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Observational Study
. 2024 Sep;39(12):2249-2260.
doi: 10.1007/s11606-024-08818-3. Epub 2024 May 31.

Racial and Ethnic Differences in Health Care Experiences for Veterans Receiving VA Community Care from 2016 to 2021

Sudarshan Krishnamurthy  1 , Yaming Li  2 , Florentina Sileanu  2 , Utibe R Essien  3   4 , Megan E Vanneman  5   6   7 , Maria Mor  2 , Michael J Fine  2   8 , Carolyn T Thorpe  2   9 , Thomas Radomski  2   8 , Katie Suda  2   8 , Walid F Gellad  2   8 , Eric T Roberts  10   11
Affiliations
Observational Study

Racial and Ethnic Differences in Health Care Experiences for Veterans Receiving VA Community Care from 2016 to 2021

Sudarshan Krishnamurthy et al. J Gen Intern Med. 2024 Sep.

Abstract

Background: Prior research documented racial and ethnic disparities in health care experiences within the Veterans Health Administration (VA). Little is known about such differences in VA-funded community care programs, through which a growing number of Veterans receive health care. Community care is available to Veterans when care is not available through the VA, nearby, or in a timely manner.

Objective: To examine differences in Veterans' experiences with VA-funded community care by race and ethnicity and assess changes in these experiences from 2016 to 2021.

Design: Observational analyses of Veterans' ratings of community care experiences by self-reported race and ethnicity. We used linear and logistic regressions to estimate racial and ethnic differences in community care experiences, sequentially adjusting for demographic, health, insurance, and socioeconomic factors.

Participants: Respondents to the 2016-2021 VA Survey of Healthcare Experiences of Patients-Community Care Survey.

Measures: Care ratings in nine domains.

Key results: The sample of 231,869 respondents included 24,306 Black Veterans (mean [SD] age 56.5 [12.9] years, 77.5% male) and 16,490 Hispanic Veterans (mean [SD] age 54.6 [15.9] years, 85.3% male). In adjusted analyses pooled across study years, Black and Hispanic Veterans reported significantly lower ratings than their White and non-Hispanic counterparts in five of nine domains (overall rating of community providers, scheduling a recent appointment, provider communication, non-appointment access, and billing), with adjusted differences ranging from - 0.04 to - 0.13 standard deviations (SDs) of domain scores. Black and Hispanic Veterans reported higher ratings with eligibility determination and scheduling initial appointments than their White and non-Hispanic counterparts, and Black Veterans reported higher ratings of care coordination, with adjusted differences of 0.05 to 0.21 SDs. Care ratings improved from 2016 to 2021, but differences between racial and ethnic groups persisted.

Conclusions: This study identified small but persistent racial and ethnic differences in Veterans' experiences with VA-funded community care, with Black and Hispanic Veterans reporting lower ratings in five domains and, respectively, higher ratings in three and two domains. Interventions to improve Black and Hispanic Veterans' patient experience could advance equity in VA community care.

Keywords: Veteran Affairs; community care; disparities.

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Conflict of interest statement

The authors declare that they do not have a conflict of interest.

Figures

Figure 1
Figure 1
Unadjusted annual ratings of Veterans’ experiences with VA community care, stratified by ethnicity and race, 2016–2021a. A Annual ratings of care experiences stratified by ethnicity (Hispanic vs. non-Hispanic Veterans)b. B Annual ratings of care experiences stratified by race (Black or African American vs. White Veterans)c. aGraphs display annual unadjusted mean ratings of Veterans’ experiences with VA community care by survey domain, assessed from the VA Survey of Healthcare Experience of Patients (SHEP) survey. Mean ratings are stratified by ethnicity (A) and race (B). Estimates are weighted using survey weights. 95% confidence bars were calculated using heteroskedasticity-robust standard errors. All scores are linearly transformed onto a common 100-point scale See “METHODS” and Appendix for definitions of survey domains and calculation of scores. bAnalyses of Veterans categorized by ethnicity included all racial groups. Ethnicity was self-reported by SHEP survey respondents. cAnalyses of Veterans categorized as Black, African American, or White included all ethnic groups. Race was self-reported by SHEP survey respondents.
Figure 1
Figure 1
Unadjusted annual ratings of Veterans’ experiences with VA community care, stratified by ethnicity and race, 2016–2021a. A Annual ratings of care experiences stratified by ethnicity (Hispanic vs. non-Hispanic Veterans)b. B Annual ratings of care experiences stratified by race (Black or African American vs. White Veterans)c. aGraphs display annual unadjusted mean ratings of Veterans’ experiences with VA community care by survey domain, assessed from the VA Survey of Healthcare Experience of Patients (SHEP) survey. Mean ratings are stratified by ethnicity (A) and race (B). Estimates are weighted using survey weights. 95% confidence bars were calculated using heteroskedasticity-robust standard errors. All scores are linearly transformed onto a common 100-point scale See “METHODS” and Appendix for definitions of survey domains and calculation of scores. bAnalyses of Veterans categorized by ethnicity included all racial groups. Ethnicity was self-reported by SHEP survey respondents. cAnalyses of Veterans categorized as Black, African American, or White included all ethnic groups. Race was self-reported by SHEP survey respondents.
Figure 2
Figure 2
Forest plots of adjusted marginal differences in the probability of reporting high and low ratings of care between Hispanic vs. non-Hispanic Veterans and Black vs. White Veterans with VA Community Care, 2016–2021a. aEach panel in this plot displays the adjusted marginal differences in the probability that Veterans who identify as Hispanic or Black report positive or negative community care experiences, relative to Veterans who identify as non-Hispanic or White (respectively)). Estimates use pooled data from 2016 to 2021. Estimates are obtained from a respondent-level logistic regression model that predicted each domain probability difference for positive or negative community care experiences as a function of Hispanic ethnicity or Black race, adjusting for all covariates indicated in Table 1 and year fixed effects. From these logistic regression models, we estimated the marginal difference (on the 0–100 percentage point scale) in the probability of the outcome. Positive experiences of care were defined by high ratings equivalent to or higher than the 90th percentile of the domain score distribution (among all SHEP survey respondents in our sample) and study years. Negative experiences of care are defined by low ratings equivalent to or lower than the 10th percentile of the distribution of the domain score (among all SHEP survey respondents in our sample) and study years. Because the distribution of some scores is discrete, a rating equivalent to or higher than the 90th percentile or lower than the 10th percentile may include more than 10% of Veterans.
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