Evidence-based Synthesis Program (ESP)- 20 -Department of Veterans Affairs

February 16, 2012

# Department of Veterans Affairs

**Transcript of Cyberseminar**

**Interventions to Improve Minority Health Care and Reduce Racial and Ethnic Disparities**

**A Systematic Review**

**Portland VA Medical Center**

**Evidence-based Synthesis Program (ESP)**

**February 16, 2012**

Moderator:  We are ready to get started.  It is the top of the hour.  So I would like to introduce our presenters for the day.  And I apologize ahead of time if I mispronounce anyone’s name.  First we have Dr. Ana Quinones.  And she is an assistant professor of public health and preventive medicine at Oregon Health & Science University.  She is also a core investigator of the Evidence-based Synthesis Center in Portland.  

We also have joining her Dr. Maya O’Neil, who is an assistant professor of psychiatry, also at Oregon Health & Science University.  She is also a statistician and clinical psychologist at the Portland VA Medical Center and a core investigator at the Portland ESP Center.  

Also joining them is Dr. Som Saha.  And he is an associate professor of medicine in the Department of Public Health and Preventive Medicine and in medical informatics and clinical epidemiology at OHSU.  And he is also a staff physician at Portland VA Medical Center and an investigator at the ESP Center in Portland.  

And finally we have Linda Lipson.  She is joining us from central office.  She is the central program manager for the women’s health research portfolio within Health Services Research and Development.  

We are very thankful to have everyone joining us to present today.  And, Ana, if you are ready and have the slideshow up in full slideshow mode I am ready to turn it over to you.   

Maya O’Neil:  Okay, great.  This is Maya, and I also have Ana and Som here with me. So we are going to start off the presentation then.  Molly, can everyone see the slides now?  

Moderator:  Yes.  They are coming through clear.  

Maya O'Neil:  Okay, perfect.  So welcome to our cyberseminar.  I am going to start it off with just a little bit of an overview about the evidence-based synthesis program and what we do because a lot of people aren’t very familiar with systematic reviews, and what that is and what we are going to be talking about today.  

And then I am going to turn it over to Ana to talk about the contents of our systematic review.  And then Som and Linda will be our discussants today.  All right, so let’s go ahead and go to the next slide?  Perfect.  

So here are the different people who are involved in our report.  You already had the introductions for most of us authors.  And then we also like to acknowledge Michele, and Randall and Devan, Stephen R. Henry that’s Randall.  They were the other authors on the report and it could not have been completed without them.  

Additionally, we have from some outstanding report reviewers who gave us very valuable feedback throughout.  And I want to emphasize that these are people that have extensive clinical, and administrative and research expertise.  

And so that was really the focus of the report was trying to make it useful for all three of those sorts of segments of the VA there, so we thank them as well.  All right, very exciting disclosure statements that you can read if you have the time later on and we will scroll right through that.  

So let me just tell you a little bit about the evidence synthesis program.  First of all we’re sponsored by QUERI, and that’s the quality enhancement research initiative for the VA.  And we really try to do exactly that, enhancing research and enhancing quality by research and let’s see.  I need to stop reading my slides, sorry.  

So the evidence-based practice center some of you might be familiar with those.  ESP centers, which are the VA’s version of the evidence-based practice centers are located in four states nationwide.  So those are the four sites listed there.  All of us here are in Portland.  Go ahead and scroll through. 

So what we do is evidence synthesis and systematic review.  So for those of you who aren’t familiar with what that is, basically we take all of the evidence that is available on a topic in a very systematic and as objective a way as possible.  

And we try to put all of that research together and synthesize that so you can get the most robust findings really to a topic of interest.  So that is a little bit about the synthesis program. 

One important thing to note is actually on that previous slide is that we do have a topic nomination process.  And I don’t know if any of you are interested in possibly nominating a topic for the program’s review, but various types of topics that we might be interested in for reviewing would be things related to clinical topics in particularly VA or DoD types of settings, research topics, et cetera, anything where the research isn’t very distilled down yet into the most useful, and meaningful and robust findings and that is what you would like us to help out with.  

So please take a look at our website and see if there is anything that you are interested in nominating.  We do have a very open nomination process and all the nomination forms are there.

Additionally on this slide you will see where all of our final reports are posted.  So if you are interested in the current research on topics that we have researched recently those are all available through the ESP website which is listed there.  

All right, so before we start on the current report we wanted to talk a little bit about, get a little bit of information from you all, the participants in the conference and find out a little bit about who you are so you can figure out who we are presenting to today.  So a couple things let’s see before we scroll on to the next slides with those questions for you all just to point out our version, the full-length version of the report is available on our ESP web site because we won’t be able to cover all of it.  

So go ahead to the next slide.  I think at this point we are going turn it over to Molly because she has all of these questions for you in a way that you can answer them.  So you should see different information on your screen than just start slides at this point.  So, Molly, is that up yet?  

Moderator:  Yes.  The poll is up so private attendees please just check the box next to the answer that closely really to why you are joining us today.  And we have already had sixty percent of people vote.  So I am going to leave it open for a few more seconds and then I will share the results with everyone.  

Maya O'Neil:  Okay, so if you all could go ahead and respond to that first question just about what your reason is for joining our cyberseminar today.  For these different questions I know this might not encompass all of the different possible responses, but we were pretty limited in the format for the questions that we could ask, so we will just apologize if you are not included in any of these options there.  I we’ll try to get that information from you and some of the other questions that you can ask in an open-ended format later.  

Moderator:  Yeah.  Actually when our attendees leave the session they will be prompted to complete a survey in which they can elaborate more on their role.  And for this question we have had about ninety percent response rate.  So I am going to go ahead and close the poll.  And I’m going to share the results with everyone.  And, Maya, you should be able to see those results now if you would like to talk through them real quick.  

Maya O'Neil:  Great.  Okay, so it sounds like we have a lot of people who have some research background in this area, and then also a good amount of clinicians as well.  And then we will see who that none of the above is in a little while.  

