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FY 2004: Research on Health Care Costs, Quality and Outcomes (HCQO) (continued)
Improving the Health of Priority Populations
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 2.5 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 medication to prevent future asthma-related hospitalizations.
AHRQ has established the Office for Priority Populations 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. AHRQ also 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, Health 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 on the NHDR.
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 Unites 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 NIH's 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 program to be developed.
AHRQ's women's health research agenda support 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.
- 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 an 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.
Recent Women's Health Findings From AHRQ Research on Breast and Cervical Cancer
Outpatient mastectomy. Outpatient 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 women 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 or 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 than traditional approaches—such as providing information through churches and community-based organizations—to increase mammography screenings. Over the past two decades, AHRQ has co-sponsored 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 care. AHRQ-supported research demonstrated the accuracy and efficacy of telecolposcopy—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.
Children and adolescents are growing and developing, and their health care needs, use of services, and outcomes are very different form 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 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 practices 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 (e.g., finances, the parents' time and availability for care, and access and barriers to health care).
Recent Findings on Children's Health Issues
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 studies 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 miters.
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 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 creases ever conducted. It involved 8,394 children up to 15 years of age who were involved in motor vehicle crashes from 1993 to 1999.
AHRQ has been investigating minority health issues for more than three decades. AHRQ's 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 approximately $55 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 the factors underlying 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 trail 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 in 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 HRSA 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 the 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.
Examples of recent findings from AHRQ-supported research in this areas include:
- An AHRQ state-of-the-art assessment of patients' experiences with care demonstrated that minorities consistently rate all aspects of their health care more negatively than whites.
- Recently reported data from MEPS found that slightly more than half of Americans age 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 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 appeared less likely to be satisfied with their physicians, while Japanese patients were least 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 did white patients.
National Healthcare Disparities Report (NHDR). AHRQ is developing the first-ever report on prevailing disparities in health care delivery in the United States. A large and consistent body of research, much of it funded by AHRQ, has demonstrated persistent disparities in health care quality and access associated with race, ethnicity, socioeconomic position, sex, age, functional disability, and place of residence.
The agency's reauthorization legislation enacted in late 1999 directed AHRQ to develop a report, beginning in 2003, on prevailing disparities in health care delivery as they relate to racial factors and socioeconomic factors in priority populations. The National Healthcare Disparities Report (NHDR) will serve as a companion document to the National Healthcare Quality Report, providing grater depth and insights into differences in health care quality for priority populations.
This report will be an unprecedented effort to present a comprehensive picture of prevailing disparities in health care in the United States, and it will identify opportunities for improving care for priority populations. The report also will provide a benchmark for evaluating the success of programs to reduce disparities in health care.
The project is being led by AHRQ and will involve collaboration with multiple components of the Department of Health and Human Services. The report is scheduled for publication in September, 2003. As of FY 2002, work on the NHDR is proceeding as follows:
Conceptual framework. The NHDR will build on the conceptual framework developed for the NHQR. This framework includes dimensions of health care quality, along with access to care, use of services, and costs of services.
NHDR measures and data sources. AHRQ has sought input from a wide range of stakeholders who helped to identify additional datasets and develop the final set of measures. The data group, which includes AHRQ staff with special expertise in data analysis has focused on defining racial and socioeconomic factors and priority populations, identifying data sources, and developing preliminary access, use, and cost measures relevant to studying disparities. A department-wide NHDR Interagency Work Group has provided valuable advice and comments on draft definitions and measures and identified new data sources for the report. AHRQ staff have also collaborated with external data experts from multiple organizations to obtain input on measures and data sources.
NHDR audience research. AHRQ is currently conducting research to identify the needs of potential audiences for the report in an effort to develop a final product that is both useful and responsive to the needs of users.
Disparities and HIV
A nationwide study sponsored by AHRQ, shows that black and Hispanic HIV patients are only about half as likely as non-Hispanic whites to participate in clinical trials of new medications designed to slow the progression of the disease.
Together, blacks and Hispanics comprise roughly 48 percent of the HIV patient population—33 percent and 15 percent, respectively. The study also found that women, regardless of race or ethnicity, are no less likely than men to participate in HIV drug studies.
About 10 percent of black patients and 11 percent of Hispanic patients participated in a clinical trial, compared with 18 percent of non-Hispanic white patients. Black patient participation in trials did not increase during the study period, and these patients were more likely to drop out of the research.
These findings underscore the need to increase the diversity of patients in research. The findings suggest that to boost minority participation in trials, we must look critically at structural barriers such as research-entry criteria, enrollment and tracking procedures, and study center operations, as well as clinical researchers' attitudes and practices.
Other factors contributing to a reduced likelihood of participation in a clinical trial were having less than a high school education, being in a commercial HMO, and receiving primary care 8 miles or more from where the clinical trial was held.
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Training and Dissemination
We continue to benefit from the efforts of a national cadre of well-trained, talented, and energetic health services researchers. One way that AHRQ contributes to excellence in health care delivery is by providing support to maintain and nurture this vital resource. Training of new investigators is fundamental to producing the next generation of health services researchers. These investments also return a more immediate payoff in the form of high-quality research findings that accrue naturally as a result of the training process. The products and lessons learned from such research are useful to regional, State, and national decisionmakers in assessing the effectiveness of current programs and planning for future policies that address the costs and financing of health care, the use of health care services, and access to care across diverse regions and populations.
