Reducing Racial and Ethnic Reducing Racial and Ethnic Disparities in Health CareDisparities in Health Care

Cecilia Rivera-Casale Ph.D.Cecilia Rivera-Casale Ph.D.

Senior Advisor for Minority HealthSenior Advisor for Minority Health

Agency for Healthcare Research and QualityAgency for Healthcare Research and Quality

Washington, D.C. – January 29, 2010Washington, D.C. – January 29, 2010

OverviewOverview

AHRQ: The BIG PictureAHRQ: The BIG Picture Quality/Disparities Quality/Disparities

Report FindingsReport Findings Comparative Comparative

Effectiveness Research Effectiveness Research SummarySummary

AHRQ’s MissionAHRQ’s Mission

Improve the quality, safety, efficiency and Improve the quality, safety, efficiency and effectiveness of health care for all Americanseffectiveness of health care for all Americans

Research At HHS Research At HHS What is AHRQ’s “Space?”What is AHRQ’s “Space?”

NIHNIH

Basic biomedical, Basic biomedical, lab bench lab bench

research and research and “efficacy” clinical “efficacy” clinical

trialstrials

CDCCDC

The public health The public health system, system,

community based community based interventionsinterventions

AHRQAHRQ

““Effectiveness” of Effectiveness” of health care health care

services and the services and the health care health care

delivery system delivery system

AHRQ PrioritiesAHRQ Priorities

Effective HealthEffective HealthCare ProgramCare Program

Medical ExpenditureMedical ExpenditurePanel SurveysPanel Surveys

AmbulatoryAmbulatoryPatient SafetyPatient Safety

PatientPatient Safety 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 PharmaceuticalOutcomes

U.S. Preventive ServicesTask Force

MRSA/HAIs

Visit-Level Information on Medical Expenditures

Annual Quality & Disparities Reports

Safety & Quality Measures,Drug Management andPatient-Centered Care

Patient Safety ImprovementCorps

Other Research & Other Research & Dissemination ActivitiesDissemination Activities

AHRQ’s National Reports on AHRQ’s National Reports on Quality and DisparitiesQuality and Disparities

The median annual rate of The median annual rate of change for all change for all qualityquality measures was 1.4%measures was 1.4%– Of 190 measures, 132 (69%) Of 190 measures, 132 (69%)

showed some improvement showed some improvement

Some reductions in Some reductions in disparitiesdisparities of care of care according to race, ethnicity, according to race, ethnicity, and incomeand income– Disparities persist in health Disparities persist in health

care quality and accesscare quality and access

Reports Released May 9thReports Released May 9th

2008 Healthcare Disparities Report2008 Healthcare Disparities Report

Key Themes:Key Themes:– Disparities persist in Disparities persist in

health care quality and health care quality and accessaccess

– Magnitude and pattern Magnitude and pattern of disparities are of disparities are different within different within subpopulationssubpopulations

– Some disparities exist Some disparities exist across multiple priority across multiple priority populations populations

2008 National Healthcare 2008 National Healthcare Disparities ReportDisparities Report

60% of quality measures 60% of quality measures have not improved for have not improved for minorities in past 6 yearsminorities in past 6 years

1 in 7 Medicare patients have 1 in 7 Medicare patients have one or more adverse eventsone or more adverse events

Patient safety measures Patient safety measures worsened by 1% each year worsened by 1% each year for past 6 yearsfor past 6 years

Central-line associated Central-line associated bloodstream infections affect bloodstream infections affect hundreds of thousands of hundreds of thousands of patients each year patients each year

Disparities Report: Key FindingsDisparities Report: Key Findings

60% of measures of quality not are 60% of measures of quality not are improving for Blacks, Asians, American improving for Blacks, Asians, American Indians/Alaska Natives (AI/AN), Hispanics, Indians/Alaska Natives (AI/AN), Hispanics, poor populations; trend for 6 yearspoor populations; trend for 6 years

80% of access measures stayed the same 80% of access measures stayed the same or got worse for Hispanicsor got worse for Hispanics

60% of access measures stayed the same 60% of access measures stayed the same or got worse for Blacks and Asiansor got worse for Blacks and Asians

57% of access measures stayed the same 57% of access measures stayed the same or got worse for poor populationsor got worse for poor populations

Disparities Report: Biggest Disparities Report: Biggest Gaps by PopulationGaps by Population

Proportion of new AIDS cases was 9.4 times Proportion of new AIDS cases was 9.4 times as high for Blacks as Whitesas high for Blacks as Whites

Rate of new AIDS cases more than 3 times as Rate of new AIDS cases more than 3 times as high for Hispanics as for non-Hispanic Whiteshigh for Hispanics as for non-Hispanic Whites

