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Research on Health Care for Priority Populations
Health Care for Minorities,Women, and Children
The agency's research emphasizes the needs of priority populations who generally are underserved by the health care system and underrepresented in research. Disparities in health care have been well-documented in recent decades across a broad range of medical conditions and for a wide range of populations, including racial and ethnic minorities, women, and children.
Disparities persist in health and health care for these groups, even though health care for the Nation as a whole has improved. For example:
- Cancer mortality rates are 35 percent higher in blacks than whites.
- Before age 75, women are more likely than men to die in the hospital after a heart attack, and women typically receive fewer high-technology cardiac procedures than men.
- Among diabetes patients, blacks are seven times more likely than whites to have amputations and develop kidney failure.
- Cervical cancer occurs five times as often in Vietnamese women in the United States as in white women.
- Infant mortality is nearly 2-1/2 times higher among blacks than among whites.
- Among preschool children hospitalized for asthma, only 7 percent of black and 2 percent of Hispanic children, compared with 21 percent of white children, are prescribed routine medications to prevent future asthma-related hospitalizations.
AHRQ has established the Office for Priority Populations Research to coordinate, support, manage, and conduct health services research on priority populations. AHRQ has a long history of conducting and supporting research on health status and health care for priority populations. Since 1999, AHRQ has funded more than 200 grants and contracts specifically related to health disparities. AHRQ is continuing a major effort, begun several years ago, to identify underlying causes of inequities in care and develop and test quality measures and quality improvement strategies that can be used to address health care disparities.
AHRQ is developing the first-ever report on prevailing disparities in health care delivery in the United States. Recent reauthorization legislation directed AHRQ to prepare and publish this report annually, beginning in 2003. This effort will be carried out in partnership with other agencies to ensure compatibility with other existing projects, including AHRQ's National Healthcare Quality Report, also in progress, Healthy People 2010, and the Department's survey integration priorities. The National Healthcare Disparities Report (NHDR) will begin to provide comprehensive answers to critical questions about disparities in health care, such as:
- Are death rates for some inpatient procedures higher for members of certain racial/ethnic groups than for others?
- Are blacks or Hispanics less likely than whites to receive necessary services?
- Are uninsured patients more likely to receive surgery in hospitals with higher rates of medical errors?
Select for more information in this report about the NHDR.
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AHRQ has been investigating minority health issues for more than three decades. These investments in minority health services research have resulted in numerous findings that are helping us to understand the disparities experienced by racial and ethnic minorities, uncover the reasons for the disparities, and identify effective strategies for overcoming and eliminating racial/ethnic disparities.
In FY 2002, AHRQ funded about $50 million in research with a major emphasis on minority health. This effort includes continued funding of the Excellence Centers to Eliminate Ethnic/Racial Disparities (EXCEED) grants, a research effort to improve our understanding of the factors that contribute to ethnic and racial inequities in health care.
Other current AHRQ research projects focused on ways to eliminate racial disparities in health care include:
- A randomized controlled trial underway at Meharry Medical College is assessing a new method for translating prevention research into practice. A nurse-mediated, single standard of practice model is being compared with physician reminders, a more traditional approach to improving adherence to recommended prevention services. Pilot testing found the single standard of practice model to be associated with substantial, sustained improvements in preventive services delivery. Physicians within the Meharry Medical Practice Plan are following nearly 900 patients from primary care clinics serving low-income, largely Medicaid-eligible populations for 2 years to measure the frequency with which preventive services are delivered and track demographic and clinical information, as well as information on physical and social functioning. The project is addressing five priority areas for reducing disparities: infant mortality, cardiovascular disease, cancer screening, HIV/AIDS, and adult and child immunizations. The project includes a partnership between researchers at two Historically Black Colleges and Universities (Meharry Medical College and Tennessee State University) and a health care practice. The objective is to magnify and accelerate the impact of the findings on clinical practice in settings that serve Medicaid populations.
- AHRQ and the Health Resources and Services Administration are working in partnership to facilitate an assessment of the Health Disparities Collaboratives, which have been used in hundreds of HRSA's community health centers to improve the quality of care they provide for a number of chronic conditions such as asthma, diabetes, and cardiovascular disease. The results of this evaluation will be very useful to HRSA and to health care organizations around the country that are looking for ways to improve care for chronic conditions, especially in settings with large numbers of vulnerable patients.
