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RESEARCH AND PRACTICE |
At the time of the study Andrea D. Gurmankin was with the Philadelphia/Pittsburgh VA Center for Health Equity Research and Promotion and the University of Pennsylvania Department of Psychology and Department of Medical Ethics. Daniel Polsky is with the Division of General Internal Medicine and the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia. Kevin G. Volpp is with the Philadelphia VA Center for Health Equity Research and Promotion, the University of Pennsylvania School of Medicine, and the Wharton School.
Correspondence: Requests for reprints should be sent to Andrea D. Gurmankin, PhD, MBe, Dana-Farber Cancer Institute, 44 Binney St, SM 253, Boston, MA 02115 (e-mail: adg11{at}cornell.edu).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Conclusions regarding racial differences in care following a newly elevated prostate-specific antigen (PSA) test at the Department of Veterans Affairs (VA) may differ depending on whether follow-up care outside the VA is considered. Consecutive Philadelphia, Pa, VA patients with newly elevated PSA tests (n = 183) were interviewed 1 year after baseline. Among exclusive VA users, Blacks had higher rates of urology referrals and prostate biopsies compared with Whites. However, these racial differences were attenuated when care obtained outside the VA also was considered.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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One possible explanation for this discrepancy is that VA disparities studies typically measure treatment and outcomes only within the VA,6–13,15 even though most patients receive some care outside the VA.16 If Whites receive a greater proportion of care outside the VA than do Blacks, assessments of service use that examine only within-VA services may show a misleading lack of disparity or "reverse disparity."
Our study compared the magnitude of racial disparities in knowledge of an elevated prostate-specific antigen (PSA) test, urology referral, and prostate biopsy among patients with a newly elevated PSA test at the Philadelphia Veterans Affairs Medical Center, depending on whether or not care obtained outside the VA was considered.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Of the 343 eligible patients identified, patients were excluded if they were deceased at time of enrollment (n = 4), uncontactable (n = 60), too ill (n=7), or not Black or White (n=5). Of the 267 remaining patients, 183 (69%) participated.
To distinguish between patients who were likely to seek follow-up care outside rather than inside the Philadelphia Veterans Affairs Medical Center, subjects were classified as either "partial VA users" or "exclusive VA users." Partial VA users reported using the Philadelphia Veterans Affairs Medical Center for prescription medications only or reported seeing a urologist outside the Philadelphia Veterans Affairs Medical Center. All others were classified as exclusive VA users. Subjects who did not know that they had received a PSA test (n = 40) were not asked about follow-up care and hence were excluded from initial analyses. Sensitivity analyses were performed by including these subjects in sequence in the exclusive VA or partial VA users’ groups because appropriate group assignment was unclear. In analyses in which these subjects were included, their response to each outcome was coded as "no."
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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In general, Blacks were more likely than Whites to know of their PSA test and to have a urology referral and biopsy among exclusive VA users and were as likely as or less likely than Whites to have these characteristics among partial VA users. The rates of each outcome among all subjects represented the combined rates of the 2 subgroups (Table 1
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Multivariate models adjusted for age and index PSA level, factors that affect the likelihood of prostate cancer and, therefore, the importance of a urology referral and a biopsy. In these models, the odds ratios for race reflected a pattern for each outcome similar to that in the unadjusted analyses (Table 2). In addition, we examined whether the odds ratios for race were different for exclusive VA users and partial VA users by combining the 2 groups into 1 multivariate model and examining an added term of being an exclusive VA user interacted with being Black. The statistical significance of this coefficient for urology referral (P= .04) suggested that the racial differences among exclusive VA users were statistically different from those among partial VA users. For the other outcomes, the racial differences between exclusive and partial VA users were not statistically different.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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These findings are likely the result of different rates of use of care outside the VA by Black compared with White VA patients. Because more Whites than Blacks receive care outside the VA, these White patients may receive less care within the VA. As a result, in assessments of racial differences among VA patients in care received at the VA, it appears that Blacks obtain more care than do Whites.
The results should be considered in light of certain limitations. We relied on patient self-reports of care, although these self-reports were largely validated by chart data. Some subjects’ PSA tests may not have been newly elevated, despite efforts to exclude these patients. However, this was more likely among partial VA users; their VA records may be less complete, which would bias against finding smaller racial differences in follow-up rates when including partial VA users.
Our results have implications for the VA studies of racial disparities in outcomes and utilization.6–8,10–13 Exclusive examination of services received by patients within the VA system may overestimate total use by Blacks compared with Whites. Interpretation of VA studies of racial disparities should consider this potential bias.
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Acknowledgments |
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The authors are indebted to David Asch, Katrina Armstrong, Lorraine Dean, Francisco Lameiro, and the Department of Veterans Affairs patients who participated in the study for their assistance with this research.
Human Participant Protection
This study was approved by the institutional review board of the Philadelphia Veterans Affairs Medical Center.
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Footnotes |
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Accepted for publication June 16, 2004.
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References |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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2. Farkas A, Schneider D, Perrotti M, Cummings KB, Ward WS. National trends in the epidemiology of prostate cancer, 1973 to 1994: evidence for the effectiveness of prostate-specific antigen screening. Urology. 1998;52:444–448.[ISI][Medline]
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7. Goldstein L, Matchar DB, Hoff-Lindquist J, Samsa GP, Horner RD. Veterans Administration Acute Stroke (VASt) study: lack of racial/ethnic-based differences in utilization of stroke-related procedures or services. Stroke. 2003;34:999–1004.
8. Jha A, Shlipak MG, Hosmer W, Frances CD, Browner WS. Racial differences in mortality among men hospitalized in the Veterans Affairs health care system. JAMA. 2001;285:297–303.
9. Washington D, Harada ND, Damron-Rodriguez J, Dhanani S, Shon H, Makinodan T. Racial variations in Department of Veterans Affairs ambulatory care use and unmet health care needs. Mil Med. 2002;167: 235–241.[ISI][Medline]
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14. Freeman VL, Durazo-Arvizu R, Arozullah AM, Keys LC. Determinants of mortality following a diagnosis of prostate cancer in Veterans Affairs and private sector health care systems. Am J Public Health. 2003; 93:1706–1712.
15. Bach P, Cramer LD, Warren JL, Begg CB. Racial differences in the treatment of early-stage lung cancer. N Engl J Med. 1999;34:1198–1205.
16. Shen Y, Hendricks A, Zhang S, Kazis LE. VHA enrollees’ health care coverage and use of care. Med Care Res Rev. 2003;60:253–267.
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