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AHRQ's Commitment to Improved Health Care for Priority Populations
The overall health of the American population has improved over the past few decades, but all Americans have not shared equally in these improvements. Among non-elderly adults, for example, 17 percent of Hispanic, and 16 percent of black Americans report they are in only fair or poor health, compared with 10 percent of white Americans.
- How much do differences in the health care that people receive contribute to disparities in health?
- What strategies can overcome these differences in care?
These are questions for health services research.
In Fiscal Year 2001, AHRQ began a major new research effort, entitled EXCEED (Excellence Centers to Eliminate Ethnic/Racial Disparities), that will improve knowledge of the factors underlying ethnic and racial inequities in health care. EXCEED will help identify practical tools and strategies to eliminate these disparities. Each project will consist of a group of four to seven studies organized around a central theme. Select for the newly funded projects.
Excellence Centers to Eliminate Ethnic/Racial Disparities (EXCEED)
Racial and Ethnic Variation in Medical Interactions. The researchers will assess the extent to which problems in doctor-patient communication contribute to racial and ethnic disparities in health care use (Baylor College of Medicine).
Overcoming Racial Health Disparities. These researchers will establish a center of excellence on overcoming racial health disparities in African American adults, particularly in rural settings (University of North Carolina).
Improving the Delivery of Effective Care to Minorities. The goal of this research project is to measure the underuse in Harlem of selected medical and surgical interventions that are known to be effective. The researchers will assess the reasons for the underuse and develop, implement, and evaluate ways to eliminate the underuse when appropriate (Mount Sinai School of Medicine).
Understanding and Reducing Native Elder Health Disparities. Four health issues of particular importance to elderly American Indians and Alaska Natives will be addressed. They are: the quality of care for diabetes, the delivery of clinical preventive services (such as immunizations for influenza and pneumonia), cancer screening, and smoking cessation (University of Colorado Health Center).
Access and Quality of Care for Vulnerable Black Populations. The researchers will explore ways to improve health care access and quality for vulnerable African Americans, particularly adults who are chronically ill and low-income children. Their goal is to identify opportunities to intervene and effective interventions to address disparities in access and quality (Morehouse School of Medicine).
Health Disparities in Minority Adult Americans. The goal of this project is to address differences between white and minority elderly populations in health status and the use of health services. It combines community linkages with academic resources to focus on health care for African Americans through effective communication and culturally sensitive health care (University of Pittsburgh).
UCLA/DREW/RAND Program to Address Disparities in Health. In this collaborative project, researchers will establish a multidisciplinary program to address racial and ethnic disparities in health. Their goal is to enhance understanding of the factors that influence health care use and behavior (University of California, Los Angeles).
Understanding and Eliminating Health Disparities in Blacks. The goal of this project is to identify solutions to known disparities in health status between African Americans and whites living in South Carolina, including those in rural areas. The researchers will focus on interventions related to providers and provider/patient interactions (Medical University of South Carolina).
Promoting Effective Communication and Decisionmaking For Diverse Populations. The researchers will assess ways to promote effective communication and decisionmaking in diverse populations. They hypothesize that racial and ethnic disparities in health may be related to less effective communication and decisionmaking skills in minorities compared with whites, which may lead to differences in the technical process of care that affect outcomes (University of California, San Francisco).
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Because children are growing and developing, they use care in ways that differ from the health care patterns of adults. Their important outcomes may differ, and, unlike adults, they are usually dependent on parents and others for access to care and evaluations of the quality of that care. Adolescents, in the transition to adulthood, also have their own unique health care needs, preferences, and patterns of use.
In Fiscal Year 2000, AHRQ significantly enhanced its child health activities by funding a substantial amount of new research and conducting research syntheses. In Fiscal Year 2000, AHRQ distributed funding for grants totaling over $18 million focusing on children.
AHRQ expanded its portfolio in quality improvement research in children's health care, and supported research on racial and ethnic disparities in care for pregnant women and newborn babies. Strategies in quality improvement are being evaluated for additional conditions and processes of care, including adolescent preventive services and acute otitis media. The range of settings for quality improvement research was broadened to include community health centers and Head Start facilities as well as academic and other health care facilities.
