Understanding and Addressing the Determinants of Racial and Ethnic Wait Time Disparities

Background: Delayed care can adversely affect morbidity and mortality. For these reasons, wait time (the amount of time it takes a patient to get an appointment) is a key indicator of overall health system performance. Wait times overall have improved at the VA, but studies, including our own continue to report racial and ethinc (R&E) wait time disparities. Further, our prior work indicated that R&E wait time disparities were largely driven by within-facility not between-facility wait time disparities (i.e., Black and Hispanic relative to White Veterans waited longer for care at the same facility vs. disproportionately getting care at facilities that have longer wait time for all). However, little is known about the factors driving these within-facility care access disparities, including the role of structural racism. Understanding the determinants of R&E wait time disparities to inform effective interventions is essential to achieving VA's goal of health equity. Significance: This study is aligned with the VA priority to ensure timely and equitable access to care and an HSR&D priority for research on health disparities and the conditions that impact Veterans of color (e.g., social determinants of health). Innovation and Impact: Our proposal to examine the determinants of wait time disparities through the lens of structural racism (i.e., rules and regulations across sectors that disadvantage people of color) reflects recent acknowledgments that prior efforts to address R&E disparities have been unsuccessful because they fail to address the root causes of disparities. Thus, our proposal to examine how structural racism play out in the outpatient specialty care appointment scheduling process to inform corrective interventions is both innovative and potentially impactful. Specific Aims: 1) Determine facility-level R&E care access disparities; 2) Map appointment scheduling pathway and pinpoint systems and processes adversely impacting Veterans of color; 3) Develop and pilot an intervention to achieve R&E care access equity. Methodology: In Aim 1, we will expand an approach employed in our prior work (using more current data and characterizing the effects of social needs in predicting wait times) to decompose wait time disparities into within and between facility disparities to identify VA facilities contributing most to R&E wait time disparities. In Aim 2, we will purposefully sample 6 to 8 facilities reflecting high and low-to-no wait time disparity sites, conduct qualitative interviews with key stakeholders (Veterans, VA providers and staff involved in scheduling), and use a positive deviance approach to understand the determinants of facility-level wait time disparities. Our inquiry will focus on the public policies, institutional practices, and attitudes that facilitate and hinder the appointment scheduling process for Black and Hispanic Veterans. Based on Aim 2 findings, in Aim 3, we will develop and pilot an intervention to address R&E wait time disparities. Next Steps/Implementation: In the long-term, this study will position us to conduct a hybrid implementation & effectiveness study to evaluate the intervention it derives (in a subsequent IIR). In the shorter and more immediate term, study findings about structural and institutional barriers to care access and how to address can be used immediately by VA facilities to improve existing appointment scheduling processes. Project Number: 1I01HX003847-01A2 | Fiscal Year: 2025 | NIH Institute/Center: Veterans Affairs (VA) | Principal Investigator: Deborah Gurewich | Institution: VA BOSTON HEALTH CARE SYSTEM, BOSTON, MA | Activity Code: I01 | Study Section: HSR-2 Behavioral, Social, and Cultural Drivers of Health and Care[HSR2] View on NIH RePORTER: https://reporter.nih.gov/project-details/11109757