39

Interventions to Improve Minority Health Care and

Reduce Racial and Ethnic Disparities Evidence-based Synthesis Program

APPENDIX A. SEARCH STRATEGY

I. Search for intervention studies to reduce racial disparities

Search Most Recent Queries Time Result

#12 Search systematic[sb] AND (#9) 15:47:12 2129

#9 Search (#8) OR #6 15:43:46 83980

#8 Search (#4) AND #7 15:43:29 25879

#7 Search “Evaluation Studies “[Publication Type] OR “Clinical Trial 

“[Publication Type]

15:43:08 751037

#6 Search (#5) AND #4 15:42:49 65155

#5 Search address OR program OR intervention* OR reduce OR 

eliminate[Title/Abstract]

15:42:38 1106596

#4 Search ((#3) OR #2) OR #1 15:42:29 491858

#3 Search ((“Population Groups”[Mesh] OR “Race Relations”[Mesh]) 

OR “Minority Groups”[Mesh]) OR “Health Services 

Accessibility”[Mesh]

15:41:47 229846

#2 Search ethnic* OR race or Racial OR disparity OR disparities OR 

blacks OR black OR hispanic* OR equity OR sociodemographic 

OR discrimination OR minority OR minorities OR “African 

american*”[Title/Abstract]

15:41:36 425423

#1 Search (((“African Continental Ancestry Group”[Mesh] OR “Hispanic 

Americans”[Mesh]) OR “Indians, North American”[Mesh]) OR 

“Inuits”[Mesh]) OR “Asian Americans”[Mesh]

15:41:16 77830

II. Update search for recently published studies using the

strategy designed for the 2007 VA- ESP review of primary VA 

studies

Search terms in PubMed Database Searched August 12, 2010

((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])) AND ((“2006/10/01”[PDat] : “3000”[PDat]))

Result: 533 
40

Interventions to Improve Minority Health Care and

Reduce Racial and Ethnic Disparities Evidence-based Synthesis Program

Search terms in HSRProj Database Searched August 12, 2010

VA and (disparity OR disparities OR equity)

and Project Status = Ongoing & Completed (Default)

and Initial Year from: 2006 To: 2010

States: All

Result: 31 Projects

III. Search for systematic reviews of intervention studies on racial disparities

Search Most Recent Queries

#12 Search systematic[sb] AND (#9)

#9 Search (#8) OR #6

#8 Search (#4) AND #7

#7 Search “Evaluation Studies “[Publication Type] OR “Clinical Trial “[Publication Type]

#6 Search (#5) AND #4

#5 Search address OR program OR intervention* OR reduce OR eliminate[Title/Abstract]

#4 Search ((#3) OR #2) OR #1

#3 Search ((“Population Groups”[Mesh] OR “Race Relations”[Mesh]) OR “Minority 

Groups”[Mesh]) OR “Health Services Accessibility”[Mesh]

#2 Search ethnic* OR race or Racial OR disparity OR disparities OR blacks OR black OR hispanic* 

OR equity OR sociodemographic OR discrimination OR minority OR minorities OR “African 

american*”[Title/Abstract]

#1 Search (((“African Continental Ancestry Group”[Mesh] OR “Hispanic Americans”[Mesh]) OR 

“Indians, North American”[Mesh]) OR “Inuits”[Mesh]) OR “Asian Americans”[Mesh]
41

Interventions to Improve Minority Health Care and

Reduce Racial and Ethnic Disparities Evidence-based Synthesis Program

APPENDIX B. INCLUSION/EXCLUSION CRITERIA FOR 

PRIMARY STUDIES AND REVIEWS

1. Is the full text of the article in English? 

Yes...............................................................Proceed to #2

No........................................................Code X1. Go to #6

2. Does the study population include adults in the U.S.? 

Yes...............................................................Proceed to #3

No........................................................Code X2. Go to #6

3. Does the article evaluate the effects of an intervention within one or more racial/ethnic minority 

group(s), or between racial/ethnic groups including at least one racial/ethnic minority group?

Yes...............................................................Proceed to #4

No........................................................Code X3. Go to #6

4. Is the publication a primary study conducted in a VA population, or a systematic review or metaanalysis (not limited to VA) that meets methodological quality criteria?

Yes...............................................................Proceed to #5

No................................................Code X4. Proceed to #6

5. Is the intervention applicable to VA care settings? 

(Applicability refers to patient populations and disease entities of documented disparities in the 

VA setting. Qualifying interventions must target services provided at the VA. Obstetric care and 

interventions designed to improve access are examples of exclusions)

Yes.............................................................Code I5. STOP

No................................................Code X5. Proceed to #6

6. Is the article potentially useful for background, discussion, or reference-mining?

Yes......................................................Add code B. STOP

No............................................................................ STOP
42

Interventions to Improve Minority Health Care and

Reduce Racial and Ethnic Disparities Evidence-based Synthesis Program

PICOTS

Population: adults in the US. Studies exclusively on children or adolescents are excluded. 

Interventions: third generation studies that evaluate the effects of an intervention within one 

or more racial/ethnic minority group(s) or between racial/ethnic groups including at least one 

racial/ethnic minority group. 

Comparator: control group within same racial/ethnic minority group, or comparison between 

racial/ethnic groups. 

Outcomes: not limited. outcomes of interest include the following: 

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)

iv. Patient-provider level mediators (e.g., communication)

v. Health outcomes (e.g., diabetic complications)

Timing: any length of followup

Setting: US
43

Interventions to Improve Minority Health Care and

Reduce Racial and Ethnic Disparities Evidence-based Synthesis Program

APPENDIX C. QUALITY RATING CRITERIA FOR REVIEWS

Overall quality rating for systematic reviews is based on the questions below. Ratings are 

summarized as: Good, Fair, or Poor:*

• Search dates reported? Yes or No

• Search methods reported? Yes or No

• Comprehensive search? Yes or No

• Inclusion criteria reported? Yes or No

• Selection bias avoided? Yes or No

• Validity criteria reported? Yes or No

• Validity assessed appropriately? Yes or No

• Methods used to combine studies reported? Yes or No

• Findings combined appropriately? Yes or No

• Conclusions supported by data? Yes or No

Definitions of ratings based on above criteria

Good: Meet all criteria: Reports comprehensive and reproducible search methods and results; 

reports pre-defined criteria to select studies and reports reasons for excluding potentially relevant 

studies; adequately evaluates quality of included studies and incorporates assessments of quality 

when synthesizing data; reports methods for synthesizing data and uses appropriate methods to 

combine data qualitatively or quantitatively; conclusions supported by the evidence reviewed.