AHRQ also published evidence reports on two common pediatric acute conditions: sinusitis and otitis media (ear infections), and continued its work in partnership with private health care organizations. AHRQ evidence reports provided the scientific basis for American Academy of Pediatrics guidelines in diagnosis and treatment of attention deficit hyperactivity disorder (ADHD) and acute otitis media.
Research Finding. Acute otitis media (AOM or an ear infection) is one of the most common diagnoses in children. An AHRQ EPC estimates that over 5 million episodes of AOM occur each year at a cost of approximately $3 billion. It is routine to use antibiotics for AOM in the United States, whereas in other countries, such as the Netherlands, the standard practice is to use "watchful waiting" for one to two days after the onset of an ear infection in children over 2 years of age, treating only if the infection fails to improve during that time.
Although the EPC did not evaluate bacterial resistance to antibiotics, it has been reported that the rate of bacterial resistance in the Netherlands is about 1 percent, compared with the U.S. average of around 25 percent.
The EPC suggests that future research examine the efficacy of antibiotics versus "watchful waiting" and a possible link to bacterial resistance.
Also in support of its quality activities, AHRQ made major enhancements to its data collection efforts for children. The Medical Expenditure Panel Survey (MEPS) will now identify more children with asthma and diabetes and collect data on the quality of their care. In addition, in Fiscal Year 2000, MEPS enhanced its ability to identify children with special health care needs using the Living With Illness measure that was developed with AHRQ's support.
In Fiscal Year 2000, AHRQ researchers reported numerous findings with implications for clinicians, health systems, policymakers, and, ultimately, children's health. These include:
- A bilingual asthma scale was developed to help clinicians assess symptoms in Latino children.
- Asthma, injuries, and mental health problems account for more hospitalizations of children over 5 years of age than any other conditions, according to a report based on AHRQ data.
- Many children dying from cancer suffer unnecessarily from pain and labored breathing because they don't receive appropriate palliative care.
- Costs are no higher for most Medicaid children than for privately insured children in the same health maintenance organization (HMO).
- Home visits on the 3rd or 4th postpartum day after early neonatal discharge have comparable infant outcomes and much higher maternal satisfaction, but higher costs, than pediatric clinic visits.
- Adolescents who weighed only 2 pounds or less at birth are smaller than, and suffer from more school difficulties and behavioral problems than their normal birthweight peers.
- Primary care providers often fail to cover the most significant injury prevention issues during well-child visits.
- Findings that children with special health care needs require more time from emergency medical services (EMS) personnel led to development of a training program for EMS providers.
Select for more information on Child and Adolescent Health.
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By the year 2030, one in four American women will be over the age of 65. Against that backdrop is another dramatic demographic trend: the racial and ethnic diversification of America. By the year 2030, 1 in 5 American women will be of Hispanic heritage, 1 in 11 will be Asian, and the number of African Americans will grow steadily.
In fact, by the year 2050, women of color will represent fully half of the adult female population in America. The result: women are living longer, facing more of the chronic diseases and conditions that accompany old age, and coming from an ever-increasing variety of cultural and economic backgrounds.
Research Finding. Of the 1 million c-sections performed annually, about 294,000 of them are done because of lack of progress in labor. In a AHRQ-funded study, researchers found that up to 24 percent of the c-sections for lack of progress may be performed too early. These women had a c-section with a dilation of only 0 to 3 centimeters—contrary to recommendations of the American College of Obstetrics and Gynecology (ACOG) that the cervix should be dilated to 4 centimeters or more before the diagnosis is made. In addition, many repeat c-sections occur subsequent to previous c-sections done for lack of progress.
The AHRQ women's health program assists the Agency in developing and disseminating research that can be used to understand and improve health care services provided to women. The Agency's current research portfolio related to women, which is estimated to be $52.3 million in Fiscal Year 2001, is evenly spread through the pipeline of research. Highlights include:
- Health care outcomes and quality. This area includes clinical studies on heart disease, breast cancer, reproductive health (including sexually transmitted diseases), violence against women, Alzheimer's disease, depression, osteoporosis, and diabetes.
