Excellence Centers to Eliminate Ethnic/Racial Disparities (EXCEED)
The health of Americans has improved over the past few decades, but not all Americans have benefited equally. Many ethnic and racial groups have not shared in the advances in health outcomes and health care. To understand the causes and factors of these inequalities, the Agency for Healthcare Research and Quality (AHRQ) has awarded grants to nine "Excellence Centers To Eliminate Ethnic/Racial Disparities" (EXCEED). Each center is investigating a different theme in an effort to identify and eliminate the causes of health disparities.
Ethnic and racial disparities in health have been well documented in recent decades across a broad range of medical conditions and for a wide range of ethnic and racial groups. These differences have been noted in health outcomes, such as quality of life and mortality; processes, quality, and appropriateness of care; and the prevalence of certain conditions or diseases.
Disparities persist despite improvements in health for the nation as a whole. For example:
- Between 1987 and 1995, mortality from ischemic heart disease decreased 20 percent for the overall population but only 13 percent for blacks.
- In 1996, the infant mortality rate was nearly 2½ times greater for blacks than whites.
- Black Medicare beneficiaries in one study received less intensive treatment from providers for selected procedures than whites, after controlling for other factors.1
- Mortality in another study was higher for black males than white males treated for colorectal cancer despite similar surgical, chemotherapy, and radiation rates.2
- The incidence rate for cervical cancer is more than five times as high for Vietnamese women in the United States as for white women (47.3 vs. 8.7 cases per 100,000 women).
- The prevalence of diabetes in Hispanics and American Indians/Alaska Natives is approximately double that in whites.
Despite being well documented, these insights have not led to significant improvements in racial and ethnic disparities overall, in part because the causes of and factors contributing to these inequalities are inadequately understood.
Expanding the Knowledge Base
In an effort to increase understanding of such factors, the Agency for Healthcare Research and Quality (AHRQ) in October 1999 published a Request for Applications (RFA) which aimed to expand the knowledge base on disparities in several clinical conditions—e.g., diabetes, infant mortality, cancer screening and management, and cardiovascular disease—for which prior research had shown a disproportionate effect on racial and ethnic minorities. The RFA, "Understanding and Eliminating Minority Health Disparities," called for Centers of Excellence that would conduct research specifically focusing on the underlying causes of these health care inequities, particularly causes that could be addressed through improvements in health services delivery and health systems.
In September 2000, AHRQ awarded grants to nine Centers to conduct a series of related studies. Now known as "Excellence Centers To Eliminate Ethnic/Racial Disparities" (EXCEED), the grants bring together teams of both new and experienced investigators in a 5-year effort to analyze underlying causes and contributing factors for racial and ethnic disparities in health care and to identify and implement strategies for reducing and eliminating them. The Centers of Excellence approach enables assembly of a critical mass of investigators to address a group of projects linked by a central theme, such as communication or cultural competency. In addition, the Centers are able to train new investigators with an interest in minority health services research.
The EXCEED program joins a series of AHRQ initiatives aimed at improving the health and health care of priority populations and eliminating racial and ethnic disparities in health outcomes and in health care access and service delivery.
The nine EXCEED projects listed below are supported by AHRQ in partnership with other agencies in the Department of Health and Human Services, including:
- The National Center on Minority Health and Health Disparities.
- The National Cancer Institute.
- The National Institute of General Medical Sciences.
- The Health Resources and Services Administration.
Each project comprises a group of four to seven studies organized around a central theme.
- Access and Quality of Care for Vulnerable Black Populations. Identifies and examines effective interventions for chronically ill African-American adults and low-income children who primarily receive care from community providers in inner-city and rural areas. (Principal investigator: Robert M. Mayberry, Morehouse School of Medicine, Atlanta, GA.)
- Health Disparities in Minority Adult Americans. Examines the effects of communication barriers and interventions to improve cultural competence on cancer screening and management of hypertension among minority elderly populations. (Principal investigator: Edmund M. Ricci, University of Pittsburgh, Pittsburgh, PA.)