So thanks for responding to that.  Let’s move on with question number two, which is the question is, are you involved in third generation research?  So let me give you a little bit of background on that question.  

Health disparities research has been conceptualized as progressing through three sequential phases or generations.  That’s just terminology that we use in this field pretty commonly.  So first generation research is really about detecting disparities, so seeing if disparities exist in a certain area.  

Second generation research is conceptualized as understanding the root causes for any of those disparities if indeed they exist, so a little bit more exploratory research to understand why.  And then third generation research is really about designing interventions and that reducing or eliminating disparities in health and health care.  

So that’s what we are asking about here.  Are you involved in any third generation research or research that is about designing interventions aimed to reduce or eliminate disparities in health or health or health care, so if you could respond to that just yes or no?  

Moderator:  I’m glad you defined those clearly as people answers did change once you got through the explanations, excellent.  We have had about eighty percent of people vote so I will leave it open for a few more seconds.  

Maya O'Neil:  All right.  

Moderator:  Okay.  The votes have stopped coming in so I am going ahead and close it and share the results with everyone now.  

Maya O'Neil:  Okay.  This is great.  So there are quite a few of you who responded that, yes, you are involved in third generation research.  And that’s a lot of what we are going to be talking about in this report, our findings and the relatively limited findings from VA settings.  

So we are really interested in hearing from folks who are involved in this type of research. Now some of those folks who said yes you are involved in this type of intervention research or third generation research, if we can go ahead and put up question number three, this question asks if you are involved in third generation research, on what type of setting that you are conducting this research in.  

So are you involved in this type of third generation intervention research in VA settings, just outside of VA settings or both in VA settings and outside of VA settings?  I know a lot of people have dual academic appointments and things like that.  So if you can let us know sort of your best estimate if you are involved in that kind of research what the setting is.  

Now there probably won’t be that many people who are going to respond to this since less than half of the people are involved in this type of research.  So, Molly, let us know when that’s completed. 

Moderator:  Okay.  We have had about forty-two percent of people respond.  

Maya O'Neil:  Great. 

Moderator:  So I am going to leave it up for just another moment.  

Maya O'Neil:  That sounds about right though because—

Moderator:  Yeah because we are dealing with a smaller group.  

Maya O'Neil:  Accept that. 

Moderator:  So we are good and I am going to share the results with you now.  

Maya O'Neil:  Okay.  So it looks like quite a few of you are involved in intervention research in VA settings.  That’s great, okay.  And we are definitely going to want to hear more from you because we didn’t find as much third generation research in VA settings as we would have hoped.  

So now this is a question, the fourth question and final question before we go into the content of her presentation.  This question relates, well it can be responded to by all of you, first of all, not just those of you who are involved in research and VA settings, so whether it’s clinicians who are interested in this topic or researchers, please feel free to respond.  

What we are asking about is what you see as the biggest challenges to intervention research conducted in the VA.  So the different options we came up with and this is definitely not an exhaustive list.  We just had to limit the number of options, but do you think that the biggest reason in terms of what is on this list is more a lack of funding, that we need more first and second generation research first?  So that would be research looking at whether or not to disparities exist and then the root causes for those disparities. 

Do you think that intervention research is just infeasible that potentially effective interventions are really too big and so that’s why we can’t do as much of this kind of research as we had hoped, that there are few well researched interventions to test or that existing interventions don’t effect meaningful outcomes.  So go ahead and respond to any of those that you think might be challenges to intervention research in the VA.  

Moderator:  Okay.  We have had about half of the attendees respond and they are still coming in so I am going to leave it open for a few more seconds.  Okay, the responses have slowed down quite a bit so I am going to close the poll and share the results now.  

Maya O'Neil:  Okay, great.  So this is really interesting information.  Hopefully you all can see different the participant perspectives on the challenges to this type of intervention research.  

And as Ana is going through her presentation in a minute here be thinking about these different types of challenges, and of course where we are really interested in any ways you can think to overcome some of these type of challenges, or as Ana is presenting on the research that has been done what some of the next steps could and should be, particularly for a VA setting.  

So, all right, at this point like I said I am going to turn it over to my colleague, Ana Quinones, who is going to talk about the content of the systematic review.  

Ana Quinones:  Great.  Okay, you should—there we go, great, fantastic.  Thanks, Maya.  So for today’s presentation I am going to discuss our recent ESP reports on intervention to improve minority health and reduce race health disparity.  

So first I will go over some background and discuss the scope of our systematic review.  Then I will move on to briefly discuss the results that were contained in the review, but I should say that if any of you are particularly interested in any of the reviewed clinical areas I will refer you to the full report which will contain much more in-depth information on the reviewed studies than we will get into in today’s presentation.    

So I will just spend some time talking about the conceptual framework that we developed and in synthesizing this body of literature.  And we will conclude with discussing some of the limitations of the review and a discussion led by Som Saha and Linda Lipson on future directions for the VA to continue efforts to deliver equitable care and reduce race disparity among Veterans.  So a 2007 systematic review from our Portland ESP Center here identified several clinical areas where race ethnic disparities in care were found to be present.  So the areas that were identified were arthritis and pain management, cancer, cardiovascular diseases, diabetes, HIV and Hepatitis C, mental health and substance abuse, preventive ambulatory care and rehabilitative and palliative care.  There was also another bin of other clinical topics which included kind of different things such as the varied in treatment, process of care, use of new technologies, patient satisfaction, medication adherence and health education.  

So this current report, the genesis of it was developed to take stock of evidence from VA intervention studies in their effectiveness in reducing disparities in care and outcome.  So during the literature process we, as Maya alluded to, we had a low yield of published primary VA intervention studies.  

So this really led our team to establish two essential key questions that we wanted to answer.  So the first examined intervention that reduced race/ethnic disparities or improved health and health care for minority Veterans within VA settings.  

The second question focused on a review, systematic reviews of interventions that were not limited to Veteran populations.  So in order to synthesize our results we divided the taxonomy for intervention studies so we could address the populations included in the study design as well as the types of interventions that were being tested.  

