision making, communication, or effort on the part of patients 

and/or providers: surgery/invasive procedures and medication adherence. 

• In studies examining quality indicators that represent intermediate health outcomes—

such as control of blood sugar, blood pressure, or cholesterol—non-white veterans 

generally fared worse than whites. This is a troubling finding, in that it may indicate that 

disparities in healthcare delivery are contributing to real disparities in health outcomes. 

Alternatively, these studies suggest that racial disparities might reflect “regressive” 

healthcare delivery; i.e., minority veterans are receiving less and lower quality health care 

despite needing more and higher quality care, as reflected by poor control of their 

diabetes, hypertension, and hyperlipidemia. 

• Most of the reviewed studies compared African American and white veterans. Fewer 

studies examined Hispanics, American Indians, and Asians. In general, disparities in the 

VA appear to affect African American and Hispanic veterans most significantly. 

• Not all disparities should be assumed to reflect underuse of health care among nonwhites, particularly in the realm of surgical and other invasive procedures. In at least one 

study, differential use of cardiovascular procedures was found to reflect overuse among 

whites rather than underuse among African Americans.31 However, in many cases, 

disparities do appear to represent inappropriate underuse of procedures (i.e., lower quality 

care) among non-whites. 

• Because white veterans tend to use non-VA care more than non-white veterans do, 

studies that do not capture non-VA utilization, particularly those using administrative 

data, may underestimate the degree of disparities, find disparities to be absent when they 

in fact exist, or find “reverse” disparities (non-whites receive more/better care) when in 

fact no disparities exist. At least two studies have demonstrated this misleading effect of 

not capturing non-VA utilization. 

Sources of Disparities

Several themes emerged from our review as likely contributors to racial disparities in VA health 

care: 

• Veteran medical knowledge and information sources. Non-white and white veterans 

differ in their degree of familiarity with and knowledge about medical interventions. 

This difference stems from different levels of experience with those interventions among 

minority vs. white veterans and their families, friends, and communities; from different 

amounts of information conveyed by healthcare providers; and from different levels of 

health literacy and understanding among veterans. Different knowledge and information 

may affect patients’ perceptions of, or degree of uncertainty about, the necessity and 

benefits of medical interventions in relation to their risks. Uncertainty about the necessity 

of interventions may in turn reduce patients’ willingness to accept and adhere to them. 

Several studies indicate that minority veterans are less informed about their care, 

compared to white veterans, and that this difference affects decision making.
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• Veteran trust and skepticism. Minority veterans also tend to harbor less trust and more 

skepticism about the benefits of medical interventions, relative to their risks. These 

perceptions appear to be influenced by lack of familiarity with medical interventions 

(described above), by historical or personally experienced discrimination, and for some 

African American veterans in particular, by a reliance on religious and spiritual avenues 

for coping with illness as opposed to medical therapies. Studies in our review suggest that 

minority veterans are more skeptical of information provided by healthcare professionals, 

as compared to white veterans. It is important, however, not to misconstrue this 

skepticism as unwarranted. White veterans’ general lack of skepticism may be more 

problematic if it leads to acceptance of unnecessary or undesired care. 

• Racial/cultural milieu. Some have suggested that a more racially and culturally 

congruent healthcare environment (including racially concordant healthcare providers) 

for minority veterans may elevate trust, reduce skepticism, and enhance the acceptability 

of care. Two studies directly examined this issue and found that African American 

veterans experienced better interactions and fared somewhat better clinically, when cared 

for by African American vs. white providers. Another study suggested that black patients 

in group therapy might fare better when grouped with other black patients.

• Patient participation. Several studies suggest that non-white veterans are less active 

participants in their care as compared to white veterans. Non-white veterans tend to ask 

fewer questions of their providers, who in turn provide less information. Less 

information, as discussed above, may lead to lower acceptance of and adherence to 

medical interventions. In addition, lower patient participation diminishes the strength of 

the patient-provider partnership, which may in turn lead to less investment by both parties 

in following recommended care plans, and to lower trust and greater skepticism among 

minority veterans. 

• Clinician judgment. Studies suggest that clinicians’ diagnostic and therapeutic decision 

making varies by veteran race. The degree to which this differential decision making is 

based on clinical factors vs. non-clinical factors, including racial stereotypes, is unclear. 

For instance, in one study clinicians judged African American veterans to be less 

appropriate candidates for coronary interventions, even after accounting for chartdocumented variables. The degree to which this judgment reflected undocumented 

clinical factors vs. non-clinical influences was not clear. Similarly, clinicians prescribe 

opioid medications less frequently to African American vs. white veterans and are more 

likely to diagnose African American veterans presenting with mental illness as having 

psychotic vs. affective disorders. The degree to which these phenomena are driven by 

racial differences in co-existing substance abuse disorders, by cross-cultural 

misunderstanding of symptom presentations, or by racial bias, remains unclear.

• Veteran social support and resources. Non-white veterans may have fewer social 

support and other external resources to help with both illness management and decision 

making. This is particularly relevant in that minority veterans may rely more heavily on 

external resources than on healthcare professionals for information and support. This 

may particularly affect adherence and decision making around high-risk procedures.
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• Healthcare facility characteristics. Some disparities are at least partly explained by the 

fact that minority and white veterans tend to receive care at different VAMCs. In some 

cases, VAMCs that disproportionately serve minority veterans have fewer available 

services or deliver lower quality care overall than VAMCs serving predominantly white 

veterans. This potential source of disparities, however, remains underexplored. It should 

be noted that many studies have demonstrated disparities within single VAMCs, 

suggesting that system-level factors are unlikely to explain all observed disparities.

Future Research Recommendations 

The findings of our review suggest several promising areas for future research to further 

elucidate and reduce/eliminate racial disparities in health care within the VA. 

• Decision aids and information tools. Because disparities may arise from different 

levels of familiarity with and information about medical interventions, tools that provide 

accurate information about the rationale, risks, and benefits of interventions have the 

potential to “even the playing field” among minority and white veterans in terms of 

knowledge. In designing decision aids and information tools for minority veterans, 

investigators should pay attention to issues of literacy, language, and culture. 

• Patient activation interventions. Interventions to make patients more active participants 

in their interactions with healthcare providers and in the management of their illnesses 

have been shown to improve health outcomes. They may also reduce disparities by 

breaking the cycle of passivity that leads to less information exchange between minority 

veterans and their healthcare providers. More active patient participation has the 

potential to improve patient adherence as well as to strengthen patient-provider 

partnerships and mutual trust. 

• Patient-centered communication training. Interventions to make veterans more active 

participants in their interactions with healthcare providers can also target providers. 

Clinicians can adopt communication strategies that help solicit patient perspectives and 

engage patient participation. As with patient activation interventions, patient-centered 

approaches to healthcare interactions hold the potential to strengthen patient-provider 

partnerships and mutual trust. 

• Determining sources of variation in clinician judgment by patient race. As described 

above, studies have found that clinicians make different judgments based on veteran race. 

However, the degree to which this variation is driven by clinical characteristics vs. nonclinical factors, such as racial bias, remains unclear. Studies exploring how and why 

patient race is associated with different clinical decisions would help determine the need 

for and inform interventions to reduce adverse consequences of racial bias among 

clinicians. 

• Interventions to promote evidence-based decision making by providers. Similar to 

decision aids and information tools for patients, guidelines and decision rules for 

providers hold the potential to improve equity by “standardizing” care. To the extent that 

providers may be biased by patient race, guidelines, decision rules, and other quality 
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improvement tools that promote evidence-based decision making may reduce the 

influence of provider bias and enhance equity of care among veterans of different race 

and ethnicity. 

• Adherence support interventions. Minority veterans appear consistently across studies 

to be less adherent to treatment plans than whites. Studies suggest that this may in part 

be due to less social support and planning among minority veterans. Interventions to 

provide adherence support—e.g., education, assistance with care planning—may help 

reduce this disparity. 

• Determining facility characteristics associated with healthcare quality and equity.

Some disparities are explained by differences in the healthcare facilities where minority 

vs. white veterans seek care. Determining the differences in structures and processes 

across minority- vs. majority-serving VAMCs would inform interventions to eliminate 

system-level sources of disparities. In addition, studies examining facility-level 

characteristics associated with more equitable care within VAMCs—including those 

related to the racial and cultural context at VAMCs, such as the racial composition of 

clinical staff—would help inform system-level interventions to eliminate disparities. 

Future research on disparities in VA healthcare should explicitly define how race is 

conceptualized within a given study. A group of VA investigators has developed a 

survey/interview tool to assess the “ecocultural” factors for which veterans’ race and ethnicity 

often serve as proxies. “Unpacking” race and ethnicity in studies of disparities will promote 

understanding and inform future interventions. Researchers should also be mindful that some 

disparities represent overuse of medical services among white veterans rather than underuse 

among non-whites. Clearly, interventions to promote greater use of services among non-whites 

in these instances is unwarranted. Finally, future studies should attempt to account for non-VA 

utilization. Because non-VA care is more prevalent among white veterans than among nonwhites, ignoring non-VA utilization may generate misleading results. 
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TABLE OF CONTENTS 

INTRODUCTION .......................................................................................................................................................1

BACKGROUND ...........................................................................................................................................................1

SCOPE AND KEY QUESTIONS .....................................................................................................................................1

METHODS...................................................................................................................................................................3

LITERATURE SEARCH AND STRATEGY.......................................................................................................................3

ELIGIBILITY CRITERIA AND STUDY SELECTION .........................................................................................................3

DATA ABSTRACTION AND QUALITY ASSESSMENT ......................................................................................................4

EVIDENCE SYNTHESIS AND DATA PRESENTATION.....................................................................................................4

ENVIRONMENTAL SCAN ............................................................................................................................................4

RESULTS.....................................................................................................................................................................5

ARTHRITIS AND PAIN MANAGEMENT ........................................................................................................................5

CANCER.....................................................................................................................................................................7

CARDIOVASCULAR DISEASES ..................................................................................................................................10

DIABETES ................................................................................................................................................................20

HIV AND HEPATITIS C.............................................................................................................................................21

MENTAL HEALTH AND SUBSTANCE ABUSE .............................................................................................................23

PREVENTIVE AND AMBULATORY CARE...................................................................................................................26

REHABILITATIVE AND PALLIATIVE CARE ................................................................................................................34

OTHER CLINICAL TOPICS.........................................................................................................................................34

ONGOING AND RECENTLY COMPLETED RESEARCH...............................................................................40

SUMMARY AND SYNTHESIS...............................................................................................................................43

PREVALENCE OF DISPARITIES ..................................................................................................................................43

SOURCES OF DISPARITIES.........................................................................................................................................45

FUTURE RESEARCH RECOMMENDATIONS................................................................................................................47

REFERENCES ..........................................................................................................................................................49

APPENDIX I. SEARCH STRATEGY....................................................................................................................58

APPENDIX II. INCLUSION / EXCLUSION CRITERIA ...................................................................................59

APPENDIX III. SEARCH AND SELECTION OF LITERATURE....................................................................60

APPENDIX IV. EVIDENCE TABLES ..................................................................................................................61

In-Text Figure and Tables

FIGURE: CONCEPTUAL FRAMEWORK..............................................................................................................................2

TABLE 1. THE USE OF SURGERY, RADIATION, AND CHEMOTHERAPY AMONG VETERANS BY RACE AND CANCER TYPE ...9

TABLE 2. THE USE OF INVASIVE PROCEDURES FOR STROKE AMONG VETERANS BY RACE, BLACK (HISPANIC WHERE 

NOTED) VS. WHITE RACE AS REFERENT................................................................................................................15

TABLE 3. THE USE OF INVASIVE PROCEDURES FOR HEART DISEASE AMONG VETERANS BY RACE, BLACK VS. WHITE 

RACE AS REFERENT .............................................................................................................................................16
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TABLE 4. POTENTIAL MEDIATORS OF RACIAL DISPARITIES IN THE USE OF INVASIVE PROCEDURES AMONG VETERANS 

WITH CVD..........................................................................................................................................................18

TABLE 5. RACIAL DISPARITIES IN COLON CANCER SCREENING IN THE VA HEALTHCARE SYSTEM................................30

TABLE 6. RACIAL DISPARITIES IN HYPERTENSION AND ITS TREATMENT IN THE VA HEALTHCARE SYSTEM..................31

TABLE 7. RACIAL DISPARITIES IN CARDIOVASCULAR RISK FACTORS (EXCLUDING HYPERTENSION) AND THEIR 

TREATMENT IN THE VA HEALTHCARE SYSTEM ...................................................................................................32

TABLE 8. STUDIES OF RACIAL DISPARITIES IN ACCESS TO THE VA HEALTHCARE SYSTEM ...........................................33

TABLE 9. PRESENCE OF DISPARITIES BY CLINICAL CONTENT AREA.............................................................................43

TABLE 10. PRESENCE OF DISPARITIES BY UTILIZATION OR OUTCOME MEASURE.........................................................43
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INTRODUCTION 

Background 

Numerous studies have demonstrated racial and ethnic differences in health care in the United 

States.1

 These studies have collectively demonstrated that both the quantity and quality of health 

care are lower for minority Americans—African Americans and Hispanics in particular—as 

compared to the white majority. Studies have found racial differences in the use of lifesaving 

surgeries and other invasive procedures, in technical processes of health care delivery, and in 

interpersonal interactions between patients and providers. The root causes of racial differences in 

health care remain unclear, but in general, they are not explained by differences in clinical 

factors or patient preferences; i.e., the differences represent inequity in health care delivery. The 

Institute of Medicine has referred to these inequitable differences as disparities. Differences in 

ability to pay for care—as measured by health insurance and income—also do not explain the 

majority of observed racial disparities.1

 Importantly, disparities in health care have been 

demonstrated in the Veterans Affairs (VA) healthcare system, where financial barriers to 

receiving care are minimized. 

The VA is committed to delivering high-quality care in an equitable manner, and as such, to 

eliminating racial and ethnic disparities in health care. To inform this effort, the VA has invested 

in research on disparities by making Equity one of the priority areas within its Health Services 

Research and Development (HSR&D) Service. Through its Equity portfolio, the VA HSR&D 

Service seeks to further knowledge of the root causes of racial and ethnic disparities in health 

care and to develop and test interventions to reduce and eliminate disparities. Over time, 

evidence about disparities in VA care has accumulated through research supported by HSR&D 

and other VA and non-VA sponsors. The HSR&D Service sought to take stock of this evidence, 

to inform future research within its Equity portfolio, particularly intervention research; i.e., what 

does the accumulated evidence tell us will be the most promising areas for interventions to 

reduce and eventually eliminate racial and ethnic disparities within the VA? 

Scope and Key Questions 

The scope and key questions for our review were defined in consultation with representatives 

from the VA HSR&D Service, the VA Evidence Synthesis Program, and an advisory group of 

technical experts in VA healthcare disparities (Said Ibrahim, MD, MPH; Judith Long, MD; 

Eugene Oddone, MD; Donna Washington, MD, MPH; and Elizabeth Yano, PhD). 

We reviewed and synthesized the existing knowledge base related to racial and ethnic disparities 

in VA health care. It is important to note that our review included only studies of racial 

disparities in health care, i.e., the utilization and quality of health care services. We did not 

review studies examining racial disparities in health, i.e., incidence, prevalence, or severity of 

disease. We did include studies examining intermediate health outcome measures used by the 

VA as indicators of health care quality (e.g., control of blood pressure, blood glucose, and 

lipids). 

Although studies from outside the VA healthcare system may hold important lessons for 

reducing racial disparities both within and outside the VA, in consultation with our technical 
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expert advisory group we chose to limit our review to studies conducted within the VA. The 

rationale for this restriction on the scope of the review was threefold: 1) as an integrated, staffmodel health care organization, the VA is different from the broader U.S. healthcare 

environment, making the causes of racial and ethnic disparities potentially different as well; 2) as 

an “equal access” system, the VA reduces the influence of potential confounders of racial 

disparities, such as insurance and income, and therefore providers a “cleaner laboratory” for 

studying disparities; and 3) the body of literature on racial disparities in healthcare is sufficiently 

large that a comprehensive review of both VA and non-VA studies would not have been feasible 

with the resources available. 

We conducted this review with the following objectives: 

1. Determine in which clinical areas racial and ethnic disparities are prevalent within the 

VA; 

2. Describe what is known about the sources of those disparities; and 

3. Qualitatively synthesize that knowledge to determine the most promising avenues for 

future research aimed at improving equity in VA health care. 

Figure: Conceptual Framework 

Race/ 

Ethnicity 

Utilization/ 

Quality 

Mediating 

Factors 

--Patient 

--Provider 

--Patient-provider 

--System 

2nd

1st

3rd 

Interventions 

The Figure illustrates the conceptual framework that guided our review and synthesis. In this 

framework, studies that document racial and ethnic differences in utilization and/or quality of 

care are considered 1st-generation studies. These are the studies that shed light on the problem of 

disparities in health care. In our review, 1st-generation studies were included to address 

Objective 1, i.e., to determine where racial and ethnic disparities are prevalent within the VA. 

Studies that examine the association of race with factors that might mediate the association 

between race and healthcare utilization and/or quality are considered 2nd-generation. These 

studies examine mediating factors related to patients, providers, patient-provider interactions or 

relationships, or healthcare facilities and systems. Some studies are simultaneously 1st- and 2ndgeneration, demonstrating racial or ethnic disparities and examining mediating factors that might 
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explain those disparities. However, most 2nd-generation studies examine only the association 

between race and potential mediating factors, without determining whether those factors truly 

mediate disparities by race or ethnicity. For example, a study might examine whether race is 

associated with trust in healthcare providers, without explicitly examining whether trust is a 

mediator of actual disparities. The potential for mediation is in these cases theoretical. We used 

2nd-generation findings to address Objective 2, i.e., to describe likely sources of disparities. 

Studies of interventions to reduce racial disparities are considered 3rd-generation studies. There 

are relatively few of these studies; 3rd-generation disparities research is still nascent. We 

therefore used our conceptual framework to propose interventions that might reduce racial 

disparities by targeting likely mediating factors identified by 2nd-generation studies (Objective 

3). 

METHODS 

The review consisted of two components: a review of the existing literature reporting the 

findings of research on racial disparities within the VA, and an environmental scan of ongoing or 

recently completed studies of racial disparities within the VA. 

Literature Search and Strategy 

We conducted a search in Medline (via PubMed) and HealthSTAR of literature published from 

1966 to October 9, 2006. The search terms and MeSH headings included the following: VA, 

veteran(s), United States Department of Veterans Affairs, ethnic, race, racial, disparity(-ies), 

black(s), Hispanic, population groups, race relations. Appendix I provides the strategy and 

search terms in detail. All citations were imported into an electronic database (EndNote 9.0) 

The search strategy was saved in the PubMed database to provide weekly automatic updates on 

new publications. We obtained additional articles from reference lists of pertinent studies, and 

by consulting authors of retrieved studies, our technical expert advisory group, and other known 

VA disparities researchers. We searched the Health Services Research Projects database to 

identify ongoing and recently completed VA research projects. 

Eligibility Criteria and Study Selection 

Two reviewers assessed for relevance the abstracts of citations identified from literatures 

searches, using the criteria described in Appendix II. Full-text articles of potentially relevant 

abstracts were retrieved and a second review for inclusion was conducted by reapplying the 

inclusion criteria. 

