National Healthcare Disparities Report, 2007

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Key Themes and Highlights From the National Healthcare Disparities Report

This 2007 report is the fifth National Healthcare Disparities Report (NHDR). It is produced by the Agency for Healthcare Research and Quality (AHRQ) on behalf of the U.S. Department of Health and Human Services (HHS) and in collaboration with an HHS-wide Interagency Work Group. The NHDR provides a comprehensive national overview of disparities in health care among racial, ethnic, and socioeconomicⁱ groups in the general U.S. population and within specific priority populations,ⁱⁱ and it tracks the progress of activities to reduce disparities. The NHDR tracks disparities related to the quality of and access to health care.

This fifth report attempts to answer the following question: Are we getting better at addressing disparities in the quality of and access to health care for priority populations in America? To do this, the report examines a set of 42 measures of quality and 8 measures of access. For each measure, the 2007 NHDR attempts to present a snapshot of the gaps between each racial, ethnic, and socioeconomic priority group and a comparison group. More importantly, where gaps exist, this report attempts to systematically discuss whether these gaps are getting bigger or smaller.

Measures of health care quality address the extent to which providers and hospitals deliver evidence-based care for specific services, as well as the outcomes of the care provided. They are organized around four dimensions of quality—effectiveness, patient safety, timeliness, and patient centeredness—and cover four stages of care—staying healthy, getting better, living with illness or disability, and coping with the end of life. Measures of health care access include assessments of how easily patients are able to get needed health care and their actual use of services. They are organized around two dimensions of access—facilitatorsⁱⁱⁱ and barriers to care and health care utilization.

The NHDR is complemented by its companion report, the National Healthcare Quality Report (NHQR), which uses the same quality measures as the NHDR to provide a comprehensive overview of the quality of health care in America. Both reports measure health care quality and track changes over time, but with different orientations. The NHQR addresses the current state of health care quality and the opportunities for improvement for all Americans as a whole.

In the 2007 NHDR, three key themes emerge:

Overall, disparities in health care quality and access are not getting smaller.
Progress is being made, but many of the biggest gaps in quality and access have not been reduced.
The problem of persistent uninsurance is a major barrier to reducing disparities.

ⁱ Socioeconomic differences include differences in education and income levels.

ⁱⁱ Priority populations specified by the Healthcare Research and Quality Act of 1999 include racial and ethnic populations, low income, women, children, elderly, individuals with special health care needs, and residents of rural and urban areas.

ⁱⁱⁱ Facilitators to health care are factors that increase the likelihood that people will get the health care they need, such as having health insurance and a usual primary care provider.

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Overall, Disparities in Health Care Are Not Getting Smaller

The 2007 NHDR finds that, across all core measures and for all priority groups, the number of measures of quality and access where disparities^iv exist grew larger between 2000-2001 and 2004-2005. To quantify the prevalence of disparities across the core measures tracked in the 2007 report, racial and ethnic minority groups and socioeconomic groups are compared with an appropriate reference group^v for each core measure.^vi Each group could receive care that is poorer than, about the same as, or better than the reference group.

Figure H.1. Change in disparities in core quality measures over time for members of selected groups compared with reference group from 2000-2001 to 2004-2005

Improving = Population-reference group difference becoming smaller at rate greater than 1% per year.

Same = Population-reference group difference changing at less than 1% per year.

Worsening = Population-reference group difference becoming larger at rate greater than 1% per year.

Key: AI/AN = American Indian or Alaska Native.

Note: "Asian" includes Asian or Pacific Islander when information is not collected separately for each group. Data presented are the most recent data available. Measures presented here for racial and ethnic minority groups are a subset of the core measures set that has data for all groups. Some measures for the poor are different from the measures used for racial and ethnic groups.

