Donna Washington, MD, MPH
LOS ANGELES — When Donna Washington, MD, MPH, moved to Los Angeles for a health services fellowship at UCLA following her residency, she imagined that she would end up working in a county or public health system.
That was where the most vulnerable patients were—those who were the most deeply impacted by racial, ethnic, and gender disparities in healthcare. While, like many physicians, she had rotated through VA facilities during medical school, she didn’t consider it a viable career choice.
She quickly discovered that not only was Los Angeles a health services research mecca but that VA offered Washington something that most research institutions cannot—the opportunity to see her research move from conception, to execution, to implementation nationwide.
Over the last 20 years, Washington’s research has laid the foundation for VA’s understanding of how race, ethnicity, gender, and socioeconomic status intersect with veteran healthcare and led directly to improvements in how the department provides that care.
“One of the unique aspects of the VA is that they have their internally funded research, basically coupling research and clinical operations,” Washington explained. “It’s an opportunity to put what we study into practice. Not just do this work in a vacuum but do something that’s translated into real benefits for vulnerable patients.”
“The veterans who use the VA differ from the larger population,” she added. “They’re more vulnerable, more likely to be members of groups underserved in healthcare. Other than the gender imbalance, [when I arrived] it very much looked like much of the other settings I was interested in practicing in.”
Washington’s work has followed two main tracks—one focusing on women veterans, another focusing on race, ethnicity, and socioeconomic status. Her attention has shifted between the two but has never neglected either.
When she first arrived at the Greater Los Angeles VA Healthcare System, the conversation was around women veterans. Specifically, it was about the need to understand what the barriers were for women to access VA care.
Washington was one of the key researchers designing those first studies, which included the National Survey of Women Veterans—a national telephone survey conducted in 2008-2009 that looked at both VA and non-VA users to see what was keeping women out of VA facilities. That survey, along with other studies, allowed VA to define what barriers existed. After that, the question became what were the best ways to overcome those barriers and improve access and care.
“It was a wonderful opportunity for me to first participate in and then lead some of the studies into healthcare delivery models for women veterans,” Washington said. “Things we take for granted now, we didn’t really know then. Of course having designated primary care providers for women or designated clinics for women are the ideal model. But myself and Dr. Becky Yano were the ones who did the studies to measure that difference of experiences and quality of care.”
At other moments in her career, the focus has shifted to race, ethnicity, and socioeconomics. Early in her career at VA, there was little understanding where the gaps in care were.
“Outside VA there are huge disparities in healthcare for racial and ethnic minorities. Within VA we knew the potential for disparities to be smaller. But there wasn’t really good information on what the gaps were in care.”
To help provide answers, VA created the Health Equity Quality Enhancement Research Initiative (QUERI) Center, where Washington serves as principal investigator. Funded in 2015, the center takes a population health approach to systematically identify where the gaps in healthcare are for vulnerable groups.
During the first years of the center’s existence, Washington and her colleagues focused on developing methods to better measure care for these veterans. For smaller populations like American Indian and Alaskan Native veterans, this was the first time methods were created by VA to gather data on them at all. For larger groups like black and Hispanic veterans, there had never been a systematic assessment of all the different aspects of their health and healthcare.
“We were able to identify and characterize the completeness and accuracy of race and ethnicity data in VA and really understand better the variations in the quality of that data,” Washington explained. “That’s informing a current initiative by the Office of Health Equity, where they’re going to the sites that have the biggest gaps in the quality of their data and working with them to improve that. One way I like to think about it is if you can’t measure it accurately, you can’t improve it.”
Social Determinants
That data cannot be limited to what’s generated when a patient visits a healthcare facility, Washington noted. More and more, researchers must expand their focus to include patients’ lives and communities, and to work to better understand the social determinants of health.
When the pandemic started, Washington and her colleagues began tracking racial and ethnic disparities in COVID infection and outcomes for VA patients. They also cross-referenced VA data with U.S. Census data to understand the characteristics of residential areas that were more deeply impacted by the pandemic. That provided information like what percentage of residents are reliant on public transportation and which don’t have reliable plumbing—both of which increased vulnerability to infection.
“At the beginning of the pandemic [I began] identifying patients who looked like they had the greatest disease burden and calling them and find out how they were doing,” Washington said. “I called one of my patients during a time when many of the states had put stay-at-home orders in place. This patient told me she was going out every day to shop for food. She didn’t have a working refrigerator.”
Shocked and appalled, Washington put the patient in touch with a VA social worker who connected her with a program that was able to provide her with a working refrigerator.
“That really reinforces the reality of how these social determinants translate to greater risk of infection and disease burden.”
The last year and a half has also driven home for Washington, and for many in the healthcare industry, that there are still institutional barriers, not just at VA but everywhere.
“Terms like structural racism weren’t part of our everyday vocabulary a few years ago. Now we have a better understanding that there are unintended consequences to the way that care is structured that lead to worse outcomes for certain groups,” Washington said. “That’s the next place. Turning our eyes to thinking about healthcare and figuring it out. What works and what needs tweaking — sort of lift the lid on some of the processes of care that we take for granted.”