Fair: Studies will be graded fair if they fail to meet one or more of the above criteria, but the 

limitations are not judged as being major.

Poor: Studies will be graded poor if they have a major limitation in one or more of the above 

criteria.

*Created from the following publications: 

Harris RP, Helfand M, Woolf SH, et al. Current methods of the US Preventive Services Task 

Force: a review of the process. Am J Prev Med. 2001:20(3S); 21-35. 

National Institute for Health and Clinical Excellence. The Guidelines Manual. London: Institute 

for Health and Clinical Excellence; 2006.

Oxman AD, Guyatt GH. Validation of an index of the quality of review articles. J Clin 

Epidemiol. 1991;44:1271-8. 
44

rity Health Care and Reduce Racial and Ethnic Disparities Evidence-based Synthesis Program

ENCE TABLE

n Setting Single-race 

(included only minority 

study participants)

Comparative 

 (included minority 

and majority 

participants with pre 

and post intervention 

comparison) 

Mostly generic 

or tailored 

interventions?

Study methodology (e.g., 

systematic review, metaanalysis) 

Study period/search 

dates

Number and hierarchy 

of studies included 

Intervention types

(i.e., community health workers)

 white

Urban VAMC (Washington DC) No Yes. Multiple groups, 

but do not analyze pre-post by race

Generic Primary article; retrospective 

chart review of HBPC enrollees. Pre-post enrollment (no control)

Patients enrolled for at least 6 months during the period of January 2001-December 2002

n/a Multiprofessional home-based primary care (HBPC) 

team: medical director, nurse practitioners, registered nurses, social workers, pharmacists, registered dietician, dental hygienist and program director.

0 

%)%)

5%)

Urban VAMC (Miami) No Yes Generic Primary study (pre-post no 

control group)

Patients enrolled for at least 9 months from May 2000-January 2002

n/a Care coordination: 2 care coordinators (nurse pract, 

licensed clin social worker), secretary and geriatrician (oversight)Telemedicine: telephone-based in-home messaging device for patient monitoring. Patients input blood sugar levels and answer educational questions. Data transmitted to messaging center, stratified into high/med/low risk for care coordinators following morning.

E < 25) 

givers; 

= 32, 

Homes of caregivers/recipients.

No Yes. Multiple groups, 

but do not analyze pre-post by race

Generic Primary article; pre-post with 

no control group

n/a n/a Screen telephones and support by care coordinators.

n 

ns

In person and telephone interviews

Yes No Tailored Primary article; tests of mean 

differences, comparisons of kappas.

n/a n/a Telephone and in person interviews to test the feasibility 

of SCID in this population/setting

n and 

rans

at 

black 

  

nnaire 

31 

Urban VAMC (Greater Los Angeles)

No Yes Tailored Primary study (pre-post no 

control group)

n/a n/a Educational videotape and tailored total knee 

replacement (TKR) decision aid

All medical settings Yes. Most included 

studies are singlerace.

No Tailored Systematic review 1965-2001 6 RCTs Clinician bias: recruitment/retention of diverse staff, 

interpreter services, cultural competence training, ed materials, culturally specific health care settings.

onals 

rity 

n/a Yes. Most included 

studies are singlerace.

No Tailored Systematic review 1980 through 2/2003 2 RCTs, 12 controlled, 

20 pre-post.

Training programs varying in lengths generally effective in improving certain aspects of provider characteristics.

ses and 

nts and 

ical 

Hospital outpatientCommunity health centerGroup practice Community care

Yes. Some included studies are singlerace.

Yes. Most included studies are comparative.

Tailored Systematic review 1980-June 2003 n=27

RCT n=20CCT n=7

Tracking/reminder systems, bypassing the physician, safe times questionnaires for pts, remote simultaneous translation
45

rity Health Care and Reduce Racial and Ethnic Disparities Evidence-based Synthesis Program

n Setting Single-race 

(included only minority 

study participants)

Comparative 

 (included minority 

and majority 

participants with pre 

and post intervention 

comparison) 

Mostly generic 

or tailored 

interventions?

Study methodology (e.g., 

systematic review, metaanalysis) 

Study period/search 

dates

Number and hierarchy 

of studies included 

Intervention types

(i.e., community health workers)

S Community (6) and clinic (3) 

settings in California, Texas, New Mexico, Colorado and Washington

Yes. All included studies are singlerace.

No Tailored Meta-analysis ended January 2009 n=9

Quasi-experimental n=6 RCT n=3

Lay-health advisor (promotoras), printed mailings, educational groups, television campaigns, accessenhancing (1 study)

anic 

ents

STD Clinics No Yes. Some included 

studies are comparative, but do not analyze pre-post by race.

Tailored Meta-analysis 1998-june 2005 18 RCTs Intervention delivered by health educator/counselor

n 

Health Care and Community Settings

Yes Yes. Some included 

studies are comparative, but do not analyze pre-post by race.

Tailored Meta-analysis January 1988 to June 

2007

37 individual and groups level intervention studies and 4 community level intervention studies.

Patient activation

ns Ambulatory care and 

community settings

Yes No Generic Systematic review 1996 - 2006 NR Counseling/education for behavior change; screening; 

changes in delivery system; exercise, stress reduction, dietary modification

whites Community and health care 

settings. Interventions had to be connected to health care organizations. 

Yes. Most included studies are singlerace.

Yes. Some included studies are comparative, but do not analyze pre-post by race.

Generic Systematic review 1995 - 2006 Overall: 52 RCT, 8 prepost, 2 non-randomized 

controlled clinical trials

Provider and care delivery interventions (e.g., patient outreach, clinic reorganization, interventions with nurses alone or with community health workers included); patient and family interventions

-health 

ed 18 

Non-face-to-face methods of contacting participants. Of the US studies, 6 were conducted in community settings, 4 were conducted in clinical/health care settings and 2 did not report recruitment activities.

Yes. One included study was single-race.

Yes Tailored Meta-analysis (and narrative 

summaries)

January 1990-December 

2007

n=16All studies were RCT or quasi-RCTAll studies included experimental group that received tailored nutrition education and control group with either generic and/or no nutrition education.11 were conducted in the US, 1 was conducted in US and Canada

Tailored nutrition education included print, email or other non-face-to-face format (excluded studies that used face-to-face delivery methods)

African 

anic 

en

n=19 in community settingsn=4 in health care settings

Yes. Most included studies are singlerace.

Yes. Some included studies are comparative, but do not analyze pre-post by race.