Eligible articles had English-language abstracts and provided primary data relevant to the key 

questions. We included studies that were conducted within the VA or with VA beneficiaries, 

reported outcomes of interest by veteran race and/or ethnicity. Outcomes of interest included on 

utilization of health care services; quality of health care services including quality metrics (e.g. 

blood pressure control), process-of-care measures (e.g. use of appropriate screening tests), 

patient evaluations of care, and direct observations of care (e.g. communication patterns); and 
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potential mediators of disparities in utilization or quality at various levels (system, provider, or 

patient). We further selected studies that focused on race—or “patient characteristics” (including 

race)—as the variable of interest, as indicated in the title or stated objectives of the study. We 

excluded studies that met other inclusion criteria but that were not specifically focused on 

comparisons by race or patient characteristics in general, to avoid potential publication bias. In 

an early assessment, we found that studies reporting comparisons by race despite not indicating 

those comparisons as part of their study objectives were substantially more likely than racefocused studies to report racial disparities to be present. These “non-race-focused” studies 

therefore skewed the overall assessment of the degree and distribution of disparities within the 

VA, since they might not have reported on racial comparisons had disparities not been found. 

Data abstraction and quality assessment 

We abstracted the following data from included studies: study design, objectives, setting, 

population characteristics (including sex, age, ethnicity, diagnosis), subject eligibility and 

exclusion criteria, number of subjects, race/ethnic groups compared, methods of outcome 

assessment, data sources for race/ethnicity and outcome data, analytic method, potential 

confounders adjusted for in the analysis, and the results for each outcome. 

Because the studies were heterogeneous in design, objectives, and outcomes, we did not 

systematically rate the validity of individual studies. We instead assessed the level of adjustment 

for potential confounders and whether race/ethnicity data was gathered by self-report, and 

considered these indicators in the qualitative synthesis of evidence. 

Evidence Synthesis and Data Presentation 

We constructed evidence tables showing the study characteristics and results for all included 

studies, organized by clinical topic. We critically analyzed studies to compare their 

characteristics, methods, and findings. We compiled a summary of findings for each clinical 

topic and drew conclusions based on qualitative synthesis of the findings. After summarizing the 

findings for each clinical topic, we synthesized the descriptions and summaries of the literature 

for each clinical topic to derive a set of “cross-cutting” themes related to the underlying causes of 

healthcare disparities. These served as the basis for a proposed set of potential interventions for 

future research aimed at reducing racial disparities in VA health care. 

Environmental Scan 

The environmental scan was intended to capture ongoing or recently completed (but 

unpublished) studies related to racial disparities within the VA. To accomplish this task, we 

communicated with the HSR&D Center for Health Equity Research and Promotion and 

consulted with established disparities researchers within the VA, including our technical expert 

advisory group. We searched the VA HSR&D website for currently and recently funded 

disparities studies to identify ongoing or recent intervention studies. Finally, we reviewed 

abstracts from the 2006 and 2007 VA HSR&D Annual Meeting for relevant studies. We 

compiled an evidence table of all relevant completed but unpublished studies. 
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RESULTS 

The initial electronic literature search generated 1098 titles and abstracts. An additional 7 titles 

were added through manual and automatic update searches. After applying inclusion/exclusion 

criteria at the abstract level, 171 full-text articles were reviewed and sorted by clinical content 

area, as shown in Appendix III. Detailed information about each study is provided in the 

evidence tables (Appendix IV). The findings for each clinical topic are summarized in the 

sections that follow. In each section, we define studies that compare health care utilization 

and/or quality by race as “1st generation” studies, and those that examine potential mediators of 

racial disparities as “2nd generation.” A single study may present both 1st and 2nd generation 

findings. In each section below, we present 1st and 2nd generation findings separately. 

Arthritis and Pain Management 

Medication use 

Five studies examined racial differences in the use of pain medications for osteoarthritis 

(Evidence Table 1, Appendix IV).2-6 Three studies used electronic files to determine race and 

medication use.2, 4, 6 Two other studies obtained patient-reported data on race and mediators of 

medication use, specifically adherence5 and perception of drug efficacy.3 Studies identified the 

following racial differences in medication use: 

Blacks were less likely to be prescribed an opioid than whites, and mean annual days’ supply of 

opioids and the maximum morphine equivalent dose were lower among blacks.2

 Blacks had 

greater use of nonselective NSAIDs and lower use of COX-2 inhibitors, filled a lower mean 

number of prescriptions, and had shorter duration of use for some medications compared with 

whites.6 Hispanics were less likely than whites to be prescribed NSAIDS with some degree of 

COX-2 selectivity, including newer agents (celecoxib and rofecoxib). Both blacks and Hispanics 

were prescribed NSAIDS for fewer days at initiation of treatment, even controlling for GI risk 

factors and the type of drug prescribed. Furthermore, blacks filled fewer prescriptions for the 

index NSAID than whites, and had a greater risk of NSAID discontinuation.4

 Although the 

reasons for these differences were not studied, the investigators suggested the possibility that 

newer, more expensive COX-2 inhibitors may be overutilized among white veterans with a low 

risk for GI bleeding. 

Black veterans rated their current analgesic and anti-inflammatory drugs as being more helpful 

than did whites, despite that symptom severity was greater among blacks in this study than 

whites.3 Blacks had significantly greater odds of non-adherence to medication, in an analysis 

that adjusted for demographic factors, disease severity, participatory decision making (PDM), 

and medication side effects. No significant racial differences in PDM were observed, and racial 

differences in adherence persisted after adjusting for PDM.5

Use of diagnostic and invasive procedures for osteoarthritis 

A study of lumbar spine radiograph utilization determined that non-whites had lumbar spine 

films more often than whites (48% v 27%, p=0.024), but race was no longer a significant 

predictor after adjustment for age, education, income, comorbidities, and severity of pain, and 

other covariates.7

 A study of the use of total knee arthroplasty found that blacks with OA were 
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significantly less likely than whites to have received the procedure during the 2-year observation 

period, in an analysis that adjusted for age, sex, and comorbidity (OR 0.72, 95%CI 0.65-0.80).8

 

Potential mediators of racial disparities in pain management 

Ten 2nd-generation research studies of five population samples used cross-sectional patient-level 

surveys to examine racial differences in perception of symptoms,9-11 coping strategies,12-14

willingness to undergo joint replacement surgery,14, 15 expectation of outcome after joint 

replacement,16 patient satisfaction and perception of access to care,17 and perceptions of the 

efficacy of various traditional and complementary care modalities.18

Self-reported severity of osteoarthritis pain, measured by the WOMACTM osteoarthritis index 

score, was significantly greater among blacks (n=51) than whites (n=141) in a single-site study 

that assessed several arthritis locations (hip, knee, back, foot/ankle),9 while no racial differences 

in pain symptoms were observed in a study at a different site that specifically assessed the knee 

and hip joints among 262 blacks and 334 whites.10 A third study reported that blacks (n=135) 

and whites (n=165) with chronic knee or hip osteoarthritis described the quality of their pain 

differently; veteran descriptions of quality of chronic knee or hip pain did not correlate with 

radiologic stage of disease.11 

In a single-site study of risk perception and “willingness” to consider joint replacement, blacks 

(n=262) were significantly more likely than whites (n=334) to expect a longer hospital course 

and express concerns about postsurgical pain and difficulty walking, and these differences were 

not explained by clinical disease status, age, or differences in socioeconomic status.16 Blacks in 

this study were more likely to respond that they would not consider hip or knee replacement 

surgery if their pain were to become more severe and the doctor recommended it, but differential 

expectations of postsurgical hospital course, pain, and function mediated the observed difference 

in "willingness"; there was no longer a racial difference in “willingness” with adjustment for 

expectation of outcomes and familiarity with the procedure (OR 0.86, 95%CI 0.45-1.63).15 

When the same study population was stratified by perception of prayer, significantly fewer 

blacks (79.3% v 86.2% of whites, p=0.02) would consider surgery among those who perceived 

prayer as helpful in the management of arthritis. Among those who considered prayer to be not 

helpful, there were no ethnic differences in the consideration of surgery. Helpfulness of prayer 

remained a significant negative predictor of consideration of surgery, regardless of ethnic 

background (OR 0.64, 95%CI 0.43-0.94).14 

Confidence in one’s primary physician was racially similar in this study population after 

adjustment for age, income, education, radiographic stage of disease, comorbidity, severity of 

pain, and function, but significantly more whites than blacks reported that it was difficult to get 

medical care when they needed it (adjusted black:white OR = 0.54, 95%CI 0.34-0.88).17 The 

proportions of veterans who received referrals for specialist care did not differ significantly by 

race, although there was a tendency favoring white veterans with regard to referral to orthopedics 

for similar indications (adjusted black:white OR 0.61, 9%CI 0.36-1.03, p=0.07).17

Studies of coping with osteoarthritis found minimal racial differences.12, 13 In one of the 

studies,12 however, blacks scored significantly higher on 2 subscales: the Solicitude subscale (i.e. 

the belief that others should respond solicitously to pain behaviors), and the Praying/Hoping 
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subscale, consistent with other studies that found that blacks had higher religiosity than whites 

(77% v 70%, p=0.001) and were more likely to perceive prayer as helpful in the management of 

arthritis.14, 18 

In a survey of self-care practices and perceptions of efficacy of various traditional and 

complementary care modalities for the treatment of osteoarthritis, blacks were more likely than 

whites to believe that prayer and other forms of "complementary care" were helpful in the 

treatment of osteoarthritis. Blacks were also more likely to indicate reliance on self-care 

elements in the management of arthritis, and were less likely than whites to perceive joint 

replacement therapy as efficacious. When asked about actual use of these forms of treatment, 

there was no significant difference between the race groups except for greater use among blacks 

of prescribed medications, massage, and prayer. Although blacks perceived chiropractic care as 

more efficacious, blacks were significantly less likely than whites to report actual use of 

chiropractic care for their knee or hip osteoarthritis.18 

Conclusions 

Studies of osteoarthritis and pain management reported racial differences in joint replacement 

surgery and analgesic medication use that generally indicate less aggressive management of 

osteoarthritis in blacks compared to whites. These differences are not likely explained by 

differences in symptom severity, as blacks tend to report similar if not greater levels of pain 

compared to whites. 

Blacks appear less willing than whites to undergo joint replacement surgery. This greater 

reluctance appears to be due to less familiarity with the procedure and worse expectations with 

regard to surgical outcomes, including post-operative recovery, chronic pain, and functioning. 

Blacks also appear to place greater value than whites on non-medical options for managing 

arthritis, particularly prayer. Belief in the helpfulness of prayer was associated with lower 

willingness to consider surgical management of arthritis, independent of race or ethnicity. 

However, the degree to which lower willingness among black veterans explains observed 

disparities in joint replacement surgery is unknown. 

Studies to date have not explored the role of symptom expression, patient-provider 

communication, provider bias, or patient trust in explaining disparities in the use of analgesic 

medications or surgery for veterans with arthritis. 

Cancer 

Four studies 19-22 reported mixed findings on whether the use of surgery, radiation therapy, and 

chemotherapy differed by race for various types of cancer (Evidence Table 2, Appendix IV). 

Two derived race data from administrative records, one did not report the source of race data,21

and one identified race by self-report.22 Blacks were less likely to have surgical resection for 

esophageal cancer, lung cancer, and colon cancer in two studies.20, 21 Two other studies found no 

association between ethnicity and the use of surgery for prostate cancer22 or colorectal cancer.19 

Blacks and non-blacks did not significantly differ in the use of radiation19, 20, 22 or 

chemotherapy,19-21 except in a subgroup of veterans with squamous cell carcinoma of the 

esophagus, among whom blacks were more likely than whites to undergo radiation and 

chemotherapy.20 The studies varied in sample size, in the race categories compared and types of 
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cancer studied, and in the proportions of veterans who received treatment, making their findings 

difficult to compare. Possible mechanisms for observed racial differences were not explored in 

these studies. Table 1 summarizes the use of cancer treatment by race category and cancer type. 

Five studies examined potential mediators of racial disparities in the treatment of prostate 

cancer

22 and lung cancer.23-26 Blacks and whites with prostate cancer were similarly optimistic 

and involved in their medical care over the 1st year after diagnosis.22 Among veterans with lung 

cancer recruited upon presentation to the oncology or thoracic surgery clinic, post-visit trust in 

physician increased significantly among whites compared with pre-visit trust, while black 

veterans’ trust remained unchanged. Racial differences in trust were primarily explained by the 

perception among black veterans that their physicians were less supportive, less partnering, and 

less informative compared with white veterans.23 Black veterans in this study also engaged less 

often in participatory communication behaviors (e.g. questions, concerns, assertions) than white 

veterans, and received less information from their provider as a consequence.24 In another study 

of patient-physician interactions during the first consultation after lung cancer diagnosis, active 

patient participation was greater among white veterans than non-white veterans.26 

The belief that exposure to air during surgery causes lung tumor spread was found to be 

significantly more prevalent among blacks than whites (61% v. 29%) in an anonymous selfadministered questionnaire.25 This belief was the basis for opposing lung cancer surgery 

significantly more among blacks than whites, and blacks were significantly less likely to accept 

their physician’s advice that this belief is false. Despite the high prevalence of this belief, a 

much smaller proportion of patients (19% of blacks and 5% of whites) indicated that they would 

oppose surgery on the basis of this belief. 

Conclusions 

Studies comparing blacks and whites with cancer suggest that for some cancers, blacks are less 

likely to undergo potentially curative surgical resection but equally likely to undergo nonsurgical interventions, such as chemotherapy and radiation. Studies exploring possible reasons 

for this disparity suggest that physicians engage in less effective partnerships with black veterans 

and provide them with less information as compared to white veterans. Part of this 

communication disparity appears to be related to black veterans’ being less assertive or active in 

their conversations with physicians. As a result of less effective partnerships and less 

information exchange between physicians and black veterans, physicians engender less trust 

among black as compared to white veterans. The degree to which these differences in 

communication, partnership, and trust actually explain disparities in cancer surgery is unknown. 

One study found that a prevalent “myth” about lung cancer—that exposure to air during surgery 

causes tumor spread—was more prevalent among blacks compared to whites. However, few 

veterans stated that they would oppose surgery based on this belief. Whether this belief plays a 

significant role in explaining disparities in lung cancer surgery is unknown.

 8 
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Table 1. The use of surgery, radiation, and chemotherapy among veterans by race and cancer typ

Percent of patients treated per race group, unadjusted Adjusted OR (95%CI), non-white vs. white race Author, 

year 

Cancer type 

N subjects per race category Surgery Chemo -

therapy 

Radiation Surgery Chemotherapy Radia

Dominitz, 200220 Esophagus 239 black 1282 white 20.5% 35.3% 45.2% 36.0% 44.8% 33.0% A* 0.54 (0.30-0.96) S* 0.45 (0.29-0.70) 

A 1.35 (0.80-2.29) S 1.74 (1.19-2.54) 

A 1.22.17) S 1.72.47) 

Akerley, 199321

Lung or colon 

127 black 577 white 

20%  29% --- 

24% 32% --- 

Dominitz, 199819 Colorectal 569 black 2607 white 70% 73% 23% 23% 17% 16% 0.92 (0.74-1.15) 0.99 (0.78-1.24) 1.10 Knight, 200422 Prostate 31 black 56 white 29% 31% --- 42%† 26%† --- *A = adenocarcinoma. S = Squamous cell carcinoma. † Radiation/hormonal therapy 
Cardiovascular Diseases 

Use of invasive procedures 

The literature search identified a total of 33 studies on cardiovascular disease (Evidence Table 3, 

Appendix IV). Studies that examined whether the use of diagnostic tests or invasive procedures 

differed by race include 4 studies of procedures for stroke,27-30 16 studies of coronary heart 

disease31-46 and 1 study of peripheral artery disease.47 Two studies assessed racial differences in 

the use of cardiac medications.48, 49 

The use of carotid artery imaging or carotid endarterectomy (CEA) among veterans with 

stroke/TIA was significantly lower among non-whites compared with whites in two studies,27, 28

but racial disparities were not observed in two others (Table 2).29, 30 One study that found 

significantly less use of ultrasound or angiography among blacks determined that differential use 

of CEA was associated with level of appropriateness for the procedure: significantly fewer 

blacks than whites received CEA if appropriateness was uncertain, but there were no significant 

racial differences among veterans determined to be appropriate candidates for CEA.28

Among veterans with heart disease, the use of invasive procedures was significantly less likely 

among blacks compared with whites in 8 studies (Table 3).33, 35-37, 40, 41, 45, 46 One study of aortic 

valve replacement, implantable cardioverter/defibrillator, dual-chambered pacemaker, and 

percutaneous coronary interventions found lower utilization rates of all 4 procedures among 

blacks compared with whites. Furthermore, hospitals with larger black populations appeared to 

have larger racial differences in procedure rates than predominantly white hospitals.46 Racial 

disparities in the use of cardiac catheterization, coronary angiography, percutaneous transluminal 

coronary angioplasty (PTCA), and coronary artery bypass graft surgery (CABG) were absent in 

4 studies,31, 32, 38, 44 and in one study an observed disparity in the use of cardiac catheterization 

was explained in part by greater overuse of the procedure among whites (i.e. 10% of procedures 

had a RAND rating of inappropriate) than blacks (7% inappropriate).31 Four studies reported 

racially equal use of some invasive procedures, and differential use of others.34, 39-41 Survival 

was similar or better among blacks in 3 studies that found racial disparities in treatment,35, 36, 39

and in 1 study that found no treatment disparities after adjustment for disease severity.32 In two 

other studies that found marginal or no disparities in procedure use, survival was worse among 

blacks.38, 42 

A study of veterans with peripheral artery disease (PAD) using administrative data found that 

race was an independent predictor of nontraumatic lower extremity amputation versus lower 

extremity bypass revascularization.47 The study included 416 Hispanic, 2337 black, and 8741 

non-Hispanic white veterans, and considered the following confounders in a stepwise regression 

analysis: diabetes mellitus, hypertension, myocardial infarction, congestive heart failure, chronic 

obstructive pulmonary disease, transient ischemic attach, stroke, impaired sensorium, weight 

loss, functional status, American Society of Anesthesiologists’ physical status classification, 

smoking, ethanol use, and emergency operation. The proportion of veterans who underwent 

lower extremity amputation vs. revasculization was 28.9% vs. 17.2% among blacks, 4.9% vs. 

3.1% among Hispanics, and 66.2% vs. 79.7% among whites. The adjusted OR (95%CI) for 

amputation vs. revascularization was 1.5 (1.4-1.7) among blacks, and 1.4 (1.1-1.9) among 

Hispanics, compared with non-Hispanic whites. Other significant predictors of lower extremity 

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amputation instead of lower extremity bypass revascularization were older age, poor functional 

status, congestive heart failure, recent weight loss, prior limb surgery, dialysis, and more severe 

PAD as captured by a history of rest pain or an open wound infection. 

