EDITORIAL Excellence and Equality in Health Care

As the United States steps up to the historic opportunity offered by the Affordable Care Act, the imperative for health care transformation to meet the needs of an increasingly diverse population is indisputable. The sheer increase of uninsured Americans signing up for coverage highlights this point. It is estimated that more than 20 million people have signed up for insurance coverage under the new law; and recently, the proportion of adults lacking coverage has fallen by 26% since the third quarter of 2014 and May 2014.1 Many of these new enrollees are likely younger, lowincome, and members of racial and ethnic minority groups because these groups are more likely to be without coverage. This is reflective of uninsured veterans who stand to benefit by the new law,2 because these groups are reflective of the growing veteran population that will likely seek out services in the Veterans Health Administration (VHA). In fact, the VHA is preparing for anticipated increases in veterans from diverse groups in the coming decades. During the rollout of the Affordable Care Act, the Department of Veterans Affairs (VA) identified 2.2 million veterans who were likely to be uninsured and eligible to enroll with the VA. As of April 2014, more than 20 400 veterans enrolled in response to the initial VA outreach efforts. Disparities in the health status of different populations linked with social, economic, and environmental disadvantages have long been known. This is reflected in a growing body of research over the past 25 years, which has

Supplement 4, 2014, Vol 104, No. S4 | American Journal of Public Health

revealed that disparities in the quality of care provided are also highly influenced by individual characteristics such as gender, race, ethnicity, education, income, age, geography, sexual orientation, and other factors. Increasingly, the VHA is recognizing that one size does not fit all, especially in the case of diverse patient populations.3 This is also true for many hospitals that have recognized the potential for diverse populations to experience disparities in health care outcomes. The Joint Commission has outlined a framework for improving the quality of care of hospitals serving diverse patients.4 Furthermore, new cadres of public health professionals are increasingly being trained to remain alert of these disparities, the mechanisms that spur disparities, and proven strategies to intervene. For example, the American Public Health Association has maintained a robust focus on social determinants and the impact on overall health.5 In fact, the theme of the 2014 annual meeting is titled “Place Matters: Transforming Lessons from the Field into Blueprints for Action.” The VA also recognizes the potential for particular health care disparities among veterans serving in different eras and experiencing military service differently. This may seem unique to the VA, but it has implications beyond the VA health care system. For example, a recent study found that combat deployments were associated with coronary heart disease in a study of young service members. Odds of having a new-onset diagnosis of coronary heart disease were nearly twice as great

among those reporting combat experiences.6 Additionally, female veterans from recent service eras (e.g., Operations Enduring Freedom, Iraqi Freedom, New Dawn) may be more likely to use VA health care compared with similar veterans in other eras.7 These additional layers superimposed on the historical vulnerabilities makes the strong case for increasing awareness and incorporating pertinent information in graduate medical education and other supportive services on the importance of a better understanding of disparities related to military eras and service. To this end, the VA is leading an effort through the VHA Office of Academic Affiliations to include veteran-specific issues in the National Board of Medical Examiners bank of questions and by extension curriculum. The National Health Care Disparities Report (NHDR), a companion to the National Healthcare Quality Report (NHQR), submitted to the Congress every year since 2003, continues to affirm the breadth and persistence of health care disparities. It also confirms that these challenges are not immutable.8 For example, 60% of those examined showed improvement across all of the examined measures, and this improvement was consistent for racial and ethnic minorities. However quality domains for women worsened in some cases, suggesting more work is needed and must be ongoing. Furthermore, advances in communications and information technology have revealed that inequality in quality of care associated with individual characteristics, including

Editorial | S527

EDITORIAL

gender, race, ethnicity, income, education, and other factors, remains pervasive.9 While disparities were shown to have been reduced over time, race/ethnicity was nonetheless associated with the type of primary care received for certain medical procedures. The continued challenge of disparities in health care must be addressed in a larger context of changing challenges confronting the health care system. Advances in biomedical science and public health have resulted in dramatic increases in longevity across all populations, albeit unevenly distributed. For example, decreased mortality from cardiovascular diseases, HIV, and some cancers has resulted in an increased disease burden attributable to chronic conditions, including behavioral health conditions. At the VHA, the increased number of veterans experiencing posttraumatic stress disorder and war-related injuries has increased focus on this growing demand and the obtainability and quality of services available.10 A health care system that excels in delivery of swift, life-saving treatments for acute cardiac events is not consistently equipped to provide superb care and support to individuals with ongoing medical conditions. In addition, numerous studies and ongoing performance monitoring continue to show jarring inconsistencies across communities and even within organizations, with a sizable gap between best possible care and that which is routinely provided. Despite improvements in the quality of care overall for the VHA, variations have been reported within facilities.11 These types of study, along with a body of growing literature, undoubtedly have helped fuel a mandate recognizing the importance of quality health care and reducing disparities. The NHDR as