Tailored Meta-analysis September 2000 - August 

2008

n=23RCT n=14All studies were experimental or quasiexperimental design. Evidence tables offered as supplemental online content

directed print materials, peer/lay health advisor education and support, telephone counseling. 

ntly 

n; 

panic; 

an; 

ve 

rican 

n=5 health care settingsn=13 community settings

Yes. Most included studies are singlerace.

Yes Generic Meta-analysis 1984-April 2009 n=18

RCT n=9Quasi-experimental non randomized n=9

1. individual-directed (in-person and phone counseling)2. Access-enhancing (reduced cost, mobile vans)3. Peer-navigator (lay health advisors)4. Community education (small group workshops/

seminars)

5. Mass media (tv, newspaper, radio campaigns)
46

rity Health Care and Reduce Racial and Ethnic Disparities Evidence-based Synthesis Program

n Setting Single-race 

(included only minority 

study participants)

Comparative 

 (included minority 

and majority 

participants with pre 

and post intervention 

comparison) 

Mostly generic 

or tailored 

interventions?

Study methodology (e.g., 

systematic review, metaanalysis) 

Study period/search 

dates

Number and hierarchy 

of studies included 

Intervention types

(i.e., community health workers)

dies 

 in 

ps. 

ns S (e.g. 

ish). 

Group and individual sessions in clinics, community medical centers, homes of participants, hospital and GP practices. Type of HE provider ranged from peer leaders, certified DM educators, bilingual nurse, CHW, podiatrist, dietician, exercise physiotherapist. 

Yes. All included studies were conducted in singlerace groups. 

No Tailored Systematic review and metaanalysis 1966 or inception thru 2007 12 RCTs Culturally appropriate health education (group sessions in the majority of included studies) defined as HE tailored 

to the cultural or religious beliefs and linguistic and literacy skills of the community being studied.

Health/drug treatment clinics, schools, community based organizations, and farm worker campsites 

Yes No Tailored Meta-analysis 1988-2006 20 studies included in 

meta-analysis

Variety of implementation methods from fotonovela to health educator/outreach worker

ns Community and clinical 

settings

Yes Yes. Most included 

studies are comparative, but do not analyze pre-post by race.

Tailored Meta-analaysis 1981-2006 78 RCTs Health education

ations All medical settings Yes. One included 

study was single-race.

No Tailored Systematic review 1/1990-3/2010 2 quasi-randomized, 2 

cluster randomized, 3 pre-post.

Cultural competence curricula



S Community setting; majority of included studies in the West 

and Southwest US

No Yes Generic Systematic review Through August 2008 N=14

RCT N=2CCT N=6

Lay health advisors (education, phone counseling, media campaign, social support, community events, mobile screening)

ite 

(mostly 

n and 

ders

Health care settings Yes. A few included 

studies are singlerace.

Yes. Most included studies are comparative.

Generic Systematic review 1986-December 2005 n=43 

(n=36 on screening, n=5 follow up testing, n=2 treatment, n=1 survivorship)RCT n=33CCT=10

Patient: reminder letters, telephone calls, written educational materials, in-person counseling, mammography vouchers, classroom educationProvider: chart reminders, chart flow sheets, written education materials, chart autids with feedback

ns and 

anders 

2 community based samples, 1 clinic sample

Yes No Tailored Systematic review 1998 - 2008 2 pre-post, 1 

nonrandomized controlled clinical trial

One study used community health workers to deliver a disease management program. Another study used group visits for hypertension counseling. 

ps in 

g at 

ntaged 

Community-based No Yes Generic Systematic review 1/2001 - 8/2009 N=15

All RCT

1. Patient mailings (mailing, tailored mailing, tailored 

mailing & phone reminder, brochure); N=3

2. Telephone outreach (scripted and unscripted phone 

assistance with mailings, care manager calls, tailored phone education); N=3

3. Electronic and multimedia (physician email system, 

preferences-based website, standardized website, multimedia computer program education, peer education/health professional video education); N=4

4. Community education (pts receiving navigator 

services, community screening behavior program, risk counseling, general counseling, cultural selfempowerment) N=5

 

 NO 

und on 

All medical settings Yes No Generic Systematic review 1/1994-7/2009 None. Extrapolate from 

white patients. 

Some recommendations at end, none based on any evidence.
47

rity Health Care and Reduce Racial and Ethnic Disparities Evidence-based Synthesis Program

n Setting Single-race 

(included only minority 

study participants)

Comparative 

 (included minority 

and majority 

participants with pre 

and post intervention 

comparison) 

Mostly generic 

or tailored 

interventions?

Study methodology (e.g., 

systematic review, metaanalysis) 

Study period/search 

dates

Number and hierarchy 

of studies included 

Intervention types

(i.e., community health workers)

s 8 

T a 

p. 

ions 

of all 

ajority 

emale 

d.

Unrestricted settings: community health workers could have delivered the intervention in the clinic, home or community setting, in either developed or undeveloped countries. 

Yes No Generic Systematic review 1966 to March 2004 18 total: 

8 RCTs, 6 before-after studies, 3 non-randomized allocation of treatment and comparison groups,1 study with postintervention measures only

Community health workers serving in a variety of roles

e 

Primary care settings (community health clinic or doctor’s offices) 

Yes. A few included studies are singlerace.

Yes. Some included studies are comparative, but do not analyze pre-post by race.

Generic Systematic review January 1985-January 

2003

n=14RCT n=5non-randomized controlled trial n=3pre-post n=3quasi-experimental n=3

Clinical reminders; peer health educators; culturally sensitive videos; audit with feedback; vouchers

older). 

ns, 

nese

white 

All 19 included trials conducted in the US, though not specified if in community or health care settings.

Yes. Most included studies are singlerace.

Yes. Some included studies are comparative. 

Generic Systematic review not specified N=19

all RCT 

Culturally tailored advice/diet counseling; individual programs; family/group programs; peer discussion groups; web-based program; 

ich 

s were 

keup, 

 

 were 

cribed. 

Patient education settings included academic primary care clinics and community based health centers. Provider intervention settings included public hospital academic general internal medicine clinics and community based private physician practices. Health care organization interventions occurred in rural and urban locations, academic and community based primary care clinics, and a public hospital diabetes clinic. 

Yes. Most included studies are singlerace.

Yes. Some included studies are comparative, but the majority do not analyze pre-post by race.

Generic Systematic review 1985-2006 22 RCTs, 7 RCTs, 13 

before/after studies, 1 observational study. 

Systematic review of patient-target interventions that sought to improve dietary habits, physical activity, or self-management activities; physician provider-target interventions; health care organization interventions; and multi-target interventions. Included culturally tailored programs. Many health care organization interventions used a registered nurse for case management and/or clinical management via treatment algorithms, often with a CHF for peer support and community outreach. 2 studies evaluated pharmacist-led medication management and patient education. Multi-target interventions involved more than one of the above targets, e.g. multidisciplinary teams.