Potential mediators of disparities 

Fourteen studies examined potential mediators of racial disparities in quality of care, including 

patient satisfaction,50 the role of religion for coping and making treatment decisions,45, 51 patientphysician communication,52, 53 refusal of or aversion to surgery,30, 44, 54-56 adherence to cardiac 

medications,48 delays in seeking treatment,57 regionalization of services,43 and physician 

recommendations for revascularization.58(Table 4) 

Aversion to invasive procedures was assessed by patient interview in five studies, with a mixture 

of findings. Blacks indicated greater aversion or less willingness to undergo procedures in 4 

studies,30, 54-56 but one study found no significant racial differences among veterans who 

explicitly declined a recommended angiogram.44 In one study that found that whites were more 

likely to say they would undergo CABG if recommended or if it would improve symptoms and 

survival, familiarity with the procedure was a stronger predictor of attitude toward 

revascularization than race.56 In another study, the receipt of CEA was racially similar within 

appropriateness categories, despite that aversion to carotid endarterectomy was higher among 

blacks. Clinical status was therefore the primary determinant of the receipt of CEA.30 

Patient-physician communication was examined in two studies.52, 53 In one study, focus groups 

were conducted with 6 black veterans and 7 white veterans who had undergone a stress test with 

or without a subsequent invasive cardiac procedure, to investigate veterans' perceptions of their 

interaction with providers regarding cardiac testing and treatment decision-making.52 Veterans 

of both races expressed concern about communication difficulties with their physicians and a 

lack of clarity, but themes did not apply equally across the racial groups. White veterans 

expressed skepticism and asserted the need to be convinced about the need for a procedure, an 

issue not raised among black veterans. Black veterans expressed the need for trust in their 

physician but whites did not express the same need for trust in physician before undergoing 

procedures. In another study, verbal behaviors were coded from audio-recordings of postangiogram consultations between 93 veterans and 8 cardiologists, to determine factors that affect 

physicians' information-giving and partnership-building.53 Physicians provided more 

information in response to a veteran's question, assertiveness, or expression for concern, but 

black veterans self-initiated these behaviors less often than did their white counterparts. When 

examining information-giving that was prompted by the patient, black veterans received, on 

average, 16.5 fewer information-giving statements from their doctor, even after controlling for 

covariates. Veterans (and companions) in race concordant visits received significantly more 

information from their doctors (99.4 vs 62.1 mean utterances, p<0.001) and were significantly 

more active participants (41.7 vs 27.2 mean utterances, p<0.001) when compared with veterans 

in racially discordant visits. Doctors' self-initiated information-giving was not significantly 

different by doctor-patient racial concordance after controlling for patient and visit 

characteristics, the presence of a companion, and clustering of veterans by doctor. When 

examining information-giving prompted by the patient, veterans in racially concordant 

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consultations received, on average, 18.5 more information-giving statements (p=0.003) from 

their doctor, adjusted for covariates. 

Racial differences in patient satisfaction, attitudes, and health-related beliefs were examined in 

two studies, with mixed results. One study reported in 2 publications used a self-administered 

questionnaire among 1045 veterans with cardiac ischemia at 5 VA medical centers to assess 

racial differences in satisfaction, attitudes, and beliefs, and whether they influence the use of 

cardiac catheterization (CC).45, 51 The study reported similar scores between blacks and whites in 

most domains, including perceived disease severity, veteran evaluation of physicians' 

interpersonal style, veteran evaluations of VA care, satisfaction with treatment decision making, 

perceived urgency of CC, vulnerability to CC, and bodily impact of CC. The racial groups 

differed in that blacks indicated less generalized trust in people, more experiences of racial and 

class discrimination, and greater importance of God and religion in coping with heart problems 

and in making treatment decisions. Blacks were also less likely to report that family/friends had 

had CC and to have been encouraged by family/friends to have a CC. Significantly more whites 

received CC than blacks in this study, but veterans' health beliefs did not explain the differential 

use of CC. Physician's ratings of CAD and the importance of CC for a veteran gathered by 

questionnaire were both higher for white veterans than for black veterans, and these variables 

contributed to the observed racial disparities in CC use beyond what could be attributed to 

clinical differences identified by chart review. In another study that assessed patient satisfaction 

and health-related quality of life by mailed questionnaire, blacks with ischemic heart disease 

reported lower satisfaction with providers and with organizational aspects of their care compared 

with whites, but these differences were site-specific and persisted at only 3 of 6 sites after 

adjustment for covariates.50 

A cross-sectional survey of cardiologists examined the recommendations for PTCA or CABG in 

54 black and 738 white veterans who had undergone coronary angiography at one of two sites: a 

VA hospital and a private university hospital in the same city, both tertiary care centers affiliated 

with a university program that performs PTCA and CABG. The study found that cardiologists at 

the VA site were less likely to recommend revascularization to black veterans than to white 

veterans, while no differences in revascularization recommendations by veteran race were found 

at the private university hospital. The observed difference was not accounted for by differences 

between the racial groups in disease severity (number of stenotic vessels) or veteran age, 

education level, previous revascularization, or self-rated health status. The reasons given for not 

recommending PTCA or CABG at the VA site were generally similar, however, in type and 

frequency for both blacks and whites. Within the VA site, the most frequent reasons for not 

recommending PTCA, comparing percent of black vs. white veterans, were insignificant 

myocardium at risk 33% v. 30%, low chance of technical success 26% v 29%, and additional 

testing needed 16% v 11% white. For CABG the most frequent reasons were insignificant 

myocardium at risk 26% v 36%, not technically feasible 16% v 21%, and additional testing 

needed 7% v 12%.58 In another study of physician’s assessments of veterans with cardiac 

ischemia, the perceived necessity of cardiac catheterization was slightly greater among white 

veterans than black veterans: 2.59 v 2.76 (p=0.11) on a scale where 1=lifesaving or crucial, 

2=benefits outweigh risks, 3=equivocal, and 4=risks outweigh benefits. Doctors rated the pretest 

probability of coronary artery disease as significantly higher among whites than blacks (74% v 

66%, p=0.005). These assessments were significant predictors of the use of CC in this study.45 

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A study of regionalization of services using the national VA database determined that the 

presence of a cardiac catheterization laboratory or a cardiac surgical program in the local VA 

facility significantly increased the likelihood that veterans with coronary disease would undergo 

invasive procedures. The effect of having a local cardiac surgical program on whether CC, 

PTCA, or CABG was used was significantly greater for blacks than for whites.43 

A study of medication adherence by drug class within a single VAMC found that blacks and 

whites prescribed beta-blockers were equally adherent. Among users of ACE inhibitors, calcium 

channel blockers, and statins, blacks were less likely to be adherent compared with whites. 

Analyses by age determined that differences in adherence were most prominent at younger (<55) 

ages.48 In another VAMC site, a cross-sectional survey of 588 hypertensive veterans found that 

both intentional and unintentional non-adherence to medication were significantly greater among 

non-whites. Compared with whites, non-whites were 2.9 times more likely to report intentional 

non-adherence, and 1.8 times more likely to report unintentional non-adherence. The study 

measured adherence behaviors using a self-report scale, and the analysis adjusted for education, 

financial status, diabetes, and number of reported adverse effects.59

A study in 753 veterans admitted for heart failure (HF) at a single VAMC examined racial 

differences in the delay in seeking treatment, defined as the amount of time between the veteran's 

awareness of symptoms and arrival at the hospital. The delay time was ascertained using 

information provided by the admitting physician when veterans presented to the hospital for 

worsening of HF symptoms. The study found that blacks were significantly more likely to delay 

seeking treatment, with a mean delay time of 3.2 days among blacks compared with 2.8 days 

among whites (p=0.019). Black race remained significantly associated with greater delay in 

seeking treatment after adjustment for age, marital status and New York Heart Association 

functional class.57

Conclusions 

There were mixed findings across studies on racial disparities in the use of invasive procedures 

in veterans with cardiovascular diseases, but the majority of studies exploring this association 

found that non-whites undergo fewer procedures than whites. In two studies, physicians 

assessed the necessity of revascularization to be greater and were more likely to recommend 

revascularization to white veterans, compared with black veterans. In one study an observed 

disparity in the use of cardiac catheterization was partly explained by greater overuse of the 

procedure among whites than blacks. Among 6 studies that assessed survival in addition to 

procedure use, blacks had better survival compared with whites in 4 studies despite lower rates 

of procedure utilization in 3 of these studies, but worse survival in 2 studies that found marginal 

or no racial disparities in procedure use. Although unequal procedure use did not result overall in 

higher mortality for blacks, its effect on other outcomes, such as coronary events, symptom 

severity, and quality of life, was not determined. 

 

Studies of potential mediators found greater aversion to invasive procedures among blacks 

compared with whites, as well as racial differences in patient satisfaction, beliefs, and attitudes, 

including lower trust among blacks and greater emphasis on religion as an alternative to medical 

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care. Notably, blacks were less familiar with cardiovascular procedures, and this lack of 

familiarity helped explain racial differences in willingness to undergo procedures in at least one 

study. 

Patient-physician communication behaviors differed between black and white veterans in two 

studies. One study identified a potential cycle of passivity in which black veterans, and veterans 

interacting with race discordant physicians, received less information overall because they less 

often engaged in communication behaviors (e.g. questions, concerns, assertions) that typically 

elicit more information from doctors. In focus groups, black veterans placed a greater emphasis 

on the need for trust in their physicians in deciding about invasive procedures, while white 

veterans placed a greater emphasis on clinical indications. 

While racial differences were apparent in factors that might influence the use of cardiac care—

e.g., aversion to surgery, trust, communication—studies that were able to examine the influence 

of these factors on actual use of invasive procedures generally found that they did not explain 

observed disparities. Physician decision making was more influential, and in one study 

physician recommendations helped explain racial disparities in cardiac procedure use, even after 

accounting for clinical variables and severity of coronary disease. The degree to which this 

difference in physician recommendations for black vs. white veterans was driven by clinical 

factors not captured by the studies, by the influence of patient preferences on physician decision 

making, or by physician bias, was not determined. 

Blacks were more likely to delay seeking treatment for heart failure symptoms and were less 

adherent (both intentionally and unintentionally) to medication regimens. Among veterans with 

PAD, blacks had higher rates of limb amputation. The reasons underlying these findings of lower 

adherence and later presentation were not investigated. 

The impact of regionalization of services was greater among blacks than whites in one study. 

The presence of a local cardiac surgical program increased the likelihood of whether CC, PTCA, 

or CABG was used to a significantly greater degree among blacks than among whites, 

suggesting that regionalization of cardiac care may have a greater impact on blacks than whites, 

exacerbating existing disparities. 
Table 2. The use of invasive procedures for stroke among veterans by race, black (Hispanic wh

white race as referent 

Author, year Patient type N subjects per race category Percent of patients treated per procedure and race group Adjusted OR (95%CI) for black (Hispanic where noted) v. white 

as referent 

CA 0.47 (0.42-0.53) Hisp. 0.78 (0.63-0.98) 27690 white Oddone, 

1993

CA 5.3 v 11, Hisp. 8.3 (--) 

27 Stroke or TIA 6526 black 

CEA 14.9 v 38.1, Hisp. 22.7 (--) CEA 0.28 (0.20-0.38) 1162 Hisp. Hisp. 0.45 (0.28-0.73) 

Ultrasound or angiography: Ultrasound or angiography: 67 v 79 (*) 0.67 (0.47-0.94) 389 black 

414 white 

Oddone, 199928 Stroke or TIA 

CE: Appropriate for CE 50 v 67 CE: Appropriate 0.75 (0.40-1.43Uncertain appropriateness 3 v 24 Uncertain 0.11 (0.01-0.79) 

>=50% stenosis in a carotid artery 

Oddone, 91 black CA 17 v 20 (ns) 200230 CEA 1.0 (0.45-2.0) 

617 white CEA 14 v 20 (ns) 

Goldstein, 255 non-white CA 3.1 v 8.5 (*) 200329 Stroke --- 

520 white CEA 0.8 v 1.5 (ns) 

(--) p-value not reported (*) statistically significant p-value (ns) p-value not significant CA = carotid angiography CEA = carotid endarterectomy TIA = transient ischemic attack HSR&D Evidence Synthesis Pilot Program – 15 Racial Disparities Review 
Table 3. The use of invasive procedures for heart disease among veterans by race, black vs. w

referent 

Percent of patients treated per procedure and race group, 

Adjusted OR (95%CI) of procedure comparing black (Hispanic where noted) to white race as referent 

N subjects per race category 

Treatmabsen

Author, year Patient type black v. white 

CAD: 3670 black 26630 white 

CC: CAD 43.3 v. 50.3 (*) VHD 43.2 v 57.5 (*) 

CC: CAD 0.61 (0.57-0.67) VHD 0.50 (0.34-0.74) 

Mirvis, 199433

CAD or VHD Prese

VHD: Cardiac surgery: Cardiac surgery: 141 black CAD 12.4 v 17.9 CAD 0.61 (0.55-0.67) 1194 white VHD 35.4 v. 42.4 ns VHD 0.67 (0.98-0.45) 

Ferguson, Unadjusted: 199735 CC 11 v 25 (*) CVD or chest CC 0.37 (0.24-0.58) 

pain 

211 black PTCA 2 v 4 (*) Prese1195 white PTCA 0.60 (0.25-1.49) CABG 1 v 6 (*) CABG 0.22 (0.08-0.63) 

Whittle, 1993 37 CC 11.8 v 19.3 (*) CC 0.72 (0.70-0.75) CVD or chest 

pain 

74570 black PTCA 0.8 v 1.8 (*) PTCA 0.67 (0.60-0.72) Prese353730 white CABG 1.6 v 5.0 (*) CABG 0.45 (0.48-0.42) 

Hospital <30% black inpatients Academic Non-academic AVR (ns)  DCP (ns)  ICD 0.65 (*) PCI 0.86 (*) 

AVR (ns) DCP (ns) ICD (ns) PCI (ns) 

Groeneveld, 200746

AVR 9.2 v 5.7 (*) 

Hospital >=30% black inpatients Academic Non-academic 

Candidates for AVR, DCP, ICD, or PCI 

45029 black DCP 70 v 51 (*) Prese255585 white ICD 57 v 42 (*) 

PCI 179 v 157 (*) 

AVR 0.45 (*) AVR (ns) DCP 0.54 (*) DCP 0.69 (*) ICD 0.54 (*) ICD 0.75 (*) PCI 0.69 (*) PCI 0.67 (*) 

36 CC 33.7 v 36.9 (*) CC 0.67 (0.62-0.72) Prese

days i

Peterson, 1994 4522 black AMI PTCA 6.2 v 4.2 (*) CABG 0.46 (0.40-0.53) 29119 white CABG 9.6 v 5.1 (*) PTCA 0.58 (0.48-0.66) 

45 Prese

physi

Kressin, 2004 Reversible 

cardiac ischemia 

236 black CC 33 v 47 (*) CC 0.56 (0.35-0.89) 809 white 

HSR&D Evidence Synthesis Pilot Program – 16 Racial Disparities Review 
Petersen, 200240 CA 93.7 v 92.8 (ns) Mixed

PTCA

606 black AMI PTCA 27.9 v 27.0 (ns) --- 4005 white CABG 6.9 v 12.5 (*) Unadj

Sedlis, 199741 Mixed

use of 

322 black PTCA 17.4 v 18.9 (ns) Underwent CC --- 1474 white Surgery 37.0 v 54.1 (*) Unadj

Maynard, CC 59 v 57 (ns) 2006 Mixed

of PT

34 680 black AMI PTCA 32 v 40 (*) PTCA 0.79 (0.71-0.88) 3529 white CABG 5 v 8 (*) 

All RAND indications: PTCA 0.86 (0.51-1.45) CABG 0.60 (0.35-1.06) 

Conigliaro, 2000 AMI or unstable 

angina and had CC 

39

326 black PTCA 17.8 v 26.5 Mixed340 white CABG 10.7 v 20.6 yrs CABG necessary: 

CABG 0.44 (0.20-0.86) 

Mickelson, 1997

CC 51 v 63, Hisp 57 (*) Marg

amonhospi

42 84 black PTCA 17 v 23.3, Hisp 19 (ns) CC 0.59 (0.35-1.02) AMI 37 Hisp. CABG 7.1 v 10.3, Hisp 16 

(ns) 

Hisp. 0.76 (0.35-1.67) 232 white 

Ferguson, CC 14 v 41 (*) 1998 CVD or chest pain 31 100 black PTCA 4v 6 (--) --- Absen

100 white CABG 3 v 11 (--) 

Hassapoyannes, 2006

CAD, CHF, cardiomyopathy, arrhythmias 

Absenseveri

32 92 black CA 11.8 v 61.4 (*) CA 0.10 (0.04-0.26) 222 white 

Gordon, 200444 Had treadmill 

test or coronary angiography 

160 black CA 79 v 90, Hisp 67 (ns) 48 Hisp. PTCA 100 v 87, Hisp 63 (ns) --- Absen473 white Surgery 50 v 78, Hisp 67 (ns) 

38 Peniston, 2000 726 black PTCA 0.96 v 1.23 (ns) CABG: no significant difference, 

results not shown 

Absen2-3 ye

Had CA 734 white CABG 0.83 v 1.50 (ns) 

(--) p-value not reported CC = cardiac catheterization (*) statistically significant p-value CHF = congestive heart failure (ns) p-value not significant CVD = cardiovascular disease AMI = acute myocardial infarction DCP = dual-chambered pacemaker AVR = aortic valve replacement ICD = implanted cardioverter/defibrillator CABG = coronary artery bypass graft surgery PCI = percutaneous coronary intervention CAD = coronary artery disease PTCA = percutaneous transluminal coronary angiopl

VHD = valvular heart disease 

HSR&D Evidence Synthesis Pilot Program – 17 Racial Disparities Review 
Table 4. Potential mediators of racial disparities in the use of invasive procedures among veter

N subjects per race group 

Potential mediator studied Author, year Subjects Summary of findings 

Mirvis, 1998

3652 black 26593 white 

CAD Region: presence 

v. absence of a local cath lab or surgical program 

The presence of a cardiac catheterization laboratory and a cardithe local VA facility significantly increased the likelihood that would undergo CC, PTCA, and CABG. The effect of having a 

program on whether CC, PTCA, or CABG was used was greatewhites. 

43

Ibrahim, 2003

54 black Had CA Physician 

recommendation for PTCA or CABG 

Black patients were less likely than whites to receive physician PTCA or CABG. OR (95%CI) adjusted for age, disease severirevascularization, educational level, and health status, blacks v

58 738 white 

VA hospital: 0.31 (0.12-0.77); University hospital: 1.69 (0.69-The disparity occurred in the VA but not in the private hospitalmost frequent reasons for not recommending revascularization significantly between blacks and whites. 

Kressin, 2002

175 black 679 white; 

Cardiac ischemia 

Patient attitudes including religion; physician assessments 

(Kressin, 2002) Very few racial differences found in 8 domains beliefs and attitudes. Differences observed only in attitudes towplaced stronger importance on God and religion in coping with making treatment decisions. Blacks were less likely to report thad CC and less likely to have been encouraged by family/frien

51

Kressin, 2004 236 black 

809 white 45

(Kressin, 2004) Blacks indicated less generalized trust in peoplof racial and class discrimination. Patients' health beliefs, howobserved racial differences in CC use. Physician's assessments importance of CC did explain some of the observed variation in 

Charles, 2003

833 black 4436 white 

Prescribed cardiac meds 

Medication adherence 

Blacks were less likely than whites to be adherent to ACEIs (81CCBs (75.3% v 81.7%, p=0.003), and statins (59.9% v 74.1%, differences were most prominent among younger African Amestatins. 

48

Evangelista, 2002

220 black 36 Hispanic 456 white 

Heart failure Delay in seeking 

treatment 

Blacks were more likely to delay seeking treatment. Mean delalonger (p=0.019) for blacks than other races: blacks = 3.2 days, 2.9, Hispanics = 2.8 

57

Ohldin, 2004

1281 black 1801 white 

Angina Patient 

satisfaction, attitudes 

Ethnic differences in satisfaction with patients' providers and thwere site-specific. Blacks reported significantly lower satisfactIHD compared with whites, but these differences persisted at 3 adjustment for covariates. 