The agency supports a variety of training and career development opportunities though individual and institutional grant programs including:
National Research Service Awards (NRSA) for predoctoral and postdoctoral training. AHRQ awards individual predoctoral and postdoctoral NRSA fellowships as well as NRSA training grants to institutions for predoctoral and postdoctoral training (the AHRQ Institutional Training Awards).
Dissertation Research Grants. Funding is available for students conducting doctoral-level research on some aspect of the health care system. These grant awards are often the first step in a health services research career. In FY 2002, AHRQ funded 10 dissertations for $308,000.
Research Career Awards. In FY 2000 AHRQ began to grant Research Career Awards. These awards 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 nurture the next generation of health services researchers. In FY 2002, AHRQ funded 6 non-patient safety Research Career Awards for $810,000 and 5 patient safety Research Career Awards for $573,000. AHRQ supports two types of career awards:
Building Research Infrastructure & Capacity Program (BRIC). The Building Research Infrastructure & Capacity Program (BRIC) was launched by AHRQ in FY 2001 to build research capacity in States that have not traditionally been involved in health service research. Geographic regions that have received lesser amounts of AHRQ funding and have demonstrated a commitment to develop their research infrastructure are eligible for these grants.
AHRQ funded six 2-year grants for over $1.7 million in FY 2001. No new grants were funded in FY 2002. These grants will stimulate sustainable improvements in capacity and/or multi-disciplinary centers supporting investigators and multiple research projects with a thematic focus. Examples of the types of BRIC research being conducted is provided in the box below.
Effects of sleep loss and night work on patient safety. This project is focused on the impact of sleep deprivation and night work on patient safety. Using comprehensive error-detection methods for the measurement of sleep, the researchers are quantifying the roles of time of day, time on duty, and sleep inertia in the occurrence of medical errors.
Doctor-patient communication and antibiotic over-prescribing. The focus of this project is the role of doctor-patient communication as a determinant of both inappropriate antibiotic prescribing for respiratory infections in children and parents' satisfaction with care. Data have been collected from 38 pediatricians working in 27 clinical sites and from parents whose children have experienced an upper respiratory illness.
Quality of diabetes care in the primary care setting. These researchers are building on previously completed projects that focus on barriers to diabetes care in family physicians' offices to examine the processes and quality of diabetes care within primary care practice.
Cost-effectiveness of domestic violence interventions. This project is focused on domestic violence intervention in primary care practice, including the effectiveness of domestic violence intervention components, cost-benefit analysis, and monitoring of outcomes with a longitudinal cohort study.
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 FY 2001, AHRQ launched the Minority Research Infrastructure Support Program (M-RISP). 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 racial and ethnic minorities. This support will enable three institutions with relatively small research programs to develop into significantly stronger health services research centers. AHRQ funded 3 grants for $1.2 million. In FY 2002, three more institutions received support for a total of $1.4 million (see box).
Minority Research Infrastructure Support Program (M-RISP)
Health Services Research in Underserved Populations (University of Texas Medical Branch). The goal is to increase this institution's ability to conduct health services research with a focus on medically underserved populations. The program will allow the university to increase the number of faculty who conduct health services research, recruit additional expert faculty, and strengthen its research capabilities.
Hawaii Minority Research Infrastructure Support Program (University of Hawaii at Manoa). The objective is to build a program at the University of Hawaii Medical School that will evaluate ethnic health disparities in the State's Asian American and Pacific Islander populations. The program also will provide mentoring and training to inexperienced researchers, facilitate collaboration between Hawaii's health care organizations, and establish a nationally recognized mentoring group to assist in the implementation of research projects.
Collaborative Minority Health Care and Quality Research (Tennessee State University). The objectives are to increase minority health care research programs at Tennessee State University and Meharry Medical College, establish collaborations with senior health services researchers at other universities, and conduct research to address racial and ethnic health care disparities.
MSM Clinical Faculty Research Training Program (Morehouse School of Medicine, Atlanta, GA). The goal of this program is to strengthen the Morehouse School of Medicine infrastructure to enhance the capacity of individual faculty members to conduct health services research aimed at improving the quality of health services for African Americans and vulnerable populations and eliminating racial and ethnic health disparities.
M-RISP Minority Elderly Research Center (Shaw University, Raleigh, North Carolina). The goal of this project is to establish infrastructure support to junior level faculty to conduct health services research on racial disparities among various minority populations by providing training, resources and mentorship opportunities through collaborative linkages with senior researchers at other universities.
Center for Minority Health Services Research (Howard University, Washington, DC). The purpose of this project to extensively expand the research of Howard University, College of Pharmacy, Nursing and Allied Health Sciences, in the area of health services research and outcomes research through the formation of the Center of Minority Health Services Research. This expansion will particularly relate to investigations of health services in minority populations, increase the numbers and competence of the faculty conducting this research and actively engage graduate level students.
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