So first we examined the racial and ethnic populations that were included in the interventions and we categorized these as single-race studies or comparative studies.  Then we also examined the types of interventions tested.  And generic studies were those that included interventions that were applied without specific sub-population means or preferences, so for example some kinds of global quality movements to the system, whereas tailored interventions really attempt to address barriers that are specific to a minority group. So for example this would be community health workers that are drawn from target populations themselves.  

So to illustrate how studies can demonstrate an increase, decrease or no change at all in the disparity we developed the following figures.  These are really hypothetical examples that demonstrate that really we can only evaluate the ability of interventions to reduce disparities if they are comparative by design.  

So without comparing pre-post differences between the advantaged and disadvantaged group we are really unable to determine if the disparity in the outcome is reduced to after the intervention.  So as a result only comparative studies provide direct evidence of a change in the observed disparity.  So the corollary to that really is that studies that include only single race can offer us only indirect evidence of the disparity reduction at best.  

So going across from 2a, 2b, 2c we can see that interventions that improve outcome for both groups that you have that positive slope for those two lines pre and before and after the intervention.  You can have a situation where you have no change in disparity if the rate of the outcome is the same for both the advantaged and the disadvantaged group.  

And so moving on to 2b we can see that it is actually possible that we can exacerbate disparities between the advantaged and disadvantaged groups if it disproportionately affects more, more advantageously affects that advantaged group versus the disadvantaged group.  And in 2c is kind of the outcome that we would hope to see an actual decrease in the disparity because that intervention may improve the outcome for both groups, but more so for the disadvantaged group.  

And then 2d, 2e and 2f, 2f really kind of continued the exercise looking at if there is no change at all the intervention is not effective.  We may see no change in disparity if it is not effective for this disadvantaged group.  Again you may exacerbate those disparities.  And if it is effective for the disadvantaged group then we see that desirable outcome of reducing the disparity.  

So to quickly go over our methods, we searched MEDLINE, and Cochrane and PsycINFO databases through 2010.  And we excluded studies that were not published in English, were not conducted on adults, did not evaluate an intervention and systematic review that did not meet methodological criteria.  

We also excluded studies that evaluated an intervention that was determined to be inapplicable to VA settings.  So for example services that are not provided at the VA like obstetric care, those studies were excluded.  

So our results we found thirty-four systematic reviews and five primary studies that were included in our report.  And these spanned the clinical areas of diabetes, arthritis, preventive care, cardiovascular disease, HIV, mental health and cross cutting clinical areas.  

So I am going to turn now briefly to reviewing the results by key questions, and again to remind you the first key question asks about evidence that we gleaned from VA intervention studies, so within VA settings.  So we found five primary studies of interventions involving minority populations.  Four of these were comparative and one was single race.  

The studies involved a broad set of interventions including tele-mental health, care coordination, decision aids and home-based primary care.  And the results of the effectiveness of these interventions really varied.  

So for example in one of the studies they were able to conclude that the intervention significantly reduced disparities.  Another found reductions in disparities only in intermediate outcomes.  A third concluded that they were no significant findings at all that were attributable to the intervention.  

Another one of the studies that we looked at did not actually examine the effects of the intervention by race group.  And the final study that we included, the answer to question one, highlighted the acceptability of the intervention in the minority population without evaluating the effect on the outcome.   

So as mentioned earlier to answer the second key question, we conducted a review of systematic reviews to capture the results from interventions in settings not limited to the VA.  So the results here I am going to try and briefly go over these, but just to give you a flavor of what we found.  

For diabetes we found five good quality reviews.  These were mostly conducted in single-race populations and the interventions themselves were a mix of generic and tailored.  So we found some evidence for benefit for interventions that focused on community health workers, care managers and culturally-tailored health education.  

We also found some provider focused interventions that reported some improvements for process measures, but these again were the computerized reminders physicians were negligible and negative.  So for arthritis we found one fair quality review.  Comparative studies were included in that review.  They were mostly tailored and the limited evidence really came from a single randomized control trial that exercised interventions may be effective in improving pain between black and white patients.  

For preventive care, which was the largest subcategory here of the clinical category that we examined, we found fourteen good quality reviews.  There was a mix of single race and comparative studies, and also a mix of generic and tailored interventions that were assessed.

So the preventive care section included several different subsections, including cancer screening, smoking cessation, and physical activity and diet.  So across these very different areas we found that there was some evidence for community health worker effectiveness and how they may improve rates of preventive health utilization, service utilization.  And overall the improvements in preventive and ambulatory care were fairly inconsistent across the different subcategory areas.  

For cardiovascular conditions we found three fair and good quality reviews.  They were mostly composed of single race and a few comparative studies.  And again it was mix of generic and tailored interventions that were tested.  

So these focused mostly on hypertension and smoking cessation.  And overall the findings for cardiovascular conditions were that nurse-based interventions and culturally tailored education may improve again proximal outcomes and reduce hospitalizations. 

So for HIV and AIDS we found four good quality reviews and these were all in single-race studies.  And they were mostly tailored.  So again we could really only glean some indirect evidence that behavioral interventions can be effective for improving service utilization for black and Hispanic minorities, black and Hispanic Veterans with HIV and AIDS. 

For mental health we found two good quality reviews.  These were a mix of comparative and single-race studies.  And again they were a mix of generic and tailored interventions. 

We found some good evidence that case management and care coordination are helpful in reducing depression disparities, but we found some insufficient findings on the effectiveness of culturally tailored interventions to reduce depression in disparities. 

So the cross cutting clinical area really consisted of five good quality reviews that spanned the cultural competency interventions and quality of care delivered in primary care interventions.  These were a mix of comparative and single-race studies and they were also a combination of generic and tailored interventions that were being tested. 

So overall the interventions in this area were designed to improve the standardized delivery of care for all patients.  And these were found to mostly effective.  However, there was insufficient evidence of disparity reductions in health outcomes for patients. 