Racial/Ethnic Disparities and HIV
A nationwide study sponsored by AHRQ found that black and Hispanic patients with HIV are only about half as likely as non-Hispanic white patients to participate in clinical trials of new medications intended to slow progression of HIV.
Together, blacks and Hispanics comprise nearly half (48 percent) of the HIV population—33 percent of patients are black and 15 percent are Hispanic. Yet only 10 percent of black patients and 11 percent of Hispanic patients had participated in an HIV clinical trial, compared with 18 percent of white HIV patients. Also, black patients who did participate were more likely than other patients to drop out of the research.
These findings underscore the need to increase the diversity of trial populations. To do so, we must carefully consider research-entry criteria, enrollment and tracking procedures, and study center operations, as well as researchers' attitudes and practices. Other factors include patients' educational levels, type of insurance, and the distance patients must travel to the clinical trial site.
Examples of recent findings from AHRQ-supported research in this area include:
- Recently reported data from the Medical Expenditure Panel Survey (MEPS) show that slightly more than half of Americans aged 18 and older (53.8 percent) always received urgent medical care as soon as they wanted it in calendar year 2000. Although there was very little difference between blacks and whites aged 18 to 64 in their reports of timeliness of receiving urgent care (51.5 percent and 52.9 percent, respectively), significantly fewer Hispanics (41.2 percent) reported always receiving urgent care when they wanted it.
- Data from the Healthcare Cost and Utilization Project (HCUP) demonstrated that Hispanics were significantly less likely to undergo numerous major therapeutic procedures than whites.
- Patients of various ethnic and racial groups have different attitudes toward primary care physicians. Among different Asian ethnic subgroups, Chinese and Filipino patients were less likely to be satisfied with their physicians, and Japanese patients were less likely to say they would recommend their doctor. Hispanic patients rated physicians' accessibility and technical skills less favorably than did white patients. Black patients gave physicians' use of the latest technology, promotion of healthy lifestyles, and psychosocial techniques a higher rating than white patients.
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AHRQ supports research focused on improving quality, achieving better outcomes, and enhancing access to effective health care for women. One specific focus of AHRQ's women's health agenda is research that enhances active life expectancy for older women. Although women in the United States are living longer than ever before, on average they experience 3.1 years of disability at the end of life. Today, heart disease, cancer, and stroke account for more than 60 percent of deaths among American women; more than one-third of deaths among women are due to heart disease.
Although we have made progress in early diagnosis and treatment of breast cancer, this disease continues to take a heavy toll on American women, particularly older women. Approximately 185,000 new cases of breast cancer are diagnosed among U.S. women each year, and nearly 45,000 women die from the disease.
AHRQ conducts and supports research on all aspects of health care provided to women, including studies that examine the differences in patterns of care between men and women. AHRQ is collaborating with the National Institutes of Health, Office of Research on Women's Health, in the Building Interdisciplinary Research Careers in Women's Health program to include a health services research component in support of the interdisciplinary focus of the programs to be developed.
AHRQ's women's health research agenda supports studies that are designed to:
- Enhance care for women with chronic illnesses and disabilities.
- Identify and reduce disparities in the health care of minority women.
- Address the health needs of women living in rural areas.
Examples of AHRQ-funded women's health research currently underway include:
- Evidence-Based Decision Aids to Improve Women's Health. This researcher is developing and testing a Web-based decision support tool that will help pregnant women weigh the benefits, risks, and consequences associated with various childbirth options. The goal is to improve shared decisionmaking, increase patient satisfaction, and reduce postpartum depression.
- Variability in Interpretation of Mammograms. In this project underway at the University of Washington, researchers are evaluating data on more than 500,000 mammograms from 91 facilities and 279 radiologists. Three geographically distinct breast cancer surveillance programs in the States of Washington, New Hampshire, and Colorado are collaborating in the study. The goal is to determine the reasons for variability among radiologists and mammography facilities in the interpretation of mammograms and to use that information to improve the quality of mammography.
