Racial and Ethnic Disparities in U.S. Veteran Health Characteristics

Effect of Changing Estimated Glomerular Filtration Rate Formula on Sugammadex Use and Pulmonary Complications for African American and non-African American Patients

BACKGROUND

Sugammadex is associated with fewer postoperative pulmonary complications than is neostigmine reversal of neuromuscular blockade. However, the Food and Drug Administration-approved package insert states that its use is "not recommended" in severe renal impairment, separately defined as creatinine clearance <30 mL/min. Recently, the formula for estimating glomerular filtration rate (GFR) was updated to remove the race variable. Compared to the prior formula, the new consensus equation lowers the estimated GFR for African American patients and raises it for everyone else. We sought to determine how this change could differently impact the use of sugammadex, and thus the rate of pulmonary complications, for both African American and non-African American patients.

METHODS

We used Monte Carlo simulation models to estimate the difference in pulmonary complications that would be suffered by patients when the change in creatine clearance calculated from the estimated GFR (using the old race-based and new race-neutral Chronic Kidney Disease Epidemiology Collaboration formulas) crossed the 30 mL/min threshold, which would require a change in sugammadex or neostigmine use.

RESULTS

We found that 0.22% (95% confidence interval 0.14%-0.36%) of African American patients' creatinine clearance would drop from above to below 30 mL/min making sugammadex not recommended and 0.19% (0.16%-0.22%) of non-African American patients would have creatinine clearance increase to >30 mL/min making sugammadex now recommended. Based on our model, we estimate that African American patients would suffer (count [95% confidence interval]) 3 [0.4-6] more pulmonary complications per 100,000 African American patients who received rocuronium or vecuronium through the change from sugammadex to neostigmine reversal to comply with labeling recommendations. Conversely, the same change in formulas would reduce the number of non-African American patients suffering pulmonary complications by 3 [2-4] per 100,000.

CONCLUSIONS

The recent change in GFR formulas may potentially be associated with an increase in postoperative pulmonary complications in African American patients and a decrease in postoperative pulmonary complications in non-African American patients through GFR-driven changes in sugammadex use.

Addressing Hispanic Veterans that Live in Rural Area's Needs to Improve Suicide Prevention Efforts

Despite the alarming recent increase in suicide rates among Hispanic Veterans, suicide among this population remains relatively understudied and little is known about their needs and how to prevent suicide in this population. A mixed methods approach was utilized to conduct a needs assessment of community suicide prevention services and resources available to Hispanic Veterans living in rural areas in the Veterans Health Administration's Veterans Integrated Services Network (VISN) 8. Five themes related to the suicide prevention's needs and gaps in services were identified: (1) lack of adequate information; (2) disruptions in social support network; (3) limited or lack of access to services; (4) risky behaviors; and (5) natural disasters. Understanding the unique needs of Hispanic Veterans in rural communities and the gaps in services in these areas can help in the development of tailored suicide prevention efforts and potentially mitigate suicide disparities.

Provision of Home & Community Based Services to Veterans by Race, Rurality, and Neighborhood Deprivation Index

Home and community-based services (HCBS) enable frail patients to remain at home. We examined whether there were neighborhood-deprivation, racial, or rural disparities in HCBS utilization provided to Veterans by the Department of Veterans Affairs (VA) or Medicare by comparing the adjusted utilization rate of a historically disadvantaged group with the predicted utilization rate had it been treated as the historically dominant group. Among the 2.7 million VA patients over 66 years old in 2019, 11.0% were Black, 39.2% lived in rural settings, 15.3%/29.2%/30.9%/24.7% lived in least/mild/moderate/most-deprived neighborhoods. On average, 11.2% received VA or Medicare HCBS. Veterans residing in more deprived neighborhoods had 0.11-0.95% higher adjusted probability of receiving HCBS than expected had they resided in the least deprived neighborhoods. Veterans residing in rural areas had 0-0.7% lower HCBS rates than expected had they been treated like urban Veterans. Black Veterans were 0.8-1.2% more likely to receive HCBS than expected had they been treated like White Veterans. Findings indicate that VA resources were equitably employed, aligning with probable HCBS needs, suggesting that VA's substantial and long-standing investment in HCBS for care of frail Veterans could serve as a model for other payers and providers in the U.S.

