Said A. Ibrahim

Racial and Ethnic Disparities in the VA Health Care System: A Systematic Review

ObjectivesTo better understand the causes of racial disparities in health care, we reviewed and synthesized existing evidence related to disparities in the “equal access” Veterans Affairs (VA) health care system.MethodsWe systematically reviewed and synthesized evidence from studies comparing health care utilization and quality by race within the VA.ResultsRacial disparities in the VA exist across a wide range of clinical areas and service types. Disparities appear most prevalent for medication adherence and surgery and other invasive procedures, processes that are likely to be affected by the quantity and quality of patient–provider communication, shared decision making, and patient participation. Studies indicate a variety of likely root causes of disparities including: racial differences in patients’ medical knowledge and information sources, trust and skepticism, levels of participation in health care interactions and decisions, and social support and resources; clinician judgment/bias; the racial/cultural milieu of health care settings; and differences in the quality of care at facilities attended by different racial groups.ConclusionsExisting evidence from the VA indicates several promising targets for interventions to reduce racial disparities in the quality of health care.

Ethnic differences in the perception of prayer and consideration of joint arthroplasty

Context. Ethnic differences in utilization of arthroplasty may reflect differences in health-related attitudes and beliefs. Objective. To examine ethnic differences in the perception and use of prayer in the treatment of arthritis and its role in patients’ decision making toward surgery. Design. A cross-sectional survey. Setting. VA Primary Care Clinics. Patients. Patients older than 50 years with chronic moderate-to-severe knee pain, hip pain, or both. Measures. The “helpfulness of prayer” in the treatment of arthritis and patients’ attitude toward joint arthroplasty. Results. Five hundred ninety-six veterans; 44% black patients, 56% white patients. Groups were comparable with respect to age (65 ± 9.5 vs. 66 ± 9), disease severity as assessed by WOMAC (47 ± 17 vs. 45 ± 17). Black patients scored higher than white patients on the religiosity scale (77 ± 17 vs. 70 ± 21). In multivariate analysis, black patients were more likely than white patients to perceive prayer as helpful in the management of their arthritis (OR, 2.1; 95% CI, 1.19, 3.72). Black patients were also less likely than white patients to consider surgery for severe hip/knee pain (OR, 0.58; 95% CI 0.34, 0.99); this relationship between ethnicity and consideration of surgery is mediated by perceptions of “helpfulness of prayer.” The odds ratio for this relationship changes to 0.70 (P = 0.215). Conclusion. In this sample, black patients were more likely than white patients to perceive prayer as helpful and to have actually used prayer for their arthritis. Perception of helpfulness of prayer may be an important explanatory variable in the relationship between ethnicity and patients’ decision in considering arthroplasty.

Self-assessed global quality of life: A comparison between African-American and white older patients with arthritis

Quality of life (QOL) perceptions influence patient decisions and preferences for care and, more importantly, physicians may render recommendations based on their impressions of the patients QOL. QOL is perceived differently by different ethnic groups. This may have implications for understanding ethnic disparities in medical procedure utilization such as joint replacement for osteoarthritis. In a study of 596 elderly male patients with moderate to severe symptomatic knee/hip osteoarthritis, we examined how African-American and white patients rate their overall QOL. We adjusted their responses for important demographic, clinical, and psychosocial potential confounders. African-American (44%) and white (56%) patients in this study were comparable, except that African-Americans reported lower socioeconomic status compared with whites. After adjusting for all other study covariates, African-American ethnicity (B= -0.121, P = 0.004) was negatively correlated with overall QOL ratings. How ethnic variations in perceptions of QOL impact observed ethnic disparity in the utilization of joint replacement therapy needs further investigation.