- Access and cost of services. Ongoing research includes studies of how changes in the organization and delivery of care are affecting access to and cost of services of particular interest to women. The Medical Expenditure Panel Survey provides critical information necessary to track and understand issues related to insurance
coverage for women. Data on the use of acute care and nursing home services are available by gender and by age, race, and ethnicity.
Fiscal Year 2000: A Selection of New Grants Related to Women
Biofeedback and Urinary Incontinence in Older Women. Poor bladder control is a serious health problem that can have severe consequences on the independence and quality of life of older women. The goal of this project is to determine the effectiveness of behavioral and pharmacological interventions in the treatment of urinary continence in older women (Bowman Gray School of Medicine).
Evaluation of Postnatal and Postpartum Care Programs. With 4 million births a year, the delivery of a child is the single most common reason for hospitalization in the U.S., yet the amount of time new mothers and their infants spend in the hospital after birth has declined continuously. The two primary goals of this study are to address gaps in our current knowledge by:
- Investigating new mothers' utilization of post discharge services, including factors influencing their decisions about use.
- Determining the impact of specific post discharge services on medical care utilization patterns, health status and breast-feeding (Battelle Memorial Institute).
Home Screening for Chlamydia Surveillance. The purpose of this randomized clinical trial is to evaluate the effectiveness of home screening for two sexually transmitted diseases (chlamydia and gonorrhea) relative to office-based screening among women with a prior diagnosis of chlamydia. Several primary and secondary outcomes will be explored. The primary outcomes of the evaluation are adherence to screening and the number of chlamydia infections detected. Secondary outcomes include: gonorrhea infections, rates of treatment, diagnosis of pelvic inflammatory disease, prevalence of chlamydia infections at the end of the study, and attitudes toward screening (University of Pittsburgh).
Prescription Patterns and Practice for Postmenopausal Therapy. Hormone replacement therapy and other postmenopausal medications are used to relieve menopausal symptoms and prevent some post-menopausal diseases, but their long term risks and benefits are uncertain. The proposed study seeks to address the current deficit of studies concerning patterns of physician counseling and geographic variations in prescribing practices. The project utilizes large national prescription databases to describe the percentages of prescriptions for various postmenopausal therapies from 1993 to 1999. These data will identify geographic variations, types of regimes prescribed, reasons for prescription of drugs (therapeutic vs. preventive), and associated patient and physician characteristics. A second data source will be a national survey of U.S. women physicians involved in care of women over age 45 (Dartmouth College).
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Activities in Support of All Goals
Health Services Research Training
As the Nation's health care delivery systems continue to change, the need for individuals trained to conduct research and perform analyses to assist decisionmakers in both health policy and health care delivery settings is crucial. AHRQ's health services research training program is supported through several mechanisms.
National Research Service Awards (NRSAs). AHRQ supports predoctoral and postdoctoral training through the National Research Service Award (NRSA) program. AHRQ awards NRSA training grants to institutions for predoctoral and postdoctoral training (the AHRQ Institutional Training Awards) as well as individual NRSA fellowships to applicants who have completed their doctoral degrees (the AHRQ Fellowship Awards).
Career Awards. AHRQ began to support career development activities in Fiscal Year 2000. These awards, provided to individuals embarking on a research career, allow individuals time and resources to gain experience in carrying out actual research. The intent is to provide transitional support for newly trained investigators in order to launch them on research careers. This program will foster the next generation of health services researchers. AHRQ supports two types of career awards:
- Independent Scientist Award (K02) in Health Services Research. The K02 provides support for newly independent investigators with a clinical or research doctoral degree to enable them to develop their research careers.
- Mentored Clinical Scientist Development Award (K08) in Health Services Research. The K08 provides support for the development of outstanding clinician research scientists who are committed to a career in health services research, with a focus on development as an independent scientist.
A summary of several career awards is below.
Selected AHRQ Career Development Awards, Fiscal Year 2000
Marielena Lara, M.D. (K08, University of California at Los Angeles). Dr. Lara's research "Improving Outcomes in U.S. Latino Children" is focused on improving health outcomes and quality of life in Latino children with asthma through evidence-based health care and community-based interventions. Research aims are to develop and evaluate a community based intervention to ensure access to high quality primary care for children with asthma. Also, this project will identify factors associated with asthma prevalence and risk in Latino children.
