1. 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

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

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

4. 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.

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

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

15. 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

16. 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

17. 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

18. Questions & Comments?