Creating an Integrated Framework for Reducing Disparities in Health Care Quality Francis D. Chesley, Jr., MD Director Office of Extramural Research, Education and Priority Populations AHRQ Annual Conference September 28, 2010

The Change/Evolution of AHRQ FY 1990 Budget: $97 million AHRQ begins sponsorship of U.S. Preventive Services Task Force activities Agency for Health Care Policy and Research (AHCPR) is established Recovery Act Funding in 2009: $300 million to AHRQ 2010 President’s FY 2011 AHRQ budget proposal: $611 million 1998 FY 1995 Budget: $154 million “Near-death experience” AHCPR becomes the Agency for Healthcare Research and Quality (AHRQ) Effective Health Care (EHC) Program created FY 2003 Budget: $318.7 million FY 2010 Budget: $397 million EHC Program launched, includes dissemination and application function by the Eisenberg Center

Setting the Context The Healthcare Research and Quality Act of 1999 directed AHRQ to conduct and support research with respect to the delivery of health care for Priority Populations The Healthcare Research and Quality Act of 1999 directed AHRQ to conduct and support research with respect to the delivery of health care for Priority Populations AHRQ published its Priority Population Inclusion Policy in February 2003 AHRQ published its Priority Population Inclusion Policy in February 2003 Established an AHRQ functional unit to assist in carrying out policy requirements Established an AHRQ functional unit to assist in carrying out policy requirements

AHRQ Priority Populations Inner city and rural areas (including frontier areas) Inner city and rural areas (including frontier areas) Low income groups Low income groups Racial and ethnic minority groups Racial and ethnic minority groups Women and children Women and children The elderly The elderly Individuals with special health care needs, including individuals with disabilities and those who need chronic care or end-of-life health care Individuals with special health care needs, including individuals with disabilities and those who need chronic care or end-of-life health care

The Policy Provides one of the cornerstones for studying and eliminating health care disparities Provides one of the cornerstones for studying and eliminating health care disparities Intended to ensure inclusion in AHRQ’s overall portfolio of research Intended to ensure inclusion in AHRQ’s overall portfolio of research Intended to foster inclusion such that research designs explicitly allow for valid analyses – including subgroup analyses where relevant Intended to foster inclusion such that research designs explicitly allow for valid analyses – including subgroup analyses where relevant Investigators should consider inclusion of one or more priority populations Investigators should consider inclusion of one or more priority populations

The Policy (cont) Encourages development of specific outreach plans to reach participant recruitment goals Encourages development of specific outreach plans to reach participant recruitment goals Encourages subgroup analyses to provide specific research results relevant to one or more priority population Encourages subgroup analyses to provide specific research results relevant to one or more priority population Requires explicit justification of exclusion, such as inappropriate with respect to the health of subjects or purpose of research Requires explicit justification of exclusion, such as inappropriate with respect to the health of subjects or purpose of research

Inclusion in Real Time Core Business Core Business – Knowledge Creation – Synthesis & Dissemination – Implementation & Use Measurement Measurement Data Data Training & Research Infrastructure Training & Research Infrastructure Research Portfolios Research Portfolios

AHRQ Portfolios Value Value – Goal: Support the development of health care activities that help reduce unnecessary waste while improving quality Innovations/Emerging Issues Innovations/Emerging Issues – Goal: Identify and support ideas and projects that have the potential for highly innovative solutions to health care challenges

AHRQ Priorities Effective Health Care Program Medical Expenditure Panel Surveys Ambulatory Patient Safety 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

Lessons Learned Common application statement – priority populations will be included in our study to extent that they exist in our study population How do I comply when I am using secondary data and subgroup numbers are small? But also, AHRQ should be explicit about specific priorities for priority populations research in each Funding Opportunity Announcements Are there “points” in peer review and funding decision making?

Lessons Learned Policy of encouragement difficult to understand and implement Policy of encouragement difficult to understand and implement True inclusion and subgroup analyses require resources True inclusion and subgroup analyses require resources Specific role for peer review Specific role for peer review Factoring inclusion as a component of funding decisionmaking is not easy Factoring inclusion as a component of funding decisionmaking is not easy We need a framework! We need a framework!

Why Is This Important? Health care disparities persist and in many cases are worsening Health care disparities persist and in many cases are worsening Ongoing and enhanced focus & activities within the DHHS Ongoing and enhanced focus & activities within the DHHS Recognized importance of quality improvement must include strategies for eliminating disparities Recognized importance of quality improvement must include strategies for eliminating disparities The ACA requires establishment of offices of minority health in HHS and focus on eliminating health disparities The ACA requires establishment of offices of minority health in HHS and focus on eliminating health disparities The ACA calls for National Quality and Prevention Strategies – each includes eliminating disparities as a core principle The ACA calls for National Quality and Prevention Strategies – each includes eliminating disparities as a core principle

ACA Provisions Related to AHRQ Community Health Team to Support Patient- Centered Model Home Community Health Team to Support Patient- Centered Model Home Medication Management Services Medication Management Services Improving the Emergency Care System Improving the Emergency Care System Shared Decision Making Shared Decision Making Collecting Data on Health Disparities Collecting Data on Health Disparities Health Care Workforce Health Care Workforce Primary Care Extension Service Primary Care Extension Service Medical Liability* Medical Liability* *Only item on the list with an appropriation. All other items authorized.

Thank You AHRQ Mission To improve the quality, safety, efficiency, and effectiveness of health care for all Americans AHRQ Vision As a result of AHRQ’s efforts, American health care will provide services of the highest quality, with the best possible outcomes, at the lowest cost