David Studdert, L.L.B., ScD. (K02, Harvard University). Dr. Studdert's research, "Improving Dispute Resolution in Health Care," examines such areas as legal issues in medical error and disputes in health care. This work is based on the hypothesis that advancing knowledge about disputes in health care can help guide policy and practice in such areas as improved quality of care, greater procedural justice for managed care enrollees, and reduced costs. The first study will examine coverage decision making in managed care organizations; this will describe and analyze denials of insurance coverage in managed care populations. A second study is centered on external review of coverage appeals, specifically among Medicare beneficiaries in managed care.
Andrew Siderowf, M.D. (K08, University of Pennsylvania). Dr. Siderowf's research, "Health Preference Assessment in Parkinson's Disease," will evaluate the validity, reliability, and responsiveness of preference-based outcomes for patients with Parkinson's disease. Preference-based outcomes are commonly used in cost effectiveness analyses. The primary research hypothesis is that pre-scored systems may not reflect societal preferences for health states encountered in Parkinson's. Specific study aims include:
- Producing vignettes that describe Parkinson's health states and eliciting societal preference weights.
- Conducting a comparison of these preferences to values derived from a pre-scored multi-attribute health classification system.
- Conducting a longitudinal study to measure reliability and responsiveness of preference-based measures to patients and caregivers.
Christopher Forrest, M.D. (K02, Johns Hopkins University). Dr. Forrest's research, "Alternative Healthcare Delivery Models for Children," will investigate the relationships among child health services research, managed care, and child health status. Specific research goals include:
- Improving the understanding of mechanisms by which managed care influences children's access to medical care, specialty care service use, and health care expenditures.
- Developing and testing a model of child health and examining its linkages with health care services.
- Examining the impact of alternative models of primary-specialty care collaboration on quality, costs, and outcomes for children with chronic and mental health disorders.
Minority Research Infrastructure Support Program (M-RISP). The Agency is committed to the Department's Initiative to Eliminate Racial and Ethnic Disparities in Health and the complementary Healthy People 2010 Goal to Eliminate Disparities in Health. A critical component in achieving these goals is to expand the nation's health workforce to be more diverse and representative of the racial and ethnic populations in America. This includes bringing needed diversity to the health services research workforce.
In Fiscal Year 2001, AHRQ launched the Minority Research Infrastructure Support Program (MRISP). The goals of the M-RISP program are to increase the number of minority health services researchers, and to build capacity for institutions to conduct health services research intended to improve health for Hispanics and African Americans. This
support will begin to enable approximately three institutions with relatively small research programs to develop into significantly stronger health services research centers.
Building Research Infrastructure and Capacity (BRIC) Program. To build research capacity in States that have not traditionally been involved in health service research, the Building Research Infrastructure and Capacity (BRIC) Program will be funded to pilot-test the feasibility of developing a program to broaden the geographic
distribution of AHRQ funding and enhance the competitiveness for research funding of institutions located in States that have a low success rate for grant applications from AHRQ.
BRIC-eligible States include the following, plus the Commonwealths of Puerto Rico and the Virgin Islands: Alaska, Delaware, Hawaii, Idaho, Kansas, Kentucky, Louisiana, Mississippi, Montana, Nevada, New Jersey, North Dakota, Oklahoma, South Dakota, Utah, Vermont, and Wyoming.
AHRQ anticipates funding 7 to 10 1—year planning grants in Fiscal Year 2001. These grants will stimulate sustainable improvements in capacity and/or multi-disciplinary centers supporting magnet investigators and multiple research projects with a thematic focus.
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AHRQ promotes widespread distribution and implementation of its information and research products through a variety of dissemination methods:
- Publication in professional journals.
- Provider and consumer materials, media events and outreach.
- Interviews and story placement with medical/trade press and organizations' newsletters.
- Articles in the popular press.
AHRQ also employs public-private partnerships, direct mail, and the World Wide Web to distribute its information.
AHRQ's Web site. Use of AHRQ's Web site, www.ahrq.gov, continued to increase in Fiscal Year 2000, with more than 18.8 million hits, compared with 15.5 million hits the previous year. User sessions almost doubled—1.5 million, up from 892,175. Page views also increased substantially for Fiscal Year 2000 at 5.4 million, compared with 3.2 million the previous year. Overall workload increased with 4,400 files and documents uploaded to the Web site, compared with 4,000 for Fiscal Year 1999.