- Treatment of Noncancerous Uterine Conditions. Researchers at the University of Maryland and the University of California, San Francisco, are conducting 5-year projects focused on the effectiveness of different treatments, such as medication and endometrial ablation, for noncancerous uterine conditions (for example, dysfunctional uterine bleeding, fibroid tumors, and endometriosis).
- Women's Experiences of Postpartum Care. Researchers from Brandeis University are investigating how social support, social class, and race/ethnicity affect women's experiences of postpartum services provided in the hospital and at home during the first week after uncomplicated labor and delivery. They will interview women who have given birth, physicians, midwives, and nurses on postpartum units in two hospitals, one in Toronto and one in Boston.
- Acupuncture Treatment of Depression During Pregnancy. In this randomized controlled study, researchers are assessing the efficacy and effectiveness of acupuncture treatment of depression during pregnancy in 180 ethnically diverse pregnant women who meet established diagnostic criteria for major depression. The acute phase of treatment consists of 16 half-hour treatment sessions delivered over 8 weeks. Participants who have full or partial response at the end of the acute phase will continue to receive treatment, although less frequently, until 10 weeks postpartum. Participants will be followed for 6 months after delivery.
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Breast and Cervical Cancer
Examples of recent findings from AHRQ research on breast and cervical cancer include:
- Outpatient mastectomy. Outpatient complete mastectomies increased dramatically in five States between 1990 and 1996: Colorado, Maryland, New Jersey, New York, and Connecticut. AHRQ researchers uncovered two key factors that influence whether a woman gets a complete mastectomy in the hospital or in an outpatient setting: the State where she lives and who is paying for it. Women in New York were more than twice as likely, and in Colorado nearly nine times as likely, as women in New Jersey to have outpatient surgery. Nearly all women covered by Medicaid or Medicare were kept in the hospital after surgery, as were 89 percent of women who had HMO coverage.
- Breast and cervical cancer screening in disabled women. Researchers from Harvard Medical School found that disabled women who have difficulty walking are less likely than other women to receive Pap smears and mammograms. Contributing factors include inaccessible examination tables and mammography equipment, physician concerns about positioning the women on exam tables, inadequate or biased attitudes of clinicians regarding the women's sexuality, and time pressures on physicians in busy practices.
- Breast cancer in older women. More than 50 percent of all breast cancers are diagnosed in women 65 years of age and older. Yet elderly women are less inclined than younger women to get mammograms. In this study of 718 elderly breast cancer patients with newly diagnosed stage I or stage II disease at 29 hospitals in 5 regions, use of mammography was associated with earlier detection and a higher likelihood of receiving breast conserving surgery with radiation than other therapies.
- Breast cancer screening in hard-to-reach populations. Researchers have documented that poor and minority women receive fewer mammograms than other women. In this study, AHRQ-supported researchers used less traditional approaches—such as providing information through churches and community-based organizations—to increase mammography screenings. Over the past two decades, AHRQ has cosponsored research that supported mobile mammography screening vans, an intervention that has increased access to mammography for poor and minority women.
- Use of telecolposcopy in rural areas. Women who have abnormal Pap smears usually are referred for followup evaluation by traditional colposcopy (use of a magnifying instrument to examine vaginal and cervical tissue). Rural women may have to travel long distances to receive this standard of care. This AHRQ-supported research demonstrated the accuracy and efficacy of telecolposcopy—in which local doctors confer with distant experts by electronically transmitting an image of the colposcopy— in rural areas. This technology may solve the travel problem for rural women and thereby enhance their access to early diagnosis and treatment of cervical cancer.
Selected Findings from AHRQ-Supported Studies on Women's Health
- The incidence of coronary heart disease in women has increased over the past decade, yet evidence suggests that women typically receive fewer high technology cardiac procedures than men. Before age 75, women are more likely than men to die in the hospital after a heart attack.
- ER doctors misdiagnose about 2 percent of patients with heart attack or stable angina because they do not have chest pain or other symptoms typically associated with heart attack. When these patients are mistakenly sent home from the ER, they are twice as likely to die from their heart problems as similar patients who are admitted to the hospital.