Exploring Racial/Ethnic Disparities in Substance Dependence and Serious Psychological Distress among US Veterans

OBJECTIVES

There are substantial racial/ethnic disparities in substance use and mental health among civilian populations, but few studies have examined these disparities in veterans using a nationally representative sample. Thus, we examined differences in substance dependence and serious psychological distress (SPD) by race/ethnicity among a national sample of US veterans.

METHODS

We pooled cross-sectional data from the 2015-2019 waves of the National Survey on Drug Use and Health (N = 7,653 veterans aged 18-64 years). Regression models were utilized to examine racial/ethnic differences in DSM-IV substance dependence and SPD with a Benjamini-Hochberg correction applied.

RESULTS

Compared to non-Hispanic White veterans: American Indian/Alaska Native veterans had significantly higher odds of past-year alcohol dependence (AOR = 2.55, 95% CI: 1.28, 5.08); Asian American veterans had significantly lower odds of past-year alcohol dependence (AOR = 0.12, 95% CI: 0.02, 0.62); non-Hispanic Black (AOR = 0.60, 95% CI: 0.48, 0.77), Hispanic (AOR = 0.47, 95% CI: 0.34, 0.65), and veterans of more than one race (AOR = 0.55, 95% CI: 0.36, 0.83) had significantly lower odds of past-month nicotine dependence; Asian American veterans had significantly lower odds of past-year illicit drug dependence (AOR = 0.05, 95% CI: 0.01, 0.35); and non-Hispanic Black veterans had significantly lower odds of past-year SPD (AOR = 0.69, 95% CI: 0.55, 0.85) after correction for multiple comparisons.

CONCLUSION

Overall, racial/ethnic disparities in substance dependence and SPD among veterans are not as stark as in civilian populations, but some disparities remain.

Association of Race and Ethnicity with Prescriptions for Continuous Glucose Monitoring Systems Among a National Sample of Veterans with Diabetes on Insulin Therapy

Introduction and Objective: Continuous glucose monitoring (CGM) can improve glycemic control in people with diabetes on insulin therapy. We assessed rates of prescriptions for CGM in a national sample of Veterans across subgroups defined by race and ethnicity. Methods: This cross-sectional analysis of data from the U.S. Veterans Health Administration included adults with type 1 or type 2 diabetes on insulin therapy. Main exposures included self-reported race and ethnicity, and primary outcome was the percentage of patients with at least one CGM prescription between January 1, 2020, and December 31, 2021. Association of race and ethnicity categories with CGM prescription was examined using multilevel, multivariable mixed-effects models. Results: Among 368,794 patients on insulin (mean age, 68.5 years; 96% male; 96.8% type 2 diabetes; 0.8% American Indian or Alaska Native, 0.7% Asian, 18.9% Black or African American, 0.9% Native Hawaiian or other Pacific Islander, 70.2% White, 2.8% multiracial, 5.7% with unknown race, and 7.0% Hispanic or Latino ethnicity), 11.2% were prescribed CGM. CGM was prescribed for 10.4% American Indian or Alaska Native, 9.7% Asian, 9.2% Black or African American, 9.3% Native Hawaiian or other Pacific Islander, 11.8% White, 11.8% multiracial, and 10.1% patients with unknown race. CGM was prescribed for 8.3% Hispanic or Latino, 11.4% non-Hispanic, and 11.5% of patients with unknown ethnicity. After accounting for patient-, clinical-, and system-level factors, Black or African American patients had significantly lower odds of CGM prescription compared with White patients (adjusted odds ratio [aOR] 0.62, 95% confidence interval [CI] 0.59-0.64), whereas Hispanic or Latino patients had significantly lower odds compared with non-Hispanic patients (aOR 0.79, 95% CI 0.74-0.84). Findings were consistent across subgroups with clinical indications for CGM use. Conclusions: Among Veterans with diabetes on insulin therapy, there were significant disparities in prescribing of CGM technology by race and ethnicity, which require further study and intervention.