S Community and health care 

settings

Yes. No. Tailored Systematic review Not specified n=22

RCTnPre-post n=13 Cost-benefit n=1RCTs: 2 in diabetes peer counseling; 2 breastfeeding; 1 food nutrition education Pre-post: 7 in diabetes peer counseling; 2 in breastfeeding; 5 in food nutrition education

Peer educators; nutrition education; nurse case management

d 

study 

st 50% 

ns

primary care settings and community based settings

Yes. A few included studies are singlerace.

Yes. Most included studies are comparative, but do not analyze pre-post by race.

Generic Systematic review 2000-2008 n=12

RCT n=8Nonrandom n=4

Mailed personalized materials; reminder letters/calls; physician reminders; case manager calls; lay health advisors; tailored phone education; physician education
48

rity Health Care and Reduce Racial and Ethnic Disparities Evidence-based Synthesis Program

n Setting Single-race 

(included only minority 

study participants)

Comparative 

 (included minority 

and majority 

participants with pre 

and post intervention 

comparison) 

Mostly generic 

or tailored 

interventions?

Study methodology (e.g., 

systematic review, metaanalysis) 

Study period/search 

dates

Number and hierarchy 

of studies included 

Intervention types

(i.e., community health workers)

single

y. 2 

med at 

 did 

. 

Various: 1 urban hospital, 2 VA’s, 1 rural NOS, 1 in Sweden, 1 in Cuba, others named by city NOS. 

Yes No Generic systematic review Jan 1985 - Dec 2000 8 RCTs

3 Uncontrolled trials using a before/after design1 RCT but results were presented using before/after analysis

Self-care interventions that aimed to change the behavior of patients, rather than simply educating them. 4 studies were designed according to cultural criteria specific to the targeted group. Techniques for cultural tailoring included focus groups, and using specific recipes for the ethnic group being studied. 

in 4 

dies 

frican 

1 

only 

ns. 1 

o have 

spanic 

ns. 

Primary Care No Yes. Some included 

studies are comparative, but do not analyze pre-post by race.

Generic systematic review Database inception to 

December 2006

9 studies (4 in UK, 4 in US, 1 in Netherlands). The 4 US studies included 2 RCTs and 2 CCTs. 

Primary care interventions, including case management, patient counseling, and reminder cards to prompt providers

s and 

Mostly primary care clinics. No Yes. Some included 

studies are comparative, but do not analyze pre-post by race.

Tailored systematic review 1/1995 through 1/2006 20 interventions total. 

12 chronic disease management (9 multicomponent (8 RCTs, 1 observational/cohort) + 3 single component (1 RCT + 2 observational/cohort); 7 case management + 4 collaborative care) + 8 tailored (3 treatment programs + 4 preventive interventions + 1 psychoeducation). 

Case management by trained layperson, nurse, or social worker. Some ethnic matching.

and 

 = 

ethnic 

PCPs, MH clinics, WIC and other targeted service clinics

No Yes Generic Systematic review 1981 through 2005 10 studies (7 RCTs, 

1 observational retrospective design, 1 case series, 1 unclear). 

QI, case management, guideline-based interventions, collaborative care, standard psychotherapies, cultural adaptations to psychotherapies.

n and 

Clinical and community No Yes Generic Meta-analysis 1984-April 2006 n=20

Studies coded as quasiexperimental or RCT, but not reported

Pharmacological (sustained-release bupropion, nicotine patches, nicotine lozenge); individual, phone and group behavioral counseling; targeted print materials; community outreach; video/radio media; multicomponent of above

anic 

Home visits, health care settings, community settings

Yes No Generic Systematic review and mini 

meta-analysis

1991-2007 n=17

n=12 for SRRCT n=5 for MA

Self help; nicotine replacement therapy; community based interventions; individual counseling; group counseling; telephone counseling

ns Community (churches, 

YMCA, community centers, public housing) and health care settings (doctor offices, hospitals)

No Yes Generic Systematic review September 2002- 

December 2006

n=29 (additional n=14 on children are not considered here)- RC=-NCT=4 (nonrandomized controlled trials-UCT=10 (uncontrolled trial)

Telephone counseling; peer counselors; structured exercise program; group exercise sessions; unstructured/unsupervised exercise

cular disease, DM – diabetes mellitus, ESP – Evidence-based Synthesis Program, GP – general practitioner, HE – health education, HSR&D – Health Services Research and Development Service, MH – mental health, NOS – not otherwise specified, PCP – primary 

ical Center, WIC - Special Supplemental Nutrition Program for Women, Infants and Children
49

rity Health Care and Reduce Racial and Ethnic Disparities Evidence-based Synthesis Program

EWER COMMENTS AND RESPONSES 

Comment Response

pe, and methods for this review clearly described?

-

-

-

 objectives for this review evolved during the review due to lack of literature evidence 

objective. This results in the somewhat confusing review which seems to stray beyond 

ntions to reduce disparities. Unfortunately, my interpretation of this is that the actual 

 of this type, given the limited literature in the area, should be questioned. 

The primary stakeholder and nominator for this review topic was HSR&D. The primary purpose for nominating the topic was to take stock of VA race/ethnicity disparities research efforts and to inform future research. We have attempted to deliver a report that serves this purpose.

 While a comprehensive literature search was done, it is not clear how the reviewers 

at were retrieved for full text review. That is, approximately 3400 abstracts were 

ed in 150 articles that underwent further review. What criteria were used to select the 

iew was not stated.

We have provided a summary of literature search methods and criteria in the methods section, pointing readers to the detailed inclusion/exclusion criteria specified in Appendix B. 

-

-

e. However, clarification is needed regarding the choice of systematic reviews. Also, 

reference to broader objectives or goals beyond the two key questions – to inform future 

tation of interventions – see individual comments in the text of the report for more detail.

We have provided a discussion of works in progress by VA disparities researchers as well as mention of informing future research in the report objectives.

-

 of bias in our synthesis of the evidence?

-

-

-

review in the background section, a sentence appears as follows, “The extent to which 

arch has been conducted in VA populations is unclear, though a review of published 

rities intervention research in the VA may be lagging behind research of interventions 

he VA setting.” It is surprising to me that such a statement would be made without 

f the “review” or more direct evidence that supports the statement. This suggests a bias 

he VA has conducted little intervention research.