50

Collins, 2002

6 black 7 white 

Positive cardiac stress test 

Patient-physician communication 

Veterans expressed concern about poor communication with thexpressed by black veterans was the desire to build a relationshbefore making a decision on an invasive procedure. White vetefor receiving information before agreeing to an invasive procedknowing the physician. 

52

HSR&D Evidence Synthesis Pilot Program – 18 Racial Disparities Review 
 Program – 19 

ities Review 

Gordon, 200553

18 black 75 white 

Had CC Patient-physician 

communication 

Compared to their interactions with white veterans, physicians less information to black veterans, but provided more informativeteran's question, assertiveness, or expression for concern. Binitiated these behaviors less often than did their white counterp

Bosworth, 200454

207 black 858 white 

Had carotid ultrasound 

Refusal/aversion to surgery 

Blacks were significantly more averse to CEA than whites. Incsurgery, lower level of chance locus of control, less trust of physupport were significant predictors of surgery aversion indepen

Gordon, 200444

160 black 48 Hispanic 473 white 

Had treadmill test or CA 

Refusal/aversion to surgery 

Veteran refusals of recommended invasive cardiac procedures explain only a small fraction of racial disparities in the use of inprocedures. 

Oddone, 199855

44 black 46 white 

Had stroke, TIA, or carotid artery imaging 

Refusal/aversion to surgery 

Blacks appear to have a stronger aversion to CEA than do whitexperience and veterans' perceptions about their current health aversion, independently of race. 

Oddone, 200230

>98% male 91 black 617 white 

50%+ carotid artery stenosis 

Refusal/aversion to surgery 

Black and white veterans were equally likely to receive CEA. greater aversion to CE, this difference did not influence receipt was the primary determinant of the receipt of CEA. Whites were more likely to say they would undergo CABG if rthey would elect CABG if it would improve symptoms and surblack-white difference in patient preferences seemed to be expladdressed familiarity with the procedures. Blacks were less famrevascularization procedures, less likely to have had a previous be awaiting CATH. In multivariate analysis, measures of familwere the most important predictors of attitude toward revasculasignificant predictor of attitudes toward revascularization exceprecommended by their physician: adjusted OR, whites v black2.79) 

Refusal/aversion to surgery 

Prescribed cardiac meds 

HSR&D Evidence Synthesis PilotRacial Dispar

114 black 234 white 

Whittle, 199756
Diabetes 

Three studies reported mixed findings on racial/ethnic disparities in diabetes care processes 

(Evidence Table 4, Appendix IV).60-62 All 3 studies found lower rates of lipid profile/lowdensity lipoprotein (LDL) testing in African American veterans with diabetes, compared to white 

veterans. Regarding the use of HbA1c testing, one study did not detect racial disparities between 

self-identified black and white veterans, based on survey responses and VA medical record 

data.61 Another study similarly found no racial disparities based on VA data alone, but upon 

incorporating Medicare data for VA patients, determined that Hispanic and black veterans were 

less likely than whites to receive HbA1c testing, as well as LDL testing.60 

Among 3 studies that evaluated outcome measures among veterans with diabetes, poorer 

glycemic control among blacks compared with whites was found in 2 studies,63, 64 but was not 

observed in the third.61 A study conducted at 21 VAMCs found no racial differences among 115 

black and 801 white veterans in the odds of having an elevated HbA1c (i.e. 7% or greater), but 

determined that blacks were more likely than whites to have poor cholesterol and blood pressure 

control.61 A smaller study conducted at 3 VAMCs in the southwest reported that mean HbA1c 

varied significantly with race, with blacks (n=35) having the highest mean HbA1c level, 

Hispanics (n=72) the second highest level, and non-Hispanic whites (n=226) the lowest level.64 

The latter study found no racial differences in lipid or blood pressure control,64 in contrast with 

the former study.61 Both of these studies used survey and medical record data but varied in 

sample size and region. The third study used regional VA data from 6,222 veterans with 

diabetes on chronic insulin therapy to determine HbA1c levels and adherence to prescribed 

insulin regimens.63 Blacks and Hispanics had significantly higher HbA1c levels and poorer 

adherence to insulin therapy in adjusted analyses, compared with whites. 

In a study evaluating the 1-year incidence of lower extremity amputation among veterans with 

diabetes (with and without renal disease), American Indians had the highest risk of amputation 

compared with whites.65 Among veterans with renal disease, American Indians had a 2.7-fold 

higher risk, blacks had a 1.4-fold higher risk, and Hispanics had a 1.2-fold higher risk of 

amputation in adjusted analyses, compared with whites. Similarly elevated risks in these ethnic 

groups occurred among veterans with diabetic nephropathy. The risk of amputation among 

Asians, however, was 73% (CI 53%-84%) less than whites among veterans with end-stage renal 

disease, and 74% (CI 52%-86%) less among veterans with diabetic nephropathy. In a similar 

pattern, proportionally fewer Asians had prevalent amputations at the inception of the study, 

while American Indians had the highest prevalence (0.69% of Asians compared with 4.2% of 

American Indians, 3.7% of blacks, 3.3% of Hispanics, and 2.5% of whites). 

nd A single-site, 2 -generation study of 26 Hispanic and 29 non-Hispanic white veterans with type 

2 diabetes evaluated the use of a set of specific ecological and cultural domains, for which 

ethnicity may be a proxy, as a more inclusive and holistic construct that may account for 

variances in health outcomes.66 The study defined this summation of ecocultural domains as 

“patient adaptation” (the patients’ ability to adapt to illness). Patient adaptation correlated 

positively with adherence to treatment and quality of life, and correlated negatively with poor 

disease management and utilization of urgent/emergent services. Patient adaptation accounted 

for more variance in all outcomes than did ethnicity but was correlated with ethnicity, and 

Hispanic veterans tended to have higher scores on adaptation than non-Hispanic whites. 

HSR&D Evidence Synthesis Pilot Program – 20 

Racial Disparities Review 
Conclusions 

Existing studies reveal mixed results regarding racial disparities in diabetes care, but overall, the 

quality of diabetes care—as measured by process measures (appropriate test ordering) and 

outcome measures (control of blood pressure, glucose, and lipids)—appears to be worse for nonwhite veterans compared to whites. Some of the difference in outcomes may be explained in 

part by lower adherence among non-white veterans. 

Importantly, one study found no disparities in quality measures when examining VA data. 

However, when non-VA health care use was included, the study revealed poorer chronic disease 

monitoring for black and Hispanic as compared to white veterans with diabetes, since white 

veterans were more likely than non-whites to receive care outside the VA. 

The potential consequences of disparities in care were suggested by a study demonstrating that 

American Indian, black, and Hispanic veterans with diabetes were more likely than whites or 

Asians to undergo lower limb amputation. 

Finally, a small but innovative study attempted to “unpack” the influence of race and ethnicity on 

diabetes care by directly measuring variables that might mediate this association. The 

investigators found that a set of “ecocultural” variables was correlated with ethnicity and had 

greater explanatory power than ethnicity in predicting utilization, disease management, 

adherence, and quality of life. 

HIV and Hepatitis C 

There were five studies that examined associations between race and treatment among veterans 

with human immunodeficiency virus (HIV) infection (Evidence Table 5, Appendix IV). Three 

studies examined adherence to HIV medications,67-69 and 2 studies assessed adherence to clinical 

practice guidelines.69, 70 One study examined the intensity of diagnostic and therapeutic care 

among veterans hospitalized with pneumocystis carinii pneumonia (PCP).71

Racial disparities in HIV medication adherence were observed in in a single-site study based on 

computerized pharmacy refill records,67 but had similar adherence in a larger 3-site study 

(VACS3) based on patient surveys.69 A qualitative study of adherence behaviors suggested that 

non-white veterans were more likely than whites to report incidents that indicated the absence of 

an established medication plan, and that supportive interactions with health care providers, 

family, and friends play a key role in increased medication adherence among non-whites.68 No 

racial disparities in clinical management were observed in a study of lipid screening guidelines 

among HIV patients using protease inhibitors,70 or in a study of veterans hospitalized with 

PCP.71 

Despite findings of no racial differences in clinical management or in adherence to HIV 

medication, age-adjusted mortality was higher in black and Hispanic veterans than in whites, 

among nationally identified HIV-positive veterans (n=5676) as well as among participants in the 

VACS3 study (n=865).69 Among nationally identified veterans, blacks (20%) and Hispanics 

HSR&D Evidence Synthesis Pilot Program – 21 

Racial Disparities Review 
(16%) were more likely than whites (11%, p<0.001) to have been first identified as HIV positive 

at an inpatient visit. Non-white veterans in VACS3 had a poorer prognosis as assessed by 

providers, lower CD4 count, more medical comorbidities, and were more likely to have 3 or 

more HIV conditions, compared with whites. Taken together, these findings suggest that within 

the VA, minority veterans are diagnosed with HIV later and have more severe illness at the time 

of diagnosis, which may compromise survival. 

Three studies examined whether racial differences exist in the treatment of hepatitis C virus 

(HCV) infection, and reported mixed findings.72-74 Racial disparities in HCV treatment were 

found in two studies that used national administrative data and excluded a large proportion of 

veterans with missing race data, and did not examine treatment eligibility.72, 73 The study authors 

noted that 15-25% of HCV-infected persons clear the viremia spontaneously and are not 

candidates for treatment, and patients with evidence of liver disease from HCV may choose to 

forego or defer treatment.72 In another study that used self-reported race data, equal proportions 

of Hispanic and white veterans with HCV infection received treatment, though significantly 

more Hispanics were eligible or considered for treatment, and Hispanics were more likely to 

discontinue treatment early.74 The differences in the methods and populations studied limit 

comparisons between studies. 

Conclusions 

Our review indicated that clinical management of veterans with HIV was generally similar 

across racial groups. Self-reported medication adherence was similar for black and white 

veterans, though objective data based on computerized pharmacy refill records revealed lower 

adherence among blacks. Non-white veterans with HIV suggested ways to improve adherence, 

including use of a medication plan and more supportive health care and social interactions. 

Despite inconsistent findings on medication adherence and racially similar clinical management, 

age-adjusted mortality is higher among nonwhite veterans with HIV. Minority veterans appear 

to be diagnosed with HIV at a later stage and have more severe illness at the time of diagnosis, 

which may contribute to survival disparities. 

Black and Hispanic veterans with HCV appear overall less likely than whites to receive antiviral 

treatment, and Hispanic veterans in one study were more likely than whites to discontinue 

treatment. The reasons underlying these disparities were not explored. 

HSR&D Evidence Synthesis Pilot Program – 22 

Racial Disparities Review 
Mental Health and Substance Abuse 

Substance abuse treatment and outcomes 

Four cross-sectional studies examined associations between race and treatment for alcohol 

dependency or substance abuse, and reported mixed findings (Evidence Table 6, Appendix 

IV).75-78 In one study, American Indians were more likely, and blacks and Hispanics less likely, 

to complete inpatient treatment for alcohol dependency, compared with whites.75 A study in 

women veterans similarly found that American Indians were more likely to undergo inpatient 

treatment for alcohol dependency compared to Whites.77 In studies of substance abuse 

treatment, blacks were significantly more likely to complete a residential treatment program for 

substance abuse78 and had higher positive perceptions of their residential treatment program, 

worked more hours, and had greater sobriety improvements, compared with whites.76 The 

authors of the latter study further determined that the racial composition of the residential 

treatment group may be a predictor of improvement in sobriety for blacks. 

Diagnosis of psychiatric illness 

Three studies examined racial differences in diagnosing psychiatric illness.79-81 A retrospective 

cohort study of over 3000 veterans found that blacks were significantly less likely than whites to 

be granted service-connection claim for post-traumatic stress disorder (PTSD) despite similar 

disease severity, whereas blacks were as likely as whites to be granted service-connection for 

other illnesses.81 In a study of elderly veterans with inpatient diagnoses of psychosis, blacks 

were significantly more likely than whites and Hispanics to be diagnosed with cognitive, 

psychotic or substance abuse disorders, and significantly less likely to be diagnosed with mood 

disorders.80 In a cross-sectional analysis of 100,000+ veterans, blacks and Hispanics were 

significantly more likely to be diagnosed with schizophrenia or schizoaffective disorder rather 

than bipolar disorder, compared with whites.79

 

Treatment and outcomes of psychiatric disease 

Six studies examined racial differences in treatment practices for various psychiatric illnesses,82-

87 and four studies examined differences in treatment outcomes.88-91 

A study of veterans with depression found that blacks were treated with antidepressants at 

inadequate doses and duration more often than whites.85 Black veterans with bipolar disorder 

were less likely than whites to be prescribed mood stabilizers and more likely to be prescribed 

antipsychotics in one study.87 In another study, blacks were less likely to have a follow-up visit 

within 90 days after an initial outpatient visit for bipolar disorder, but there were no racial 

differences in classes of drug treatment.82 A third study of bipolar disorder reported that blacks 

were more likely than whites to have cocaine abuse, and more likely to be involuntarily 

committed to inpatient stays.83 

Racial differences in the use of novel antispychotics for schizophrenia were observed in two 

studies. Blacks and Hispanics with schizophrenia received ziprasidone less often than whites, 

during the early use of the novel antipsychotic.86 In a study of veterans recently admitted for 

HSR&D Evidence Synthesis Pilot Program – 23 

Racial Disparities Review 
schizophrenia, non-whites were significantly less likely than whites to receive prescriptions for 

novel antipsychotics.84 

Of four studies of treatment outcomes, one reported mixed results for outcome disparities in 

intensive inpatient PTSD treatment.88 Blacks had greater improvement in PTSD severity and 

were perceived by their physicians as more committed to treatment, but blacks had less 

improvement in violent behavior compared with whites. Hispanics had greater satisfaction with 

the program but smaller post-treatment gains in employment income than whites. There were 

multiple comparisons in this study, some of which individually met significance but none of 

which were significant after correcting for multiple comparisons. A prospective, single-site 

cohort study in 197 elderly veterans admitted for behavioral disturbances observed no 

differences in treatment outcomes.90 Diagnoses were made using validated interview 

questionnaires and treatments were determined by a pre-specified protocol, which might have led 

to more similar patient outcomes than typically occur in inpatient settings. A study of treatment 

outcomes in 156 black and 236 white homeless men with chronic mental illness, improvement 

was similar among those who received residential treatment, but less improvement occurred 

among blacks than whites among those who received only case management services without 

residential treatment.89 A study of 224 veterans with schizophrenia or schizoaffective disorders 

randomly selected from 2 mental health clinics found that blacks were somewhat more likely 

than non-blacks to receive poor management of antipsychotic side effects.91

Mental health services utilization 

Nine studies reported findings on mental health services utilization among veterans.92-100 Some 

studies were national in scope, while others were regional or local. Some studies focused on 

women while others focused solely on a specific racial group. None of the studies were diseasespecific, although in one study most of the subjects had PTSD. The inclusion/exclusion criteria 

and outcome variables varied substantially, making comparisons of the studies difficult. The 

outcomes examined included inpatient hospitalizations, outpatient visits, use of self-help groups, 

and scores from patient satisfaction surveys. 

Among the more robust studies was a study of 500+ women at a women’s comprehensive health 

clinic at a single VAMC that reported that blacks desired mental health services more often than 

whites.99 Veterans of both racial groups were equally likely to receive mental health services, 

however, after adjustment for potential confounders including education, symptoms of 

depression, and eating disorders. Another study described readmission and outpatient visit 

patterns among elderly psychiatric patients recently discharged from inpatient psychiatric units, 

and found mixed results.97 Blacks with psychosis had fewer outpatient visits compared with 

whites and Hispanics, but blacks with substance abuse had more outpatient visits following 

discharge. The strengths of these two studies include the large sample size, self-report data on 

race, cohort design, and adjustment for appropriate variables. 

Other studies of utilization reported varied findings. Among veterans of the Vietnam era, blacks 

and Hispanics were less likely to use non-VA mental health care than whites.92 Changes in 

health care utilization and patient satisfaction during the 1990s VA organizational change—

including the establishment of Veterans Integrated Service Networks and managed care 

HSR&D Evidence Synthesis Pilot Program – 24 

Racial Disparities Review 
models—were examined in two studies by the same investigators.95, 101 Using several measures 

of inpatient quality, outpatient quality and continuity of care, the authors found mixed results. 

Blacks were less likely than whites, but as likely as Hispanics, to have post-hospitalization 

outpatient visits. Among those with outpatient visits, all three groups had similar numbers of 

outpatient visits. Disparities between whites and blacks decreased over time, but disparities 

between Hispanics and whites appeared to increase over time.95 In the study of patient 

satisfaction, blacks were more satisfied with mental health care than Hispanics in some domains 

but not others, and this difference in satisfaction did not change substantially over time.101

Potential mediators of racial disparities 

Four studies examined potential mediators of racial disparities in treatment and outcomes among 

veterans with psychiatric illness or substance abuse.76, 100, 102, 103

 

One study of a residential work therapy program for addiction disorders.76 examined thirteen 

measures of program participation. Whites had higher participation scores than blacks on 2 of 13 

measures, to a non-significant degree. Blacks had higher participation scores in the remaining 11 

measures, but only 2 of these reached statistical significance. Analysis of treatment outcomes 

determined that blacks had significant improvement compared to whites on three measures: 

sobriety at 3 months, the Addiction Severity Index, and days housed (i.e. not homeless) in the 

past three months. The investigators postulated that a greater percentage of black participants in 

the program would lead to improved outcomes, and found that a high composition of blacks 

(>50%) was predictive of sobriety at 3 months compared to low composition (<30%), but not 

predictive of improved participation, ASI or days housed. After correcting for multiple 

comparisons, the predictive value of racial composition for sobriety at 3 months was attenuated 

to non-significance. 

Another study by the same investigators examined whether racial concordance vs. discordance of 

the clinician-patient pair was associated with participation and outcomes in PTSD care.102 The 

study assessed 24 measures of participation in treatment, and 15 measures of improvement. 

Blacks had significantly lower participation than whites on 10 of 24 measures. Whites had lower 

participation on three of these measures, though none reached statistical significance. Blacks 

had lower improvement ratings than whites on 14 of 15 measures, though none of these 

differences were significant. An analysis of the effect of patient-physician racial concordance 

found that black veterans treated by white clinicians had significantly lower participation scores 

on 4 of 24 measures, and lower improvement on 1 of the 15 measures, compared with racially 

concordant pairs. There were no significant differences between racially discordant and 

concordant pairs on most measures. 

A study of medical inpatients at a single VAMC found strong correlations between religious 

coping during inpatient stays, severity of physical illness, and decreased depressive 

symptomatology.103 Black race was associated with higher levels of religious coping. 

A community-based survey of American Indian veterans in the Upper Midwest reported that 

many perceived barriers to VA mental health care exist, and most often occur among those who 

use alternative traditional medicine and have higher rates of psychiatric illness. Interviews with 

HSR&D Evidence Synthesis Pilot Program – 25 

Racial Disparities Review 
subjects revealed the lack of coordination between the Indian Health Service and VA as a 

barrier.100

Conclusions 

Studies comparing utilization and outcomes of mental health care by veteran race do not reveal 

consistent patterns. In general, the quality of inpatient and residential treatment for substance 

abuse and psychiatric illness appeared to be similar across racial groups; disparities were 

observed more often in outpatient settings 

Clinicians tend to more frequently diagnose black veterans with mental illness as having 

psychotic disorders (e.g., schizophrenia) and white veterans as having affective disorders (e.g., 

bipolar disorder, depression). Accordingly, black veterans with bipolar disorder were more likely 

than whites in one study to be treated with antipsychotics vs. mood stabilizers. However, among 

patients with schizophrenia, black veterans were less likely than whites to be prescribed a newer 

(2nd generation) agent. The underlying causes of these disparities in diagnostic and treatment 

patterns remain unclear. 