Contextual factors influencing the association between the Affordable Care Act's Medicaid expansion and Veteran VA-Medicaid dual enrollment

OBJECTIVE

To evaluate changes in dual enrollment after Affordable Care Act Medicaid expansion by VA priority group, (e.g., service connection), sex, and type of state expansion.

STUDY SETTING

Our cohort was all Veterans ages 18-64 enrolled in VA and eligible for benefits due to military service-connection or low income from 2011 to 2016; the unit of analysis was person-year.

STUDY DESIGN

Difference-in-difference and event-study analysis. The outcome was dual VA-Medicaid enrollment for at least 1 month annually. Medicaid expansion, VA priority status, whether a state expanded by a Section 1115 waiver, and sex were independent variables. We controlled for race, ethnicity, age, disease burden, distance to VA facilities, state, and year.

DATA EXTRACTION METHODS

We used data from the VA Corporate Data Warehouse (CDW) regarding age and VA Priority Group to select our cohort of VA-enrolled individuals. We then took the cohort and crossed checked it with Medicaid Analytic Extract (MAX) and T-MSIS Analytic Files (TAF) to determine Medicaid enrollment status.

PRINCIPAL FINDINGS

Service-connected Veterans experienced lower dual-enrollment increases across all sex and state-waiver groups (3.44 percentage points (95% CI: 1.83, 5.05 pp) for women, 3.93 pp (2.98, 4.98) for men, 4.06 pp (2.85, 5.27) for non-waiver states, and 3.00 pp (1.58 to 4.41) for waiver states) than Veterans who enrolled in the VA due to low income (8.19 pp (5.43, 10.95) for women, 9.80 pp (7.06, 12.54) for men, 10.21 pp (7.17, 13.25) for non-waiver states, and 7.39 pp (5.28, 9.50) for waiver states).

CONCLUSIONS

Medicaid expansion is associated with dual enrollment. Dual-enrollment changes are greatest in those enrolled in the VA due to low income, but do not differ by sex or expansion type. Results can help VA identify groups disproportionately likely to have potential care-coordination issues due to usage of multiple health care systems.

Mental health treatment utilization among Gulf War era veterans with probable alcohol use disorder

INTRODUCTION

Alcohol use disorder (AUD) is prevalent among veterans, and excessive alcohol use is associated with significant mental and physical health consequences. Currently, the largest cohort of veterans seeking services at the VA are those from the 1990s Gulf War Era. This cohort of veterans is unique due to the nature of their deployment resulting in a myriad of unexplained symptoms collectively known as "Gulf War Illness" and higher rates of mental health problems. The present study sought to examine the association between probable AUD and mental health treatment utilization in a sample of 1126 (882 male) Gulf War-era veterans.

METHODS

Veterans completed a self-report survey including the AUDIT-C, questions about mental health treatment engagement, and demographic questions.

RESULTS

Results demonstrated that approximately 20 % of the sample screened positive for probable AUD, determined by standard AUDIT-C cutoff scores. Among those screening positive for AUD, 25 % reported engaging in mental health treatment in the past year. Veterans with probable AUD who use VA care had 3.8 times the odds of receiving mental health services than veterans not using VA care. Use of mental health services was associated with mental health comorbidity and identifying as Black/African American.

CONCLUSIONS

The results of the present study highlight a significant unmet need for mental health treatment among Gulf War-era veterans with AUD.

Association of Posttraumatic Stress Disorder and Race on Readmissions After Stroke

BACKGROUND

There is limited research on outcomes of patients with posttraumatic stress disorder (PTSD) who also develop stroke, particularly regarding racial disparities. Our goal was to determine whether PTSD is associated with the risk of hospital readmission after stroke and whether racial disparities existed.

METHODS

The analytical sample consisted of all veterans receiving care in the Veterans Health Administration who were identified as having a new stroke requiring inpatient admission based on the International Classification of Diseases codes. PTSD and comorbidities were identified using the International Classification of Diseases codes and given the date of first occurrence. The retrospective cohort data were obtained from the Veterans Affairs Corporate Data Warehouse. The main outcome was any readmission to Veterans Health Administration with a stroke diagnosis. The hypothesis that PTSD is associated with readmission after stroke was tested using Cox regression adjusted for patient characteristics including age, sex, race, PTSD, smoking status, alcohol use, and comorbidities treated as time-varying covariates.

