African Americans hospitalized at Veterans Affairs Medical Centers have a 25 percent lower mortality than white patients, according to researchers from the San Francisco VA Medical Center and University of California, San Francisco. The researchers suggested that the equal access to care provided at VAMCs might partially explain the findings.
The study, conducted by Ashish Jha, MD, chief medical resident at SFVAMC and UCSF, and his colleagues, is published in the January 17 issue of JAMA.
"This result was surprising," Jha said. "We expected that equal access would lead to equal outcomes, not better outcomes for African Americans," he said.
Several previous studies have found that blacks have a higher hospital death rate than whites, Jha noted. And one plausible explanation was that blacks had poorer access to health care, as was demonstrated in other studies.
To compare mortality on a more level playing field, Jha and his colleagues studied VA medical centers, which are government-funded and have few financial barriers to getting care. "The VA operates a large, single-payer system with equal access to care. So we sought to determine whether African Americans and whites admitted to VA hospitals would have equal survival," Jha said.
They surveyed the records for nearly 40,000 patients admitted to 147 VA medical centers in the US during 1996 for one of six common conditions such as heart failure and pneumonia. They compared the death rates at one month, and six months for patients who self-identified as black or white.
"Surprisingly, African American patients had about a 25 percent better survival rate than white patients. For every disease we studied, and among both older and younger patients, in both urban and rural hospitals, and in nearly every region of the country, African Americans veterans had better survival than white veterans," Jha said.
While the results of the study are clear, interpreting them is more difficult, he said. "We have no definitive explanation," he said.
Equal access to care and the high quality of care provided by VA medical centers may have helped the blacks in this study do better than in previous studies. "Other research has shown that African Americans and whites receive similar care at the VA, which we believe is a major success of this system. In contrast, in many other settings of American healthcare, racial disparities are pervasive," Jha said.
Other studies have shown that blacks are less likely to have health insurance, less likely to have a primary care physician, and less likely visit a doctor for chronic medical conditions, he said. Studies also suggest that blacks are treated differently - they are less likely to receive an angiography after a heart attack, less likely to receive surgery for lung cancer, and more likely to have a delay in being referred to a kidney specialist, Jha noted.
"It's possible that care in the VA is much more standardized and consistent than non-VA care. This might contribute to good outcomes for all patients and especially for traditionally underserved patients like African Americans," Jha said.
However, Jha warns against making too many broad assumptions based on the current study because veterans differ in many ways from the general population. For instance, women were not included in the study group because so few women are admitted to the VA system, Jha explained. VA patients also tend to be sicker than patients at other hospitals. As a result of differences like these, it's impossible to know whether the improved outcomes seen for blacks in this study would be replicated by providing equal access to care to the general population. However, the researchers say, all hospitals should work to eliminate inequities in care based on race. "Other health care settings need to catch up to the care provided for minorities in the VA system," Jha said.
In future studies, the researchers hope to learn what gave blacks an advantage over whites in the VA system. "Investigating the intriguing survival advantage of African American veterans may help to extend these benefits outside the VA system," Jha said.
Other authors on the paper included Michael Shlipak, MD, MPH, UCSF assistant professor of medicine and physician at SFVAMC; former SFVAMC physician Warren Browner, MD, MPH, now scientific director at California Pacific Medical Center; Craig Frances, MD, a former SFVAMC physician; and former SFVAMC research assistant Wylie Hosmer.
Journal
JAMA