Perceived Discrimination in Health Care and Use of Preventive Health Services

ObjectiveTo examine the relationship between perceived discrimination and preventive health care utilization.Design and ParticipantsCross-sectional analysis using the 2004 Behavioral Risk Factor Surveillance System “Reactions to Race” module (N = 28,839).MeasurementsOutcomes were self-reported utilization of seven preventive health services. Predictors included perceived negative and positive racial discrimination (vs. none) while seeking health care in the past year. Multivariable models adjusted for additional patient characteristics.Main ResultsIn unadjusted models, negative discrimination was significantly associated with less utilization of mammogram, pap test, PSA test, blood stool test, and sigmoidoscopy/colonoscopy (ORs = 0.53–0.73, p < .05), but not flu or pneumococcal vaccines (ORs = 0.76 and 0.84). Positive discrimination was significantly associated with more utilization of all services (ORs = 1.29–1.58, p < .05) except pap test (OR = 0.94). In adjusted models, neither negative nor positive discrimination was predictive of utilization, except for PSA test (positive discrimination OR = 1.33, p < .05).ConclusionsPerceived racial discrimination in health care does not independently predict preventive health care utilization.

The impact of race and ethnicity on receipt of family planning services in the United States.

OBJECTIVE This study sought to examine the independent effect of patient race or ethnicity on the use of family planning services and on the likelihood of receiving counseling for sterilization and other birth control methods. METHODS This study used national, cross-sectional data collected by the 2002 National Survey of Family Growth (NSFG). Our analysis included women aged 18-44 years who had heterosexual intercourse within the past 12 months, who were not actively seeking to get pregnant, and who had not undergone surgical sterilization. The primary outcome was receipt of family planning services within the past 12 months. Specific services we examined were (1) provision of or prescription for a method of birth control, (2) checkup related to using birth control, (3) counseling about sterilization, and (4) counseling about birth control. RESULTS Although we found no racial/ethnic differences in the overall use of family planning services, there were racial/ethnic differences in the specific type of service received. Hispanic and black women were more likely than white women to receive counseling for birth control (adjusted OR 1.5, 95% confidence interval [CI] 1.2, 1.8, and adjusted OR 1.3, 95% CI 1.1, 1.7, respectively). Hispanic women were more likely than white women to report having been counseled about sterilization (adjusted OR 1.5, 95% CI 1.0, 2.3). CONCLUSIONS Minority women were more likely to receive counseling about sterilization and other birth control methods. However, there were no differences in access to family planning services by race or ethnicity. Future studies are needed to examine the quality and content of contraceptive counseling received by minority compared with nonminority women.

Everything I know I learned from my mother...Or not: perspectives of African-American and white women on decisions about tubal sterilization.

BACKGROUNDAfrican-American women have had higher rates of female sterilization compared to white women since its emergence as a contraceptive method. The reasons underlying this observed racial difference are unknown.OBJECTIVESThe goals of this study were to (1) explore what factors shape black and white women’s decisions about tubal sterilization as a contraceptive method and (2) generate hypotheses about the relationship of race to the decision-making process.DESIGNWe conducted six focus groups stratified by tubal sterilization status and race. During each of the audio-recorded sessions, participants were asked to discuss reasons that women choose sterilization as a contraceptive method.PARTICIPANTSThe participants of the study were 24 African-American women and 14 white women.APPROACHTranscripts of the sessions were qualitatively analyzed with particular attention to factors that might be unique to each of the two racial groups.RESULTSPersonal factors shaped black and white women’s decisions regarding tubal sterilization. Preference for a convenient, highly effective contraceptive method was the main reason to get a tubal sterilization for women of both racial groups. We also identified socio-cultural differences that might explain why black women are more likely than white women to choose tubal sterilization over other contraceptive methods. An unanticipated, but clinically important, finding was that women often reported feeling that their doctors and the health-care system served as barriers to obtaining the desired procedure.CONCLUSIONSocio-cultural differences may help explain why black and white women choose different contraceptive methods.