To facilitate comparisons across racial and ethnic groups, this year's report focuses on 16 of the 42 core measures of quality and 6 core measures of access that support reliable estimates for all groups, including Whites, Blacks,^vii Asians,^viii American Indians and Alaska Natives (AI/ANs), and Hispanics. (Core measures that did not have estimates for one or more groups due to data reliability or availability are not included in this summary analysis.) Comparisons by income group focus on 17 core measures of quality and 6 core measures of access that support reliable estimates by income.^ix For this analysis of trends, for each core measure, racial and ethnic minority groups and socioeconomic groups are compared with a designated reference group at different points in time (Figure H.1).^x Significant trends in disparities are identified using the following method:

^iv Consistent with Healthy People 2010, the NHDR defines disparities as any differences among populations. In addition, all disparities discussed in the NHDR meet criteria based on statistical significance and size of difference described in Chapter 1, Introduction and Methods.

^v For all measures, Blacks, Asians, and American Indians and Alaska Natives are compared with Whites; Hispanics are compared with non-Hispanic Whites; and poor individuals are compared with high income individuals.

^vi For a list of all core measures and the core measures included in these summary analyses, go to Chapter 1, Introduction and Methods.

^vii The NHDR officially uses the term "Blacks or African Americans" in accordance with the U.S. Office of Management and Budget. However, the text of the NHDR often refers simply to "Blacks."

^viii "Asian" includes Asian or Pacific Islander when information is not collected separately for each group.

Core measures for which the relative differences are changing less than 1% per year are identified as staying the same.
Core measures for which the relative differences are becoming smaller at a rate of more than 1% per year are identified as improving.
Core measures for which the relative differences are becoming larger at a rate of more than 1% per year are identified as worsening.

Figure H.1 shows that:

Some disparities are getting smaller. For Hispanics, just under half of disparities in quality of care are improving. For Blacks, AI/ANs, and poor populations, over one-third of disparities in quality are lessening.
At the same time, for Blacks, Asians, AI/ANs, and poor populations, over 60% of disparities in quality are not getting smaller. For Hispanics, 56% of disparities in quality are not getting smaller.

Getting into the health care system and receiving appropriate health care in a timely fashion is a key factor in determining whether health care services are effective. Many Americans enjoy good access to primary and hospital care, but for many priority populations, barriers exist to getting needed health care. Reducing disparities can improve overall quality. All population groups should receive comparable quality of care. Figure H.2 is a summary of trends in the core measures of access with data available for all racial and ethnic groups. For each core measure, racial and ethnic minority groups and socioeconomic groups are compared with a designated reference group at different points in time.

^ix Readers will note that findings in the 2007 Highlights suggest a snapshot of disparities similar to that shown in the 2006 report. Specifically, in the 2006 NHDR, a uniform set of quality measures and access measures is analyzed for all racial, ethnic, and income groups. However, four of the core measures with data available for all groups were changed this past year due to new calculation methods. Therefore, it is not possible to compare these measures over time. For a list of measures that changed between the 2006 and 2007 reports and the methods for determining statistical differences, go to Chapter 1, Introduction and Methods.

^x Consistent with Healthy People 2010, disparities are measured in relative terms as the percentage difference between each group and a reference group; changes are measured by subtracting the percentage difference between the baseline and the most recent year. The change in each disparity is then divided by the number of years between the baseline and most recent estimate to calculate change in disparity per year. Note that statistical significance is not required to label a disparity as improving or worsening; very few changes in disparities over time are statistically significant at the 0.05 level.

Figure H.2. Change in disparities in core access measures over time for members of selected racial/ethnic and income groups compared with reference group from 2000-2001 to 2004-2005*

Improving = Population-reference group difference becoming smaller at rate greater than 1% per year.

Same = Population-reference group difference changing at less than 1% per year.

Worsening = Population-reference group difference becoming larger at rate greater than 1% per year.

Key: AI/AN = American Indian or Alaska Native.

Note: "Asian" includes Asian or Pacific Islander when information is not collected separately for each group. Data presented are the most recent data available.

*The most recent year data for AI/ANs is 2003.

For AI/ANs, 60% of the core measures that can be tracked over time are improving.
For Blacks, Asians, Hispanics, and poor populations, at least half of the core measures used to track access are not improving.
For Hispanics, 80% of core access measures have either remained unchanged or gotten worse.
For Blacks, 60% of core access measures have either remained unchanged or gotten worse.

