Racial And Ethnic Disparities Persist At Veterans Health Administration Patient-Centered Medical Homes

Abstract

Patient-centered medical homes are widely promoted as a primary care delivery model that achieves better patient outcomes. It is unknown if their benefits extend equally to all racial/ethnic groups. In 2010 the Veterans Health Administration, part of the Department of Veterans Affairs (VA), began implementing patient-centered medical homes nationwide. In 2009 significant disparities in hypertension or diabetes control were present for most racial/ethnic groups, compared with whites. In 2014 hypertension disparities were similar for blacks, had become smaller but remained significant for Hispanics, and were no longer significant for multiracial veterans, whereas disparities had become significant for American Indians/Alaska Natives and Native Hawaiians/other Pacific Islanders. By contrast, in 2014 diabetes disparities were similar for American Indians/Alaska Natives, blacks, and Hispanics, and were no longer significant for Native Hawaiians/other Pacific Islanders. We found that the modest benefits of the VA's implementation of patient-centered medical homes were offset by competing multifactorial external, health system, provider, and patient factors, such as increased patient volume. To promote health equity, health care innovations such as patient-centered medical homes should incorporate tailored strategies that account for determinants of racial/ethnic variations. Evaluations of patient-centered medical homes should monitor outcomes for racial/ethnic groups.

Explaining racial-ethnic differences in hypertension and diabetes control among veterans before and after patient-centered medical home implementation

“…to narrow racial-ethnic gaps in hypertension and diabetes control among a national sample of veterans [10]. The contribution of non-clinical factors to overall disparities is unknown, along with whether contributors to disparities change over time.…”

“…= 38,887). We did not examine outcomes among smaller minority groups (i.e., American Indian/Alaska Native, Native Hawaiian/other Pacific Islander, Asian, multi-race) who were part of the original study [10]. Study patients had a VHA visit during the previous 13-24 months, as well as a VHA primary care visit during the 12 months prior and during the preceding month of sampling.…”

“…Smaller, regional studies have found that PCMH implementation may demonstrate racial-ethnic disparity reductions in preventive screenings [6] and even in patient outcomes related to diabetes management [7,8]. Nonetheless, PCMHs have not been observed to narrow racial-ethnic disparity gaps in clinical care across diverse patient populations in larger, national studies of health systems [9][10][11].…”

Exploring the association of care fragmentation and patient ratings of care quality: A mediation analysis of women Veterans’ experience with VA care

“…Women Veterans (WVs) constitute the fastest growing segment of VA patients, but represent a numerical minority within VA facilities (<10 percent of VA users) . Delivering women's health (WH) services, maintaining provider competencies in WH, and providing gender‐sensitive care environments have been challenging for VA facilities traditionally oriented toward the care of male patients .…”

“…4,5 Women Veterans (WVs) constitute the fastest growing segment of VA patients, but represent a numerical minority within VA facilities (<10 percent of VA users). 6 Delivering women's health (WH) services, maintaining provider competencies in WH, and providing gender-sensitive care environments have been challenging for VA facilities traditionally oriented toward the care of male patients. [7][8][9] Furthermore, while overall the need for specific genderrelated care has increased across VA due to changes in patient demographics and significant increases in enrollment of younger female patients, individual facilities may still lack the ability to deliver this type of care as locally it represents a low volume of patients.…”