Studies investigating the effect of the “racial environment” on mental health and substance abuse 

outcomes suggest that black veterans may derive benefit from having a racially concordant 

clinician, and from being in a racially concordant treatment group. These findings are 

considered preliminary and warrant validation in future studies. 

Preventive and Ambulatory Care 

Colorectal cancer screening 

Three studies examined colorectal cancer screening and follow-up by veteran race (Table 5 and 

Evidence Table 7, Appendix IV).104-106 A single-site study evaluated rates of physicians’ 

recommendations for colorectal cancer screening tests (fecal occult blood test or FOBT, flexible 

sigmoidoscopy/colonoscopy) and patients’ completion of these tests among 1599 veterans. 

Rates of physician recommendation for screening tests were similar across racial groups (71% of 

black vs. 68% of white veterans among unscreened veterans). Actual screening rates for blacks 

were higher than for whites (36.3% v. 28.9%, p=0.03).104 A similar, larger study used data from 

39,870 veterans in the VA’s Office of Quality and Performance evaluation process.106 Sixty-one 

percent of eligible veterans were screened, and blacks were marginally less likely to be screened 

than whites (RR 0.92, 95%CI 0.89-0.96). Fifty-nine percent of veterans in the follow-up sample 

had a follow-up test performed, and there were no significant racial differences in the likelihood 

of receiving follow-up care. The third study examined rates of follow-up evaluation (i.e. 

colonoscopy or double contrast barium enema plus flexible sigmoidoscopy) after a positive 

FOBT, based on chart abstraction of 538 veterans at a single VAMC.105 Approximately 44% of 

the sample underwent full colon evaluation within 12 months of positive FOBT, and the 

proportion increased to 50% after 18 months. Blacks and whites were equally likely to receive 

full colon evaluation follow-up. Taken together, these findings suggest that while racial 

disparities in colon cancer screening appear to be minimal, screening is underutilized overall. 

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Hypertension 

Studies at two separate VAMCs in the South reported that black veterans with hypertension had 

lower rates of blood pressure control compared with whites (Table 6).107, 108 Factors contributing 

to racial differences in blood pressure control were examined in two studies.59, 107 One study 

examined intentional and unintentional non-adherence behaviors. Low education and non-white 

race increased the likelihood of both types of non-adherence. Those reporting more than 5 

adverse events were 3.6 (95%CI 1.9 to 7.0) times more likely to report intentional non-adherence 

than those who reported fewer adverse events.59 In another study conducted at the same VAMC, 

blacks reported greater non-adherence to blood pressure medications compared with whites. 

Adjustment for non-adherence and other characteristics, however, did not fully explain the 

increased likelihood of poor blood pressure control among blacks.107 

Cardiovascular risk factors 

A multi-site study of 236 black and 809 white veterans with coronary heart disease found no 

racial differences in the use of cholesterol screening, treatment, and in achievement of target 

LDL levels (Table 7).109 A single-site study of 127 black and 522 white veterans taking 

simvastatin monotherapy determined that blacks had a greater average decline in cholesterol than 

whites, but were less likely to achieve the target LDL-C of 100 dg/mL due to higher baseline 

levels. The target LDL-C was achieved by 56.9% of whites compared with 40.9% of blacks 

(p=0.001).110

Results of two studies of nicotine replacement and smoking cessation therapies were mixed, with 

the larger (n=1606) showing disparities in use of these treatments.111 Blacks were more likely 

than whites to attempt smoking cessation, but both blacks (adjusted OR, 0.53; 95% CI, 0.34-

0.83) and Hispanics (adjusted OR, 0.55; 95% CI, 0.28-1.08) were less likely than whites to use 

nicotine replacement therapy. The other study (n=1045) found no disparity in nicotine 

replacement therapy or the use of aspirin in veterans with established coronary artery disease.112 

 

In focus groups conducted among 39 white and 27 black veterans at a single VAMC, stress due 

to racism was perceived by some black participants as a contributor to heart disease.113 Although 

several participants of both races described difficulties in communication with their physicians, 

one participant viewed his physician’s dismissal of his concerns as an example of racism. Blacks 

indicated less health literacy and knowledge of cardiovascular disease risk factors, and displayed 

less assertiveness in their interactions with physicians than whites. 

Influenza vaccination 

A survey on influenza vaccination mailed to 121,738 veterans receiving care at VA outpatient 

clinics during flu season determined that non-Hispanic blacks were significantly less likely than 

non-Hispanic whites to be vaccinated (75% v. 81%), after adjustment for age and other 

confounders.114 Adjusted rates of vaccination among Hispanics, American Indian/Alaska 

Natives, and Asian/Pacific Islanders were similar to whites. The majority (59.2%) of 

unvaccinated respondents reported that they did not want a flu shot, and blacks and whites cited 

this reason in similar proportions. Among those who received the vaccination, blacks and 

Hispanics were more likely than whites to report that a reminder by a healthcare provider 

HSR&D Evidence Synthesis Pilot Program – 27 

Racial Disparities Review 
influenced their decision to get a flu shot (39.8% of whites vs. 58.7% blacks and 54.5% 

Hispanic; p<.01). Among those not vaccinated, blacks and Hispanics were more likely than 

whites to report that they did not know that they needed a flu shot (9.5% of blacks and 16.8% of 

Hispanics vs. 5.8% whites; p<.01). The study did not assess veteran knowledge, preferences, 

beliefs, and attitudes regarding immunization, and could therefore not determine whether racial 

disparities in vaccination resulted from differences in these patient-level factors or in 

interpersonal care and health education efforts by providers. 

Patient satisfaction 

A mailed survey assessed quality of care and patient satisfaction of women veterans seen in VA 

primary care clinics or women’s clinics in 5 states.115 Respondents included 1234 white, 164 

black, and 49 women of other race. The study reported that race was not associated with any 

domain of satisfaction or primary care quality. Black women in the study tended to be younger, 

unmarried, more educated, and of higher income, compared with white respondents. Black 

women more frequently reported having a regular female VA provider, and that gynecological 

care was provided in the VA, compared with whites. 

Ambulatory care use 

The association between racial differences in ambulatory care use and the presence of unmet 

health care needs was examined using data form the 1992 National Survey of Veterans (Table 

8).116 The distribution of self-reported race among the 7549 participants was 85.4% white, 9.6% 

black, 3.7% Hispanic, 0.8% American Indian or Alaska Native, and 0.5% Pacific Islander. 

After adjustment for confounders, blacks and Hispanics were significantly more likely than 

whites to use VA ambulatory care, while American Indians/Alaska Natives and Asian/Pacific 

Islanders did not significantly differ from whites in use of VA ambulatory care. Overall, 6.4% of 

veterans reported they needed medical care at some point in the 12 months preceding the study 

but were unable to get it due to lack of insurance or financial barrier. After adjustment for 

sociodemographic characteristics, having insurance, and use of VA vs. use of only non-VA 

ambulatory care, American Indian/Alaska Natives and Hispanics were significantly more likely 

than whites to report an inability to obtain needed medical care, while blacks and Asian/Pacific 

Islanders were similar to whites on this outcome measure. 

A more recent study by the same authors assessed racial/ethnic variations in patterns of VA 

ambulatory care use among veterans within VISN22 (southern California and southern 

Nevada).117 The study involved a telephone survey of ambulatory care utilization in the prior 12 

months, among 3227 users and non-users of VA care. The distribution of self-reported race 

among respondents was 37% white, 28% black, 28% Hispanic, and 8% Asian/Pacific Islander. 

Overall, 38.3% of respondents reported no healthcare visits in the past 12 months, while 12.3% 

reported any VA use, and 49.4% reported use of only non-VA ambulatory care. In an analysis 

that adjusted for sociodemographic and health-related characteristics, blacks, Hispanics, and 

Asian/Pacific Islanders were significantly less likely than whites to use any ambulatory care, 

whether VA or non-VA. Among nonusers of VA health care, interpersonal aspects of care were 

the most commonly cited barrier among ethnic minorities, followed by lack of knowledge about 

VA eligibility and services, and dissatisfaction with the VA. 

HSR&D Evidence Synthesis Pilot Program – 28 

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Racial Dispar

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Conclusions 

Studies of preventive and ambulatory care use by veteran race reveal mixed findings. For some 

services—e.g., colorectal cancer screening, lipid lowering therapy—racial disparities do not 

appear to be prevalent. Studies did reveal disparities in some primary care outcome measures, 

including achieving blood pressure and lipid goals, but these findings may have explained in part 

by more severe disease among non-whites. Non-whites with hypertension were less adherent to 

medications, both unintentionally and intentionally, part of which was related to medication side 

effects. Qualitative research findings suggested that disparities in cardiovascular risk 

management may be related to low health literacy, less knowledge, and less assertiveness with 

physicians among black, as compared to white, veterans. 

Blacks were less likely than whites to receive influenza vaccinations. Additionally, both blacks 

and Hispanics were less likely than whites to know they needed a vaccination and more likely to 

rely on physician recommendations and reminders to receive vaccinations. 

Non-white veterans are generally more likely than white veterans to use the VA healthcare 

system. American Indian/Alaska Natives and Hispanics were more likely than whites to have 

unmet health needs, while blacks and Asian/Pacific Islanders were similar to whites on this 

outcome measure. Non-white veterans identified interpersonal care, knowledge about VA 

services and eligibility, and dissatisfaction with the VA as barriers to obtaining VA care, though 

a study of women veterans found no racial differences in satisfaction among women using VA 

primary care.
Table 5. Racial disparities in colon cancer screening in the VA healthcare system 

Author, year 

Aims N subjects Characteristics of study population Results 

538 312 white Approximately 44% of the samp

evaluation within 12 months of pthe time was extended to 18 mon46%. African American race waperformance of full colon evaluawith missing race data were less than those with recorded race dat

Fisher, 2006

To document the factors associated with undergoing a full colon evaluation after a positive Fecal Occult Blood Test. 

105 154 black 

72 missing 

905 480 African 

American 

Among the 905 unscreened veterrecommendation rates for colorewere similar and actual screening Americans were 1.3 times higher veterans. 

Dolan, 2005

To evaluate rates of physicians' recommendations for colorectal cancer-screening tests and patients' completion of these tests among white and African American veterans who received care at an urban VA general medicine clinic. 

104

425 white 

Black veterans were slightly less than white veterans. There were ethnic differences in the likelihooup care. 

Screening population: 

Etzioni, 2006

To examine patterns of colorectal screening and followup among VA patients. 

Screening: 39,870 106

26, 029 white 

Follow-Up: 4,242 black 313 9,599 other 

Follow-up population: 219 white 33 black 61 other 

HSR&D Evidence Synthesis Pilot Program – 30 Racial Disparities Review 
HSR&D Evidence Synthesis Pilot Program – 31 

Racial Disparities Review Table 6. Racial disparities in hypertension and its treatment in the VA healthcare system 

Author, year 

Aims N subjects Characteristics of study population Results 

Bosworth, 2006107

The research sought to determine the social, economic, and physical factors that may explain racial differences in blood pressure controls and determine the extent to which modifiable and non-modifiable factors are related to blood pressure control. 

569 98% male 

veterans 41% African American 59% white 

African Americans were more likely to have pressure control compared with whites and adherent. African Americans were likely to very serious vs. serious, to report a relative illiterate, and to report increased urination awhich were linked to poor blood pressure coodds of AA having poor blood pressure consignificant, as did increased urination. 

Rehman, 2005108

To determine if the VA does better at reducing disparities in blood pressure control between African American and white hypertensive men than non-VA healthcare. 

12366 VA, 7734 non-VA 

Black men: 4379 VA, 2754 nonVA; White men: 7987 VA, 4980 non-VA 

Among VA patients whites were more likelat the last visit. African American and whitsimilar number of prescriptions at VA sites; however, had more clinic visits in the previo

Lowry, 200559

To examine associations between patient characteristics, including reported adverse events, and both intentional and uninterntional non adherence among hypertension patients. 

588 42.5% non white Individuals who reported intentional non-ad

significantly more likely to be non-white, reeffects, and were less likely to have diabeteadherence was more likely among non-whitless than a 10th grade education. In generalnonadherence were more likely to have unc

Sharkness, 1992118

To examine veterans' understanding of hypertension control and relate it to medication compliance. 

125 74% black Univariate analysis showed that although 70

as a symptomatic condition, symptoms were associated with pharmacy compliance. Unithat perceived lifetime treatment of hypertenyear history of medication use, perceived caother than diet, use of more than one hypertreported departure from prescribed regimenhistory and Caucasian race were associated multivariate analysis, drug abuse history, pehypertension and pattern of medication use compliance with hypertension regimens. 
HSR&D Evidence Synthesis Pilot Program – 32 

Racial Disparities Review Table 7. Racial disparities in cardiovascular risk factors (excluding hypertension) and their trea

healthcare system

Author, year 

Aims N subjects Characteristics of study population Results 

Williams, 2002110

To evaluate compliance with NCEP goals and ATP III clinical guidelines in white and African American veterans at high risk for cardiovascular disease after implementation of a Lipid Management Program. 

649 127 African 

American (AA); 522 white 

AAs had significantly higher baseline total, LDL-C, white veterans. Additionally, AAs experienced a sigin LDL-C after simvastatin therapy. Nonetheless, Ato achieve the target LDL-C measure of 100 dg/mL (while 56.9% of white veterans achieved it (p=.001). significantly different in the rates of hypertension an

Woodard, 2004109

To examine whether racial differences exist in cholesterol monitoring, use of lipid lowering agents, and achievement of guideline recommended LDL levels for secondary prevention of coronary heart disease. 

1045 236 AA; 

809 white 

AAs and whites were equally likely to receive choleall veterans AAs were less likely to receive lipid-low

when analysis was restricted to the 544 veterans who ideal candidate for treatment with lipid-lowering ageequally likely to receive treatment. AA and white veto achieve target LDL levels. 

Fu, 2005111

To examine ethnic variations in the use of nicotine replacement therapy (NRT) in an equal access health care system. 

1606 1153 white; 

 307 AA;  146 Hispanic 

AA and Hispanic smokers were less likely than whitnicotine replacement therapy and less likely to have cessation program. 

Ambriz, 2004112

(see Woodard 2004) 

To examine whether disparities exist in guideline-recommended secondary treatment for CAD, in the use of aspirin and smoking cessation interventions in a cohort of veterans with established CAD. 

1045 236 AA; 

809 white 

AAs and whites were equally likely to receive smokiprescribed smoking cessation medications. There wthe race groups in the rate of aspirin therapy and amoAAs were more likely to receive aspirin therapy. Ahypercholesteremia and previous CVA, white veterareceive aspirin. 

Woodard, 2005113

To explore coronary heart disease (CHD) health care experiences and beliefs of African American and white veterans to elicit potential causes of racial disparities in CHD outcomes. 

24 14 white and 10 

AA: Group 1: 8 white males, 56-75 years old; Group 2: 6 white males, 57-68 years old; Group 3: 4 AA males 48-83 years old; Group 4: 6 AA males 52-80 years old. 

Four themes emerged in the discussions: Risk-factor patient communication, access to care, and treatment experiencing racism and they displayed less specific cardiovascular risk factors and the impact of these faOverall the findings suggest lower health literacy amdifferences in physician-patient communication were patient assertiveness, with whites being more likely tWhite participants believed that perhaps they would health care providers if they could pay and AAs wormedications used by the VA were not as effective as 
 Program – 33 

ities Review 

Table 8. Studies of racial disparities in access to the VA healthcare system 

Author, year 

Aims N subjects Characteristics of study population Results 

Among this VISN 22 samplewere less likely to use the VA white veterans. Minority vetelikely to report the following health care use: poor interperVA car, dissatisfaction with Vveterans were more likely to knowledge about eligibility. 

Washington, 2005117

Assess racial/ethnic variations in patterns of ambulatory care use among Department of Veterans Affairs health-care eligible veterans. 

3227 27% white 

28% black 28% Hispanic  8% Asian/Pacific Islander 

In this national sample, blackAmerican Indian/Eskimo vetlikely to use VA ambulatory veterans while Asian/Pacific were less likely to use VA amAfter adjusting for VA health and other sociodemographic variables, the data show that Indian/Eskimo and Hispanic more likely than white veterainability to get needed medicusers were less likely than noto report an inability to get nehowever those who use both healthcare had the greatest inneeded medical care. 

7549 85.4% white 

 9.6% black  3.7% Hispanic  0.8% American Indian or Eskimo  .5% Pacific Islander 

HSR&D Evidence Synthesis PilotRacial Dispar

To describe racial and ethnic variation in VA ambulatory care use and to examine the association of these variations with the presence of unmet health care needs. 

Washington, 2002116
Rehabilitative and Palliative Care 

Five studies examined racial differences in rehabilitative or palliative care among veterans, and 

reported mixed findings (Evidence Table 8, Appendix IV).119-123 Three studies assessed racial 

differences in hospice care perceptions or utilization. A pilot program for an outpatient palliative 

care clinic determined that black veterans (n=64) delayed hospice enrollment longer than did 

white veterans (n=33).123 In a study of 254 veterans with advanced cancer, significantly fewer 

black veterans had advanced planning directives (49.7% v 72.5%) or knowledge of hospice care 

(46.7% v 77.1%) compared with white veterans, and a greater proportion of black veterans than 

whites died in the hospital (78.4% v 52.9%, p<0.0001).122 In another study by the same 

investigators, there were no significant racial differences in referral to hospice care among 89 

veterans who died of prostate cancer (49% of blacks v. 34% of whites) or in the percent who 

died in the hospital (64% of blacks v. 54% of whites).121 The selection of subjects and study 

design differed between these two studies, and the reasons for these apparently inconsistent 

findings are unclear. 

A study of percutaneous endoscopic gastrostomy (PEG) tube feeding for 6,464 veterans with 

dementia reported that black veterans were 77% more likely than whites to have a PEG tube 

placed. The use of PEG tubes over time differed by race as well, and the year of highest PEG 

tube use occurred 2 years later for blacks than white dementia patients.119 

A study in 738 veterans with acute stroke who were hospitalized within the VA between 1995-

1997 and referred to inpatient rehabilitation found no differences between blacks and whites in 

the total number of in-hospital contacts with rehabilitation personnel, in the proportion of stroke 

patients who were referred to inpatient rehabilitation, or in the intensity of rehabilitation.120 

Conclusions 

Studies of end-of-life care were mixed but suggest that in some cases, black veterans are less 

likely than whites to have advanced directives or to engage in hospice care. Black veterans in 

one study were more likely to die in the hospital and in another study were more likely to 

undergo PEG tube placement. Together, these studies suggest that black veterans receive a less 

palliative approach to care at the end of life. Reasons for these findings have not been explored. 

Other Clinical Topics 

Disparities in treatment, process of care, and use of new technology 

A study of dental procedures determined whether the use of tooth extraction vs. tooth-preserving 

root canal treatments varied by race (Evidence Table 9, Appendix IV).124 The study included 

54423 veterans in the national VA Patient Treatment File (PTF) database who had received any 

tooth extraction or root canal therapy in fiscal year 1998, excluding prophylactic extractions of 

third molars. Frequency of root canal therapy varied by race and eligibility for VA dental care. 

