A Publication of the VA Office of Research & Development, Health Services Research & Development Service,

Management Decision and Research Center, in conjunction with the Academy for Health Services Research

and Health Policy

continued on page 2

Special Populations and the VA: Serving

Veterans in a Multi-Cultural Society

By Robert H. Roswell, M.D., Network Director, VISN 8, and

John Dandridge, Jr., Network Director, VISN 9

FORUM

VA HEALTH SERVICES RESEARCH & DEVELOPMENT JUNE 2000

VA is the largest health care delivery system in the world; it may

also be the most diverse. We serve

people of virtually all races and cultural backgrounds, including

African Americans, Hispanic

Americans, Native Americans,

Asians and Pacific Islanders, and

whites. In addition, we are serving

growing numbers of women.

Going beyond race and gender, VA

also provides services to many

patients who are poor and have no

other source of care. These

patients frequently have special

needs, and a significant number of

them are homeless.

VA’s mission is to provide the

best possible care to all American

veterans. Yet our own research

has documented substantial racial,

ethnic, and gender-based variations in care within the VA service

population. As a result, we know

that many veterans — for a variety of reasons, some of which are

rooted in socio-economic factors —

are not getting needed services.

But there is still a great deal that

we do not know, because solid evidence on the causes and implications of these variations is lacking. 

Sweeping changes within VA

highlight key steps that VA has

taken to address this issue – and,

at the same time, underscore the

need to do even more. Fueled by

the vision of former VA Under

Secretary for Health Kenneth

Kizer and aided by new eligibility

legislation, VA during the past few

years has evolved from an archaic

collection of hospitals into a comprehensive, state-of-the-art health

care system. Greater emphasis on

outpatient-based primary care and

hundreds of new community-based

clinics have helped make the VA

system more accessible to our

patients. 

Not only do veterans have better

access to the VA health care system, but VA providers also have

better access to their veteran

patients, in terms of their ability to

treat the whole patient and not just

his or her service-connected condition, thanks to recent eligibility

reform legislation. As a result, for

the first time in VA’s history, we

have the opportunity to focus on

preventive care and services, and a

new opportunity to more fully

address the health of our nation’s

veteran population. 

Coupled with these changes, we

have made tremendous strides in

our ability to monitor the health

C DIRECTOR’S LETTER OMMENTARY

This issue of Forum highlights

the importance that HSR&D

places on special populations.

The homeless and, to some extent,

racial minorities and women

receive less care and fewer procedures in the VA than do their

Caucasian male counterparts.

The difficult question that the VA

must address is: Why is this

occurring? 

HSR&D is attempting to

answer this and related questions

through a series of studies. During

the past four years, just under $6

million has been committed to

investigating causes of disparity.

We have highlighted several ongoing studies in this issue, some of

which include interventions for

narrowing these differences.

One important study investigates why African American

patients both within and outside

VA are less likely than whites to

receive carotid endarterectomy to

prevent ischemic stroke. With the

growing number of women serving in active duty over the past

two decades, another highlighted

study looks at women’s health

needs and what’s required of VA

to provide quality health care to

women. Interventions that reach

out and provide care to homeless

veterans are critical. Another

study looks at the case management

and residential treatment programs

for the homeless and still another

looks at how racial and ethnic 

differences affect access and 

utilization of VA ambulatory care. 

HSR&D will continue to look

for causes and interventions that

will help eliminate disparities

among groups of veterans and

that aim to provide the highest

quality health care to all veterans.

John G. Demakis, M.D.

Director, VA HSR&D Service

O ur own research has

documented substantial

racial, ethnic, and genderbased variations in care

within the VA service population.
2

care delivery process. With the

help of new clinical practice guidelines and clinical outcomes monitoring systems, we can track the

effects of an array of preventive services and chronic disease interventions that are now routinely

provided to our veteran patients. 

Despite Progress,

Challenges Remain

Clearly, when we improve the system as a whole, all of our patients

benefit. But we have to do even

more if we are to fully meet the

needs of all veterans. We must couple the significant improvements in

our infrastructure and regulatory

environment with an equally

expansive understanding of the cultural, gender-based, and ethnic

influences on veterans’ preferences,

utilization, and outcomes associated with health care delivery.

Without this vital knowledge, our

efforts to provide high-quality,

patient-focused care will fall short. 