We believe there is some confusion about our usage of the word “review” in this selected sentence. We were not referring to a particular systematic review but were referring more generally to our review of the published literature in the report as a whole. We have amended this sentence.

-
50

rity Health Care and Reduce Racial and Ethnic Disparities Evidence-based Synthesis Program

Comment Response

that the systematic reviews were assessed for selection bias (good). However, how 

 selection bias is not described. Also, Appendix C implies that they were not assessed 

ntial biases (e.g., how they assessed other types of potential bias of the individual 

n them).

We appreciate that our quality criteria are not elaborated in detail; however, we provide citations that inform our quality guidelines. 

benefit from descriptions of methodology utilized to assess the risk of bias of any 

uded in the primary literature review. The PRISMA guidelines for assessing bias might 

ltman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, et al. (2009) The PRISMA Statement 

tic Reviews and Meta-Analyses of Studies That Evaluate Health Care Interventions: 

oration. PLoS Med 6(7): e1000100. doi:10.1371/journal.pmed.1000100

We thank the reviewer for providing PRISMA guideline references. The primary objective of the report is to inform VA stakeholders on the state of interventions research in the VA. We have included these primary studies according to inclusion criteria, as well as with regard to our study quality criteria, as indicated in Appendix C. Additionally, these quality criteria appear consistent with PRISMA guidelines.

nt on page 11 implies that some poor quality reviews may have been included (e.g., 

eview available for a given topic, covering a particular time frame, it was always 

): “If there were several reviews available for a given topic area covering a similar 

ed poor quality reviews as defined by previously developed criteria.” If it is true, it 

o say that all poor quality reviews were excluded.

We have made this change.

-

-

-

d or unpublished studies that we may have overlooked?

-

-

-

 other literature that was not reviewed in this report. -

-

nson Foundation’s Finding Answers: Disparities Research for Change program is 

an evaluation of a provider incentive program designed to improve quality of care 

can American patients with hypertension. The evaluation is designed to assess the 

 incentive intervention on disparities in the 12 participating VA medical centers. 

luding contact info for the PI, can be found here: http://www.solvingdisparities.org/

Thank you for the information provided.

of. -

ds to be a discussion of current VA funded intervention research, which includes a 

 should be informative.

We thank the reviewer for the suggestion. We have included a discussion of ongoing race/ethnic disparities intervention projects in the Discussion section.
51

rity Health Care and Reduce Racial and Ethnic Disparities Evidence-based Synthesis Program

Comment Response

g paper included in any of your reviews? It is such a great disparities intervention trial: 

lturally Sensitive Approach to End-of-Life Planning for Long-Term Dialysis Patients.

ne Swartz, MA, Stephanie Brown, PhD, Dylan Smith, PhD,

and Richard Swartz, MD

Thank you for this suggestion. This study did not get captured in our search because it was published prior to our search date, but it is very relevant to the topic. We have added this study to the section on cultural competence interventions. 

l suggestions or comments below. If applicable, please indicate the page and line numbers from the draft report.

o prior work as coming from the “VA HSR&D ESP”, not the “Portland ESP”. We have made this change.

en Key Questions 1 and 2 is not particularly useful given the paucity of VA-specific 

f the text is much improved by combining VA and non-VA intervention studies 

n or disease. Suggest that your Executive Summary and Text both take that combined 

We thank the reviewer for the comment. Several reviewers had concerns about the wording of the two key questions. Consequently, we have reframed our presentation of Key Questions 1 and 2 to avoid confusion.

ealth System Leadership” as a key stakeholder for this evidence synthesis. We have made this change.

and the distinction between “targeted” and “deficit” studies – I believe more 

eded.

Several reviewers were unclear about our categorization scheme. As a result, we have decided to revamp our taxonomic language for clarity and utility in categorizing existing disparities interventions studies. We hope the new scheme will serve this purpose.

re): Given the likelihood that multicomponent interventions with at least some 

rt are needed to address health disparities, what are the implications for study 

l RCTs really feasible? What is the role of community-based participatory research? 

-methods designs? 

We have added a brief discussion of implications for study design in the Discussion section. It will be important for researchers to conduct well-designed and clearly described interventions in Veteran populations to improve the evidence base. It remains to be determined what specific kinds of designs best address these important research questions.

r the case that VHA does not consistently collect race/ethnicity data. It is a 

 However, it is taking the system some time to “catch up”. Suggest contacting Denise 

t to get current assessment of the completeness and accuracy of race/ethnicity data.

We thank the reviewer for the up-to-date information on VA data collection activities. We are encouraged to hear that it is now a VA policy requirement to collect race/ethnicity for all Veterans. We have amended the recommendations of the report to reflect these developments.

recommendation to create a separate Race/Ethnicity Registry. Race/ethnicity data 

n the VA Corporate Data Warehouse, and our data architecture needs to be configured 

eneration of specific patient cohorts according the shared characteristics that include 

Mole is leading the effort to establish such design principles, so I suggest you contact 

We thank the reviewer for the input, and have removed this recommendation from the report.
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Comment Response

esentation confusing in a number of ways (detailed below), and the take home message 

gest. I do recognize that the authors were struggling with a fundamental problem – not 

 topic of interest and thus they needed to make an effort to find other literature to speak 

nthesis.

We thank the reviewer for the comment and acknowledgement of the difficulty of the report task. We have made vast changes in an effort to make the take-home message more clear and digestible.

s was referred to as a ‘preliminary’ review in the Exec Summary background – it 

.

We removed reference to the review as “preliminary”.

, I found it confusing that although the first section was entitled “...Interventions 

settings”, studies of veterans and in VA were included in the second section, which 

ventions outside VA health care settings”.

Several reviewers had concerns about the wording of the two key questions. Consequently, we have reframed our presentation of Key Questions 1 and 2 to avoid confusion.

why in the summary of key question #1 on page 2, results were described which were 

cant. The terms used to refer to the strength of the results were also a bit confusing – 

‘may’ reduce disparities” or “the intervention’s impact on disparities is ‘uncertain’ ” 

rd to interpret.

We have revised our discussion of the results in Key Questions 1 and 2 to be clearer about the strength of evidence.

r Disease Interventions” on page 3, reference is made to smoking cessation 

ior section, but that information did not seem to be there.

Reference to smoking cessation findings from the previous section is omitted in the Executive Summary of Cardiovascular Disease Interventions.

ot of reference to the quality of the evidence, e.g. ‘good’, etc. – seems important to 

y in the report, rather than solely in the appendix.

We now introduce our quality criteria from Appendix C in the Methods section.

defined at first use – e.g. HBPC on page 4 and many others throughout (TKR, etc). We have made this change.

e 6 that ‘Minority recruitment efforts to diversify VA personnel will not be effective 

e minority patient data recording” comes out of nowhere – no supporting information 

statement is provided.