AHRQ handled 3,500 electronic inquiries during Fiscal Year 2000 through its Web site mailbox, up from nearly 3,000 in Fiscal Year 1999. These inquiries included requests for:
- Agency information products.
- Funded research.
- Consumer health issues and concerns.
- Technical assistance.
- Referrals to other resources.
- Requests to use AHRQ electronic content on other Web sites or in electronic or print products.
A popular feature on the Web site was a "Spanish" button, Información en español, which provides translations of our consumer health and patient information materials, and averages about 1,200 visits each month. Many users are the Spanish-speaking public, but clinicians with large Hispanic patient populations also use these materials for their patient education efforts.
The AHRQ Web site also provides access to the summaries of reports issued from the Evidence-based Practice Centers. The full text of these reports can be obtained at the National Library of Medicine, accessible through the AHRQ Web site. The Agency continued to work with the National Library of Medicine to upload evidence reports, technology assessments, and preventive services materials for clinicians on the full-text retrieval system HSTAT.
The healthfinder™ gateway site, developed and maintained by the Department of Health and Human Services, was prominently featured on the AHRQ site, and in turn provided 50,000 referrals to the Agency's online consumer health and patient information materials. Nearly 10,000 external Web sites link to the AHRQ Web site home page or content within the site, almost double that of the previous year.
The site was redesigned this year to address feedback from an online customer satisfaction survey. Usability testing has also been conducted with various constituencies to ensure the quality has been upgraded, the content is accessible, and the navigational approaches facilitate information retrieval for users. The site will further be
refined based on the results of this effort.
A followup online evaluation occurred and the redesigned Web site was highly rated on content, presentation, and ease of use, and for the quality, quantity, and timeliness of information.
Based on feedback, various audience groups came to the site for:
- New funding opportunities and subsequent award announcements.
- Press releases with contact information on key staff involved.
- Informative electronic newsletters on research activities.
- Clinical research resources to improve practice and health outcomes.
- Strategic planning to establish priorities and directions for State health programs.
- Facilitating health services research at the university level.
- Summaries of evidence-based information for medical practice.
- Research information related to treatment of specific health conditions, such as diabetes, arthritis.
- Recommendations on quality of care issues and suggestions for improving health care.
- Learning more about AHRQ and related resources.
- Keeping abreast of new developments and up-to-date information on the changing health care system.
- Best practices and information on reducing the cost of providing health insurance.
- Data and statistics on health care costs and use.
The following characterizes requests from outside organizations for use of electronic content from the AHRQ Web site:
- Consumer materials on specific conditions and also to better understand the health care system have been incorporated on numerous consumer health Web sites as well as in corporate intranets for employees, e.g., low back pain, quit smoking, and health insurance choices.
- Clinical materials have been adapted for medical Web sites oriented for clinicians as well as in hospital and health plan systems. Clinical and research materials have been included in course packs for both medical education programs and graduate training in public health issues.
- Information on reducing medical errors has been distributed by managed care organizations through their member Web sites and newsletters.
- Preventive services information for both adults and children have been used for health education initiatives of health plans and employers.
Publications Clearinghouse. A listing of the most recent releases and ordering information is provided in the Publications Catalog. Requests for a copy of the latest catalog, publications, and general information about the Agency and its programs may be made as follows.
- In the United States, call the toll-free number 800-358-9295, 24 hours a day, 7 days a week.
- Hearing impaired persons may call 888-586-6340 for the TDD service.
- Outside of the United States, call (703) 437-2078.
- Written requests may be sent to: AHRQ Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907-8547.
- Electronic requests may be made to: AHRQPubs@ahrq.hhs.gov.
NTIS Inventory of Products. To search the AHRQ bibliographic records of information products available from NTIS, use the Information Product Search function at: http://ahcpr.fedworld.gov/
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The funding summary for HCQO follows.
Authorizing Legislation—Section 927 (c) of the Public Health Service Act
2001 Final Appropriation
PHS Evaluation Funds
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Prior Year Funding
Funding for the HCQO program during the last 5 years has been as follows.
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