Several studies have documented

that access to primary care services

is associated with better health status, and, more importantly, that

the severe adverse effects of income

inequalities on health can largely

be eliminated by providing primary

care. Unfortunately, other studies

have shown significant variations

based on ethnicity and period of

military service in the utilization of

VA ambulatory care. Still other

studies have documented racial differences in adherence to treatment

regimens. As a result, it seems reasonable to conclude that at least

some veterans are not realizing the

full health benefits of VA’s effort to

make primary care universally

available. More research is needed

to clarify these differences in utilization, ascertain their root cause,

and implement programs or services that can overcome them. 

We must also make an effort to

understand differences in clinical

outcomes and their implications.

Commentary

continued from page 1

C OMMENTARY

For example, the increased incidence

of hypertension and the greater

severity of strokes in African

Americans is well documented. Yet

VA researchers have shown that this

group of veterans, who ostensibly

have a greater need for clinical intervention, actually receive carotid

endarterectomy less frequently than

their white counterparts. Part of

the reason is a greater aversion

among African Americans to this

procedure. Although clinician education, practice guideline modification, greater diversity in provider

staff, and other interventions are all

possible solutions to this problem,

our top priority should be to clarify

causation. Only through sound

research can we devise effective

strategies for eliminating these

types of racial and ethnic differences

in clinical outcomes.

Diversifying the VA

Workforce

We must also take a harder look at

our workforce. Research indicates

that diversity in the general health

care workforce affects access to

care. For example, several studies

have shown that minority physicians are much more likely than

non-minority physicians to serve

those patients who have the most

difficulty getting care: minorities

and the poor. In addition, minority

patients appear to prefer providers

who can relate to them culturally.

These findings carry implications

for VA as well. We need to consider the composition and deployment

of our workforce. 

VA has attempted to address this

issue in its recruitment of facility

and clinical directors whose racial

and ethnic backgrounds reflect the

communities they are being asked

to serve. It is difficult to say

whether we have gone far enough in

enough areas, especially with

respect to communities that have

large Spanish-speaking populations.

VA is probably doing as much as

any other organization in this area –

maybe more. But the reality is that

more may need to be done.

These are difficult issues to deal

with effectively. In fact, outside

VA, we are seeing an alarming

retreat from efforts to encourage

diversity. Several states, for example, have enacted laws ending affirmative action in state university

medical education programs. It

will probably get worse before it

gets better. 

VA has an opportunity to provide

strategic leadership on medical

workforce diversity and shed light

on how diverse populations are

affected by workforce composition.

What we need, first of all, is a didactic root cause analysis of the factors

that contribute to our inability to

address workforce diversity at the

research and policy levels. 

We will make better progress if

we can advocate outside the box:

taking account of those barriers to

care that are part of the broader

environment in which VA operates

and doing what we can to remove

them. For example, how does managed care, with its emphasis on

cost containment, affect minority

populations, which, because of

socio-economic factors, are frequently more expensive to serve

than other populations? By looking at the broader picture, VA ultimately can become a more effective

agent for change. 

Research underway within VA’s

HSR&D will help provide answers

to some of these questions. VA

has a unique opportunity to

improve the health and well-being

of all of our nation’s veterans. It

will not be easy work, but it is necessary work. Our patients deserve

no less. 

O nly through sound

research can we devise

effective strategies for

eliminating these types of

racial and ethnic differences in clinical outcomes.
3

Concurrent with its special obligation to achieve equity in health care

delivery, VA has a history of helping

the nation understand the complex

reasons for racial and ethnic variations in care. VA investigators were

among the pioneers in identifying

where these disparities occurred,

uncovering significant disparities in

the receipt of invasive cardiovascular procedures, screening tests, utilization of primary care services,

treatment for mental health disorders, and other health care services.

This early research was instrumental in raising national awareness of

treatment disparities in an equal

access health care system, where

the financing of health care did not

confound the observed differences.

The VA HSR&D Service was

quick to embrace these findings,

launching a special research initiative to support projects that would

go beyond the simple observation

of differences and explore their

root causes. Since 1996, 10 projects throughout the country have

been funded to address areas of

access to care, health care-seeking

behavior, complex medical decision

making, and the impact of provider

recommendations on receipt of

care. This represents a commitment of just under $6 million to

investigate disparities among

patient groups that include African

Americans, Hispanic Americans,

American Indians, and Asians and

Pacific Islanders. 