S528 | Editorial

a vital companion to the NHQR furthers this point. Advances in information technology have made it feasible to examine patterns of care across multiple organizations and communities. The use of electronic health records and telemedicine has been a vital tool in addressing access barriers, especially among rural patients and facilities located in these geographic regions.12 As an integrated health care system, the VHA has a unique ability to use data from multiple sources to better understand the impact of social determinants of health throughout the patient experience. The VA is also exploring the incorporation of nontraditional determinants of health into electronic health records to include these factors in the overall health plan of the patients. The VHA has recognized the importance of better understanding and intervening on health care disparities. As the nation’s largest integrated health care system the VHA has the advantage of providing care without financial or other barriers to care. Additionally, these disparities have long been the focus of the Health Services Research & Development (HSR&D) program. Since 1999, HSR&D-affiliated clinical and behavioral researchers have published more than 400 peerreviewed articles.13 Further evidence of this importance is reflected in the recent creation of the Office of Health Equity (OHE). As the key champion of quality and equity, OHE works to ensure that issues of quality and equity are essential frameworks that inform care. As demonstrated by the VHA Strategic Plan, and the work of OHE, the VHA will ensure that all veterans receive quality and equitable care regardless of their membership in groups linked to

historic discrimination and exclusion. The OHE has also officially added military era and service to the list of vulnerable populations on target for elimination of health and health care disparities. The goal of achieving health equity is a shared one throughout the VA health care system. Championing this effort for OHE is accomplished through a department-wide coalition inclusive of facility and agency leadership. Each representative ensures that the necessary support and resources are available to elevate the VHA as a leader in quality and equity. Taken together, these steps are establishing the VHA as a leader when it comes to institutional approach to excellence and equality in health care. j Carolyn M. Clancy, MD Uchenna S. Uchendu, MD Kenneth T. Jones, PhD

About the Authors Carolyn M. Clancy is with the US Department of Veterans Affairs, Washington, DC. Uchenna S. Uchendu and Kenneth T. Jones are with the Veterans Health Administration, Washington, DC. Uchenna S. Uchendu is also a guest editor for this supplement issue. Correspondence should be sent to Uchenna S. Uchendu, Executive Director, Veterans Health Administration, Office of Health Equity (10A6), 810 Vermont Avenue NW, Washington DC, DC 20420 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph. org by clicking the “Reprints” link. This article was accepted July 20, 2014. doi:10.2105/AJPH.2014.302217 Note. The views expressed in this editorial are those of the authors and do not necessarily represent those of the Department of Veterans Affairs.

Contributors All of the authors worked together to develop the content of this editorial.

References 1. Blumenthal D, Collins SR. Health care coverage under the Affordable Care Act—a progress report. N Engl J Med. 2014;371(3):275---281. 2. Tsai J, Rosenheck R. Uninsured veterans who will need to obtain insurance coverage under the Patient Protection and

Affordable Care Act. Am J Public Health. 2014;104(3):e57---e62. 3. Saha S, Freeman M, Toure J, Tippens K and Weeks C. Racial and Ethnic Disparities in the VA Healthcare System: A Systematic Review. Washington, DC: Department of Veterans Affairs, Health Services Research & Development Service, Evidence Synthesis Pilot Program; 2007. 4. Wilson-Stronks A, Lee KK, Cordero CL, Kopp AL, Galvez E. One Size Does Not Fit All: Meeting the Health Care Needs of Diverse Populations. Oakbrook Terrace, IL: The Joint Commission; 2008. 5. American Public Health Association. 142nd APHA Annual Meeting and Exposition Online Program. Available at: https://apha.confex.com/apha/142am/ webprogram/Paper310204.html. Accessed July 16, 2014. 6. Crum-Cianflone NF, Bagnell ME, Schaller E, et al. Impact of combat deployment and post-traumatic stress disorder on newly reported coronary heart disease among US active duty and reserve forces. Circulation. 2014;129(18):1813---1820. 7. Washington DL, Bean-Mayberry B, Hamilton AB, Cordasco KM, Yano EM. Women veterans’ health care delivery preferences and use by military service era: findings from the National Survey of Women Veterans. J Gen Intern Med. 2013;28(2):571---576. 8. National Healthcare Quality and Disparities Reports. Agency for Healthcare Research and Quality. 2013. Available at: http://www.ahrq.gov/research/findings/ nhqrdr/index.html. Accessed July 16, 2014. 9. Franks P, Fiscella K, Meldrum S. Racial disparities in the content of primary care office visits. J Gen Intern Med. 2005;20(7):599---603. 10. Rosenheck RA, Fontana AF. Recent trends in VA treatment of post-traumatic stress disorder and other mental disorders. Health Aff (Millwood). 2007;26 (7):1720---1727. 11. Trivedi AN, Grebla RC, Wright SM, Washington DL. Despite improved quality of care in the Veterans Affairs Health System, racial disparity persists for important clinical outcomes. Health Aff (Millwood). 2011;30(4):707---715. 12. Hogan TP, Wakefield B, Nazi KM, Houston TK, Weaver FM. Promoting access through complementary eHealth technologies: recommendations for VA’s Home Telehealth and personal health record programs. J Gen Intern Med. 2011;26(2):628---635. 13. Health Services Research and Development. Citations database search results. Available at: http://www.hsrd. research.va.gov/research/citations/ single_citation.cfm?title=Disparities. Accessed July 16, 2014.

American Journal of Public Health | Supplement 4, 2014, Vol 104, No. S4

Excellence and equality in health care.

Excellence and equality in health care. - PDF Download Free
435KB Sizes 0 Downloads 3 Views