AFRICAN AMERICAN ETHNICITY AND CARDIOVASCULAR RISK FACTORS ARE RELATED TO AORTIC PULSE WAVE VELOCITY PROGRESSION

BACKGROUND Accelerated central arterial stiffening as represented by progression of aortic pulse-wave velocity (PWV) may be influenced by cardiovascular disease (CVD) risk factors. Little is known about the relationships between CVD risk factors and PWV progression among women transitioning through the menopause, or whether these relationships vary by ethnicity. METHODS We conducted a subgroup analysis of 303 African-American and Caucasian participants in the Study of Womens Health Across the Nation (SWAN) Heart Study which received PWV scans at baseline examination and at a follow-up examination at an average of 2.3 years later. CVD risk factors were also assessed at baseline. RESULTS Systolic blood pressure (SBP) and waist circumference were the strongest predictors of PWV progression, after adjustment for age, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol, diastolic blood pressure (DBP), glucose, and triglyceride levels. The magnitude of the influence of SBP, DBP, LDL-C, and glucose on PWV progression varied by ethnicity (difference in slopes: P = 0.02 for SBP, P = 0.0009 for DBP, P = 0.005 for LDL-C, and P = 0.02 for glucose). The positive relationship between SBP and PWV progression was significant among women of both ethnicities. LDL-C, DBP, and, to a lesser extent, glucose levels were positively associated with PWV progression only among African Americans. CONCLUSIONS Blood pressure, LDL-C, glucose, and excess body size may be important targets for improving vascular health and preventing clinical outcomes related to arterial stiffening, particularly among African-American women.

BRIEF REPORT: Gender and Total Knee/Hip Arthroplasty Utilization Rate in the VA System

AbstractOBJECTIVE: Osteoarthritis (OA) is a leading cause of disability and is more prevalent in women than men. Total joint arthroplasty is an effective treatment option for end-stage OA. We examined gender differences in utilization rates of total knee/hip arthroplasty in the Veterans Administration (VA) system. METHODS: The sample consisted of all VA patients for fiscal year (FY) 1999, 50 years of age or older, with or without the diagnosis of OA in any joint. We calculated the odds of patients undergoing total knee/hip arthroplasty adjusting for age, comorbidities, and presence of OA. We included the hospital site as a random effects variable to adjust for clustering. RESULTS: Of the 1,968,093 (2.3% women) VA patients in FY 1999 who were 50 years of age or older, 329,461 (2.9% women) patients carried a diagnosis of OA. For women, 2-year adjusted odds of undergoing total knee or hip arthroplasty were 0.97 (0.83 to 1.14) and 1.00 (0.79 to 1.27), respectively. CONCLUSION: Among patients potentially at risk for the procedure, men and women in the VA system were equally likely to undergo knee/hip arthroplasty.

Getting funded: Career development awards for aspiring clinical investigators

For aspiring clinical investigators, career development awards provide a primary mechanism for “getting funded.” The objective of this article is to provide information that will facilitate a successful application for a research career development award. Specifically, we discuss important issues that cut across the diverse array of awards, and we highlight the most common sources of funding, including the unique opportunities that are available for underrepresented minorities. The target audience includes junior faculty and fellows who are pursuing or considering a research career in academic medicine, as well as their mentors and program directors.

Does vasectomy explain the difference in tubal sterilization rates between black and white women

OBJECTIVE To examine whether the observed difference in tubal sterilization rates between black and white women is dependent on racial/ethnic differences in vasectomy rates. DESIGN Secondary analysis of national, cross-sectional survey. SETTING 2002 National Survey of Family Growth. PATIENT(S) Women 15 to 44 years old with a current partner who were able to provide information about their partners vasectomy status. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) The primary outcome was tubal sterilization. Among women with a current partner who had not undergone vasectomy, a multivariable logistic regression model was used to estimate the effects of race/ethnicity on tubal sterilization after adjusting for potential confounders. RESULT(S) Of the 3,391 women in the sample, 14% of white women had a current partner who had undergone vasectomy compared with 5% of Hispanic women and 4% of black women. Among the 3,064 women whose partners had not undergone vasectomy, black women were more likely to undergo tubal sterilization (odds ratio: 1.6; 95% confidence interval: 1.1, 2.2) on the basis of adjusted multivariable analysis. CONCLUSION(S) After controlling for partner vasectomy status, black women were still more likely to undergo tubal sterilization than white women.