Other organizations have followed VA’s lead. A major new component of the Department of

Health and Human Services’

Healthy People 2010 program sets

specific goals for reducing ethnic

and racial differences in six specific

areas: infant mortality, cancer

screening and management, cardiovascular disease, diabetes, HIV

infection/AIDS, and immunizations. 

To achieve equity in access to

care and improve health outcomes,

we must now move beyond the first

generation of descriptive studies to

test interventions designed to

achieve parity. Effective interventions are likely to be multidimensional and must be tested within a

wider context of race relations.

This makes our overall goal both

complex and, at times, politically

sensitive. Successful interventions

must take into account a wider

range of factors, some of which are

difficult to measure, including clinical appropriateness, patients’ preferences, cultural differences in

communication and health literacy,

and the role of providers.

Although it is difficult to define

the extent to which prejudice

accounts for racial differences in

health care, we must explore the

nature of patient-provider interaction more fully. We must also consider the extent to which improving

the cultural competency of health

care providers leads to reduced

racial disparities in health care.

VA has a long tradition of leadership in the area of race and

health. Our large and racially

diverse population is unencumbered by the financial forces that

often cloud the picture of race

research in other health care settings. This makes the VA system

the perfect laboratory to test and

export effective interventions. In

the same way that VA achieved the

goals of Healthy People 2000 ahead

of any other health care agency, we

are poised to embrace the more difficult goals of achieving parity in

the areas defined in Healthy People

2010. In partnership with patients,

providers, administrators, and

health service researchers, we can

help the nation understand the

importance of achieving parity in

care for all its people.

The Role of HSR&D in Shedding Light on Health Disparities

By Eugene Oddone, M.D., M.H.Sc., Center for Health Services Research in Primary Care, 

Durham VAMC, and Jay Freedman, Ph.D., VA HSR&D

R ESPONSE

HSR&D Deputy Director Shirley Meehan, M.B.A.,

Ph.D., who played a critical role in building

HSR&D’s career development program and supporting primary care research at VA, is the recipient of

the prestigious Elnora M. Rhodes SGIM Service

Award for the year 2000. The Society of General

Internal Medicine presents the annual award to an

individual for outstanding service to the society and

to its mission of advancing patient care, research,

and education in primary care internal medicine.

Stephan Fihn, M.D., M.P.H., Past President of

SGIM and current Director of the HSR&D Center of

Excellence in Seattle, presented the award. He

noted Dr. Meehan’s tireless work on behalf of the

many SGIM members who call VA home for their

clinical activities and health services research. Dr.

Meehan joined HSR&D in 1972 and has since helped

develop and guide HSR&D programs that contribute

to quality health care in VA. “This year’s Rhodes

award,” Dr. Fihn said, “recognizes [Dr. Meehan’s]

steadfast service.” Dr. Meehan thanked HSR&D

leaders for their support, and urged SGIM members

who are interested in health services research to consider VA HSR&D.

SGIM Recognizes HSR&D’s Shirley Meehan 

with Elnora M. Rhodes Award
4

R ESEARCH HIGHLIGHT

HSR&D Study Investigates Racial Differences in Use 

of Carotid Endarterectomy

By Eugene Oddone, M.D., M.H.Sc., 

Center for Health Services Research in Primary Care, Durham VAMC

Stroke is the third leading cause of

death and a leading cause of disability among adults in the U.S. Of the

approximately 750,000 people who

have a stroke every year, about onethird die. Half of those who survive

have significant residual disabilities.

African Americans are at higher

risk of stroke than whites, and

recent reports indicate that stroke

mortality among African Americans

may be increasing. Although new

treatments for acute stroke seem

promising, preventive practices are

particularly important for reducing

overall disease burden. Carotid

endarterectomy (CE) is known to

be effective in preventing ischemic

stroke for many patients with highgrade carotid artery stenosis.

Despite their higher risk for stroke,

African American patients both

within and outside VA are only onethird to one-fourth as likely as

whites to receive CE. 

Led by a research team in

Durham, VA HSR&D investigators

recently shed new light on the

underlying causes for the steep

racial disparity in CE utilization.

Using clinical appropriateness criteria for CE developed by RAND, they

examined the interaction between

patients’ signs and symptoms as

potential mediators in explaining

the racial difference in CE use. 