So that was kind of a litany of what we found in our report.  So just to recap really the things that really pull out of our report findings are that many of the reviews really include single-race populations or do not report changes in a comparative fashion. 

So a few of the comparative studies that we included in our review reported results by race before and after the intervention.  So it seems to us that really not many people have moved along that continue to track changes and observe disparities.  And also, the evidence that we found was limited by some methodological issues and really the other standout findings that relatively few published studies of intervention were found that involved these populations. 

So based on our review, interventions that include personnel, so for example care managers and community health workers that provide increased connectedness between patients and their health care systems provide some positive indirect and direct evidence of disparity reductions.  So those most promising interventions really involved again care coordination, care management, community health workers and culturally tailored education interventions. 

So to try to make sense of these findings we developed a framework for conceptualizing the reach of interventions that is guided by our evidence review.  So we found the greatest support for interventions that really spanned from these patient provider interactions here through to interactions with health care systems, to interactions with the communities and the neighborhoods that Veterans live in, all the way to interactions with individual home environments.  

So they were in the greatest support for those culturally tailored education interventions, community health workers and care management interventions.  And these really spanned across these settings to consider an expanded purview of interventions around health outcomes.  So under this framework we also recognized that there are underlying factors around health seeking behaviors for individual patients, which we tried to incorporate in our conceptual thinking of the literature and the findings in this area.  

So we should also acknowledge some limitations of the literature.  So first there are relatively few intervention studies conducted in the VA that are disseminated in the literature.  Excuse me.  

So in order to benchmark progress towards reducing and eliminating racial and ethnic disparities in the VA we need direct evidence drawn from comparative studies that include multiple race ethnic groups.  Also most studies focused on process of care outcomes and few examined outcomes on more distal health outcomes. 

For operational purposes interventions need to be described in more detail in order to identify those effective components.  So for example in interventions that included community health workers and care managers there was very poor specification of training of these personnel.  

Maya O'Neil:  This is Maya.  Before Ana goes over the future research priorities I wanted to ask people who are listening in.  This might be a good time for you to jump in on your questions that where you can type in the message there that will just go to the organizers and us panelists, which we’re reviewing now.  

So what I’d like you all to think about since quite a few of you are involved in this kind of research, Ana is going to be talking about the future research priorities.  What do you think the future research priorities should be for health disparities reduction, particularly in VA settings?  

And then for those of you who are working in this area in research or clinical settings, what are you working on in terms of this type of intervention research that we’ve been talking about since we’re going to be talking about future research priorities and Som and Linda are going to be addressing some of those questions in a bit here.  So if any of you are working in those areas please drop us a little note via your message button there and let us know what kind of areas you’re working in.  And Ana will talk a little bit about future research priorities that we found.  Thanks.  

Ana Quinones:  So we identified several potential areas for priorities.  The vast majority of reviewed interventions relied on results from small-scale study settings with limited geographic scope and over limited periods of time.  

So this raises questions of generalizability of the results and VA capacity for scaling of these demonstration projects to larger and more geographically representative Veteran populations. So because it’s difficult to scale up promising pilot studies from small tailored interventions we should probably examine the potential for partnering with already deployed large multicenter programs, and care coordination and care management such as the patient aligned care team.  So in this way really multiple initiatives that require access to a large pool of Veteran populations can be addressed in a single research investment. 

So other recommendations include providing details of intervention elements, which we alluded to before, integrate community health workers into VA settings.  So this could involve really gathering Veteran peer advisors that come from the communities where Veterans reside, enhance the capacity to tailor patient education materials and address the specific needs of minority Veterans, and consider funding studies explicitly designed to measure pre-post changes in interventions between minority and white Veterans. Also we should continue to encourage the inclusion of less well studied minority Veteran groups such as Asian, Pacific Islander and Native Americans in the design and implementation of disparity studies.  

So I’d like to enlist our discussants to tackle some questions about what needs to be done in the VA to keep forward momentum.  So I’ll turn it over to Som and to Linda to discuss a few questions around implementing challenges just for implementing changes and augmenting the evidence base.  

Som Saha:  Okay.  So shall we just march through the questions?  Okay, so thanks, everyone, for being here.  My name is Som Saha.  I consider myself a researcher who does focus on disparities.  And I was involved in this review.  

So I guess based I think sort of to sum up what this review found a couple of I think the key points are that most research out there that we use to glean information about how to reduce disparity is not what I think purists would call disparities research or to have disparities research you really need to look at a baseline and then a difference at follow up, so difference-in-difference type of research.  And there’s a lot of research out there that we call disparities research that really isn’t that kind of difference-in-difference research.  

So that’s one key issue.  And the other key issue is that I think a lot of what was found in terms of where there was a signal about what’s effective were the interventions that Ana highlighted that basically have kind of reached beyond the health care system and into people’s lives.  

And as we found this in the review it sort of it kind of the light bulb went off I think for all of us that really that makes sense that what the reason that we see disparity whether it’s in health, or health care or any other realm of life is that people have—that our society is structured such that some groups are disadvantaged and some are advantaged and that many of the disparities we see are socially determined.  

They are not necessarily related to things that are going on within the walls of a hospital, or a clinic or a health care system.  And so to reduce disparities we really need to address the underlying route causes which are socially determined.  

And I think many people have in the past thought well that’s not the purview of the health care system.  We are not out to sort of fix society.  And I think what we saw in some of these interventions was that we can do things that aren’t intended to fix society, but that can actually sort of bridge our health care systems with people in their lives and meet them where they are so that they get the right health care and have the right health outcomes. 

So those two big findings I think create major challenges.  So if we take the first issue of needing more comparative studies, more difference-in-difference studies, well that’s a big challenge because to do a difference-in-difference study it takes a lot more people.  And if you do the statistical calculations it takes a bigger sample size, a longer study, and that turns out to cost a lot of money if you’re just if you’re doing traditional research, and you want to double the size of the population or triple the size of the population and extend the course of the study for a longer period of time.  It’s just going to take a lot more time. 