We agree that it is unclear how this recommendation derives directly from the results presented in the report. We have removed this recommendation.

t under #1 – should probably clarify that interventions could be oriented towards either 

me. 

d indicate that non-VA settings were included.

beginning ‘In addition’ – could add, after ‘the following’ “approaches to intervention 

We have made this change (#1, bullet 2)For #1, only primary studies involving VA settings were considered; non-VA settings were only considered for systematic reviews discussed in #2. We have made the suggested change (#2, sentence starting with “In addition)”.

uestion #1, focused on studies of ‘interventions involving multiethnic Veteran 

ce these were not necessarily disparities reduction interventions, should probably 

 on page 11, under DM interventions, Summary section, it is mentioned that 5 

ns of interventions in _single race_ populations were reviewed. This is confusing – 

vant to disparities reduction?

We have provided a discussion of our inclusion of single-race and multi-race (comparative) studies as potentially offering indirect and direct evidence of disparities reduction, respectively. This discussion is presented with the taxonomy of intervention studies in the state of intervention research subsection.
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graph – a study is described which only kept 13 patients over time – is this making too 

mall study?

e tense varies within paragraphs, which makes the text harder to follow. Suggest 

ast or present, and sticking with it throughout.

We thank the reviewer for bringing this to our attention and have addressed these points.

ular Disease Interventions – it states “no intervention studies were specifically 

parities” – so I wondered, “why were they included?”

We agree with the reviewer that these studies do not provide direct evidence of interventions to reduce disparities; however we see value in including studies conducted in single-race populations to assess the state of disparities interventions research and to examine specific interventions that appear promising.

d new categorization of approaches to delivering interventions was interesting, and can 

in the future.

We thank the reviewer for the encouraging remarks.

oth the Executive Summary, as well as the full body of the report was somewhat 

ar, I continually wondered why the results of primary studies involving multiethnic 

ubsumed by Key Question 1, were summarized and presented under the results for 

We thank the reviewer for the comment. Several reviewers had concerns about the wording of the two key questions. Consequently, we have reframed our presentation of Key Questions 1 and 2 to avoid confusion.

on the presentation of findings for Key Question 1 and 2 seems to be an inconsistency 

2 is defined throughout the report. In many sections, the question states that 

 VA healthcare settings” will be assessed, whereas in others, the question states that 

ited to VA healthcare settings” will be assessed.

We have referenced Key Question 2 throughout the document as interventions “not limited” to VA settings.

d benefit from a consistent definition of Key Question 2, and it would benefit from 

estions 1 and 2 being presented under appropriately labeled sections.

We have made this change.

1, the topic sentence beginning, “Examination of non-VA reviews....” We have revised this sentence.

, I had a difficult time discerning the differences between targeted and deficit third 

udies. Improvements to increase clarity would be helpful.

We have significantly revised our taxonomic language presented in the report. Specifically, we categorize studies by population included – single-race or comparative studies as potentially offering indirect and direct evidence of disparities reduction, respectively. We also present categorization of intervention types as generic or tailored. This discussion is presented with the taxonomy of intervention studies in the state of intervention research subsection, which we hope is more digestible than the “generic,” “tailored” and “deficit” distinctions.

 bullet, beginning “Integrate the use....” is awkwardly stated and requires better 

on.

We have made this change.
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Comment Response

concept of “improving health and healthcare quality” rather than “improving health 

d be added to the Key Study Questions.

Thank you for this suggestion. We have made this change.

the search strategy for Key Question 2 again states, “studies not limited to VA 

We have kept this reference to “not limited to” consistent throughout the report.

d Methods do not adequately describe how quality was assessed and factored into the 

s. I realize quality scoring is described in an Appendix, but it is not well integrated into 

We have better integrated a discussion of quality ratings in the Methods section and throughout the report.

to have better integration of citations throughout. Thank you for this suggestion. We have endeavored to 

improve the integration of citations in the report.

2, there is a typo, “or” should be “of.” We have made this change.

graph, I question whether the study should be kept if no data and purely an opinion piece. Noted.

agraph, second sentence, I am not sure what is meant by “are characterized by poor 

We have clarified this sentence.

agraph, not sure why you used a quote from this article, but none of the others. This 

objective or evidence-based.

We have edited this paragraph.

sentence three, please clarify what is meant by “interpersonal connections between 

care system.”

We have clarified this sentence.

ion, the authors make the point that very few difference in differences studies (AA vs. 

med. A more detailed discussion of the sample size, feasibility, and cost implications 

i-center RCT of this nature would be very informative.

We have provided a discussion of the methodological and practical challenges (sample size, feasibility, cost) involved in providing more robust differencein-difference study designs, and the advantages of partnering with existing large demonstration projects in order to benefit from large outlays in research efforts.

Again, I am having a hard time understanding the difference between target and deficit 

s.

We have revised the categorization language for improved clarity.

Topic sentence, This concept of CBOCs Networks is not well explained or justified. In 

do CBOCs actually exist where low-income, minority Veterans reside?

We have removed mention of CBOCs in the results section (in Summary of Results Across Interventions) and have instead limited discussion of community based outpatient clinics to the Discussion section, where we elaborate on the ability of CBOCs to increase care access for Veterans in less-populated areas.

Last sentence; Please clarify what is meant by “boast a robust primary care personnel 

We have amended this sentence.
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Comment Response

h, In addition to comprehensively collecting accurate race data, it will be important 

n ethnicity, sex, literacy, and SES given the complex interrelationships of these social 

We agree with the reviewer’s assessment. We have included a brief discussion of the importance of considering patient demographics (e.g., SES, gender and literacy) when designing interventions in the Conceptual Framework section of the Discussion. 

Topic sentence is not clear and requires revision. We have made this change.

discusses distal health outcomes, but I believe references BP, lipid levels, and 

ch are actually intermediate outcomes.

We have clarified this sentence.

sure how minority recruitment efforts to diversify personnel relates to the actual 

nd its background needs to be better explained.

We agree that it is unclear how this recommendation derives directly from the results presented in the report. We have removed this recommendation.

on of the review quite confusing. I read the executive summary and put myself in the 

of such a summary. The summary of findings are organized by the 2 key questions 

 of interventions for disparity reduction in VA healthcare settings and results of 

he VA health care setting. Despite this clear organization, much of what is mentioned 

are settings actually concerns VA studies. While there is some justification for this that 

d buried in the review, this organization was quite distracting.