RESULTS

Our final cohort consisted of 93 651 patients with inpatient stroke diagnosis and no prior Veterans Health Administration codes for stroke starting from 1999 with follow-up through August 6, 2022. Of these patients, 12 916 (13.8%) had comorbid PTSD. Of the final cohort, 16 896 patients (18.0%) with stroke were readmitted. Our fully adjusted model for readmission found an interaction between African American veterans and PTSD with a hazard ratio of 1.09 ([95% CI, 1.00-1.20] P=0.047). In stratified models, PTSD has a significant hazard ratio of 1.10 ([95% CI, 1.02-1.18] P=0.01) for African American but not White veterans (1.05 [95% CI, 0.99-1.11]; P=0.10).

CONCLUSIONS

Among African American veterans who experienced stroke, preexisting PTSD was associated with increased risk of readmission, which was not significant among White veterans. This study highlights the need to focus on high-risk groups to reduce readmissions after stroke.

Epidemiology of Coccidioidomycosis in the Veterans Health Administration, 2013-2022

We describe the epidemiology of coccidioidomycosis among a national cohort of Veterans. Using electronic health record data from adults tested for coccidioidomycosis between 1 January 2013 and 31 December 2022, we analyzed differences in baseline demographics (age, sex, race/ethnicity, birth country, comorbidities, residence, and Charlson Comorbidity Index score) between 4204 coccidioidomycosis-test-positive and 63,322 test-negative Veterans. Log-binomial regression models with adjusted risk ratios (aRRs) were used to evaluate risk factors associated with coccidioidomycosis including dissemination, hospitalization, and mortality. Case counts and incidence rates were highest in select counties in Arizona and California where Coccidioides is endemic. Coccidioidomycosis-positive Veterans were younger, more likely to be male, and Philippine-born. The risk factors most highly associated with being coccidioidomycosis-positive included Native Hawaiian/Pacific Islander (aRR 1.068 [95%CI: 1.039-1.098]), Asian (aRR 1.060 [95%CI: 1.037-1.083]), Black (aRR 1.029 [95%CI: 1.022-1.036]), American Indian/Alaska Native (aRR 1.026 [95%CI: 1.004-1.048]) race, and Hispanic/Latino ethnicity (aRR 1.021 [95%CI: 1.013-1.028]). Black race (aRR: 1.058 [95%CI: 1.037-1.081]) and Hispanic/Latino ethnicity (aRR 1.018 [95%CI: 1.0003-1.036]) were also associated with disseminated coccidioidomycosis, strengthening the evidence for the association of coccidioidomycosis, including severe infections, with specific racial and ethnic groups. There were no statistically significant differences in hospitalization within 45 days of testing or 30-day all-cause mortality. Improving our understanding of coccidioidomycosis risk factors is important for targeted prevention strategies and to reduce delays in diagnosis and ineffective treatment.

Interventions to improve lung cancer screening among racially and ethnically minoritized groups: A scoping review

Lung cancer screening (LCS) decreases lung cancer related mortality among high-risk people who smoke cigarettes and has been endorsed by the US Preventive Services Task Force (USPSTF) since 2013. However, adoption of LCS has been limited, and disparities in LCS among racially and ethnically minoritized groups have become apparent. While recommendations to improve disparities in LCS have been made, there is a lack of information on how these recommendations have been implemented and their relative effectiveness in improving screening disparities. This scoping review addresses this knowledge gap by examining interventions that have been implemented to improve LCS among racially and ethnically minoritized groups in the United States. A comprehensive search of MEDLINE (via PubMed), EMBASE (via Elsevier), CINAHL Complete (via EBSCO), and Scopus (via Elsevier), for articles from the period 1 January 2010 through 22 October 2021 was completed. Out of 17,045 references screened, only 11 studies describing an intervention to improve disparities in LCS were identified, underscoring the dearth of data on established interventions. The interventions discussed could be categorized into three groups -- patient level (n = 3), clinic/institution level (n = 3), and community level (n = 5) interventions. Of those studies reporting effectiveness data (n = 8), there was substantial heterogeneity in the outcomes measured and their relative effectiveness. We found that interventions which streamlined the LCS process at the level of a single clinic or institution were the most effective in improving LCS. Community-level interventions that focused on engagement and education had the greatest potential to target racially and ethnically minoritized groups. Our study underscores the need for more robust research on addressing barriers to LCS by identifying effective patient, clinic, and community-level interventions to improve LCS disparities and the need for potential standardization of intervention effectiveness outcomes.