So that’s one major challenge.  And then the other challenge is that we are a health care system in the VA and the idea of reaching into communities is not necessarily something that we’re used to thinking about so much.  

And so with those two big challenges I think where we need to—where I think we sort of need to start thinking creatively.  And one way I think that we need to start thinking is that the VA really is not a static health care system.  

The VA is constantly experimenting with new programs, new ways of delivering health care.  It is constantly experimenting.  It’s a laboratory where experiments are being conducted all the time.  

And I think as researchers we ought to sort of take advantage of the fact that we actually live in this laboratory, and not necessarily do research in always in the traditional way of I come up with a research question.  I design a study to look at it.  I start from scratch.  I apply for funding to get the research done and then I look at the results, but we ought to basically be looking at the sort of ongoing initiatives within the VA and then and really seeing what’s going on in real time.  

Can we take advantage of the fact that the programs that the VA implements, the delivery models that we test on an ongoing basis provide lots of data potentially that we could tap to see, if you remember Ana’s slide with those six figures, what’s going on in different populations.  Are we making, having no effect in both?  Are we having a positive effect in both?  Are we exacerbating disparities, reducing disparities?

And I think we ought to—we need to start thinking more about the VA as a laboratory that we can collect data and answer questions in real time.  Now that requires that we have the data.  And that’s not a small challenge, but it’s something that I think is something the VA is actively working on and will be less of a barrier in the future. 

So I’m going to stop there and I guess just sort of leave those as my major points that we need to start looking at the VA as a laboratory that we can use to do large scale studies without actually necessarily collecting primary data, but we ought to sort of not think of—I think we’ve typically thought of reducing disparities as less to do research to figure out what works, and then once we figure out how that it works we’ll sort of implement it in a limited fashion in a demonstration project.  And then once we figure out that that works we will deploy it wholesale.

And I think we ought to sort of think about it in a different way that the VA is constantly implementing things across—and the VA really is each [visn] is a demonstration project.  And so each VA facility is doing different things differently, and that we ought to actually be doing research in a way that marries both implementation and science and that we ought to also then I think sort of start thinking about health care systems as not sort of castles on the hill that really if we want to improve health, and especially if we want to improve health for disadvantaged populations we need to think a little bit about how we reach out to people where they live and address some of the factors that really drive disparities which are socially determined. 

Linda?

Linda Lipson:  Okay, Som.  Thank you for I think some very insightful and interesting comments.  And this is Linda Lipson.  I would just mention that I do manage the disparities equity portfolio, which is the reason I’m here today, which is certainly equally important as women’s health. 

And I really think that this report I thank everyone who’s been involved in preparing it.  It is very thoughtful and gives us a lot of food for thought, so to speak, and some very constructive analyses. 

I think you all know that disparities research providing equity, equitable care to all Veterans is an important goal of VA and VA research, but obviously we can see here that we still have a lot of work to do both in disparities research and to reduce disparities.  We have been emphasizing intervention research, third generation research in the last several years and we’ve seen a number of intervention studies that have come out and been funded as a result of that. 

We still do fund some more second generation research with high profile, high importance that was funded recently that relates to satisfaction of VA care looking at racial and ethnic disparities. I think the recommendations about priorities are really very important guidance.  I think what Som said it was eye opening to me in terms of looking at single-race studies versus comparative. 

And so I looked at our existing intervention studies and there are certainly more single-race studies than there are comparative.  So I think this is something that we need to be mindful of.

That’s not to say that those interventions that are aimed at improving care for minority populations in a certain area aren’t important.  They are.  But clearly that does then only gets us so far and doesn’t really address this issue of reducing the disparities. 

With regard to the health outcomes aspect I think obviously disparities research is no different than other health services research where it’s difficult to look at that long term.  And I think it’s true with some [then terms] we need.  And others in the report have said needing more long-term studies they cost more so that’s a challenge that is going to be difficult to address, but certainly one that we can think about. 

I think there are some other issues too that in looking at how this is organized I still am not certain what that balance is between looking at interventions that look at to seize specific conditions versus the more cross cutting areas.  And I wonder at what point we could start to generalize about evidence to implement more broad-based interventions. 

And then again with the coaching and personnel support interventions we still need to consider what’s feasible within VA to implement and what are the costs.  I think one of the things we haven’t talked about as much, but certainly have alluded to is the complexity of both the research for disparities and how we can address them. 

And this is certainly evidence from studies we’re not seeing.  And I think the really important thing to note and I think very encouraging thing is that I think our VHA leadership is more cognizant of this as well. 

As Som mentioned there has been at times when researchers have wanted to look at more what we would call social covenants of health.  There have been questions about so what can VA the health care system really do about Veterans in their neighborhoods, whether they have stores to buy healthy food or parks to do exercise in. 

And so it’s a challenge in terms of how to address that, but I think we have seen recently just in the last few months VHA leadership has actually asked us what studies are you doing that look at factors beyond the health care system that are going to impact health care?  So this is really the first time I’ve seen that type of interest so I think that’s very encouraging. 

And it’s obviously important.  I serve on the Federal Collaboration and Health Disparities Research, a federal interagency group. And social determinants are certainly a main topic in conversation with the exception of DoD.  None of these federal agencies have the health care system as we do, so their focus really is on outside the health care system what can be done in addition to also providing better access to disadvantaged people throughout the country. 

I think as I said it’s been a challenge for our VA researchers sometimes to address these social determinants, but I think the point of view within VHA leadership is changing now.  We certainly see the emphasis on patient-centered care and I would definitely say that there is a heightened interest in this whole issue of health equity within VHA leadership.  So think that’s really those are really good signs. 

So I think HSR&D certainly the priority of doing disparities and equity research is still very important and it will continue to be.  Intervention and implementation research are also important in terms of our focus because we do want to see that impact on care and realizing of course that that they have these challenges.  

I think that this evidence emphasis should stimulate our thinking about how future research should be framed and directed.  And I think that more collaboration and linkages with other VA health care system initiatives like that really does make good sense.   

