Disparities in Wait Times for Care Among US Veterans by Race and Ethnicity

Abstract

Importance: Prior studies indicate that Black and Hispanic vs White veterans wait longer for care. However, these studies do not capture the COVID-19 pandemic, which caused care access disruptions, nor implementation of the US Department of Veterans Affairs (VA) Maintaining Internal Systems and Strengthening Integrated Outside Networks Act (MISSION), which is intended to improve care access by increasing veterans' options to use community clinicians.

Objective: To determine whether wait times increased differentially for Black and Hispanic compared with White veterans from the pre-COVID-19 to COVID-19 periods given concurrent MISSION implementation.

Design, setting, and participants: This cross-sectional study used data from the VA's Corporate Data Warehouse for fiscal years 2019 to 2021 (October 1, 2018, to September 30, 2021). Participants included Black, Hispanic, and White veterans with a new consultation for outpatient cardiology and/or orthopedic services during the study period. Multivariable mixed-effects models were used to estimate individual-level adjusted wait times and a likelihood ratio test of the significance of wait time disparity change over time.

Main outcomes and measures: Overall mean wait times and facility-level adjusted relative mean wait time ratios.

Results: The study included 1 162 148 veterans (mean [SD] age, 63.4 [14.4] years; 80.8% men). Significant wait time disparities were evident for orthopedic services (eg, Black veterans had wait times 2.09 [95% CI, 1.57-2.61] days longer than those for White veterans) in the pre-COVID-19 period, but not for cardiology services. Mean wait times increased from the pre-COVID-19 to COVID-19 periods for both services for all 3 racial and ethnic groups (eg, Hispanic wait times for cardiology services increased 5.09 [95% CI, 3.62-6.55] days). Wait time disparities for Black veterans (4.10 [95% CI, 2.44-5.19] days) and Hispanic veterans (4.40 [95% CI, 2.76-6.05] days) vs White veterans (3.75 [95% CI, 2.30-5.19] days) increased significantly from the pre-COVID-19 to COVID-19 periods (P < .001). During the COVID-19 period, significant disparities were evident for orthopedic services (eg, mean wait times for Hispanic vs White veterans were 1.98 [95% CI, 1.32-2.64] days longer) but not for cardiology services. Although there was variation in wait time ratios across the 140 facilities, only 6 facility wait time ratios were significant during the pre-COVID-19 period and 26 during the COVID-19 period.

Conclusions and relevance: These findings suggest that wait time disparities increased from the pre-COVID-19 to COVID-19 periods, especially for orthopedic services for both Black and Hispanic veterans, despite MISSION's goal to improve access. Facility-level analyses identified potential sites that could be targeted to reduce disparities.

Figure 1.. Adjusted Facility Risk Ratios by Race and Ethnicity and Time Period for Cardiology Consultations

The pre–COVID-19 period was designated as October 1, 2018, to March 10, 2020; the COVID-19 period was designated as March 11, 2020, to September 30, 2021. VA indicates US Department of Veterans Affairs.

Figure 2.. Adjusted Facility Risk Ratios by Race and Ethnicity and Time Period for Orthopedics Consultations

The pre–COVID-19 period was designated as October 1, 2018, to March 10, 2020; the COVID-19 period was designated as March 11, 2020, to September 30, 2021. VA indicates US Department of Veterans Affairs.