Fewer blacks (20.1%) and more Asians (31%) received root canal therapy instead of tooth 

extraction. Although fewer blacks (24.8%) and Hispanics (38.7%), and more Asians (67.9%) 

and whites (45.3%) were eligible for comprehensive dental care.(p=0.0001), adjustment for 

dental insurance coverage did not eliminate variations in care. The adjusted odds (95%CI) of 

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receiving root canal over tooth extraction over all types of dental care coverage, compared with 

whites, was 0.597 (p<0.05) among blacks, 0.881 (p=ns) among Hispanics, and 1.633 (p<0.05) 

among Asians, after controlling for medical and psychiatric comorbidities, sociodemographic 

characteristics, prior use of preventive dental care services (considered a proxy for the value 

patients place on tooth preservation), prior tooth extraction and root canal therapy, and clustering 

by geographic region. The study notes that in the PTF database, race is assigned by the 

registration clerk based on visual inspection. Self-reported race data from "the 1999 Large 

Survey of Veterans" was also used in this study, decreasing unknown race from 26% to 17%. 

A study of the use of antiresorptive drug treatments among 41 white women and 26 black 

women with low bone mass at a single VAMC found that white women were significantly more 

likely to be taking calcium or antiresorptive medications than black women.125 Information 

about veterans’ race and use of medications was gathered by self-administered, mailed 

questionnaire, with a 68% response rate. Ninety percent of white women v. 69% of black 

women were using calcium supplements (p=0.048). Clinical practice guidelines recommend 

calcium supplements for all postmenopausal women with low bone mass, regardless of 

osteopenia or osteoporosis. Seventy-one percent of white women and 35% of black women were 

using antiresorptive drugs.(p=0.004) White women were 3.7 (95%CI 1.24-11.1) times more 

likely than black women to be using antiresorptive medication, even after adjusting for the 

higher prevalence of osteoporosis and fractures among whites. 

A study of referrals for liver transplantation reviewed the medical records of 199 veterans with 

liver disease for 1) any mention of liver transplantation within 1 year of encounter; 2) 

documented intention of referral for possible liver transplant; or 3) documented consultation 

initiated by a referral.126 Additional data included demographics, etiology and severity of liver 

disease, potential contraindications to liver transplantation, and adherence to guidelines for 

referral for liver transplant. For encounters that did not result in mention or referral of transplant, 

reasons for the lack of mention/referral were ascertained, either documented or inferred. The 

veteran sample included 44 blacks, 23 Hispanics, and 132 whites. Among all veterans, only 21% 

(41 of 199) who had an identifiable potential indication for liver transplant had any mention of 

liver transplantation in the medical record. In an analysis that adjusted for age, HCV, hepatitis B 

infection, alcoholic liver disease, spontaneous bacterial peritonitis, encephalopathy, childTurcotte-Pugh B or C class, active alcohol use, and congestive heart failure, blacks were 

significantly less likely than whites to have mention of liver transplantation in their medical 

record. The adjusted OR (95%CI) of mention of liver transplantation in encounters with 

veterans satisfying AASLD referral guidelines for possible liver transplantation was 0.15 (0.02-

0.96) for blacks, and 0.12 (0.01-1.40) for Hispanics, compared with whites. Authors note the 

limitation that study depends on the accuracy of documentation of discussions pertaining to liver 

transplantation, and that undocumented attitudes of patients and providers toward liver 

transplantation might have influenced mention of liver transplantation in the medical record. 

The use of the medical futility rationale in do-not-attempt-resuscitation orders was examined in a 

survey of 44 residents leading inpatient medicine or cardiology teams, who were interviewed 

weekly by telephone about each of 145 patients who had received a do-not-attempt-resuscitation 

(DNAR) order in the preceding week at one of two hospitals, a VAMC and a municipal hospital. 

The scripted phone interviews were conducted 0-23 days after a DNAR order was written. 

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Questions about the patient included demographics, underlying chronic illnesses, and acute 

medical conditions; organ failure; functional status, immobile, in intractable pain or discomfort, 

or unable to communicate; and the probability of patient surviving to hospital discharge after 

cardiopulmonary resuscitation (CPR). Residents were asked whether 1) patient or surrogate 

choice and 2) medical futility applied to the patient, and 3) whether quantitative and/or 

qualitative futility applied to the patient. Of 44 residents, 25 were women (57%), and 40 were 

non-Hispanic whites (91%); of 4 non-whites, 2 were Asian, 1 was black, 1 was American Indian. 

Of 145 patients, 27 were non-whites (14 blacks, 10 Asian/Pacific Islander, 2 Hispanic, 1 

American Indian), 11% were female, and 2/3 of patients were hospitalized at the VAMC, 1/3 at 

the municipal hospital. Medical futility applied in 91 of the 145 DNAR orders and was the only 

rationale for the DNAR order in 17 cases (i.e. without patient or surrogate choice). In all cases, 

residents reported that they discussed the DNAR order with either the inpatient attending 

physician or the individual patient’s primary care physician before writing the order. There were 

11 patients for whom quantitative futility was invoked as a rationale for the DNAR order, in the 

absence of patient or surrogate choice. The study found that non-white race was a strong 

predictor of the use of the quantitative-futility rationale (i.e. a very low or no likelihood of 

surviving to hospital discharge after CPR) even after controlling for severity of disease and for 

the residents' prediction of CPR survival: the adjusted OR (95%CI) of quantitative futility 

associated with non-white race was 2.7 (1.1-6.3) compared with white race. There were 61 

patients for whom qualitative futility was invoked (i.e. the intervention is futile because it will 

not produce an acceptable quality of life). Race was not a significant predictor for the use of the 

qualitative futility rationale. Controlling for hospital site had minimal effects on the estimates 

for both quantitative and qualitative futility analyses. The study authors suggest as one 

explanation that white patients might have been more likely to request DNAR orders when 

futility was not perceived by the physicians, creating the association between race and 

quantitative futility. However, since resident's prediction of the probability of surviving CPR 

was controlled for, this finding suggests that residents may have been influenced by race per se 

in determining quantitative futility. 

A case-control study based on PTF data studied process of care among inpatients hospitalized for 

diabetes (DM), congestive heart failure (CHF), or chronic obstructive pulmonary disease 

(COPD) during 1987-1989.127 Veterans readmitted within 30 days of the index stay served as 

cases in the study. Controls were matched with cases based on hospital, diagnosis, and one of 

four 6-month periods of hospital discharge, and were not readmitted within 30 days of the index 

admission. For each veteran, an adherence score was computed as the percentage of applicable 

criteria performed during the hospital stay, using diagnosis-specific explicit criteria for process 

of hospital care. The criteria were categorized with respect to timeline of hospitalization: 1) 

admission work-up, 2) evaluation and treatment during hospital stay, and 3) readiness for 

discharge. The patient sample included 875 veterans with CHF (22.7% black, 4.3% Hispanic), 

1299 veterans with COPD (12.4% black and 2.2% Hispanic), 678 veterans with DM (25.5% 

black and 5.3% Hispanic). In analyses adjusted for age, severity of illness (APACHE score), 

comorbidities, teaching hospital status, number of previous hospitalizations, and other covariates, 

the resulting admission adherence scores, treatment, and discharge scores were similar among 

black, Hispanic, and white veterans with any of the three diagnoses. In stratified analysis, 

veterans admitted to a teaching hospital had higher admission and treatment scores compared 

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with non-teaching hospitals. Process of inpatient care did not differ by race after adjusting for 

admission to a teaching hospital and other covariates. 

In a study of racial differences in the adoption of laparoscopic cholecystectomy in place of open 

cholecystectomy, PTF data were used to identify 1932 black and 14249 white veterans with 

gallbladder disease who underwent either procedure during the year before introduction of 

laparoscopic cholecystectomy (1991) and the first 4 years of the procedure’s use (1992-1995).128 

A separate, nurse-compiled dataset contained detailed clinical information about veterans who 

had gallbladder or biliary disease and underwent either procedure during the same years. Among 

veterans undergoing cholecystectomy at VAMCs from 1992 to 1995, 35.4% of black veterans 

and 42.6% of white veterans underwent laparoscopic cholecystectomy (p<0.001). After 

adjustment for potential confounders, blacks were 0.74 (95%CI 0.66-0.83) times as likely as 

whites to undergo the laparoscopic procedure during the 4 study years. In the nurse-compiled 

prospective clinical data set, laparoscopic cholecystectomy was performed in 22.1% of black 

veterans and 28.6% of white veterans (p<0.001). After adjustment for confounders, blacks were 

0.68 (95%CI 0.55-0.84) times as likely as white veterans to undergo laparoscopic vs. open 

cholecystectomy. The differences in rates of adoption of laparoscopic surgery did not appear to 

be from more comorbid illnesses among black veterans, and the study did not determine whether 

veterans differed by race in their preference for new surgical procedures, or whether VA 

physicians may have been less likely to recommend laparoscopic cholecystectomies to black 

veterans. 

In a survey of attitudes toward innovative medical technology, 171 veterans in waiting areas of 

primary clinics at a single VAMC were asked to complete a self-administered survey (5-point 

Likert-scale) with 6 items on attitudes toward new concepts in general, and 6 items on attitudes 

toward new medical drugs, devices, and procedures.129 A final component was a vignette 

describing either a hypothetical implantable device or new prescription drug, each to reduce risk 

of heart disease. The survey asked veterans about their attitudes toward the new technology. 

The study included 108 blacks and 63 whites. Sixty to 65% of participants had cardiovascular 

disease. Black veterans had less positive attitudes toward new medical technology (p=0.01) 

compared with whites. The analysis adjusted for sex, age, annual income, education, 

cardiovascular disease, having >2 comorbid conditions, having <2 prior medical procedures, and 

risk-attitude score. Whites had more positive attitudes towards new medical technology and 

were more likely to accept the hypothetical new prescription drug, but did not differ from blacks 

in acceptance of the new implantable device. 

Conclusions

These studies collectively suggest that black and other non-white veterans tend to receive less 

aggressive medical care than whites. Part of this may relate to greater skepticism among black 

veterans towards new medications and medical technology. Some of the variation seen in large 

national database studies may also be related to regional or facility-level practice variation, but 

findings of racial variation in single-center studies indicate that this explanation cannot account 

for many of the observed disparities. The degree to which racial bias among healthcare providers 

is responsible for racial disparities in care remains unclear but is suggested by the finding in one 

study that physicians were more likely to write do-not-resuscitate orders based on medical 

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Racial Disparities Review 
futility among non-white compared to white patients, independent of the same physicians’ 

predictions of the likelihood that the patients would survive resuscitation efforts. 

Patient satisfaction 

Two studies assessed patient satisfaction in different veteran populations and settings.130, 131 In a 

study that assessed patient perceptions of ward atmosphere among 17 black and 17 white 

inpatients in the psychiatric ward of a VA hospital, blacks rated the ward lower than whites on 

all 10 subscales of the questionnaire, though a significant racial difference occurred on only 5 

subscales, namely: involvement, spontaneity, autonomy, personal problem orientation, and 

anger and aggression. The analysis did not adjust for age, chronicity, or SES, though previous 

surveys of different veterans on the unit had shown general racial agreement on these factors.130 

Another study analyzed 34,359 mailed surveys to examine patient satisfaction with inpatient 

medicine, inpatient surgery, and hospital-based outpatient care among 135 VA hospitals.131 The 

analysis adjusted for demographic and institutional characteristics, and found that non-white 

veterans reported lower satisfaction than did white veterans to a significant degree in all 3 

settings. The study further determined that most of the variation in patient satisfaction scores for 

hospital care was not attributable to either the demographic characteristics of veterans or the 

institutional characteristics of the hospitals, which accounted for between 8% and 15% of the 

variation in patient satisfaction scores. Based on this finding, the study authors suggested that 

hospital managers and clinicians can affect patient satisfaction through improvements in service 

processes. 

These studies suggest that non-white veterans might experience lower quality interpersonal care 

than white veterans do in hospital settings. Notably, though, these studies are somewhat dated, 

and improvements in overall customer satisfaction with VA care over the last decade warrant a 

more up-to-date look at veteran ratings of quality by race and ethnicity. 

Race and the provider-patient relationships 

Focus groups with 174 veterans about access and acceptability of VA health care determined that 

only 8 of the 174 participants expressed the preference that their physician be of the same 

ethnicity.132 Overall, the focus group participants indicated that it was not necessary for doctors 

to be of the same racial/ethnic group as their patients to effectively treat them. The study’s 

recruitment methods included community-based strategies aimed at minority veterans, and 

participants included blacks, Asians, and Hispanics. The distribution of ethnicity among the 

focus group participants was not reported, although the authors noted that the 8 who preferred 

same-ethnicity practitioners were spread about equally across the ethnic/racial groups. 

In a study of VA social counselors’ perspectives on their cross-racial effectiveness, 33 white and 

20 non-white VA employees who provided counseling services to Vietnam veterans in outreach 

centers in the southeastern US were asked to fill out a questionnaire while attending a training 

conference.133 Counselors were asked: On a scale of 1 to 7, how successful do you think you 

are in working with minority clients/with white clients? The study found that white and minority 

counselors perceived themselves to work about equally well with white clients, but white 

counselors perceived themselves to be less successful with minority clients, compared with 

HSR&D Evidence Synthesis Pilot Program – 38 

Racial Disparities Review 
minority counselors. Minority counselors reported a greater frequency of racism during crossracial counseling experiences than white counselors, and white counselors reported that their 

non-white clients perceived them to have insufficient understanding of what it means to be a 

member of the client’s racial group. Counselors were also asked to indicate the factor they 

believed contributed most to their white and minority client's problems: the clients themselves, 

other people, or situations in clients' environment. Both white and minority counselors perceived 

a difference in the source of the problems experienced by white versus minority clients: the 

source of white clients' problems was perceived by 62% of counselors to exist within the clients 

themselves. In contrast, the source of minority clients' problems was perceived by 62% of 

counselors to be a function of situations in client's environment. The authors suggest that both 

white and non-white practitioners may need to be more cognizant of their class biases in their 

perceptions and subsequent treatment of client difficulties, particularly for low-income white 

clients who may be ascribed greater responsibility for their misfortunes than is warranted by their 

social realities and life opportunities. 

General medication adherence 

A single-site study of medication adherence among 319 men with chronic conditions found that 

non-whites were at greater risk for non-adherence than whites.134 Adherence was defined as 

between 80-110% of the dose taken for any prescribed medications, which ranged from 1-7 

prescriptions per patient. Thirty-three percent of white veterans were adherent, compared with 

18% of non-whites (p=0.009). Ethnicity remained a significant predictor of non-adherence in a 

multivariate analysis that adjusted for age, Standard Depression Scale index, Mini Mental State 

score, number of pills, and marital status (OR for noncompliance comparing non-whites to 

whites: 1.44, p=0.03). 

Health education and communication 

In a postal survey sent to 5000 veterans from 4 war eras, participants were asked to rate the 

helpfulness of different media for obtaining health information on a 10-pt scale, and to answer 

items regarding access to and use of the Internet.135 Veterans of all races assigned the highest 

helpfulness mean rating to “own doctor: 7.3 among whites, 6.8 among non-whites (p=ns). Nonwhites rated a variety of media more favorably than did whites, suggesting greater receptivity to 

a wider array of information sources (e.g. VSO newsletter, web site, and television). Internet 

access and use was greater among whites compared with non-whites, and this difference was 

largest (nearly 20%, p<0.001) among older participants (i.e. Vietnam veterans) and narrowed 

over time (12% for Persian Gulf War veterans, p<0.001 and 2% for Bosnia-Kosovo veterans, 

p=ns). The study authors note that these findings reinforce the role of the primary health care 

provider as the most helpful resource for health risk communication. Despite that non-whites 

used the Internet less than whites, Internet access among Vietnam veterans (77%, 50-87 years 

old) was higher than that among the general US population (62% of 50-58-year-olds, 46% of 59-

68-year-olds). The authors suggested that these findings indicated high Internet use among 

veterans and that the Internet may offer an important channel for delivering health risk 

information to combat veterans. In another study that did not report results by race for VA 

subjects separately, among patients undergoing radiotherapy for prostate cancer, only 5% of VA 

patients owned a home computer and 8% used the Internet, compared with 64% of patients at an 

HSR&D Evidence Synthesis Pilot Program – 39 

Racial Disparities Review 
academic center who owned a home computer and 48% used the Internet. Blacks overall owned 

a home computer and used the internet significantly less in this study.136

In a study of the effectiveness of the informed consent procedure, 59 male veterans 

consecutively scheduled for the screening sigmoidoscopy were interviewed before and after the 

procedure in a tertiary care academic health center, to assess whether veterans understood the 

indications for the procedure, its associated risks, benefits, and alternatives, and the name of their 

treating physician.137 The study included 6 black, 5 Hispanic, and 46 white veterans. The study 

observed a similar lack of informed consent across all ethnic groups studied, including being 

informed of risks and alternatives to the proposed procedures (e.g. 60% read none of the form; 

14% read all of the form; 14% had never heard the word "polyp" before; 39% could describe no 

indication other than doctor recommendation). Despite the lack of informed consent, most of the 

veterans failed to ask further questions of their physicians and claimed that they had sufficient 

information to proceed with the procedure. The study also reported that only 27% of non-whites 

associated polyp with malignancy, compared with 78% of whites (p=0.001). The study authors 

note that this ethnic difference in understanding the relationship between polyps and cancer 

emphasizes the need to engage veterans in asking questions, as this may emphasize important 

issues to them as well as remind physicians of the variations in the veteran's baseline knowledge 

and subsequent comprehension. 

 

ONGOING AND RECENTLY COMPLETED RESEARCH 

Our environmental scan identified 43 ongoing or recently completed studies of racial disparities 

in VA populations, the results of which have not yet been published (Evidence Table 10, 

Appendix IV). Data available from these studies were primarily in abstract form and were thus 

not fully evaluable. We describe the content of those studies here. 

Three studies are randomized controlled trials of intervention strategies to improve racial equity 

in healthcare. One study tests whether a decision aid video and motivational interviewing 

techniques improve willingness to consider knee replacement for osteoarthritis (Ibrahim SA). 

Another study examines whether the use of a plain-language decision aid among prostate cancer 

patients is effective for decision-making and interacting with physicians, and influences the 

receipt of active treatment (Fagerlin A). The third study is a physician-based intervention that 

employs computerized reminders and training on patient-centered counseling to improve 

communication with patients about hypertension medication use (Kressin NR). 