One of the things that I think we have to be careful of is the difference between research and evaluation.  So I think in terms of using the natural laboratory we have is great, but we still have to approach it with scientific questions and research questions so it doesn’t just become an evaluation of the program. 

I think that we do need to be more strategic in our approach and in our research.  And this evidence as synthesis really does launch us in that direction.  So I’m happy to answer questions as we go along, but I hope that provides some sense of what we’re thinking here in central office.  

Maya O'Neil:  Okay, great.  Thank you so much, Linda and Som, for all of those comments.  We’ve had some questions pouring in that I’ve been trying to sort through here.  So I’m going to just start turning those over to Linda, and Som and Ana as they are coming in.  

Let’s see.  One of our first questions it really just relates to that first poll.  That lack of funding seems to be perceived as a major challenge to disparities research.  And so, Linda and Som in particular, can you talk about VA funding streams and priorities related to health disparities research? There were some follow-up questions specifically related to if there is an interest in structural determinants research by leadership, so maybe you can address that in there as well. 

Linda Lipson:  So I was actually a little surprised to see that high proportion of individuals who said lack of funding because from my perspective certainly we’ve had—there’s uncertainty that comes with budgets and funding.  And we’ve had some of that this year, but we have not—we have been able to fund high quality disparities research projects.  

What I have noted is that we haven’t had as many submissions of disparities research proposals in the last couple rounds.  That’s a little bit changed in the review that’s coming up in March.  

So it’s I guess I’m not quite on that same wavelength in terms of funding availability.  Now there are caps obviously so that some of these longer term, more extensive studies that might be an issue.  And it may be something that we might need to address in some way in a coordinated way, I think creates in some way, may provide an opportunity for maybe not one large-scale study, but at least multiple studies to work together with a common aim.  

In terms of structural determinants I think it would really depend on what the study is focusing on with regards to homelessness.  There are obviously programs that link in with housing. 

It’s a little hard for me to see how the VA would do that in a broader sense, but I think there are certainly maybe opportunities to look at various community linkages.  So that’s really going to be up to researchers to come up with a plan that is going to be feasible within VA and it would be attractive to VA. 

Maya O'Neil:  Okay.  And we had a related question to that as well.  One of our participants wanted to know if HSR&D in particular wanted more proposals, more grant proposals about new interventions or existing interventions?  

Linda Lipson:  Well I don’t think you can really answer that question per se.  It depends on what intervention we’re talking about.  Obviously we want to see innovations.  I don’t think that we want—we talked about this like how many tele-health interventions do you have to do in each disease condition type of thing, which is something that I kind of alluded to before.  At what point can you generalize and say this is ready for implementation?  

And that’s the other part of this is we want to have interventions that can be moved into implementation.  So those interventions should be developed and tested in a way that would enable that and certainly facilitate that in a timely way.  

Maya O'Neil:  Okay.  We also had a couple questions from both researchers and clinicians who wanted information on resources available to them on this topic.  Specifically we had one suggestion that the VA needs a single portal for information and research on health disparities.  And I’m wondering if Som and Linda could speak a bit to what resources are available, whether that’s for policymakers, researchers, clinicians, et cetera. 

Some Saha:  Well I can go first, Linda, I guess.  

Linda Lipson:  Okay. 

Some Saha:  I think it’s a great point and I think that we are in the disparities research world.  We are not alone in that sort of wanting for there to be a greater level of sort of coordination so that everybody, the right arm always knows what the left arm is doing.  I think that’s just a problem with any—it’s an issue with any system and in my life outside the VA it’s the same everywhere I go that it’s not always easy to figure out what’s going on, and where to find the right information, and to coordinate efforts so that people who are doing disparities research in California and people who are doing it in New York aren’t sort of reinventing each other’s wheels.  

I think that’s an issue in a lot of places.  That’s one of the reasons that we did the synthesis is to basically cull everything that’s out there and put it together so that we can all have some common starting point.  

My understanding is that I think the VA is making efforts to there will be a lot of effort coming down the pike in terms of creating sort of a centralized, coordinated way of giving people who are interested in disparities from an administrative, clinical and research side, sort of a central clearing house to allow for greater coordination and across elevations. 

Linda, you—?

Linda Lipson:  And, yeah, I certainly I think that’s correct.  I think the evident syntheses are really an excellent way of putting together what we know and in a central place.  There is a disparity. There are equity interest grouped [parts], and Clark is a person to contact about being on that interest group.  It has not been that active to date and I think there are some materials that are sent out at the HSR&D national meeting.  

There’s also an interest group breakfast on for researchers and individuals interested in disparities and equity.  And I’m sure that I think that we could certainly look at ways to provide better linkages than we have now.  So if someone has some suggestions we certainly would look at it, but I think and I think there will be some new actions, new efforts underway that will facilitate that as well. 

Maya O'Neil:  Okay.  We did have some related comments from a lot of our clinicians who are participating in this cyberseminar today just talking about different examples of what they’re doing kind of on the frontlines with patients that they’re serving in the absence of a lot of solid research findings about effective intervention.  And so we had a couple questions that are related to what both policymakers and clinicians should do in the absence of clear research findings related to effective interventions for minority populations.  

So I don’t know, Som or Linda, I know, Linda, you spoke a little bit earlier about almost well when is the right time to extrapolate research findings from let’s say one population or one clinical area to another.  So maybe you and Som could speak to that a little bit for some of the clinicians and policymakers on the line.  

Some Saha:  Well I will sort of offer my opinion that I think it’s refreshing to hear that people are trying things.  Again I believe that this sort of dichotomy between kind of research and practice is part of the problem that basically we ought to be trying things in real time and that the researchers ought to be studying them.  

It doesn’t necessarily need to be a sequential process and we do want to have evidence-based practice, but we also want to have practice-based evidence.  And so I think it’s a two-way street.  And I think if we wait to, if we wait for sort of to dot the I’s and cross the T’s on research before we try things that we have a hunch might work I think we’re going to—it’s just going to be a very slow process and we’re not going to make—we’re going to be in low gear in our efforts to reduce disparities.  