The study enrolled 803 patients

from four geographically diverse VA

medical centers who had a diagnosis of stroke or transient ischemic

attack. Half of the patients were

white and half were African

American. African Americans were

more likely than white patients to

present with stroke (78 percent versus 55 percent) but less likely to

present with transient ischemic

attack (22 percent versus 45 percent). There was no racial difference in medical comorbidity or

pre-operative risk. 

The researchers found that many

patients were missing a key diagnostic step in determining appropriateness for CE: African

American patients were less likely

to have an imaging study of their

carotid arteries (67 percent versus

79 percent). Race remained an

independent predictor of imaging,

even after adjusting for important

clinical factors. Because of the

higher prevalence of significant

carotid artery stenosis, however,

whites were significantly more 

likely than African Americans to be

assessed as appropriate candidates

for surgery, using the RAND criteria (18 percent versus 4 percent).

These findings indicate that, after

controlling for clinical presentation,

patient race is still a significant

influence on the decision to have

carotid artery imaging, which is a

critical step in determining eligibility for CE. Adjustment for appropriateness of CE reduces but does not

eliminate the importance of race. 

It appears that patient preferences and racial dynamics in

patient-physician communication

may play important roles in

explaining racial differences in use

of CE. HSR&D researchers have

found that African Americans

appear to have a strong preference

for less invasive care. In addition,

other researchers outside VA have

found that physicians may have different thresholds for referring

patients for invasive tests that vary

by race. HSR&D is funding studies

to address these two important

research questions. Results from

these studies, expected this fall, will

further advance our understanding

of race and health. We will then

need to fashion interventions

directed at patients and/or physicians to fully achieve our goal of

high-quality care for all patients.

Under Secretary’s Award for Health

Services Research Presented to Nelda Wray

Nelda P. Wray, M.D., M.P.H, received the year 2000 Under Secretary’s

Award for Outstanding Achievement in Health Services Research.

Thomas L. Garthwaite, M.D., Deputy Under Secretary for Health, presented the award at the VA HSR&D Annual Meeting, March 22-24, in

Washington, DC. 

Dr. Wray is an active clinician, pre-eminent researcher, respected

mentor, and vigorous contributor to HSR&D. This award recognizes

her outstanding career accomplishments, particularly her work on the

use of administrative databases to assess and improve the quality and

effectiveness of health care, and the development of techniques to better understand patient preferences and incorporate them into health

care decision making. Throughout an exceptional career, Dr. Wray has

applied these methodologies to areas of particular importance to veterans, such as heart failure and prostate cancer. In addition, as a teacher

and mentor she has inspired new investigators, while enhancing the

visibility and reputation of VA research nationally. Continuing her

work at the Houston Center of Excellence, Dr. Wray has created an

environment and infrastructure that fosters interdisciplinary health

services research. 
5

R ESEARCH HIGHLIGHT

Homeless Veterans Benefit from Case Management and

Residential Treatment Programs

By Robert Rosenheck, M.D., VA Northeast Program Evaluation Center and Yale Medical School

On any given night, as many as

250,000 American veterans sleep on

the streets or in shelters. Perhaps

twice as many experience homelessness over the course of a year. The

veterans at highest risk for homelessness entered the military after

the establishment of the All Volunteer Force in 1973. At that time,

military service was unpopular and

the prevalence of mental illness,

including substance abuse and antisocial personality disorders, was

higher among recruits than among

civilians of similar age. Nearly 40

percent of homeless veterans suffer

from severe, persistent, and disabling

mental illnesses. Half of them also

have substance abuse disorders.

The VA is the single largest

direct care provider for homeless

people in the U.S. It operates two

major programs for homeless veterans: the Domiciliary Care for

Homeless Veterans (DCHV)

Program, which provides residential treatment on VA grounds, and

the Health Care for Homeless

Veterans (HCHV) programs, which

emphasize community-based outreach and provide residential treatment through contracts with

community agencies. Both programs grew out of the original

Homeless Chronically Mentally Ill

(HCMI) program.

The VA Northeast Program

Evaluation Center (NEPEC), which

has studied homelessness among veterans since 1987, has evaluated

these programs and continues to

monitor their operation. Participation in both is associated with significant improvement in psychiatric

distress, alcohol and drug use,

employment, and housing status.

Duration of involvement in case

management and participation in

residential treatment were found to

be associated with superior outcomes.