Nineteen studies conducted/are conducting 1st-generation research to determine racial differences 

in indicators of utilization or quality, listed below by clinical topic (and indicating the number of 

studies): 

Cardiovascular disease (2) 

• The use of invasive cardiac procedures (Kressin NR; Urech TH) 

Diabetes (4) 

• Processes of care and intermediate outcomes (Bean-Mayberry B; Heisler M; Wright SM) 

HSR&D Evidence Synthesis Pilot Program – 40 

Racial Disparities Review 
• The use of angiotensin converting enzyme inhibitors and angiotensin receptor blockers in 

patients with diabetes and hypertension (Barnett MJ) 

HIV/Hepatitis C (2) 

• Utilization of HIV screening (Owens D) 

• Receipt of antiviral treatment for hepatitis C (Rousseau CM) 

Mental health and substance abuse (3) 

• Participation in treatment for PTSD (Spoont MR) 

• Pharmacotherapy for bipolar disorder (Kilbourne AM) 

• Validity of psychometric test data used in evaluation for PTSD (Boggs CD) 

Palliative care (3) 

• Deaths occurring in-hospital (Mularski RA) 

• Utilization of aggressive medical treatments in end-of-life care (Yu W) 

• Use of noninvasive vs. mechanical ventilation for COPD (Cannon KT) 

Preventive care (2) 

• Completion of FOBT screening (Fisher D) 

• Use of pneumococcal and influenza vaccinations (Bean-Mayberry B) 

Other topics (3) 

• Use of procedures by hospital racial composition of patients (Groeneveld PW) 

• 30-day mortality and outcomes by hospital racial composition (Jha AK) 

• Diagnosis setting and treatment for epilepsy (Hope OA) 

nd Potential mediators of racial disparities are investigated in 22 ongoing 2 -generation studies: 

Arthritis/pain management (5) 

• Patient expectations regarding joint replacement (Groeneveld PW) 

• Patient perceptions and willingness to consider joint replacement (Kwoh K) 

• Patient referrals, acceptance, and satisfaction with joint replacement surgery, and the role 

of patient-physician communication (Ibrahim SA) 

• Patient preferences and perceptions of physician's participatory decision-making style 

(Golightly YM) 

• Provider decision-making for pain management in inpatient and outpatient settings 

(Crowley-Matoka M) 

Cancer (1) 

• Effect of health literacy, social support, and use of screening tests on stage of 

presentation for prostate, colorectal, and lung cancer (Arozullah AM) 

Cardiovascular disease (4) 

• Relationship of physician-patient communication to outcomes in chronic heart failure 

(Gordon HS) 

HSR&D Evidence Synthesis Pilot Program – 41 

Racial Disparities Review 
• Recognition of stroke warning signs/symptoms and appropriate first action (Ellis C and 

Egede L) 

• Physician's attitudes about race-based therapies—BiDil for congestive heart failure 

(Frank D) 

• Interactions, views, and decisions of patients and providers regarding invasive v. 

noninvasive diagnosis and treatment of ischemic heart disease (Siminoff LA) 

Diabetes (2) 

• Trust in physicians and distrust of health care systems, in relation to personal health 

practices and outcomes (Egede LE) 

• Barriers to glucose control (Shacter HE) 

Mental health and substance abuse (4) 

• Impact of 2002 policy increase in prescription copayment on medication use and 

psychiatric admissions for schizophrenia (Zeber JE) 

• Perceptions of the trust and satisfaction with healthcare environment in relation to 

medication adherence in bipolar disorder (Zeber JE) 

• Severity of psychiatric disorders and readiness for change at initiation of psychiatric 

treatment, and satisfaction with treatment after 6 months (Tiet QQ) 

• PTSD service connection (receiving vs. not receiving disability benefits) and long-term 

outcomes, including symptom severity, social adjustment, functioning, income, 

employment, health care utilization and costs, homelessness, and mortality (Murdoch M) 

Preventive and ambulatory care (4) 

• Patient factors in colorectal screening behavior including knowledge, values and 

preferences, and stage of readiness (Partin MR) 

• Physician-patient communication in engaging patients in hypertension management and 

adherence (Bokhour B) 

• Associations between patient race, experiences with clinicans, attitudes and beliefs about 

hypertension and medication adherence (Kressin NR) 

• Examines dual utilization of VA and Indian Health Services among AIAN veterans to 

identify barriers, fragementation and overlap of services (Kramer B) 

Other areas (1) 

• Factors (e.g. insurance, income, caregiver distress, social support, distance) that affect 

hospitalizations for ambulatory care sensitive conditions such as diabetes and 

hypertension, among community-residing veterans with dementia (Van Houtven CH) 

HSR&D Evidence Synthesis Pilot Program – 42 

Racial Disparities Review 
SUMMARY AND SYNTHESIS 

Prevalence of disparities 

In the tables below, we categorize the findings of reviewed studies by clinical content area 

(Table 9) and by utilization or outcome measure (Table 10). 

Table 9. Presence of Disparities by Clinical Content Area 

Clinical Content Area 

Disparities Disparities 

Present Not Present 

Arthritis/pain management 6 1 

Cancer treatment 2 2 

Diabetes 7 2 

Heart and vascular disease 20 10 

HIV/Hepatitis C 4 3 

Mental health/substance abuse 11 10 

Preventive/ambulatory care 8 4 

Rehabilitation and palliative care 2 2 

Table 10. Presence of Disparities by Utilization or Outcome Measure 

Utilization or Outcome Measure 

Disparities Disparities 

Present Not Present 

Surgery and invasive procedures 21 11 

Medication use 

 Prescribing 9 7 

 Adherence 5 0 

Basic services/processes of care* 13 10 

Referral 1 2 

Patient satisfaction 2 3 

Intermediate outcomes ** 5 1 

 * E.g., lab tests, outpatient visits 

 ** E.g., control of blood pressure, blood glucose, lipids 

In Table 9, we categorized each unique study in our review as finding disparities to be present 

vs. not present. When a single study examined multiple utilization or outcome measures, the 

findings for each measure were entered into Table 10 (e.g., if a study found racial differences in 

the use of a surgical procedure but no racial differences in the use of a prescription medication, it 

would have contributed one point to the “Disparities Present” column under “Surgery and 

Invasive Procedures,” and one point to the “Disparities Not Present” column under “Medication 

Use/Prescribing.” In addition, when studies found more or higher-quality care for non-white 

veterans compared to whites, that study was counted in the “Disparities Not Present” column, to 

maintain consistency with the vast majority of the literature demonstrating less or lower quality 

care for non-whites. The one exception to this rule involved cases in which non-whites received 

more services that generally indicate lower quality care or worse outcomes (e.g., limb 

amputation). 

These tables are intended to provide a rough “landscape” of the existing literature. They should 

not be construed as an accurate quantification of the distribution of disparities within the VA, 

since they do not account for the quality, sample size, or generalizability of the individual 

HSR&D Evidence Synthesis Pilot Program – 43 

Racial Disparities Review 
studies, or for the degree of disparities found (i.e., effect size). In addition, studies under the 

“Disparities Not Present” column did not necessarily establish the absence of disparities, but 

rather did not find disparities to be present; these studies often did not have adequate power to 

definitively demonstrate equivalence between racial groups. 

There are several points worth noting with regard to the presence of disparities within the VA. 

• There is no clear indication that disparities are more prevalent in some clinical content 

areas than others. Although there have been more studies in the area of cardiovascular 

disease than in other realms (as is also true in the non-VA literature), disparities appear to 

exist in all clinical arenas. 

• Disparities appear to be more consistently observed for processes that entail more risk or 

require more intensive decision making, communication, or effort on the part of patients 

and/or providers: surgery/invasive procedures and medication adherence. 

• In studies examining quality indicators that represent intermediate health outcomes—

such as control of blood sugar, blood pressure, or cholesterol—non-white veterans 

generally fared worse than whites. This is a troubling finding, in that it may indicate that 

disparities in healthcare delivery are contributing to real disparities in health outcomes. 

Alternatively, these studies suggest that racial disparities might reflect “regressive” 

healthcare delivery; i.e., minority veterans are receiving less and lower quality health care 

despite needing more and higher quality care, as reflected by poor control of their 

diabetes, hypertension, and hyperlipidemia. 

• Most of the reviewed studies compared African American and white veterans. Fewer 

studies examined Hispanics, American Indians, and Asians. In general, disparities in the 

VA appear to affect African American and Hispanic veterans most significantly. 

• Not all disparities should be assumed to reflect underuse of health care among nonwhites, particularly in the realm of surgical and other invasive procedures. In at least one 

study, differential use of cardiovascular procedures was found to reflect overuse among 

whites rather than underuse among African Americans.31 However, in many cases, 

disparities do appear to represent inappropriate underuse of procedures (i.e., lower quality 

care) among non-whites. 

• Because white veterans tend to use non-VA care more often than non-white veterans do, 

studies that do not capture non-VA utilization, particularly those using administrative 

data, may underestimate the degree of disparities, find disparities to be absent when they 

in fact exist,60 or find “reverse” disparities (non-whites receive more/better care) when in 

fact no disparities exist.138 At least two studies have demonstrated this misleading effect 

of not capturing non-VA utilization.60, 138

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Racial Disparities Review 
Sources of disparities 

Firm conclusions about the sources of disparities within the VA are limited by several issues. 

First, relative to the number of studies examining the presence or absence of disparities, there are 

far fewer studies examining potential causes of disparities. Second, the VA disparities literature 

is complex. Studies are highly varied in terms of study settings and populations, clinical topics 

and services, data collection methods, and measures. This variability makes it difficult to 

generate unifying theories that are generalizable across settings and services. Finally, most 

studies examining potential sources of disparities focus on whether a hypothesized cause (e.g., 

communication patterns) varies by veteran race or ethnicity, but not on the degree to which that 

cause helps explains the disparity that motivated the study (e.g., differential use of cancer 

surgery by race). For example, one study found that African American veterans with lung cancer 

are less likely to undergo surgical tumor resection than white veterans.21 In a subsequent study, 

investigators hypothesized that this disparity might be explained by different patterns of patientphysician communication and veteran trust in physicians, by race.23, 24 They found that 

communication patterns and trust did indeed differ by race. However, because of the relatively 

small number of patients in their study, they were not able to examine whether differential 

communication patterns and trust helped explain differences in lung cancer surgery. This is a 

pervasive limitation, because the detailed data needed for studies exploring potential causes of 

disparities—which often involve surveys, chart review, or qualitative research methods—are 

often difficult to collect in numbers large enough to determine whether those potential causes 

explain observed disparities, which are often documented using large administrative data sets. 

Acknowledging the limitations described above, several themes emerged from our review as 

likely contributors to racial disparities in VA health care. These themes are rooted in our 

systematic review of the evidence but are based on qualitative rather than quantitative synthesis 

(e.g., meta-analysis). Our synthesis of research findings should therefore be considered a guide 

for future research, as opposed to firm, statistically derived conclusions. 

• Veteran medical knowledge and information sources. Non-white and white veterans 

differ in their degree of familiarity with and knowledge about medical interventions. 

This difference stems from different levels of experience with those interventions among 

minority vs. white veterans and their families, friends, and communities; from different 

amounts of information conveyed by healthcare providers; and from different levels of 

health literacy and understanding among veterans. Different knowledge and information 

may affect patients’ perceptions of, or degree of uncertainty about, the necessity and 

benefits of medical interventions in relation to their risks. Uncertainty about the necessity 

of interventions may in turn reduce patients’ willingness to accept and adhere to them. 

Several studies indicate that minority veterans are less informed about their care, as 

compared to white veterans, and that this difference affects decision making.23, 24, 53, 113, 

114, 122, 137

• Veteran trust and skepticism. Minority veterans also tend to harbor less trust and more 

skepticism about the benefits of medical interventions, relative to their risks. These 

perceptions appear to be influenced by lack of familiarity with medical interventions 

(described above), by historical or personally experienced discrimination, and for some 

African American veterans in particular, by a reliance on religious and spiritual avenues 

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Racial Disparities Review 
for coping with illness as opposed to medical therapies. Studies in our review suggest that 

minority veterans are more skeptical of information provided by healthcare professionals, 

as compared to white veterans.23, 45, 51, 52, 54 It is important, however, not to misconstrue 

this skepticism as unwarranted. White veterans’ general lack of skepticism may be more 

problematic if it leads to acceptance of unnecessary or undesired care. 

• Racial/cultural milieu. Some have suggested that a more racially and culturally 

congruent healthcare environment (including racially concordant healthcare providers) 

for minority veterans may elevate trust, reduce skepticism, and enhance the acceptability 

of care. Two studies directly examined this issue and found that African American 

veterans experienced better interactions and fared somewhat better clinically, when cared 

for by African American vs. white providers.53, 102 Another study suggested that black 

patients in group therapy might fare better when grouped with other black patients.76

• Patient participation. Several studies suggest that non-white veterans are less active 

participants in their care as compared to white veterans.24, 26, 53, 102,113 Non-white veterans 

tend to ask fewer questions of their providers, who in turn provide less information. Less 

information, as discussed above, may lead to lower acceptance of and adherence to 

medical interventions. In addition, lower patient participation diminishes the strength of 

the patient-provider partnership, which may in turn lead to less investment by both parties 

in following recommended care plans, and to lower trust and greater skepticism among 

minority veterans. 

• Clinician judgment. Studies suggest that clinicians’ diagnostic and therapeutic decision 

making varies by veteran race. The degree to which this differential decision making is 

based on clinical factors vs. non-clinical factors, including racial stereotypes, is unclear. 

For instance, in one study clinicians judged African American veterans to be less 

appropriate candidates for coronary interventions, even after accounting for chartdocumented variables.45 The degree to which this judgment reflected undocumented 

clinical factors vs. non-clinical influences was not clear. Similarly, clinicians prescribe 

opioid medications less frequently to African American vs. white veterans2

 and are more 

likely to diagnose African American veterans presenting with mental illness as having 

psychotic vs. affective disorders.79, 80 The degree to which these phenomena are driven 

by racial differences in co-existing substance abuse disorders, by cross-cultural 

misunderstanding of symptom presentations, or by racial bias, remains unclear.

• Veteran social support and resources. Non-white veterans may have fewer social 

support and other external resources to help with both illness management and decision 

making. This is particularly relevant in that minority veterans may rely more heavily on 

external resources than on healthcare professionals for information and support. This 

may particularly affect adherence and decision making around high-risk procedures.68

• Healthcare facility characteristics. Some disparities are at least partly explained by the 

fact that minority and white veterans tend to receive care at different VA Medical 

Centers.61 (Heisler M, unpublished; Groeneveld PW, unpublished) In some cases, VA 

Medical Centers that disproportionately serve minority veterans have fewer available 

HSR&D Evidence Synthesis Pilot Program – 46 

Racial Disparities Review 
services or deliver lower quality care overall than VAMCs serving predominantly white 

veterans. This potential source of disparities, however, remains underexplored. It should 

be noted that many studies have demonstrated disparities within single VAMCs, 

suggesting that system-level factors are unlikely to explain all observed disparities.

Future Research Recommendations 

The findings of our review suggest several promising areas for future research to further 

elucidate and reduce/eliminate racial disparities in health care within the VA. 

• Decision aids and information tools. Because disparities may arise from different 

levels of familiarity with and information about medical interventions, tools that provide 

accurate information about the rationale, risks, and benefits of interventions have the 

potential to “even the playing field” among minority and white veterans in terms of 

knowledge. Such tools, many of which use computer technology to help patients better 

understand not only medical interventions but also their own preferences, also have the 

potential to make patients more active participants in their medical care, which may 

improve understanding and adherence. In designing decision aids and information tools 

for minority veterans, investigators should pay attention to issues of literacy, language, 

and culture. 

• Patient activation interventions. Interventions to make patients more active participants 

in their interactions with healthcare providers and in the management of their illnesses 

have been shown to improve health outcomes. They may also reduce disparities by 

breaking the cycle of passivity that leads to less information exchange between minority 

veterans and their healthcare providers. More active patient participation has the 

potential to improve patient adherence as well as to strengthen patient-provider 

partnerships and mutual trust. 

• Patient-centered communication training. Interventions to make veterans more active 

participants in their interactions with healthcare providers can also target providers. 

Clinicians can adopt communication strategies that help solicit patient perspectives and 

engage patient participation. As with patient activation interventions, patient-centered 

approaches to healthcare interactions hold the potential to strengthen patient-provider 

partnerships and mutual trust. 

• Determining sources of variation in clinician judgment by patient race. As described 

above, studies have found that clinicians make different judgments based on veteran race. 

However, the degree to which this variation is driven by clinical characteristics vs. nonclinical factors, such as racial bias, remains unclear. Studies exploring how and why 

patient race is associated with different clinical decisions would help determine the need 

for and inform interventions to reduce adverse consequences of racial bias among 

clinicians. 

HSR&D Evidence Synthesis Pilot Program – 47 

Racial Disparities Review 
• Interventions to promote evidence-based decision making by providers. Similar to 

decision aids and information tools for patients, guidelines and decision rules for 

providers hold the potential to improve equity by “standardizing” care. To the extent that 

providers may be biased by patient race, guidelines, decision rules, and other quality 

improvement tools that promote evidence-based decision making may reduce the 

influence of provider bias and enhance equity of care among veterans of different race 

and ethnicity. 

• Adherence support interventions. Minority veterans appear consistently across studies 

to be less adherent to treatment plans than whites. Studies suggest that this may in part 

be due to less social support and planning among minority veterans. Interventions to 

provide adherence support—e.g., education, assistance with care planning—may help 

reduce this disparity. 

• Determining facility characteristics associated with healthcare quality and equity.

Some disparities are explained by differences in the healthcare facilities where minority 

vs. white veterans seek care. Determining the differences in structures and processes 

across minority- vs. majority-serving VAMCs would inform interventions to eliminate 

system-level sources of disparities. In addition, studies examining facility-level 

characteristics associated with more equitable care within VAMCs—including those 

related to the racial and cultural context at VAMCs, such as the racial composition of 

clinical staff—would help inform system-level interventions to eliminate disparities. 

Future research on disparities in VA healthcare should explicitly define how race is 

conceptualized within a given study. A group of VA investigators has developed a 

survey/interview tool to assess the “ecocultural” factors for which veterans’ race and ethnicity 

often serve as proxies.66 “Unpacking” race and ethnicity in studies of disparities will promote 

understanding and inform future interventions. Researchers should also be mindful that some 

disparities represent overuse of medical services among white veterans rather than underuse 

among non-whites. Clearly, interventions to promote greater use of services among non-whites 

in these instances is unwarranted. Finally, future studies should attempt to account for non-VA 

utilization. Because non-VA care is more prevalent among white veterans than among nonwhites, ignoring non-VA utilization may generate misleading results. 

HSR&D Evidence Synthesis Pilot Program – 48 

Racial Disparities Review 
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24. Gordon HS, Street RL, Jr., Sharf BF, Souchek J. Racial differences in doctors' 

information-giving and patients' participation. Cancer. Sep 15 2006;107(6):1313-1320. 

25. Margolis ML, Christie JD, Silvestri GA, Kaiser L, Santiago S, Hansen-Flaschen J. Racial 

differences pertaining to a belief about lung cancer surgery: results of a multicenter 

survey. Ann Intern Med. Oct 7 2003;139(7):558-563. 

26. Street RL, Jr., Gordon HS. The clinical context and patient participation in postdiagnostic consultations. Patient Educ Couns. Jul 19 2006;(in press). 

27. 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. Dec 27 1993;153(24):2781-2786. 

28. Oddone EZ, Horner RD, Sloane R, et al. Race, presenting signs and symptoms, use of 

carotid artery imaging, and appropriateness of carotid endarterectomy. Stroke. Jul 

1999;30(7):1350-1356. 

29. 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. Apr 2003;34(4):999-1004. 

30. Oddone EZ, Horner RD, Johnston DC, et al. Carotid endarterectomy and race: do clinical 

indications and patient preferences account for differences? Stroke. Dec 

2002;33(12):2936-2943. 

31. Ferguson JA, Adams TA, Weinberger M. Racial differences in cardiac catheterization use 

and appropriateness. Am J Med Sci. May 1998;315(5):302-306. 

HSR&D Evidence Synthesis Pilot Program – 50 

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32. 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. 

33. 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. Nov 1 1994;24(5):1297-1304. 

34. 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. 

35. Ferguson JA, Tierney WM, Westmoreland GR, et al. Examination of racial differences in 

management of cardiovascular disease. J Am Coll Cardiol. Dec 1997;30(7):1707-1713. 

36. 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. 

37. 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. 

38. 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. 