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Progress Is Being Made, but Many of the Biggest Gaps in Quality Have Not Been Reduced

In publishing the NHDR, it is hoped that the data can be used to identify the most important gaps in care as well as improvements for priority populations. Such data would allow targeting of resources and efforts to improve care and narrow the gaps in care for racial and ethnic minorities and poor populations. Some selected improvements in preventive care, chronic care management, and access to care have led to the elimination of disparities for some priority populations. At the same time, many of the largest disparities have not changed significantly.

A summary of improvements in disparities among the core measures in the report is presented in Table H.1. A relative rate is a ratio that compares one group with the reference group. (Whites are used as the reference group to compare with racial/ethnic minorities, and high income is used to compare with low income.)

Table H.1 Relative rates for core measures that showed reduction in disparities for selected groups over time, 2000-2001 to 2004-2005^a

Group	Measure	Relative rate^b for earliest year in NHDR	Relative rate^b for most recent year in NHDR
Black compared with White	Hemodialysis patients with adequate dialysis (urea reduction ratio 65% or greater)*	1.29	1.08
	New AIDS cases per 100,000 population age 13 and over	10.4	10.0
	Children 19-35 months who received all recommended vaccines	1.31	1.14
Asian compared with White	Persons who have a usual primary care provider*	1.40	1.13
	Children 19-35 months who received all recommended vaccines	1.21	1.12
	Tuberculosis patients who completed a curative course of treatment within 12 months of initiation of treatment	1.09	.97
AI/AN compared with White	High-risk short-stay nursing home residents who developed pressure sores	1.15	1.06
AI/AN compared with White	High-risk long-stay nursing home residents who developed pressure sores	1.17	1.07
Hispanic compared with Non-Hispanic White	Adult perforated appendix per 1,000 admissions with appendicitis*	1.06	1.01
	Adults who can sometimes or never get care for illness or injury as soon as wanted	2.00	1.62
	Children 19-35 months who received all recommended vaccines	1.28	1.18
	New AIDS cases per 100,000 population age 13 and over	3.64	3.52
	Pregnant women receiving prenatal care in first trimester	2.12	2.03
Poor compared with High income	Adult perforated appendix per 1,000 admissions with appendicitis*	3.47	1.10
Poor compared with High income	Persons under age 65 with health insurance	6.15	4.86

Key: Relative rate >1.0 means the priority population group rate was worse than the reference group. Relative rate 1.0 means the priority population group rate is the same as the reference group. Relative rate <1.0 means the priority population group rate was better than the reference group.

^a Measures selected from core measure set if findings met two criteria: (1) if the gap between the minority group and reference group decreased as indicated by a decrease in relative rate from earliest year to most recent year and (2) if the difference between the priority population group estimate for the most recent year and the earliest year was statistically significant and improved by at least 1% per year (go to Methods section in Chapter 1 on criteria for reporting change over time).

^b Relative rates are used to quantify the magnitude of disparities between the priority population and reference group. The relative rate for each group is calculated by dividing the group rate by the reference group rate.

* No disparity between selected group and reference group was reported in the most recent year for this measure since the most recent year estimate was not statistically different from the White estimate.

Overall, four of the core measures showed disparities getting smaller and have been eliminated:

From 2001 to 2005, the proportion of Black hemodialysis patients with adequate dialysis improved (from 82% to 87%; in 2005 this rate was not statistically different from Whites), and the gap between Blacks and Whites decreased (from a relative rate of 1.29 to 1.08).
From 2002 to 2004, the proportion of Asians with a usual primary care provider improved (from 69.3% to 75.2%), and the gap between Asians and Whites in having a usual primary care provider decreased (from a relative rate of 1.40 to 1.13).
From 2001 to 2004, the proportion of Hispanics who had a hospital admission for perforated appendix decreased (from 322.4 per 1,000 admissions to 291.8 per 1,000 admissions), and the gap between Hispanics and non-Hispanic Whites decreased (from a relative rate of 1.06 to 1.01).
From 2001 to 2004, the proportion of people living in poor communities who had a hospital admission for perforated appendix decreased (from 344.2 per 1,000 admissions to 307.7 per 1,000 admissions), and the gap between poor and high income decreased (from 3.47 to 1.10).