As part of an economic evaluation of the HCHV program, comprehensive cost data were obtained

on 1,748 veterans from nine program sites. General VA health care

costs, including inpatient and outpatient psychiatric and medical

care, increased significantly, from

$6,414 per patient per year in the

year before first outreach contact

to $7,269 in the year after entry.

When HCMI program costs for case

management ($315) and residential

treatment ($1,115) were added,

total per-patient costs in the year

after first outreach contact rose to

$8,699. That represents a 35.6 percent increase from the previous

year. These data show that, especially when effective, outreach can

be costly. This is not surprising

since the very reason for conducting outreach is to enhance access

to services for the underserved.

A comparison was also made of

veterans admitted to residential

treatment and veterans who only

received case management. Outcomes were generally superior in the

residential treatment group.

General VA medical and mental

health costs, exclusive of HCMI program costs, were not significantly

different between those admitted to

residential treatment ($9,053/year)

and those who were not ($8,205/

year). However, when special program costs for case management

and residential treatment are

included, costs for those admitted to

residential treatment were substantially higher than for those who

were not ($13,693/year versus

$8,978/year). HCMI contract residential treatment is thus associated

with significantly better outcomes at

53 percent greater cost.

Additional research is needed to

identify other interventions that

will foster exit from homelessness,

long-term housing stability, and

vocational rehabilitation. Evaluations of several programs designed

to address those needs are underway.

HSR&D’s Peter Ubel Garners 

Presidential Award 

Peter A. Ubel, M.D., is among the distinguished scientists to receive

this year’s Presidential Early Career Award for Scientists and

Engineers. These awards recognize some of the finest scientists and

engineers who, while early in their research careers, show exceptional

potential for leadership at the frontiers of scientific knowledge.

President Clinton describes the Presidential Award as “the highest

honor bestowed by the U.S. government on outstanding scientists and

engineers beginning their independent careers.” The awards are conferred annually at the White House, following recommendations from

participating agencies, which include the National Science Foundation,

NASA, the Department of Veterans Affairs, the National Institutes of

Health, and others. 

Dr. Ubel’s research explores the overlap between medical ethics and

decision psychology. Specifically, he is interested in measuring moral

attitudes toward health care rationing and in understanding how people faced with rationing dilemmas decide how to resolve their dilemmas. In addition to his many other awards and honors, Dr. Ubel is a

recipient of VA’s HSR&D Career Development Award.
6

P ERSPECTIVE

Changing Role of Women Veterans Raises Issues 

About Health Care Service Delivery

By Joan Furey, Center for Women Veterans

Twenty-five years ago, the face of

the U.S. military was virtually all

male. But that is starting to

change, not only as more women

continue to enlist in the armed

forces, but also as they take on

increasingly responsible and

diverse roles. This trend holds

important implications for the

development of VA health care benefits and delivery models. 

Prior to 1973, women accounted

for only 2 percent of the active duty

military and the military occupations open to them were limited.

Today, women make up more than

15 percent of the active duty forces

and 20 percent of new recruits.

Women are being deployed in

greater numbers throughout the

world, and in a wider variety of military occupations than ever before

in the history of our country. 

VA projects that by the year

2010, women veterans will make up

over 10 percent of the veteran population — more than double the

current number. This increase,

combined with questions surrounding the impact of military service

on women’s health, explains why

VA has designated women’s health

as a special emphasis program 

Over the last 15 years, VA has

invested considerable effort in

enhancing its programs for women.

For the most part, these efforts

have been very successful. During

the past eight years, the number of

women using VA health care programs has surged by 64 percent.

Yet, as the VA reorganization continues, there is concern that the

progress made in health care for

women veterans will be lost and

that, once again, women veterans

will find themselves treated as

“one of the boys.” 

Support for Gender-Specific

Care Wanes

Why the concern? With the implementation of the primary care

treatment model, some VA facility

directors felt that the general

women’s health clinic was no

longer necessary. Thus, women’s

clinics were discontinued and

women veterans were assigned to

the new primary care teams on a

rotating basis. This practice, often

referred to as “mainstreaming,” is

based on the assumption that any

primary care practitioner, regardless of gender, can provide basic

primary care to any veteran.