39. 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. 

40. 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. 

41. 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. 

42. Mickelson JK, Blum CM, Geraci JM. Acute myocardial infarction: clinical 

characteristics, management and outcome in a metropolitan Veterans Affairs Medical 

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43. Mirvis DM, Graney MJ. Impact of race and age on the effects of regionalization of 

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44. Gordon HS, Paterniti DA, Wray NP. Race and patient refusal of invasive cardiac 

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45. 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. 

46. 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. 

47. Collins TC, Johnson M, Henderson W, Khuri SF, Daley J. Lower extremity nontraumatic 

amputation among veterans with peripheral arterial disease: is race an independent 

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48. 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. 

49. Deswal A, Petersen NJ, Urbauer DL, Wright SM, Beyth R. Racial variations in quality of 

care and outcomes in an ambulatory heart failure cohort. American Heart Journal. Aug 

2006;152(2):348-354. 

50. Ohldin A, Young B, Derleth A, et al. Ethnic differences in satisfaction and quality of life 

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51. 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. 

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52. Collins TC, Clark JA, Petersen LA, Kressin NR. Racial differences in how patients 

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53. Gordon HS, Street RL, Jr., Kelly PA, Souchek J, Wray NP. Physician-patient 

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54. Bosworth HB, Stechuchak KM, Grambow SC, Oddone EZ. Patient risk perceptions for 

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55. Oddone EZ, Horner RD, Diers T, et al. Understanding racial variation in the use of 

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1998;90(1):25-33. 

56. Whittle J, Conigliaro J, Good CB, Joswiak M. Do patient preferences contribute to racial 

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273. 

57. Evangelista LS, Dracup K, Doering LV. Racial differences in treatment-seeking delays 

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58. Ibrahim SA, Whittle J, Bean-Mayberry B, Kelley ME, Good C, Conigliaro J. 

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59. Lowry KP, Dudley TK, Oddone EZ, Bosworth HB. Intentional and unintentional 

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8):1198-1203. 

60. Halanych JH, Wang F, Miller DR, et al. Racial/ethnic differences in diabetes care for 

older veterans: accounting for dual health system use changes conclusions. Medical Care. 

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61. Heisler M, Smith DM, Hayward RA, Krein SL, Kerr EA. Racial disparities in diabetes 

care processes, outcomes, and treatment intensity. Medical Care. Nov 2003;41(11):1221-

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62. Safford M, Eaton L, Hawley G, et al. Disparities in use of lipid-lowering medications 

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63. Cramer JA, Pugh MJ. The influence of insulin use on glycemic control: How well do 

adults follow prescriptions for insulin? Diabetes Care. Jan 2005;28(1):78-83. 

64. Wendel CS, Shah JH, Duckworth WC, Hoffman RM, Mohler MJ, Murata GH. Racial 

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HSR&D Evidence Synthesis Pilot Program – 52 

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American veterans with type 2 diabetes: the Diabetes Outcomes in Veterans Study. BMC 

Health Serv Res. 2006;6:58. 

65. Young BA, Maynard C, Reiber G, Boyko EJ. Effects of ethnicity and nephropathy on 

lower-extremity amputation risk among diabetic veterans. Diabetes Care. Feb 

2003;26(2):495-501. 

66. Walsh ME, Katz MA, Sechrest L. Unpacking cultural factors in adaptation to type 2 

diabetes mellitus. Med Care. Jan 2002;40(1 Suppl):I129-139. 

67. Singh N, Squier C, Sivek C, Wagener M, Nguyen MH, Yu VL. Determinants of 

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1996;8(3):261-269. 

68. 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. Mar 

2001;15(3):117-127. 

69. McGinnis KA, Fine MJ, Sharma RK, et al. Understanding racial disparities in HIV using 

data from the veterans aging cohort 3-site study and VA administrative data. Am J Public 

Health. Oct 2003;93(10):1728-1733. 

70. Korthuis PT, Asch SM, Anaya HD, et al. Lipid screening in HIV-infected veterans. J 

Acquir Immune Defic Syndr. Mar 1 2004;35(3):253-260. 

71. Bennett CL, Horner RD, Weinstein RA, et al. Racial differences in care among 

hospitalized patients with Pneumocystis carinii pneumonia in Chicago, New York, Los 

Angeles, Miami, and Raleigh-Durham. Arch Intern Med. Aug 7-21 1995;155(15):1586-

1592. 

72. Butt AA, Justice AC, Skanderson M, Rigsby M, Good CB, Kwoh CK. Rate and 

predictors of treatment prescription for hepatitis C. Gut. Sep 27 2006. 

73. Butt AA, Justice AC, Skanderson M, Good C, Kwoh CK. Rates and predictors of 

hepatitis C virus treatment in HCV-HIV-coinfected subjects. Aliment Pharmacol Ther. 

Aug 15 2006;24(4):585-591. 

74. Cheung RC, Currie S, Shen H, et al. Chronic hepatitis C in Latinos: natural history, 

treatment eligibility, acceptance, and outcomes. Am J Gastroenterol. Oct 

2005;100(10):2186-2193. 

75. Booth BM, Blow FC, Cook CA, Bunn JY, Fortney JC. Age and ethnicity among 

hospitalized alcoholics: a nationwide study. Alcohol Clin Exp Res. Dec 1992;16(6):1029-

1034. 

76. 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. Aug 

1998;155(8):1029-1034. 

77. Ross R, Fortney J, Lancaster B, Booth BM. Age, ethnicity, and comorbidity in a national 

sample of hospitalized alcohol-dependent women veterans. Psychiatr Serv. May 

1998;49(5):663-668. 

78. Stack K, Cortina J, Samples C, Zapata M, Arcand LF. Race, age, and back pain as factors 

in completion of residential substance abuse treatment by veterans. Psychiatr Serv. Sep 

2000;51(9):1157-1161. 

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79. Blow FC, Zeber JE, McCarthy JF, Valenstein M, Gillon L, Bingham CR. Ethnicity and 

diagnostic patterns in veterans with psychoses. Soc Psychiatry Psychiatr Epidemiol. Oct 

2004;39(10):841-851. 

80. Kales HC, Blow FC, Bingham CR, Copeland LA, Mellow AM. Race and inpatient 

psychiatric diagnoses among elderly veterans. Psychiatr Serv. Jun 2000;51(6):795-800. 

81. Murdoch M, Hodges J, Cowper D, Fortier L, van Ryn M. Racial disparities in VA service 

connection for posttraumatic stress disorder disability. Med Care. Apr 2003;41(4):536-

549. 

82. Kilbourne AM, Bauer MS, Han X, et al. Racial differences in the treatment of veterans 

with bipolar disorder. Psychiatric Services. Dec 2005;56(12):1549-1555. 

83. Kilbourne AM, Bauer MS, Pincus H, Williford WO, Kirk GF, Beresford T. Clinical, 

psychosocial, and treatment differences in minority patients with bipolar disorder. 

Bipolar Disord. Feb 2005;7(1):89-97. 

84. Owen RR, Feng W, Thrush CR, Hudson TJ, Austen MA. Variations in prescribing 

practices for novel antipsychotic medications among Veterans Affairs hospitals. 

Psychiatr Serv. Nov 2001;52(11):1523-1525. 

85. Charbonneau A, Rosen AK, Ash AS, et al. Measuring the quality of depression care in a 

large integrated health system. Med Care. May 2003;41(5):669-680. 

86. Valenstein M, McCarthy JF, Ignacio RV, Dalack GW, Stavenger T, Blow FC. Patientand facility-level factors associated with diffusion of a new antipsychotic in the VA 

health system. Psychiatr Serv. Jan 2006;57(1):70-76. 

87. Kilbourne AM, Pincus HA. Patterns of psychotropic medication use by race among 

veterans with bipolar disorder. Psychiatr Serv. Jan 2006;57(1):123-126. 

88. Rosenheck R, Fontana A. Black and Hispanic veterans in intensive VA treatment 

programs for Posttraumatic Stress Disorder. Med Care. Jan 2002;40(1 Suppl):I52-61. 

89. Rosenheck R, Leda C, Frisman L, Gallup P. Homeless mentally ill veterans: race, service 

use, and treatment outcomes. Am J Orthopsychiatry. Oct 1997;67(4):632-638. 

90. Akpaffiong M, Kunik ME, Hale D, Molinari V, Orengo C. Cross-cultural differences in 

demented geropsychiatric inpatients with behavioral disturbances. Int J Geriatr 

Psychiatry. Oct 1999;14(10):845-850. 

91. Young AS, Sullivan G, Duan N. Patient, provider, and treatment factors associated with 

poor-quality care for schizophrenia. Ment Health Serv Res. Dec 1999;1(4):201-211. 

92. Rosenheck R, Fontana A. Utilization of mental health services by minority veterans of 

the Vietnam era. J Nerv Ment Dis. Dec 1994;182(12):685-691. 

93. Rosenheck R, Stolar M. Access to public mental health services: determinants of 

population coverage. Med Care. Apr 1998;36(4):503-512. 

94. Becerra RM, Greenblatt M. The mental health-seeking behavior of Hispanic veterans. 

Compr Psychiatry. Jan-Feb 1981;22(1):124-133. 

95. Greenberg GA, Rosenheck RA. Change in mental health service delivery among blacks, 

whites, and Hispanics in the Department of Veterans Affairs. Adm Policy Ment Health. 

Sep 2003;31(1):31-43. 

96. Grubaugh AL, Frueh BC, Elhai JD, Monnier J, Knapp RG, Magruder KM. Racial 

differences in psychiatric symptom patterns and service use in VA primary care clinics. 

Psychiatr Serv. Mar 2006;57(3):410-413. 

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97. Kales HC, Blow FC, Bingham CR, Roberts JS, Copeland LA, Mellow AM. Race, 

psychiatric diagnosis, and mental health care utilization in older patients. Am J Geriatr 

Psychiatry. Fall 2000;8(4):301-309. 

98. Leda C, Rosenheck R. Race in the treatment of homeless mentally ill veterans. J Nerv 

Ment Dis. Aug 1995;183(8):529-537. 

99. Bosworth HB, Parsey KS, Butterfield MI, et al. Racial variation in wanting and obtaining 

mental health services among women veterans in a primary care clinic. J Natl Med Assoc. 

May 2000;92(5):231-236. 

100. Westermeyer J, Canive J, Thuras P, Chesness D, Thompson J. Perceived barriers to VA 

mental health care among Upper Midwest American Indian veterans: description and 

associations. Med Care. Jan 2002;40(1 Suppl):I62-71. 

101. Greenberg GA, Rosenheck RA. Changes in satisfaction with mental health services 

among blacks, whites, and Hispanics in the Department of Veterans Affairs. Psychiatr Q. 

Winter 2004;75(4):375-389. 

102. Rosenheck R, Fontana A, Cottrol C. Effect of clinician-veteran racial pairing in the 

treatment of posttraumatic stress disorder. Am J Psychiatry. Apr 1995;152(4):555-563. 

103. Koenig HG, Cohen HJ, Blazer DG, et al. Religious coping and depression among elderly, 

hospitalized medically ill men. Am J Psychiatry. Dec 1992;149(12):1693-1700. 

104. 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. 

105. 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. 

106. 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. 

107. 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. 

108. 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. 

109. 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. 

110. 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. 

111. 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. 

112. 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. 

113. 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. 

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114. 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;31(5):375-382. 

115. Bean-Mayberry B, Chang CC, Scholle SH. Brief report: lack of a race effect in primary 

care ratings among women veterans. J Gen Intern Med. Oct 2006;21(10):1105-1108. 

116. 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. 

117. 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. 

118. Sharkness CM, Snow DA. The patient's view of hypertension and compliance. Am J Prev 

Med. May-Jun 1992;8(3):141-146. 

119. Braun UK, Rabeneck L, McCullough LB, et al. Decreasing use of percutaneous 

endoscopic gastrostomy tube feeding for veterans with dementia-racial differences 

remain. J Am Geriatr Soc. Feb 2005;53(2):242-248. 

120. Horner RD, Swanson JW, Bosworth HB, Matchar DB. Effects of race and poverty on the 

process and outcome of inpatient rehabilitation services among stroke patients. Stroke. 

Apr 2003;34(4):1027-1031. 

121. Hwang SS, Chang VT, Alejandro Y, et al. Study of hormone refractory prostate cancer: 

hospital care and palliative care resource use at a VA medical center. Cancer Invest. 

2004;22(6):849-857. 

122. 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. Sep 2003;1(3):221-230. 

123. Casarett DJ, Hirschman KB, Coffey JF, Pierre L. Does a palliative care clinic have a role 

in improving end-of-life care? Results of a pilot program. J Palliat Med. Jun 

2002;5(3):387-396. 

124. Kressin NR, Boehmer U, Berlowitz D, Christiansen CL, Pitman A, Jones JA. Racial 

variations in dental procedures: the case of root canal therapy versus tooth extraction. 

Med Care. Nov 2003;41(11):1256-1261. 

125. Wei GS, Jackson JL, Herbers JE, Jr. Ethnic disparity in the treatment of women with 

established low bone mass. J Am Med Womens Assoc. Summer 2003;58(3):173-177. 

126. Julapalli VR, Kramer JR, El-Serag HB. Evaluation for liver transplantation: adherence to 

AASLD referral guidelines in a large Veterans Affairs center. Liver Transpl. Nov 

2005;11(11):1370-1378. 

127. Gordon HS, Johnson ML, Ashton CM. Process of care in Hispanic, black, and white VA 

beneficiaries. Med Care. Sep 2002;40(9):824-833. 

128. Arozullah AM, Ferreira MR, Bennett RL, et al. Racial variation in the use of laparoscopic 

cholecystectomy in the Department of Veterans Affairs medical system. J Am Coll Surg. 

Jun 1999;188(6):604-622. 

129. Groeneveld PW, Sonnad SS, Lee AK, Asch DA, Shea JE. Racial differences in attitudes 

toward innovative medical technology. J Gen Intern Med. Jun 2006;21(6):559-563. 

130. Flaherty JA, Naidu J, Lawton R, Pathak D. Racial differences in perception of ward 

atmosphere. Am J Psychiatry. Jun 1981;138(6):815-817. 

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131. Young GJ, Meterko M, Desai KR. Patient satisfaction with hospital care: effects of 

demographic and institutional characteristics. Med Care. Mar 2000;38(3):325-334. 

132. Damron-Rodriguez J, White-Kazemipour W, Washington D, Villa VM, Dhanani S, 

Harada ND. Accessibility and acceptability of the Department of Veteran Affairs health 

care: diverse veterans' perspectives. Mil Med. Mar 2004;169(3):243-250. 

133. Davis LE, Gelsomino J. An assessment of practitioner cross-racial treatment experiences. 

Soc Work. Jan 1994;39(1):116-123. 

134. Graveley EA, Oseasohn CS. Multiple drug regimens: medication compliance among 

veterans 65 years and older. Res Nurs Health. Feb 1991;14(1):51-58. 

135. Schneiderman AI, Lincoln AE, Curbow B, Kang HK. Variations in health 

communication needs among combat veterans. Am J Public Health. Dec 

2004;94(12):2074-2076. 

136. Smith RP, Devine P, Jones H, DeNittis A, Whittington R, Metz JM. Internet use by 

patients with prostate cancer undergoing radiotherapy. Urology. Aug 2003;62(2):273-

277. 

137. Basson MD, Gomez R, Fishman L, Panzini L. Informed consent for screening 

sigmoidoscopy in a Veterans Administration population. Dis Colon Rectum. Nov 

2004;47(11):1939-1946. 

138. Gurmankin AD, Polsky D, Volpp KG. Accounting for apparent "reverse" racial 

disparities in Department of Veterans Affairs (VA)-based medical care: influence of outof-VA care. Am J Public Health. Dec 2004;94(12):2076-2078. 

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APPENDIX I. SEARCH STRATEGY 

Search terms and MeSH headings: 

((VA [tw] OR veteran* [tw]) OR (United States Department of Veterans Affairs [mh] OR 

veterans [mh] OR veterans hospitals [mh])) AND ((ethnic* [tw] OR race [tw] OR racial [tw] OR 

disparity [tw] OR disparities [tw] OR blacks [tw] OR black [tw] OR Hispanic* [tw]) OR 

(population groups [mh] OR race relations [mh])) 

Databases searched: Medline via PubMed, HealthSTAR, and Health Services Research Projects 

(HSRProj). The HSRProj database identified ongoing and completed VA research projects, and 

indicated whether these studies had been published. 

Dates searched: 1966-October 9, 2006. 

Automatic updates: The search strategy is saved in the PubMed database to provide weekly 

updates on new publications. 

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ities Review 

APPENDIX II. INCLUSION / EXCLUSION CRITERIA 

Inclusion / Exclusion Codes for abstracts and full-text articles 

Code Include / 

Exclude 

Reason 

I1 Include Published studies that: 

a. Are conducted within VHA or with VA beneficiaries AND 

b. Report data by patient race and/or ethnicity AND 

c. Report data on 

i. Utilization of health care services 

ii. Quality of health care services 

1. Process-of-care measures (e.g., use of 

appropriate screening tests) 

2. Outcome measures used by VHA as quality 

metrics (e.g., blood pressure control) 

3. Patient evaluations of care (e.g., patient 

satisfaction) 

4. Direct observations of care (e.g., 

communication patterns) 

iii. Potential mediators of racial/ethnic disparities in 

utilization or quality 

1. System level mediators (e.g., distribution of 

services) 

2. Provider level mediators (e.g., racial bias) 

3. Patient level mediators (e.g., trust) 

4. Patient-provider level mediators (e.g., 

communication) 

I2 Include Systematic review or meta-analysis of studies meeting I1 

I3 Include Unpublished research meeting I1 

I4 Include Background or review articles relevant to racial disparities in VHA (for 

review of reference lists) 

I5 Include Other (specify) 

X1 Exclude Outcomes that are not clear indicators of utilization or quality of care or 

potential mediators of disparities in utilization/quality (e.g., reports on health 

outcomes that are not clearly markers of health care quality) 

X2 Exclude Non-U.S.VHA setting and non-VA population 

X3 Exclude Data not stratified by patient race and/or ethnicity 

X4 Exclude No original data 

X5 Exclude Non-English language, no abstract 

X6 Exclude Non-human, animal 

X7 Exclude Other (specify) e.g. NRF 
HSR&D Evidence Synthesis Pilot

Racial Dispar

1098 abstracts imported from Medline via 

PubMed, HealthSTAR 

(1966-October 9, 2006) 

+ 7 from manual and automatic updates 

934 abstracts ex

171 full-text articles pulled and reviewed 

with inclusion/exclusion criteria, sorted by 

clinical content area 

Arthritis/pain 

management 

Diabetes Heart/CVD HIV/HCV Rehab/ 

palliative 

care 

Mental 

Health 

Preventive/

ambulatory 

care 

Cancer 

17 incl 8 incl 

4 excl 

7 incl 

7 excl 

35 incl 

6 excl 

8 incl 

1 excl 

29 incl 

7 excl 

14 incl 

6 excl 

5 incl 

1 excl 

 Program – 

ities Review 60 

APPENDIX III. SEARCH AND SELECTION OF LITERATURE 
APPENDIX IV. EVIDENCE TABLES 

Please see MS Excel spreadsheets available for download from the HSR&D website: 

www.hsrd.research.va.gov/publications/esp/AppendixIV-EvidenceTables.xls 

This MS Excel file contains all ten Evidence Tables as well as the List of Abbreviations. 

HSR&D Evidence Synthesis Pilot Program – 

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