Other improvements among core measures include:

Children who received recommended vaccines among Blacks, Asians, and Hispanics.
New AIDS cases for Blacks and Hispanics.
Tuberculosis treatment for foreign-born Asians.
Nursing home residents who developed pressure sores for AI/ANs.
Adults who can sometimes or never get care as soon as wanted and prenatal care for pregnant women for Hispanics.
For the poor, people under age 65 with health insurance.

These findings show there has been some progress in decreasing disparities. Each racial and ethnic group showed improvements in some areas. However, not all improvements closed the gap between these groups and reference groups.

In 2005, the NHDR reported on the biggest gaps that existed in health care quality in America for Blacks, Asians, AI/ANs, Hispanics, and poor populations. As a reference to examine whether progress has been made in addressing disparities, this year's NHDR presents the same analysis using the most currently available data. The "biggest gaps" are defined as those quality measures with the largest relative rates between Whites and racial and ethnic minorities and between high income and poor individuals. This analysis is presented in Table H.2.

Table H.2. Three largest disparities in quality of health care for selected groups: measure and rate relative to reference group, 2005 NHDR versus 2007 NHDR (Measures that have the largest gaps in both the 2005 and 2007 NHDR are in italics.)

Group	2005 NHDR		2007 NHDR
Group	Measure	Relative rate	Measure	Relative rate
Black	New AIDS cases per 100,000 population age 13 and over	10.4	New AIDS cases per 100,000 population age 13 and over	10.0
	Hospital admissions for pediatric asthma per 100,000 population ages 2-17	4.0	Hospital admissions for pediatric asthma per 100,000 population ages 2-17	3.8
	Percent of patients who left the emergency department without being seen	1.9	Hospital admissions for lower extremity amputations in patients with diabetes per 100,000 population	3.8
Asian	Persons age 18 or older with serious mental illness who did not receive mental health treatment or counseling in the past year	1.6	Composite: Adults who reported poor communication with health providers	1.6
	Adults who can sometimes or never get care for illness or injury as soon as wanted	1.6	Long-stay nursing home residents who were physically restrained	1.5
	Adults age 65 and over who did not ever receive pneumococcal vaccination	1.5	Adults age 65 and over who did not ever receive pneumococcal vaccination	1.5
AI/ANs	Women not receiving prenatal care in the first trimester	2.1	Women not receiving prenatal care in the first trimester	2.1
	Composite: Adults who reported poor communication with health providers	1.8	Composite: Adults who reported poor communication with health providers	1.8
	Children ages 2-17 with no advice about physical activity	1.3	Women age 40 and over who reported they did not have a mammogram within the past 2 years	1.8
Hispanic	New AIDS cases per 100,000 population age 13 and over	3.7	New AIDS cases per 100,000 population age 13 and over	3.5
	Adults who can sometimes or never get care for illness or injury as soon as wanted	2.0	Hospital admissions for lower extremity amputations in patients with diabetes per 100,000 population	2.9
	Composite: Children whose parents reported poor communication with their health providers	1.8	Women not receiving prenatal care in the first trimester	2.0
Poor	Composite: Children whose parents reported poor communication with their health providers	3.3	Composite: Children whose parents reported poor communication with their health providers	3.0
	Adults who can sometimes or never get care for illness or injury as soon as wanted	2.3	Adults who can sometimes or never get care for illness or injury as soon as wanted	2.4
	Children ages 2-17 who did not have a dental visit	2.0	Women age 40 and over who reported they did not have a mammogram within the past 2 years	2.1

Note: Relative rate is used to compare one group with its reference group. It is calculated by dividing the group's estimate by the reference group's estimate. For example, the relative rate of new AIDS cases for Blacks compared with Whites is 10.0 in the 2007 NHDR. This means that Blacks have a rate that is 10 times higher than Whites for this measure.