- Blacks and women have statistically significant lower odds of being referred for cardiac catheterization than whites and men.
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Another major focus for AHRQ's research on women's health involves studies to improve the response of health care organizations and clinicians to victims of domestic violence, the second leading cause of injuries and death among women of childbearing age. Estimates are that 2 percent to 4 percent of all women seen in hospital emergency departments have acute trauma associated with domestic violence, and another 10 to 12 percent of women have a recent history of domestic violence. Although most injuries sustained as a result of domestic violence are classified as superficial, an estimated 73,000 hospitalizations and 1,500 deaths among women are attributed to domestic violence every year. Direct health care costs associated with domestic violence are estimated to be $1.8 billion per year.
Examples of AHRQ activities focused on domestic violence include:
- Developing a tool for assessing hospital-based domestic violence screening and intervention programs (see box for more details).
- Developing a research-based performance standard for health care provided to victims of domestic violence.
- Convening a meeting of experts to develop a health services research agenda focused on the health aspects of domestic violence. This activity is in collaboration with other HHS agencies.
- Hosting a senior scholar-in-residence to work on projects that will provide information on the cost, quality, and outcomes of domestic violence intervention programs in health care settings.
- Developing a report to Congress on evidence-based clinical practices used by health professionals who provide care to victims of sexual assault—including child molestation—and training of health professionals in performing medical evidentiary examinations for victims of sexual assault, elder abuse, domestic violence, and child abuse and neglect.
AHRQ Tool Helps Hospitals Assess Their Domestic Violence Programs
AHRQ recently announced the availability of a new evaluation instrument that hospitals can use to assess the quality and effectiveness of their domestic violence screening and intervention programs. The tool asks 38 questions and provides guidance to hospitals in assessing their programs.
Hospitals can use this instrument to find out how well they are doing in:
- Training clinicians to recognize domestic violence.
- Screening patients to determine risk and potential for future injury.
- Intervening, including medical treatment, victim advocacy services, and followup.
The tool was developed by AHRQ's Domestic Violence Senior Scholar-in-Residence in collaboration with the Family Violence Prevention Fund. Many nationally known experts in the field provided their expertise to the project, and the tool has been extensively field-tested.
The instrument and instructions for its use are available from AHRQ in print and on the agency's Web site at http://www.ahrq.gov/research/domesticviol/.
In FY 2002, AHRQ continued four research projects begun in FY 2000 to evaluate health system responses to domestic violence. These studies are the first of their kind and move beyond studying prevalence, screening, and training to take a rigorous look at a variety of health care interventions for domestic violence and their effectiveness. Women are being evaluated over time to identify interventions that improve their health and safety, predict and improve health care use, prevent and reduce the occurrence of domestic violence, and develop better techniques to identify women at risk for domestic violence.
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Children and adolescents are growing and developing, and their health care needs, use of services, and outcomes are very different from those of adults. Unlike adults, children and adolescents usually are dependent on parents and others for access to care and evaluations of the quality of that care. Furthermore, adolescents differ from younger children. They are moving from childhood to adulthood and have their own unique health care needs, preferences, and patterns of use.
Improving outcomes, quality, and access to health care for America's 70 million children and adolescents is a continuing priority for AHRQ. This special research focus is necessary if we are to realize improvements in the health care provided to young people of all ages.
AHRQ's work helps to fill the major gap that exists in evidence-based information on the health care needs of children and adolescents. Such information is essential to appropriately guide clinical and policy decisions. A special urgency was created with implementation of the State Child Health Insurance Program (SCHIP) and our need to have better information about children's health status, their needs, and their outcomes.
To address the scarcity of quality measures for children, AHRQ is supporting the development, testing, and implementation of the new Pediatric Quality of Life Measure. Also, the National Committee for Quality Assurance adopted the children's component of AHRQ's CAHPS® survey for inclusion in HEDIS®. CAHPS® is the first health-plan-oriented survey of children to be administered nationwide. The CAHPS® measure now permits users to distinguish quality of care for children with chronic illnesses and disabilities.
In FY 2002, AHRQ is supporting child-relevant studies focused on outcomes, quality and patient safety, the use and cost of care, and access to care. Researchers involved in these studies are working to:
- Develop the first comprehensive analysis of the management of suspected child abuse in primary care practices.