So I personally think that maybe we don’t take enough leaps of faith.  Now taking leaps of faith it’s easy if it’s a small program.  It’s a little harder if you’re going to roll something big out, but again I think people experimenting and doing their own little demonstration projects is a great idea.  

And I think if there were more than people in the clinical realm can partner with researchers so that the researchers can actually learn from what they’re doing the better.  And I think it is important to in the world of disparities to really foster this kind of experimentation because a lot of what we see in disparities is context specific.

What is underlying disparities in the mid-Atlantic may not be what’s underlying disparities in the Southwest.  And so I think people who are working in those settings and know the populations well are the best people to sort of come up with context-specific solutions.  And I guess my hope is that the researchers will climb on board with this experimentation so that we can learn from it and that both practice and research can be sort of a two-way street. 

Linda Lipson:  I agree with what Som said.  I think that the researcher/clinician partnership is really important.  And certainly if anybody has any suggestions about how to stimulate that I’d love to hear it.  

I think doing it in the context of QUERI might be a possibility.  We have something going on in terms of women’s health, which is a practice-based research network that is aimed at stimulating that kind of small scale demonstration quality improvement built on what’s being done in practice and then expanded. So I don’t know that we can duplicated practiced-base research networks, but I certainly think that we need to create those partnerships and I would really be interested in hearing any suggestions about individuals interested in doing that.   

Maya O'Neil:  Okay.  We also had a relatively specific question about conducting this kind of research and possibly doing this kind of clinical work with a focus on outcomes.  A person wanted to know about how we should define positive outcomes.  Should those be defined in terms of narrowing the disparity or completing reversing the disparities?

Some Saha:  Well I think generally we use the term equity when we talk about this research because that is the goal.  It is not to say we don’t want to improve quality for all.  We do, but at the same—so the other side of that balance is that we want to deliver care equitably.  

I don’t think anybody, and you can tell me, Linda, if you feel differently, but I don’t think anybody is looking to create different kinds of disparities or reverse disparities.  I think really we just want to narrow the gap and with equity as the goal.  

Maya O'Neil:  Okay, great.  We have—let’s see.  I’ll do another pretty specific question here that I’m going to send over to Ana.  A participant was wondering, how did you determine the quality of the reviews that we’re talking about in the systematic reviews?

Ana Quinones:  Yes.  So when we discussed the exclusion/inclusion criteria for our systematic reviews we used quality rating criteria for the systematic reviews that were essentially based on methods developed by the U.S. Preventive Service Task Force, as well as guided by a couple of other publications.  So essentially those were specific to the review of reviews.  

And they included essentially summaries for a good fair core.  And they included such criteria as where the states reported, where the search methods reported.  Was it a comprehensive search for the inclusion criteria reported?  Was selection bias avoided, validity criteria reported, these kinds of specific types of criteria that allowed us to summarize the good fair and core. 

Maya O'Neil:  Okay.  Let’s see.  I’m sorting through a bunch of questions here.  We’ve had a bunch of research, a bunch of comments related to getting research done in VA settings, almost more process types of questions, so some questions related to if there are any fellowships, or post-doctoral opportunities or training opportunities specifically related to health disparities, and so questions from clinicians and researchers alike who are on the call asking about to get protected time and how to build some of those bridges between clinicians and researchers.  So I don’t if you would want to speak to some of those questions now?

Some Saha:  Linda, do you want to comment on—?

Linda Lipson:  I don’t know of it.  You might be more aware.  I don’t know of specific training or fellowships.  Are you aware?

Some Saha:  No.  Well I guess I think that if people are looking for sort of protected time for research it’s really the same for any type of research, whether it’s disparities or otherwise. The VA has kind of a researcher development pipeline program that if you’re interested in health services just search the HSR&D web page is a resource to sort of look at what we’ve got.

There is a—for those who are looking for—so there’s a career development program for people in the early part of their faculty careers or developing early as researchers there are training programs, fellowship programs that are in different places around the country for people to do in health services research training, mainly at centers of excellence and at some of the other research centers.  The center in Pennsylvania in the center of excellence in Pennsylvania which is both Pittsburgh and Philadelphia is where we—is a center of excellence that focuses on disparities research explicitly, although there are many of us around the country to do disparities research who aren’t necessarily in that particular center, but the center for health equity and research.  Health equity research and promotion in Pennsylvania is the place where they dedicate themselves to equity research.  

Linda Lipson:  Right.  And I think career development award is again it’s not a fellowship training program, but the information on our web site is available, and you would, someone would specify a particular area that they were interested in.  It is a competitive process as well, but that at a certain level is one way of getting into research there.  There are—in women’s health we have done a number of cyberseminars that encourage at least gaining education, but that’s not the same thing as a formal training fellowship program. 

Some Saha:  It should also be just to sort of comment that outside the VA there also are lots of opportunities that do focus on specifically on disparities and on disparities research.  So that’s again the NIH actually prioritizes the development of minority researchers in particular, but also people who are doing health disparities research and their loan repayment programs for people who are interested in that type of research that allows you to sort of have some at least funding input and potentially protected time. 

There are programs that are run by different foundations.  The Robert Johnson Foundation has a minority faculty development program.  The Kellogg Foundation has a program focused on training for disparities research.  So there are other places out there that are also supporting the training of people who are interested in health disparities research. 

Maya O'Neil:  Okay.  We had a question, let’s see, a question about outcomes of interest to the VA.  So one of our participants wanted to know if we know the extent to which various kinds of disparities impact outcomes of interest to the VA, so things like costs or service utilization, things like that.  So are there specific examples of how health disparities impact those types of outcomes?

Some Saha:  So I think a lot of disparities research has focused on health outcomes.  There have been studies obviously to look at utilization and costs.  I guess if the question is does the fact that we health disparities result in potentially great utilization and costs that could be stemmed if we address these disparities that it makes sense. 

