title: Racial/ethnic differences in initiation of and engagement with addictions treatment among patients with alcohol use disorders in the veterans health administration.
abstract: Specialty addictions treatment can improve outcomes for patients with alcohol use disorders (AUD). Thus, initiation of and engagement with specialty addictions treatment are considered quality care for patients with AUD. Previous studies have demonstrated racial/ethnic differences in alcohol-related care but whether differences exist in initiation of and engagement with specialty addictions treatment among patients with clinically recognized alcohol use disorders is unknown. We investigated racial/ethnic variation in initiation of and engagement with specialty addictions treatment in a national sample of Black, Hispanic, and White patients with clinically recognized alcohol use disorders (AUD) from the US Veterans Health Administration (VA).
  
  
  
  National VA data were extracted for all Black, Hispanic, and White patients with a diagnosed AUD during fiscal year 2012. Mixed effects regression models estimated the odds of two measures of initiation (an initial visit within 180days of diagnosis; and initiation defined consistent with Healthcare Effectiveness Data and Information Set (HEDIS) as a documented visit ≤14days after index visit or inpatient admission), and three established measures of treatment engagement (≥3 visits within first month after initiation; ≥2 visits in each of the first 3months after initiation; and ≥2 visits within 30days of HEDIS initiation) for Black and Hispanic relative to White patients after adjustment for facility- and patient-level characteristics.
  
  
  
  Among 302,406 patients with AUD, 30% (90,879) initiated treatment within 180days of diagnosis (38% Black, 32% Hispanic, and 27% White). Black patients were more likely to initiate treatment than Whites for both measures of initiation [odds ratio (OR) for initiation: 1.4, 95% confidence interval (CI) 1.4-1.4; OR for HEDIS initiation: 1.1, 95% CI: 1.1-1.1]. Hispanic patients were more likely than White patients to initiate treatment within 180days (OR: 1.2, 95% CI 1.2-1.3) but HEDIS initiation did not differ between Hispanic and White patients. Engagement results varied depending on the measure but was more likely for Black patients relative to White for all measures (OR for engagement in first month: 1.1, 95% CI: 1.0-1.1; OR for engagement in first three months: 1.2, 95% CI: 1.1-1.2; OR for HEDIS measure: 1.1, 95% CI: 1.0-1.1), and did not differ between Hispanic and White patients.
  
  
  
  After accounting for facility- and patient-level characteristics, Black and Hispanic patients with AUD were more likely than Whites to initiate specialty addictions treatment, and Black patients were more likely than Whites to engage. Research is needed to understand underlying mechanisms and whether differences in initiation of and engagement with care influence health outcomes.
authors.affiliation: Department of Health Services, Magnuson Health Sciences Center, University of Washington, 1959 NE Pacific St, Room H-680, Box 357660, Seattle, WA, 98195-7660, USA; Veterans Health Administration (VA), Denver Seattle Center of Innovation for Veteran-Centered Value Driven Care, VA Puget Sound Health Care System, 1660 S. Columbian Way, Mailstop S-152, Seattle, WA 98108, USA. Electronic address: kbensley@uw.edu.
authors.forename: Kara M
authors.initials: KM
authors.lastname: Bensley
authors.affiliation: Center for Innovation to Implementation, VA Palo Alto Health Care System, Center for Innovation to Implementation, 795 Willow Road (152-MPD), Menlo Park, CA, 94025, USA. Electronic address: Alexander.Harris2@va.gov.
authors.forename: Alex H S
authors.initials: AH
authors.lastname: Harris
authors.affiliation: Center for Innovation to Implementation, VA Palo Alto Health Care System, Center for Innovation to Implementation, 795 Willow Road (152-MPD), Menlo Park, CA, 94025, USA. Electronic address: Shalini.Gupta2@va.gov.
authors.forename: Shalini
authors.initials: S
authors.lastname: Gupta
authors.affiliation: Center for Innovation to Implementation, VA Palo Alto Health Care System, Center for Innovation to Implementation, 795 Willow Road (152-MPD), Menlo Park, CA, 94025, USA. Electronic address: Anna.Rubinsky@va.gov.
authors.forename: Anna D
authors.initials: AD
authors.lastname: Rubinsky
authors.affiliation: University of Minnesota, Division of Epidemiology & Community Health, 1300 South Second Street, Suite 300, Minneapolis, MN 55454, USA. Electronic address: jones010@umn.edu.
authors.forename: Rhonda
authors.initials: R
authors.lastname: Jones-Webb
authors.affiliation: University of Wisconsin-Madison, 307 School of Social Work, University of Wisconsin-Madison, 1350 University Ave., Madison, WI 53706, USA. Electronic address: jglass2@wisc.edu.
authors.forename: Joseph E
authors.initials: JE
authors.lastname: Glass
authors.affiliation: Department of Health Services, Magnuson Health Sciences Center, University of Washington, 1959 NE Pacific St, Room H-680, Box 357660, Seattle, WA, 98195-7660, USA; Veterans Health Administration (VA), Denver Seattle Center of Innovation for Veteran-Centered Value Driven Care, VA Puget Sound Health Care System, 1660 S. Columbian Way, Mailstop S-152, Seattle, WA 98108, USA. Electronic address: Emily.Williams3@va.gov.
authors.forename: Emily C
authors.initials: EC
authors.lastname: Williams
mesh_terms: D000328:Adult; D001741:Black or African American / Q000208:ethnology*; D000368:Aged; D019973:Alcohol-Related Disorders / Q000208:ethnology* / Q000628:therapy*; D005260:Female; D006630:Hispanic or Latino / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010342:Patient Acceptance of Health Care / Q000208:ethnology*; D014481:United States / Q000208:ethnology; D014493:United States Department of Veterans Affairs / Q000706:statistics & numerical data; D058014:Veterans Health / Q000208:ethnology*; D044465:White People / Q000208:ethnology*; D055815:Young Adult
keywords: Alcohol use disorder; Ethnicity; Race; Treatment; Utilization, veterans