Reducing Racial and Ethnic Disparities in Health Care Cecilia Rivera-Casale Ph.D. Senior Advisor for Minority Health Agency for Healthcare Research and Quality Washington, D.C. – January 29, 2010

Overview AHRQ: The BIG Picture Quality/Disparities Report Findings Comparative Effectiveness Research Summary

AHRQ’s Mission Improve the quality, safety, efficiency and effectiveness of health care for all Americans

Research At HHS What is AHRQ’s “Space?” NIH Basic biomedical, lab bench research and “efficacy” clinical trials CDC The public health system, community based interventions AHRQ “Effectiveness” of health care services and the health care delivery system To further help differentiate AHRQ’s research from CDC’s and NIH’s research, I’ll use an example related to diabetes--a condition that occurs with great frequency within the African American population.. NIH research identifies what can work to improve patient health. NIH’s primary orientation is laboratory bench science, which seeks to broaden our understanding of basic biology and the biological mechanisms of disease, and clinical trials, designed to establish the potential usefulness of new interventions under ideal conditions (“efficacy”). For example, how does type A and B diabetes differ and what treatments might be instituted to cure the disease. CDC evaluates health behaviors and tests community interventions that might be used to reverse unhealthy behaviors or reinforce healthy ones. For example, programs to increase exercise or improve diet. By contrast, AHRQ develops evidence to help clinicians and patients select the best interventions for that individual. For example, do multiple medications control the patient’s diabetes or does it work better to combine medication therapy with support from team made up of doctors, nurses, and exercise coaches? AHRQ research then helps providers develop measures to evaluate what works best. This research relates to quality improvement efforts. In its clinical research, AHRQ assesses the effectiveness in daily practice of promising new interventions, compares their benefits, costs, and side-effects with existing approaches, and when effective interventions are not being used, identifies options for overcoming barriers to their widespread use. AHRQ’s clinical research is unique in two other ways: its focus on the interaction between patients and their care-givers and patient-centered research (rather than treating each disease in isolation), recognizing that the number of individuals with multiple chronic conditions is growing and the care for their different conditions must be coordinated. AHRQ’s research on the health care delivery system reflects the belief that health care services are not delivered in a vacuum. The outcomes, effectiveness, and quality of health care interventions are influenced by who delivers the service, the extent to which the systems in which clinicians work support or frustrate their efforts, and the financial incentives or barriers to provide the right service at the right time in the right way. For example, research related to the development of effective disease management strategies and improved coordination of care draws upon both clinical and health systems research.

AHRQ Priorities Patient Safety Effective Health Care Program Medical Expenditure Panel Surveys Ambulatory Patient Safety Patient Safety Health IT Patient Safety Organizations New Patient Safety Grants Comparative Effectiveness Reviews Comparative Effectiveness Research Clear Findings for Multiple Audiences Quality & Cost-Effectiveness, e.g. Prevention and Pharmaceutical Outcomes U.S. Preventive Services Task Force MRSA/HAIs Visit-Level Information on Medical Expenditures Annual Quality & Disparities Reports Safety & Quality Measures, Drug Management and Patient-Centered Care Patient Safety Improvement Corps Other Research & Dissemination Activities

AHRQ’s National Reports on Quality and Disparities Reports Released May 9th The median annual rate of change for all quality measures was 1.4% Of 190 measures, 132 (69%) showed some improvement Some reductions in disparities of care according to race, ethnicity, and income Disparities persist in health care quality and access

2008 Healthcare Disparities Report Key Themes: Disparities persist in health care quality and access Magnitude and pattern of disparities are different within subpopulations Some disparities exist across multiple priority populations

2008 National Healthcare Disparities Report 60% of quality measures have not improved for minorities in past 6 years 1 in 7 Medicare patients have one or more adverse events Patient safety measures worsened by 1% each year for past 6 years Central-line associated bloodstream infections affect hundreds of thousands of patients each year

Disparities Report: Key Findings 60% of measures of quality not are improving for Blacks, Asians, American Indians/Alaska Natives (AI/AN), Hispanics, poor populations; trend for 6 years 80% of access measures stayed the same or got worse for Hispanics 60% of access measures stayed the same or got worse for Blacks and Asians 57% of access measures stayed the same or got worse for poor populations

Disparities Report: Biggest Gaps by Population Proportion of new AIDS cases was 9.4 times as high for Blacks as Whites Rate of new AIDS cases more than 3 times as high for Hispanics as for non-Hispanic Whites AI/AN women more than twice as likely to lack prenatal care as White women Asians more likely than Whites to not get timely care for illness or injury Poor adults more than twice as likely as high-income adults not to get timely care for an illness or injury

Example of Local Level Application: Hispanic Elderly Initiative HHS pilot initiative aimed at improving the health and quality of life for Hispanic elders. Eight large metropolitan communities selected to participate in the pilot: Chicago, Houston, Los Angeles, McAllen, Miami, New York, San Antonio and San Diego. Medicare participation and diabetes care are target areas of work for each of the communities

Comparative Effectiveness and the Recovery Act The American Recovery and Reinvestment Act of 2009 includes $1.1 billion for comparative effectiveness research: AHRQ: $300 million NIH: $400 million (appropriated to AHRQ and transferred to NIH) Office of the Secretary: $400 million (allocated at the Secretary’s discretion) Federal Coordinating Council appointed to coordinate comparative effectiveness research across the federal government

Definition: IOM Comparative effectiveness research (CER) is the generation and synthesis of evidence that compares the benefits and harms of alternative methods to prevent, diagnose, treat and monitor a clinical condition or to improve the delivery of care. The purpose of CER is to assist consumers, clinicians, purchasers and policy makers to make informed decisions that will improve health care at both the individual and population levels. National Priorities for Comparative Effectiveness Research Institute of Medicine Report Brief June 2009 Delivery of care is key to conducting CER

Conceptual Framework Stakeholder Input & Involvement Dissemination & Translation Horizon Scanning Evidence Need Identification Evidence Synthesis Generation Career Development Research Training

CER and Innovation CER will enhance the best and most innovative strategies Can include new populations and sub-populations i.e. minorities and other priority populations, children, elderly, patients with multiple chronic conditions, persons with disabilities and other. Can bring early attention to emerging issues

CER and Priority Populations Include data sources for evidence based studies in diverse populations Increase minority participation in research protocols using pragmatic settings Prepare next generation of diverse researchers that focus on underserved populations Utilize more CBPR studies

Comparative Effectiveness Challenges/Opportunities Anticipating downstream effects of policy applications Making sure that comparative effectiveness is "descriptive, not prescriptive” Creating a level playing field among all stakeholders, including patients and consumers Using research to address concerns of diverse patients and clinicians

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