Although this practice may

work well in the private sector, I

believe that a number of factors

need to be addressed before we

adopt it in VA. Consider:

■ Women make up more than half

of most private practitioners’ primary care panels; by contrast,

women veterans represent less

than 5 percent of the VA patient

population treated. 

■ Women veterans’ clinics and

comprehensive care centers were

established because VA primary

care providers rarely provided care

to women and were generally less

familiar with women’s health

issues and less skilled in routine

gender-specific care than privatesector practitioners.

■ Mainstreaming further reduces

the ratio of women to men in any

one VA practitioner’s caseload.

That makes it less likely that the

clinician will gain the clinical exposure necessary to develop and

maintain expertise in women’s

health.

The high rate of sexual trauma

among women veterans is another

important issue. Research has

shown that 30 to 50 percent of

women veterans using VA services

report experiencing at least one

incident of sexual trauma during

their lifetime. Studies also indicate that the physical, emotional,

and psychological consequences of

sexual assault may persist for

many years.

These experiences commonly

give rise to complex health needs.

Women who have a history of sexual trauma often feel greater discomfort and distress when seeking

routine health care than other

women. In VA, this discomfort is

often compounded by the disparate

ratio of men to women in VA

health care settings. The failure of

a clinician to recognize or secure

treatment for the psychological

and physical consequences of sexual trauma may well lead to higher

use of all health care services by

these women – which ultimately

increases the cost of health care

delivery. 

These few factors underscore the

need for VA to develop creative and

innovative approaches to providing

health care for women veterans.

Fortunately, VA has a cadre of

health care professionals with

expertise in assessing and addressing the health care needs of women

veterans. Given the opportunity,

these professionals can help inform

VA’s strategic planning activities

on the local, regional, and national

levels to ensure high-quality, comprehensive health care services for

women veterans. 

T oday, women make up

more than 15 percent of

the active duty forces and

20 percent of new recruits. 
7

R ESEARCH HIGHLIGHT

The VA Women’s Health Project: 

Identifying the Health Care Needs of Women Veterans

By Katherine Skinner, Ph.D., Center for Health Quality, Outcomes and Economic Research, Bedford VAMC

Little is known about the military

experiences and post-military

health of women. Recent findings

from the VA Women’s Health

Project indicate that the health

care needs of women veterans are

very different from those of male

veterans. Funded by HSR&D, this

project was designed to characterize the health status of women veterans and to examine the effects of

military duty on women. 

Respondents were randomly

selected from all women veterans

who had a VA outpatient visit

between July 1, 1994, and June 30,

1995. Data were collected from

3,632 women who completed a

mailed questionnaire. 

We asked detailed questions

about various aspects of women

veterans’ military experience.

Respondents said that they volunteered for the military to learn new

job skills, to travel, or to receive

financial aid for college. Many

women reported difficulties when

re-entering civilian life, including

health problems, difficulty getting a

job, feeling depressed, or feeling

lost for a time. Strikingly, 23 percent of women reported that they

were sexually assaulted while they

were in the military. The military

experience of those women, as well

as their physical, mental, and social

functioning, varied significantly

from those of other women veterans. Accordingly, we recommend

that VA health care providers routinely screen all women veterans

for a history of sexual assault.

In comparing male and female

veterans, we found that women VA

users were younger (average age of

52 for women, versus 62 for men),

better educated (65 percent of

women attended college, versus 35

percent of men), and less likely to be

married (26 percent of women versus

48 percent of men). Women veterans reported higher physical functioning scores but consistently lower

emotional and social functioning.

Almost two-thirds of women using

VA services received all or most of

their health care through the VA,

although most (80 percent) had private health insurance, Medicare, or

Medicaid. Most women (69 percent) rated the location of VA facilities and the ease of making

appointments for outpatient care as

good or excellent. Yet one out of

five women reported that she did

not feel welcome as a woman

receiving care at the VA. Although

VA has done a great deal to

enhance services for women veterans, more may still need to be done

to assure that this minority population feels welcome.

The number of women serving

on active duty has increased steadily since 1973. Although only 4 percent of current VA users are

women, this proportion will certainly increase as the number of

women serving in the military

grows, as women become more

aware of services provided by VA,

and as VA health care continues to

become more user-friendly for

women. The findings from this

study point out key differences in

the health care needs of male and

female veterans. It is important for

health care providers to understand

the complex medical and mental

health needs of women veterans

and to develop the knowledge,

skills, and sensitivity required to

provide them with high-quality

health care.