I think there are inside the VA I’m not sure that there’s been a careful analysis of the degree to which disparities actually affect utilization and costs that could be stemmed if we try to reduce disparities.  There has been sort of a theoretical analysis done.  It was done I think by a guy named Steve Wolf and I can’t remember.  He might have published it in the American Journal of Public Health, looking at sort of if we focused on reducing disparities how much could we actually improve the quality and reduce utilization and costs as a nation. 

It’s an interesting question.  I think it’s partly we are driven by the concept of equity, but there are people who are out there who do make the business case for reducing disparities because if you can reduce disparities you may actually have the health system become more efficient and effective overall. 

Linda Lipson:  Right.  I don’t think that business case has been the driving force.  I haven’t seen studies that have looked at what the costs might be related to disparities.  Most of what we see has to do with performance measures, quality of care, disparities and screening rates for instance, or needing levels of hemoglobin, A1C, that type of thing, and also in terms of satisfaction.  

So I think that’s the level.  That’s not to say that there may not be some value for someone to come in, and try to make a business case and to shape some research that relates to that.  

Some Saha:  Now the issue, I think the issue that’s maybe tangential to that particular question about sort of disparities in utilization of health care I think it’s worth commenting that one of our own disparities is one our researchers, [Amalsha Beatty] published a paper last year that basically looked at sort what’s happened to kind disparities in basic health care utilization that really sort of were very prevalent in the ‘90s and the early part of the last decade, both within and outside the VA.  And what his analysis showed is that the VA’s efforts to improve quality across the board have really worked and have reduced most of the disparities that have been that are sort of what I call inside the house. 

So we’ve sort of fixed our own house in terms of trying to reduce disparities and say how many people with diabetes get all the right lab tests done and get their eyes checked?  And how many people with heart disease get their cholesterols checked? 

Where we haven’t reduced disparities so much is in the actual outcomes of whether or not people are actually getting their diabetes controlled, whether people are having their, those people with heart disease have their cholesterol controlled.  And I think one of the points of that study was that we basically we have done our due diligence in terms of making sure that when people walk through the door they get the right care.  So we may not have had a major impact on health because we really need to reach outside and bridge between where patients live and where they get their care. 

Maya O'Neil:  Okay.  It looks like we have about five more minutes, so I’ll summarize a couple other comments that we had and then ask one other final question.  Related to what Som and Linda were just discussing we just had a comment about if there is any research that anyone knows of on health disparities and awarding service-connected disabilities or not.  

And I know that we have certainly didn’t find anything on that topic for the systematic review that we conducted.  And so I don’t know, Som or Linda, do you?  I don’t know of any other research on that topic.  

Linda Lipson:  There was one study by Maureen Murdock several years ago where she was looking at PTSD related service connections, and looked at those racial and ethnic differences and women, gender differences related to PTSD, but that’s the only one that I actually know of.  

Maya O'Neil:  Okay. 

Some Saha:  That does bring up the issue of that I think is kind of a hot topic and I think was something that people are interested in the disparities world is whether race bias contributes to disparities, either in things like awarding of service connection or in the delivery of care.  I think that there’s some ongoing research in that area and I think it’s an area that is worth exploring.  

Maya O'Neil:  And just a final question to close it out and there’s a general question about VA structures and services perpetuate or exacerbate disparities, and also how VA structures and services can help reduce some of those disparities in ways that other types of health care systems might not be able to.  

Some Saha:  Well I think it’s a great question.  It’s a hard question to answer.  I think kind of looking I think the question relates if you sort of reframe it is, does institutional racism exist and does it contribute to the disparities that we see?  

And I think in general in our society we would say that’s definitely true.  So why wouldn’t it be true for the VA?  

Now trying to sort of answer that question through research is difficult because how do you look?  The VA is that you can consider the VA a structure.  Now one to look at it is to see if there is variation across different VA facilities and see if certain facilities have certain characteristics that seem to be associated with fewer disparities and others are associated with more disparities and try to sort that out.  And I think that’s an interesting concept. 

I think one thing that to sort of keep in mind is that we need to be doing research that really informs how the VA might restructure itself or improve within its own purview the way that care is delivered for different populations.  So it might be that the presence of a community-based outpatient clinic in a certain area has the ability either to really reduce disparities just by allowing geographic access.  I think those kinds of, that kind of research would be very informative. 

Linda Lipson:  And I think VA certainly has the potential because it is a health care system that if we find that there are either structural changes or other kinds of changes that could be implemented that potentially would reduce disparities there is a possibility to do that.  It isn’t a matter of issuing kind of a policy and issuing a research finding or whatever that could be implemented at will based on what the facility was. 

So I think there is some potential there.  There’s certainly a lot of potential there.  And that’s the advantage in working in the system.  And hopefully we’ll be able to with some increased attention that I think this whole area of health equity is going to have coming up that there will be more potential to do that. 

Ana Quinones:  Great.  So thank you, Som and Linda, for some very interesting discussion.  We appreciate you fielding most of those questions.  And thank you to the program to the seminar participants for asking some very interesting questions.  And thanks, Maya, for facilitating all this and for contributing to the presentation.  

So, Molly, I think we’re just about out of time and I’m just going to turn it over to you. 

Moderator:  Great.  Well I would like to also express [siter’s] gratitude for all of you presenting on your expertise today.  We really appreciate it.  And also thank you to our attendees for their thoughtful questions and for sticking around. 

Also you will be when you exit the session you will be prompted to complete a survey.  Please do take just a moment to answer those few short questions as we do take into account your feedback and it helps influence where we go next with the cyberseminar program.  

And on that same note I would like to plug our next ESP session, which will be taking place on the 29th of this month also at 12 p.m. Eastern.  And the topic is efficacy of complementary and alternative medicine therapies for Posttraumatic Stress Disorders.  So please look to our catalogue to register for that.  

So thank you again to all of our presenters.  And this does formally conclude today’s HSR&D cyberseminar.  

**[End of Recording]**

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