The Impact of Mental Health Intensive Case Management on Functioning and Clinical Outcomes of Older Black and White Veterans With Serious Mental Illness

OBJECTIVES

To examine differences in service delivery, functioning, and clinical outcomes between older Black and White veterans participating in a national Veterans Health Administration (VHA) program of intensive case management.

DESIGN

Secondary analysis of national program evaluation data.

SETTING

VHA Intensive Community Mental Health Recovery (ICMHR) program.

PARTICIPANTS

Black (n = 1327) and White (n = 4402) veterans age 55 and older who enrolled in ICMHR between 2000-2013.

MEASUREMENTS

Measures evaluated sociodemographic factors, service delivery, functioning, and clinical outcomes. ANOVA and chi-squares were used to evaluate differences in enrollment characteristics and service delivery between Black and White veterans. Regression analyses were used to examine changes in outcomes over 6 months controlling for confounding baseline differences and service delivery. Cohen's d of .20 was used as a threshold for a clinically meaningful effect.

RESULTS

Black veterans were more likely to be diagnosed with schizophrenia, alcohol use disorder, and drug use disorder. Although case managers spent significantly less time with Black veterans, there was no difference in the frequency of contacts. Medication management and substance use treatment were more often provided to Black veterans. Black veterans experienced substantially greater improvement in anxiety/depression than White veterans with a small effect size (Cohen's d =-0.25). Changes in all other outcome measures did not meet criteria for clinically meaningful differences.

CONCLUSIONS

Black veterans experienced meaningfully greater improvements than White veterans on anxiety/depression but not on other measures. Provision of high-intensity services in an equal-access setting may reduce health disparities between Black and White older adults with serious mental illness.

Social Determinants of Health: Considerations for Care of Older Veterans

Social determinants of health (SDOH), the environments and circumstances in which people are born, grow, live, work and age, are potent drivers of health, health disparities, and health outcomes over the lifespan. Military service affords unique experiences, exposures, and social and health vulnerabilities which impact the life course and may alter health equity and health outcomes for older veterans. Identifying and addressing SDOH, inclusive of the military experience, allows person-centered, more equitable care to this vulnerable population. Nurses and other health professionals should be familiar with how to identify and address health-related social needs and implement interdiciplinary, team-based approaches to connect patients with resources and benefits specifically available to veterans.

Disparities in Excess, All-Cause Mortality among Black, Hispanic, and White Veterans at the U.S. Department of Veterans Affairs during the COVID-19 Pandemic

Background: From 2019 to 2020, all-cause mortality in the U.S. increased, with most of the rise attributed to COVID-19. No studies have examined the racial disparities in all-cause mortality among U.S. veterans receiving medical care (VA users) at the U.S. Department of Veterans Affairs (VA) during the pandemic. Methods: In the present paper, we conduct a longitudinal study examining the differences in mortality among White, Black, and Hispanic veterans, aged 45 years and older, during the first, full year of the pandemic (March 2020–February 2021). We calculated the Standardized Mortality Rates (SMRs) per 100,000 VA users for each racial and ethnic group by age and gender. Results: The highest percentage increase between the number of deaths occurred between pre- and post-pandemic years (March 2020–February 2021 vs. March 2019–February 2020). For Hispanics, the all-cause mortality increased by 34%, while for Blacks, it increased by 32%. At the same time, we observed that an 18% increase in all-cause mortality occurred among Whites. Conclusion: Blacks and Hispanics were disproportionately affected by the COVID-19 pandemic, leading both directly and indirectly to higher all-cause mortality among these groups compared to Whites. Disparities in the all-cause mortality rates varied over time and across groups. Additional research is needed to examine which factors may account for the observed changes over time. Understanding those factors will permit the development of strategies to mitigate these disparities.