Most of the largest gaps reported in 2005 remain the largest gaps in this year's NHDR. The two largest gaps reported in 2005 remain among the largest gaps in the 2007 NHDR:

For Blacks, large disparities remain in new AIDS cases despite significant decreases. The proportion of new AIDS cases was 10 times higher for Blacks than Whites. Black children have also consistently had the greatest proportion of children with asthma hospitalizations. The proportion of Black children who were hospitalized due to asthma was almost four times higher than White children.
For Asians, disparities remain in preventive care for pneumonia. Asians age 65 and over were more likely than Whites to lack immunization against the pneumonia virus.
For AI/ANs, disparities remain in prenatal care. AI/AN women were twice as likely to lack prenatal care as White women. Also, AI/AN adults continued to be more likely than Whites to report poor communication with their health providers.
For Hispanics, large disparities also remain in new AIDS cases despite significant decreases. The proportion of new AIDS cases was over three times higher for Hispanics than for non-Hispanic Whites.
For the poor, disparities remain in communication with health providers. The proportion of children whose parents reported communication problems with their health providers was three times higher for poor children than for high income children. Poor adults were also twice as likely to not get timely care for an illness or injury.

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Uninsurance Is a Major Barrier to Reducing Disparities

The growing rate of uninsurance in America has been the subject of considerable examination during the past 10 years in both the popular press and academic literature. AHRQ's Medical Expenditure Panel Survey publishes data on uninsurance rates in America. In 2004, 14% of persons under age 65 were uninsured for the whole year. This figure is even higher for racial and ethnic minorities. Among people under age 65, 14% of non-Hispanic Whites were uninsured for the whole year, but the figure climbs to 29% for Hispanics, 15% for non-Hispanic Blacks, and 12% for Asians. Uninsurance can lead to the lack of a usual source of health care and delayed care for necessary services. Hispanics and Blacks both report lower rates of having a usual source of care and higher rates of delaying necessary care than Whites.

The 2007 NHDR examines the growing problem of uninsurance in America, with particular emphasis on its impact on quality in terms of both processes and outcomes of care. Uninsured individuals are compared with individuals who have some private health insurance on nine core quality measures and six core access measures.

In addition, many risk factors for poor quality (poverty, race/ethnicity, gender, education, and geography) are related. To account for these multiple relationships, the 2007 NHDR summarizes the results of multiple regression analyses that examined the independent effect of uninsurance after controlling for these other factors. Figure H.3 compares the core measures of access and quality for uninsured individuals and individuals with private insurance.

Figure H.3. Uninsured compared with individuals with some private insurance on measures of quality and access in the most recent data year, 2004-2005

Stacked columns chart shows ininsured compared with individuals with some private insurance on measures of quality and access. Quality (9 CRM): Worse, 8; Same, 1; Better, 0. Access (6 CRM): Worse, 6; Same, 0; Better, 0.

Better = Population received better quality of care or had better access to care than the reference group.

Same = Population and reference group received about the same quality of or access to care.

Worse = Population received poorer quality of care or had worse access to care than reference group.

Key: CRM = core report measures. Core access measures include measures such as insurance status, source of ongoing care and primary care, and delayed care.

Note: The measures included here are a subset of the core measure set that has data available by insurance status. Individuals with public insurance are not included in this summary.

Uninsured individuals do worse than privately insured individuals on almost 90% of quality measures.
Uninsured individuals do worse than privately insured individuals on all access measures.

Measures with the largest disparities for uninsured individuals compared with privately insured individuals are presented in Table H.3.

Table H.3. Core measures with the largest disparities between uninsured and privately insured individuals

Measures with largest disparities	Relative rate
Access
Persons who have a specific source of ongoing care, 2005	6.03
Persons without a usual source of care who indicate a financial or insurance reason for not having a source of care, 2004	4.10
Persons who have a usual primary care provider, 2004	6.03
Quality
Adults who can sometimes or never get care for illness or injury as soon as wanted, 2004	2.89
Women age 40 and over who reported they did not have a mammogram within the past 2 years, 2005	2.39
Composite: Children whose parents reported poor communication with their health providers, 2004	2.32

Note: The relative rate is used to compare one group with its reference group. It is calculated by dividing the group's estimate by the reference group's estimate.

Compared with insured persons:

Uninsured individuals are about six times as likely to lack a usual source of care and four times as likely to be without a usual source of care for financial reasons.
Uninsured individuals are nearly three times as likely to not get care as soon as wanted for illness or injury, over twice as likely to not have a mammogram (for women over 40), and over twice as likely to have communication problems with their child's provider.