- Develop and evaluate a computerized laptop system for use in the examining room of primary care physicians as an extension of an existing in-house prescribing system to improve the care of children with attention-deficit hyperactivity disorder.
- Establish a Developmental Center for Education and Research in Patient Safety in neonatal intensive care to reduce medical errors and enhance patient safety for high-risk newborns.
- Determine whether the skills acquired within a simulated environment can be put into practice in the delivery room and whether practicing these skills results in improved patient safety.
- Investigate the impact of having a child with asthma and the burden this condition causes on the family's resources (finances, parents' time and availability to provide care for the child, and access/barriers to health care).
Examples of recent findings from AHRQ-supported research on children's health issues include:
- Care for children with asthma. National asthma care guidelines stress the importance of reducing indoor allergens and irritants that worsen childhood asthma. However, few parents in this study had adopted such environmental control measures. Researchers at Northwestern University studied 638 children (ages 3 to 15 years) with asthma; 30 percent lived in households that included a smoker, 18 percent had household pests (cockroaches or mice), and 59 percent had furry pets. Other exposures included bedroom carpeting (78 percent), increasing exposure to dust mites. Most children did not have appropriate mattress covers (65 percent) or pillow covers (84 percent) to reduce exposure to dust mites. Receipt of instructions about how to reduce environmental triggers was not associated with efforts to do so—45 percent of parents had received written instructions about avoiding asthma triggers, and 42 percent had discussed household asthma triggers with a clinician in the past 6 months. The researchers note that some household asthma triggers closely linked to housing problems (e.g., cockroaches and mold due to unrepaired leaks) may be difficult for families living in multi-unit buildings to change.
- Lack of health insurance among adolescents. A study of the health insurance status of a nationally representative sample of 17,670 middle and high school students found that adolescents who live outside of two-parent families are significantly more likely to be uninsured than adolescents in two-parent families. Adolescents living in households headed by grandparents are the most likely to be uninsured, according to researchers in AHRQ's Center for Cost and Financing Studies.
- Triage of pediatric trauma victims. AHRQ-supported researchers at Harbor-UCLA Medical Center have identified three critical factors that will help emergency medical personnel quickly and appropriately triage children involved in car crashes. The three factors are: evaluating the child's degree of consciousness (coma score), determining the extent of passenger space intrusion from the other car or object, and identifying appropriate use of seatbelt or other restraint. According to the researchers, this triage approach could potentially prevent 80 fatalities per year in children younger than 16 years involved in car crashes. These findings are from the largest pediatric trauma triage study of motor vehicle crashes ever conducted. It involved 8,394 children up to 15 years of age who were involved in motor vehicle crashes from 1993 through 1999.
Selective testing finds most urinary tract infections in infants. The current recommendation is that doctors test the urine of all febrile infants younger than 3 months for urinary tract infection (UTI). Instead, many physicians test the urine of young infants with fever according to their clinical judgment rather than routinely.
Although this differs from the recommendations, a recent AHRQ study found few late diagnoses of UTIs among more than 800 infants whose urine was not initially tested and who were not initially treated with antibiotics. According to the researchers, doctors tend to order urine tests selectively, focusing on younger and more ill-appearing febrile infants and those who have no apparent fever source.
They studied the urine testing practices of 573 pediatricians from 219 practices who evaluated and treated 3,066 infants 3 months or younger with a temperature of 100.4ºF or higher. Over half (54 percent) of the infants initially had their urine tested, and 10 percent of those tested had a UTI. Among 807 patients not initially tested or treated with antibiotics, only 2 had a subsequent documented UTI, and both did well. Male infants who were not circumcised had nearly 12 times the likelihood of UTI, females had 5 times the likelihood of UTI, compared with circumcised infants, and infants with a fever lasting 24 or more hours had 80 percent greater odds of developing UTI.
The researchers conclude that urine testing should focus on uncircumcised boys, girls, the youngest (bacteremia rates among infants with a UTI ranged from 6 percent in 2-3 month-old infants to 17 percent in infants younger than 1 month) and sickest infants, and those with persistent fever.
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