The association between low clinic reach and racial disparity in trauma-focused psychotherapy initiation across the US Veterans Health Administration: Secondary analysis of national program evaluation data

Abstract

Reach of trauma-focused psychotherapies (TFPs) varies across clinics for posttraumatic stress disorder (PTSD) in the US Veterans Health Administration but it is unknown if access is equitable across patient subgroups. We conducted secondary analysis of program evaluation data to examine the association between clinic reach (low vs. high) and racial equity in TFP initiation over time. We compared the odds of TFP initiation for Black and White patients and changes in the odds of TFP initiation using Difference in Difference effect estimation. 60,607 (18,671 Black and 41,936 White) patients with PTSD received psychotherapy in one of 112 PTSD clinics (17 in the Northeast, 42 in the South, 29 in the Midwest, 24 in the West) across two 6-month evaluation periods (July 2020–December 2020; October 2021–March 2022). There was no difference between race groups in the odds of TFP initiation in the 61 clinics with high baseline reach. In the 51 clinics with low baseline reach, Black patients had reduced odds of TFP initiation (adjusted odds ratio [AOR] = 0.821, 95% Confidence Interval [CI]: 0.718–0.938). When reach improved at follow-up, there was no longer a race-group difference in the odds of TFP initiation. The magnitude of improvement in the odds of TFP initiation was greater for Black than White patients (adjusted ratio of odds ratios [ROR] = 1.196; 95% CI: 1.018–1.438). Research should evaluate whether there are subgroups disproportionately disadvantaged by limited reach of an evidence-based intervention and whether strategies to improve access also impact health care equity.