A number of priority populations have high rates of uninsurance. To examine the independent effect of uninsurance on disparities in quality and access, analyses were performed on a subset of 12 measures^xi for which uninsurance and risk factors could be analyzed concurrently. Multiple regression analyses were conducted, examining race, ethnicity, income, age, gender, education, and geography (urban versus rural status), as well as insurance status.

^xi The criteria for selecting these 12 measures were that data were available on a full range of patient-level factors such as those listed above. The measures are: (1) diabetes composite with three recommended services; (2) adult smokers age 18 and over given advice to quit smoking; (3) obese adults age 18 and over given advice about exercise; (4) children ages 2-17 given advice about healthy eating; (5) children ages 3-6 with a vision check; (6) adults who sometimes or never get care for illness or injury as soon as wanted; (7) children who sometimes or never get care for illness or injury as soon as wanted; (8) adult patient centeredness composite with four sometimes/never responses; (9) child patient centeredness composite with four sometimes/never responses; (10) people under age 65 uninsured all year; (11) people with a usual primary care provider; and (12) adults with a dental visit in the past year. A description of the methods for these analyses can be found in Chapter 1, Introduction and Methods.

Being uninsured has a large negative impact on the quality of health care individuals receive. Measures for multivariate analyses were selected from the Medical Expenditure Panel Survey. Even accounting for a full range of other important risk factors such as race, ethnicity, and income, being uninsured was the most important risk factor in six out of seven measures for poor quality health care.
For two measures for children, the uninsured do as well as or better than privately insured individuals: the percentages of children whose parents stated that they were able to get access to care for illness or injury as soon as wanted and who reported poor communication with their health providers.
Two examples of these multivariate analyses are presented in this year's NHDR: percentage of obese adults who received counseling about exercise (in the Heart Disease section in Chapter 2, Effectiveness) and percentage of people with a usual source of primary care (in Chapter 3, Access).

While insurance status is an important factor in improving disparities and quality of care, it remains important to consider its interaction with many other risk factors that contribute to poor quality of care, including poverty, race/ethnicity, gender, education, and geography. Disparities exist across racial and ethnic groups not only among uninsured individuals but also among those with health insurance.

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Moving Forward

Since its initial publication in 2003, the NHDR has provided a broad and detailed examination of disparities for at-risk priority populations in U.S. health care. The ability to monitor and track improvements in disparities is critical. Growing interest in public reporting for quality improvement activities continues to improve not only the quality of data but also the quality of care provided.

This 2007 report summarizes the many areas where little to no progress has been achieved at reducing disparities. However, it also highlights progress that is being made in key conditions that disproportionately affect priority populations. Many factors contribute to disparities in health care quality and access, and it is a major challenge to address them. Yet a number of promising programs at AHRQ and other agencies in HHS are doing just that.

The Federal Collaboration on Health Disparities Research (FCHDR) was developed by the Centers for Disease Control and Prevention in collaboration with the Office of Public Health and Science's Office of Minority Health and co-sponsored by AHRQ to identify and support research priorities for cross-agency collaboration to hasten the elimination of health disparities. This collaboration is led by the HHS Health Disparities Council and the Interagency Committee on Disability Research of the Department of Education. Identifying priority research topics on health disparities was one of FCHDR's primary outcomes in 2006. Through FCHDR, Federal partners have formed subject matter expert work groups around four initial research topic areas for collaboration: obesity, built environment (which includes homes, schools, workplaces, parks and recreation areas, business areas, transportation systems, etc.), mental health care, and comorbidities. These priorities represent opportunities for Federal agencies and other partners to collaborate on innovative research.

The Health Disparities Roundtable was convened in 2006 under co-sponsorship by the Office of Minority Health and AHRQ and also in partnership with the Institute of Medicine. The purpose of the IOM roundtable is to generate action and engage interested parties from academia, industry, government, philanthropy, the corporate sector, and the community to reduce racial and ethnic health disparities. It fills an important role in being a focus for public-private partnership on research and policy discussions to address topics such as the following:

Effective cultural competency techniques and cross-cultural education in health care settings.
Strategies to expand and strengthen research to develop effective treatments for those diseases that disproportionately affect minority populations, as well as research that focuses on the complex interactions of biological and social factors as determinants of health.
Educational strategies to end health disparities.
Developing and promoting effective strategies to increase minority representation in medicine and health professions.
Understanding the causes of health and health care disparities and best solutions.