A lthough VA has done

a great deal to enhance

services for women veterans, more may still need to

be done to assure that this

minority population feels

welcome. Seminar Explains the Ins and Outs of

Government Databases for Researchers

The use of federal and state databases in health services research is the

topic of a seminar that HSR&D is co-sponsoring with the Academy for

Health Services Research and Health Policy this fall. The seminar will

take place Oct. 30-Nov. 1 at Georgetown University Conference Center

in Washington, DC, and will feature six to eight databases over the

three-day period. The agenda for the first day includes an overview,

lessons learned from the field, the status of federal data privacy regulations, and state perspectives on protecting patient privacy. For each of

the following two days, participants will enroll in a full-day course on a

selected database. The objectives of the seminar are to facilitate the

use of federal and state databases by health services researchers; to provide an opportunity for participants to learn from others’ experience in

using these databases and to ask questions of the experts; and to network

with other researchers and professionals in the field. The seminar is

the third in a series being offered by AHSRHP. For registration information, please contact Kari Root, tel. 202/292-6745, email kroot@ahsrhp.

org, or visit the AHSRHP website at www.ahsrhp.org/seminars/fall2000. 
8

Race-ethnicity and military experience appear to play a role in veterans’ perceptions of VA health care

quality, according to preliminary

findings from research at the West

Los Angeles Healthcare Center on

how racial-ethnic differences affect

access and utilization of VA ambulatory care. Researchers of the

Veteran Identity Program (VIP) are

finding that minority veterans have

different military experiences that

appear to shape their perceptions of

VA ambulatory care. These observations point to the need for targeted

outreach that takes into account

veteran identity based on military

history, race-ethnicity, and medical

assessment. 

Now in its third of four years of

HSR&D funding, the VIP was

designed to 1) establish baseline levels of ambulatory care utilization

among minority veteran groups; 

2) identify sociodemographic,

health-related, and military service

predictors of ambulatory care utilization and determine how these

predictors vary among racial-ethnic

groups; 3) understand how factors

related to race-ethnicity and veteran identity influence utilization of

ambulatory care services and how

these factors vary among racial-ethnic groups; and, 4) use these findings to develop program and

practitioner interventions for

improving access of minority veterans to ambulatory care.

Sociodemographic, health-related, and military service factors are

being assessed as predictors of

ambulatory care utilization among

four racial-ethnic groups: African

Americans, Asian Americans,

Hispanic Americans, and White

Americans. Study researchers are

using a triangulated methodology

that consists of a secondary analysis

of the 1993 National Survey of

Veterans, in-depth interviews and

focus groups, and a targeted telephone survey of minority veterans.

Results from this study are

already being used to help VA staff

provide more culturally sensitive care

to veterans of different racial-ethnic

backgrounds and military experiences. For example, a 20-minute

video based on 32 hours of focus

group discussions highlights veterans’ perceptions about their military

experience, the advantages and disadvantages of military service, VA

health care, and medical care in general. This video and supporting material will be included as part of an

intervention to educate VA staff and

remove cultural and other barriers to

care for minority veterans. Further

dissemination is planned following

completion of this study.

Study Highlights Importance of Veteran Identity in 

Use and Perceptions of VA Care

By Herb Shon, M.S.W. , West Los Angeles Healthcare Center

Martin P. Charns, D.B.A., Editor-in-Chief

Mary Darby, Editor

Geraldine McGlynn, Co-editor

ADVISORY COMMITTEE

John G. Demakis, M.D., Director, VA HSR&D

Rodney A. Hayward, M.D., VA HSR&D

Center of Excellence, Ann Arbor

David H. Law, M.D., VA Medical Center, 

Bay Pines, FL

Shirley Meehan, M.B.A., Ph.D., VA HSR&D

Alan S. Perry, M.H.A., FACHE, VA Medical

Center, Fresno, CA

Robert M. Roswell, M.D., VA Network #8,

Bay Pines, FL

Hanna B. Rubins, M.D., M.P.H., VA HSR&D

Center of Excellence, Minneapolis

Forum is a Publication of the VA Office of Research &

Development, Health Services Research & Development

Service, Management Decision and Research Center, in

conjunction with the Academy for Health Services Research

and Health Policy.

F O R U M

R ESEARCH HIGHLIGHT