We thank the reviewer for the comment. Several reviewers had concerns about the wording of the two key questions. Consequently, we have reframed our presentation of Key Questions 1 and 2 to avoid confusion.

e title of this report “Interventions to Reduce Racial and Ethnic Disparities” and then 

ntent of the report concerns articles that frankly are not designed to reduce disparity but 

mes in minority populations, the actual report is quite disappointing. This may reflect 

re in that there are few studies regarding interventions that are published but if that’s 

tual need for such an extensive report, I think, is questionable.

We thank the reviewer for their very frank comments. We have worked to improve the organization and title of the report to reflect the contents more accurately. However, we do believe there is benefit to assessing the current state of intervention research in the VA and highlight opportunities for improving the evidence base.

onsider reorganizing this report and changing the title to “Interventions to Improve the 

pulations” as most of the articles that were reviewed and the statement summarizing 

mprove outcomes concern this topic.

We have revised the title of the report in response to the suggestion.
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Comment Response

 to reference work by Tom Sequist in which he presents findings that a) providers are 

 the existence of disparities in general, but less likely to acknowledge the existence of 

n health care system/clinic and least likely to acknowledge the existence of disparities 

anel. Thus, the importance of collecting RE(L) data is important not only to identify 

gin to help providers become more aware of, and open to, the existence of disparities 

nization and practice. Sequist’s work also shows that simply providing providers 

isparities with their own patients (along with cultural competence training) is, while 

fficient to reduce or eliminate disparities. Disparity interventions will likely need to be 

r to have a measurable impact. Citations:

mpetency Training and Performance Reports to Improve Diabetes Care for Black 

Cluster Randomized, Controlled TrialAnn Intern Med. 2010.152:40-46

erformance and Racial Disparities in Diabetes Mellitus CareArch Intern Med. 2008. 

5-1151

re Clinician Perceptions of Racial Disparities in Diabetes CareJ Gen Intern Med. 

 678-684

Thank you for suggesting this body of work by Tom Sequist. We have added the findings from the intervention study (suggested paper #1) to the section on cultural competence interventions and have included some of your suggested phrasing. 

 on page 7-8 are strong. However, it is not clear how recruiting a more diverse staff 

ck of patient-level RE data. Is the recommendation that patient-level RE data is a pre

a staff that is representative of the patient population?

We thank the reviewer for the encouraging remarks. We agree that it is unclear how this recommendation derives directly from the results presented in the report. We have removed this recommendation.

evant due to my lack of exposure to language disparities in VA populations (or lack 

to offer the possibility that language may be more of an important factor in VA health 

view assumes. Even if all Veterans speak English, is it possible that many still have a 

at is not English? In such cases, these patients might experience a higher quality of care 

health care is provided in their preferred language. Also, if families and communities 

 into specific interventions, or the care system in general, they may require services in 

ge.

We considered this issue. However, language barriers have not been identified as a concern in published studies in Veteran populations. It may be a topic of interest for future research, particularly given that the family and communities supporting Veterans may be non-English speaking.

nd perhaps elsewhere, there is an implied assumption that relevant disparities are 

 patients (better care and outcomes) compared to racial/ethnic minority groups (worse 

owever, relevant disparities may exist in which a minority group has better care 

ed to whites, one minority group has better care and outcomes compared to another 

dler (2006; Appendix D in Examining the Health Disparities Research Plan of the 

Health: Unfinished Business. Gerald E. Thomson, Faith Mitchell, Monique Williams, 

n the Review and Assessment of the NIH’s Strategic Research Plan and Budget to 

y Eliminate Health Disparities; PDF is available from the National Academies Press 

u/catalog/11602.html) provides a informative overview of different methods to 

asure disparities. Different approaches may be relevant for a variety of VA settings.

We thank the reviewer for this nuanced discussion point. Although reverse disparities and disparities between minority ethnic groups are indeed important considerations, the commission of this report is focused on taking stock of intervention studies that have potential for reducing and eliminating disparities for minority Veterans, as identified in the 2007 ESP report. We have not sought to exclude studies comparing multiple minority ethnic groups, and have also described the results of interventions with these study populations in this report.
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Comment Response

to incorporate and evaluate the use of community health worker (CHW) and/or other 

ns can be strengthened by advising the use of focus groups, consisting of the target 

explore what they believe are the relevant characteristics of CHW identity that will be 

rtant (e.g., from the same neighborhood/community, same R/E, Veteran status, gender, 

iagnosis). The relevant characteristics may vary widely by patient population and/or 

 may significantly influence the potential impact of a CHW program. In other words, it 

sable to standardize what defines CHW status because this may change by the patient 

th disparity targeted. Finally, directly involving the target population (and resisting the 

design of any intervention will increase the chances of reducing the targeted disparity.

We thank the reviewer for pointing this out. We have re-worded our recommendation so as not to imply that standardization of interventions is necessary. What we do recommend is for components of interventions to be clearly and fully described to allow for comparison across studies.

 of “generic”, “targeted” and “deficit” at the bottom of page 10, and elsewhere, 

ion comes partly because the term “targeted” is often used in the wider disparities 

scribe intervention design (not study design). In the context of intervention design, 

unction with the term “tailored” (targeted - an intervention that is not designed for 

n/group, but simply directed at them; tailored - an intervention that is specifically 

ific needs, in a culturally competent manner, of a particular population/group). The 

itions offered do not seem to be complete and/or encompass more than one concept. 

y differentiated from one another (e.g., the target populations of the intervention, who 

on -or not, and what process and outcomes are measured -or not)? Perhaps it would be 

he existing disparities research by study design, what process and outcome variables 

adequacy of the control/comparison group (none, internal, external).

We have significantly revised our taxonomic language presented in the report. Specifically, we categorize studies by population included – singlerace or comparative studies as potentially offering indirect and direct evidence of disparities reduction, respectively. We also present categorization of intervention types as generic or tailored. This discussion is presented with the taxonomy of intervention studies in the state of intervention research subsection, which we hope is more digestible than the “generic,” “tailored” and “deficit” distinctions.

 accurate if the arrows for “community health workers” and “care coordination” extend 

cluding community, neighborhood and individual/home environments. The definitions 

ors and their contributions to the model are not clear.

We have made the suggested change, and have provided more discussion of the underlying factors in the conceptual framework section.

many important/critical recommendations. I have not taken the time to write about 

ong and clearly defined. However, I want to acknowledge that they are there and 

We appreciate the reviewer’s encouragement.

rs are small in comparison to African American/Hispanic Veterans, efforts should be 

/Pacific Islander and American Indian Veterans as these groups experience significant 

utcomes also.