AI/AN women more than twice as likely to lack AI/AN women more than twice as likely to lack prenatal care as White womenprenatal care as White women

Asians more likely than Whites to not get Asians more likely than Whites to not get timely care for illness or injurytimely care for illness or injury

Poor adults more than twice as likely as high-Poor adults more than twice as likely as high-income adults not to get timely care for an income adults not to get timely care for an illness or injuryillness or injury

Example of Local Level Example of Local Level Application: Hispanic Elderly Application: Hispanic Elderly

InitiativeInitiative

HHS pilot initiative aimed at HHS pilot initiative aimed at improving the health and quality improving the health and quality of life for Hispanic elders.of life for Hispanic elders.

Eight large metropolitan Eight large metropolitan communities selected to communities selected to participate in the pilot: Chicago, participate in the pilot: Chicago, Houston, Los Angeles, McAllen, Houston, Los Angeles, McAllen, Miami, New York, San Antonio Miami, New York, San Antonio and San Diego. and San Diego.

Medicare participation and Medicare participation and diabetes care are target areas of diabetes care are target areas of work for each of the communities work for each of the communities

Comparative Effectiveness Comparative Effectiveness and the Recovery Act and the Recovery Act

The American Recovery and The American Recovery and Reinvestment Act of 2009 includes Reinvestment Act of 2009 includes $1.1 billion for comparative $1.1 billion for comparative effectiveness research:effectiveness research:

– AHRQ: $300 millionAHRQ: $300 million

– NIH: $400 million (appropriated to NIH: $400 million (appropriated to AHRQ and transferred to NIH)AHRQ and transferred to NIH)

– Office of the Secretary: $400 million Office of the Secretary: $400 million (allocated at the Secretary’s discretion)(allocated at the Secretary’s discretion)

Federal Coordinating Council appointed to coordinate comparative Federal Coordinating Council appointed to coordinate comparative effectiveness research across the federal governmenteffectiveness research across the federal government

Definition: IOMDefinition: IOM

Comparative effectiveness research (CER) is Comparative effectiveness research (CER) is the generation and synthesis of evidence that the generation and synthesis of evidence that compares the benefits and harms of compares the benefits and harms of alternative methods to prevent, diagnose, treat alternative methods to prevent, diagnose, treat and monitor a clinical condition or and monitor a clinical condition or to improve to improve the delivery of carethe delivery of care. The purpose of CER is . The purpose of CER is to assist consumers, clinicians, purchasers to assist consumers, clinicians, purchasers and policy makers to make informed decisions and policy makers to make informed decisions that will improve health care at both the that will improve health care at both the individual and population levels.individual and population levels.

National Priorities for Comparative Effectiveness ResearchNational Priorities for Comparative Effectiveness ResearchInstitute of Medicine Report BriefInstitute of Medicine Report Brief

June 2009June 2009

Conceptual FrameworkConceptual Framework

Dissemination& Translation

HorizonScanning

Evidence Need Identification

Evidence Synthesis

EvidenceGeneration

Career DevelopmentCareer Development

Research TrainingResearch Training

Stakeholder Input Stakeholder Input & Involvement& Involvement

CER and InnovationCER and Innovation CER will enhance the best CER will enhance the best

and most innovative and most innovative strategiesstrategies

Can include new Can include new populations and sub-populations and sub-populations i.e. minorities populations i.e. minorities and other priority and other priority populations, children, populations, children, elderly, patients with elderly, patients with multiple chronic conditions, multiple chronic conditions, persons with disabilities and persons with disabilities and other. other.

Can bring early attention to Can bring early attention to emerging issuesemerging issues

CER and Priority PopulationsCER and Priority Populations

Include data sources for evidence based studies in diverse Include data sources for evidence based studies in diverse populationspopulations

Increase minority participation in research protocols using Increase minority participation in research protocols using pragmatic settingspragmatic settings

Prepare next generation of diverse researchers that focus on Prepare next generation of diverse researchers that focus on underserved populations underserved populations

Utilize more CBPR studiesUtilize more CBPR studies

Comparative Effectiveness Comparative Effectiveness Challenges/OpportunitiesChallenges/Opportunities

Anticipating downstream effects of policy Anticipating downstream effects of policy applicationsapplications

Making sure that comparative effectiveness Making sure that comparative effectiveness is "descriptive, not prescriptive”is "descriptive, not prescriptive”

Creating a level playing field among all Creating a level playing field among all stakeholders, including patients and stakeholders, including patients and consumersconsumers

Using research to address concerns of Using research to address concerns of diverse patients and cliniciansdiverse patients and clinicians

Questions & Questions & Comments?Comments?