- Improving the Delivery of Effective Care to Minorities. Assesses reasons for the underuse of effective interventions for managing premature birth, breast cancer, stroke, and hypertension in ethnically diverse Harlem communities and evaluates ways to eliminate underuse. (Principal investigator: Mark R. Chassin, Mount Sinai School of Medicine, New York, NY.)
- Overcoming Racial Health Disparities. Focuses on addressing health disparities in cancer, hypertension, and HIV disease among African American adults, particularly in rural settings; includes collaborative research partnerships with two historically black universities. (Principal investigator: Timothy S. Carey, University of North Carolina, Chapel Hill, NC.)
- Promoting Effective Communication and Decision Making for Diverse Populations. Assesses strategies to enhance communication and decisionmaking by ethnic/racial minority populations, including developing decision aids for use in coronary disease and cancer screening. (Principal investigator: A. Eugene Washington, University of California, San Francisco, CA.)
- Racial and Ethnic Variation in Medical Interactions. Assesses the extent to which problems in doctor-patient communication contribute to racial and ethnic disparities in health care use. Also aims to develop effective strategies for disseminating information and building research capacity. (Principal investigator: Carol M. Ashton, Baylor College of Medicine, Houston, TX.)
- UCLA/Drew/RAND Program To Address Disparities in Health. Identifies principal factors responsible for ethnic/racial disparities and tests randomized interventions to address those factors for infant mortality, colon cancer, diabetes, and ischemic heart disease. (Principal investigator: Martin F. Shapiro, University of California, Los Angeles, CA.)
- Understanding and Eliminating Health Disparities in Blacks. Examines strategies to address disparities in health status between African Americans and whites, including those in rural areas, with specific clinical conditions including HIV disease, cardiovascular disease, and cancer. Principal investigator: Barbara Tilley, Medical University of South Carolina, Charleston, SC.)
- Understanding and Reducing Native Elder Health Disparities. Investigates issues relating to reducing health inequities among elderly American Indians/Alaska Natives, such as diabetes care and increasing participation in cancer screening and other clinical preventive services. (Principal investigator: Spero M. Manson, University of Colorado Health Sciences Center, Denver, CO.)
AHRQ expects that lessons learned from understanding and eliminating racial and ethnic disparities in health and health care as well as the practical tools and strategies to eliminate these disparities would be generalizable beyond the communities studied. By focusing on attributes of the ethnic and racial groups, the underlying etiologies for the disparities, and components and conditions of interventions to eliminate the disparities, these projects should produce findings that are widely applicable for minority as well as majority populations across the country.
Building Research Capacity
Building capacity for health services research that seeks to reduce racial/ethnic inequities entails augmenting the research skills and abilities of ethnically diverse researchers and institutions and developing sustainable and meaningful research relationships with communities and community organizations. One of the goals of EXCEED is to foster such capacity-building efforts.
Training. Although AHRQ's EXCEED program focuses on understanding and eliminating inequalities in health outcomes and care, it will also facilitate development of greater capacity both for health services research by minority individuals and institutions and for health services research that is focused on reducing racial and ethnic inequities in health care. Such a lack of capacity has been highlighted by the Association of American Medical Colleges.3 Toward this aim, several EXCEED projects link new researchers with more experienced investigators through both formal and informal mentoring and career development opportunities.
Research partnerships. The EXCEED program also aims to yield greater capacity for the study of disparities by encouraging the formation of new research relationships as well as building on existing partnerships between researchers, professional organizations, and community-based organizations instrumental in helping to influence change in local communities. The Centers are involved in participatory research efforts in which community members are involved in all stages and aspects of the studies. Several EXCEED projects are being conducted in collaboration with community health centers and other health care organizations serving ethnically diverse populations. AHRQ expects that these participatory research partnerships will help lead to more effective implementation of research findings that address the social, cultural, and economic conditions of the community.
1. Lee AJ, Gehlbach S, Homer DW, Reti M, Baker CS. Medicare treatment differences for blacks and whites. Medical Care 1997;35:1173-89.
2. Dominitz JA, Samsa GP, Landsman O, Provenzale D. Race, treatment, and survival among colorectal carcinoma patients in an equal-access medical system. Cancer 1998;82:2312-20.
3. Association of American Medical Colleges. Draft recommendations from the AAMC meeting on minority health services research, July 1997.