QUERI – Quality Enhancement Research Initiative

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QUERI E-news
March 2019

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Partnered Research Evaluates Mortality Disparities in VA

Health disparities are differences in health outcomes and their determinants between segments of the population as defined by social, demographic, environmental, geographic, health, and other attributes. Equitable access to high-quality care for all Veterans is a major tenet of the VA healthcare mission, however, disparities are still present in VA for many important health outcomes. One of the goals of VA’s Office of Health Equity (OHE) is to improve the availability, coordination, and utilization of data and diffusion of research and evaluation outcomes to facilitate VA’s progress towards the achievement of health equity in care for all Veterans.

QUERI projects examine VA data to identify opportunities to improve care, develop or adapt effective interventions to improve quality of care, and implement and test strategies to spread quality improvement programs. In accordance with these principles, the Office of Health Equity and QUERI, in partnership, called for a Health Equity-QUERI National Partnered Evaluation Initiative. Objectives of the Office of Health Equity-QUERI National Partnered Evaluation Initiative include evaluating the extent to which there are observed disparities in healthcare and outcomes of care for vulnerable groups in VA, the mechanisms underlying those disparities, and innovations to achieve health equity.

Mortality disparities among Veterans who use VA healthcare are an area of inquiry with incomplete evidence and inconsistent findings. To fill part of the gap, Health-Equity QUERI investigators evaluated variations in all-cause mortality and suicide mortality for rural-dwelling Veterans and for Veterans with mental health disorders. Using data from the CDC National Death Index, the DoD, and VA, investigators assessed mortality risk by rurality as well as by mental health diagnosis for 5,030,722 Veterans using VA healthcare in fiscal year 2009, with 14,442,554 person-years of follow-up.

Study findings show that:

  • Age and sex-adjusted all-cause mortality risk did not differ between urban and rural Veterans, or between urban and highly rural Veterans.
  • Compared with urban dwelling Veterans, age and sex-adjusted suicide mortality risk was elevated for Veterans living in rural and highly rural settings.
  • Age and sex-adjusted all-cause mortality risk was elevated for Veterans with serious mental illness (SMI) and for those with diagnosed depression or anxiety without SMI compared with Veterans with no mental health diagnosis.
  • Compared with Veterans with no mental health diagnosis, age and sex-adjusted heart disease, cancer, and suicide mortality risk all had the greatest elevation for those with SMI, followed by those with depression or anxiety without SMI.

The scientific literature is sparse on rural-urban differences in mortality among Veterans using VA healthcare and on the association of mental health comorbidity with a broad number of causes of mortality. This evaluation provided national statistics on Veterans’ mortality risk by rurality and mental health comorbidity, and detected groups with elevated rates of heart disease, cancer, and suicide mortality. Elucidating the causal pathways by which mental health comorbidity and rural residence are linked to excess mortality risk – and examining the interactions among these vulnerabilities – could inform disparity-reduction activities that could mitigate some of the VA mortality disparities identified.

For more information about Health-Equity QUERI or this particular study, please contact Donna Washington, MD, MPH, at Donna.Washington@va.gov .

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