The Disparity Reducing Advances Project is a multiyear, multistakeholder project co-sponsored by AHRQ and others, including the Centers for Disease Control and Prevention, the National Cancer Institute, the American Cancer Society, a Florida hospital agency, the Robert Wood Johnson Foundation, and the University of Texas Medical Branch. This project will identify the most promising strategies for bringing health gains to poor and underserved populations and accelerating the development and deployment of these strategies to reduce health care disparities.

The Think Cultural Health Web site (http://www.thinkculturalhealth.org) is sponsored by the Office of Minority Health. The Web site offers the latest resources and tools to promote cultural competency in health care. Users can access free online courses accredited for continuing education credit as well as supplementary tools to help providers and organizations promote respectful, understandable, and effective care to an increasingly diverse patient population. This Web site provides access to online courses such as "A Physician's Practical Guide to Culturally Competent Care" and "Culturally Competent Nursing Care," as well as interactive tools such as the "Health Care Language Services Implementation Guide."

The AHRQ National Health Plan Collaborative, which has 10 participating health plans with a total of 87 million enrollees, is co-funded by the Robert Wood Johnson Foundation to identify and implement approaches to reduce racial and ethnic disparities and improve quality among health plan enrollees. In Phase II of the collaborative, three task forces are addressing primary data collection and language access and are building the business case for reducing disparities. The collaborative builds on the continued interest of health plans in reducing disparities and improving health care for minorities.

The AHRQ Learning Partnership to Decrease Disparities in Pediatric Asthma selected six States (Arizona, Maryland, Michigan, New Jersey, Oregon, and Rhode Island) to participate in this project. Through technical assistance and tools (such as geographic information system mapping and an asthma return-on-investment calculator) provided by AHRQ, States identified several areas of need, including identifying disparities by geographic area, making the case to State governments for further action on asthma disparities, and addressing cultural competency issues. The partnership has resulted in tools, resources, and strategies created by States in partnership with AHRQ. These will be shared widely with other States that may have similar issues related to pediatric asthma disparities.

The AHRQ Hispanic Diabetes Disparities Learning Network in Rural and Urban Community Health Clinics focused on decreasing disparities in diabetes in adult Hispanics. Community health centers in two areas were targeted to document the differing challenges that may occur in urban versus rural settings: the greater Washington, DC, metropolitan area and rural Colorado. The learning network helped clinics begin process improvement on an important component of the chronic care model, improving patient self-management.

An HHS pilot project, Improving Hispanic Elders' Health: Community Partnerships for Evidence-Based Solutions, is bringing together teams of local leaders from communities with large numbers of Hispanic elders to review the latest research findings, examine promising practices, and develop local plans for addressing one or more health disparities. AHRQ, the Administration on Aging, the Centers for Disease Control and Prevention, the Centers for Medicare & Medicaid Services, and the Health Resources and Services Administration are collaborating to assist local communities in developing more coordinated strategies for improving the health and well-being of Hispanic elders. The project encourages broader use of preventive services under Medicare and emphasizes the importance of working across organizational boundaries to link aging services providers, medical care providers, Hispanic community organizations, and public health agencies. Eight communities have been selected to participate in this pilot project: Chicago, Illinois; Houston, Texas; Los Angeles, California; McAllen, Texas; Miami, Florida; New York, New York; San Antonio, Texas; and San Diego, California.

These are only a few of the many activities at AHRQ that address the challenges in reducing health care disparities. There are many other contributions from other HHS agencies that address disparities in health services delivery, health care finance, and clinical research, in addition to both Federal and State efforts to expand access. What they have in common are the focus on multiple stakeholders and the need for tailored solutions depending on the particular disparities issue and the populations involved. With the publication of this fifth NHDR, AHRQ stands ready to contribute to efforts like those above to encourage and support the development of national, State, tribal, and "neighborhood" solutions using national data and benchmarks in disparities. We hope that the progress and gaps outlined in this fifth NHDR will help catalyze improvement efforts over the next 5 years.

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