We have included this recommendation in our discussion of Future Research Gaps and Implications for VA Health Care Settings (p. 31 last bulleted item).

t review option to make extensive comments throughout the report.

urrent list of HSR&D funded studies (some have been completed). The abstracts are 

website and ART.

We have addressed the comments in the trackedchanges copy of the report, and have provided a summary table of ongoing HSR&D funded intervention studies.

ts in text. We have adopted the edits and addressed comments 

made in the text.
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Comment Response

 performance measures, programs, quality improvement measures, patient care services, or conferences that will be directly affected by this 

form the efforts of the Health Equity Workgroup that has been established by Dr Jesse. Thank you for the suggestion.

-

e Science of Dissemination and Implementation (http://conferences.thehillgroup.com/

ml) and

n Quality Improvement in Health Care

ferings/Conferences/Forum2011/Pages/default.aspx)

Thank you for suggesting these conferences.

HA Health Care Equality Work Group – “chartered to leverage talent across VA to 

esponse should be to ensure equity for all Veterans.”

Thank you for the suggestion.

ding. Thank you for the suggestion.

ommendations on how this report can be revised to more directly address or assist implementation needs.

 how little is known about what works. Our investments need to be in multiple pilots 

han huge initiatives.

We thank the reviewer for the suggestion. Our discussion now includes recommendations for enhancing the evidence base by funding future pilot intervention studies.

major hindrances to disseminating promising practices/interventions to reduce disparities 

nformation about intervention implementation and maintenance costs (and cost

 information is critical for obtaining buy-in from organization leadership and payers of 

recommendations for future research should include gathering, at minimum, basic start

sts for the intervention being evaluated. Whenever possible, cost-benefit analyses should 

so, the lack of specific information about the intervention design and implementation 

t obstacle to dissemination and ongoing evaluation of best practices and promising 

w noted, interventions utilizing community health workers or other peer-based models 

f identifying staff/volunteers, training methodologies, supervision methodologies, scope 

e.g., education, counseling, home interventions) and the degree of integration into the 

k of necessary details (training protocols, forms, software programming) is inherent in 

ervention evaluation literature. Whenever possible, the documentation and dissemination 

ails (including unanticipated challenges and solutions) should be encouraged.

We profusely thank the reviewer for the eloquent discussion of one of our key findings of the report. We have elaborated on these points, per the reviewer’s suggestion, in the Future Research and Implications in the Discussion section of the report. Thank you for your insightful comments.

-
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Comment Response

p survey should be helpful. But I also think that further discussion of what the health 

do regarding the social determinants (if anything is possible) would be helpful.

We thank the reviewer for making this important point. We have included a discussion of the importance of considering social factors in the delivery of health care (Conceptual Model section of the Discussion). More work needs to be done on how best to incorporate this information to help shape interventions and tailor clinical encounters to improve care and outcomes for minority Veterans. 

comments. You mention in the last review you included studies that were underway 

. You only found 5 published studies. I think it would be very important to know 

ies studies have not been publicly reported on and why. You might also include some 

rently underway studies. As an FYI I am hoping my (I think) targeted intervention 

ded by the VA but conducted in the VA will soon be accepted for publication. It will 

o late to be included in this report.

We have reviewed the abstracts of recently funded and ongoing projects in the HSR&D Equity Portfolio and have added our findings to the Discussion. We agree that it would be useful to understand why VA disparities studies have not been publicly reported and have proposed a qualitative survey that hopes to gather insights on this issue.

od the taxonomy of 3rd generation studies. You define it three times and I was never 

it study was and how it was different from a targeted study.

We have significantly revised our taxonomic language presented in the report. Specifically, we categorize studies by population included – singlerace or comparative studies as potentially offering indirect and direct evidence of disparities reduction, respectively. We also present categorization of intervention types as generic or tailored. This discussion is presented in the state of intervention research subsection, which we hope is more digestible than the “generic,” “tailored” and “deficit” distinctions.
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Comment Response

ection addressing the methodological challenges of performing intervention studies 

erences in differences. There is a reason there are so few intervention studies of this nature 

he VA. Differences in differences studies usually require huge numbers to detect significant 

ful differences in outcomes. They are usually performed with secondary administrative data 

ations. They have been mostly used to look at the association between policy changes and 

erimental designs. Below are some issues relating to choosing intervention designs.

problem might be much more prevalent in minorities (e.g., poor colon cancer screening) but 

n helps all people with the problem (e.g., care coordination). You do a study offering colon 

rdination to all people who have not been appropriately screened and see no differences 

 and whites in uptake of screening. That does not mean the intervention would not reduce 

eally do a difference in difference study you need to study the entire population (including 

 been screened and those who have not). But this is not feasible. What should you do?

st you do a targeted study showing the program works in the at risk population.

ou do an implementation generic study showing it works in a broad array of patients who 

creened and that a program of this nature can be implemented.

n convince the VA they should pay for this.

nly after it becomes policy and it is broadly adopted can you do a quasi-experimental study 

 at change over time in colon cancer screening by race to determine if the intervention 

educes disparities in colon cancer screening.

t over the top but unless you think your intervention is going to be much more effective 

r the majority population it is very hard to show that an intervention reduces disparities. 

rventions that are as effective and race specific as the paper on advanced directives cited 

ons work on all people with the problem but as you mention in the report, because of social 

ple in minority groups are affected by the problem. I think you made an excellent point 

ns to large existing programs like PACT but need to address specifically the methodological 

these studies.

We thank the reviewer for bringing up this important point. We have included a discussion of power implications/methodological challenges for performing the interventions recommended. We appreciate your careful examination of the methodological design challenges inherent in conducting “optimal” disparities reduction intervention studies. As the reviewer points out, large demonstration projects need to serve multiple purposes, and providing large populations of minority Veterans to conduct intervention demonstration projects seems a good opportunity to do so. 

 contact details of any additional individuals/stakeholders who should be made aware of this report.

toria Davey to get input from the Office of Public Health in VHA. Also, you may wish to 

Palo Alto to talk about the Registry/Cohort capabilities of the Corporate Data Warehouse.

Thank you for the suggestion.

USH, who is convening an Equity Healthcare Working group currently (and Susan 

with him and is coordinating that effort)

Thank you for the suggestion.

ould be made available to the Center for Minority Veterans and to Dr. Jesse’s VA Health 

Thank you for the suggestion.

u for this opportunity. Thank you for the suggestion.

A, Director, Patient Centered Care and Cultural Transformation and Dr Garth Graham, 

e of Minority Health and ExOfficio member of VA’s Advisory Committee on Minority 

Thank you for the suggestion.