Eliminating Disparities in Health Care

AHRQ is leading Federal research efforts to develop knowledge and tools to help eliminate health care disparities in the United States. AHRQ supports and conducts research and evaluations of health care with emphasis on disparities related to race, ethnicity, and socioeconomic status. The Agency focuses on priority populations including minorities, women, children, the elderly, low-income individuals, and people with special health care needs such as people with disabilities or those who need chronic or end-of-life care.

National Healthcare Quality and Disparities Reports

The National Healthcare Quality Report (NHQR) and its companion report, the National Healthcare Disparities Report (NHDR) are the fifth editions since the reports' inaugural release in 2003. These reports are mandated by Congress and are read widely by policymakers, health care analysts, public health advocates, health insurers, journalists and consumers. This year's NHQR synthesizes more than 200 "quality measures," which range from how many pregnant women received prenatal care to what portion of nursing home residents were controlled by physical restraints. The NHDR summarizes which racial, ethnic or income groups are benefiting from improvements in care.

While the quality of health care is continuing to improve at an average annual rate of 2.3 percent (based on data from 1994 to 2005), the reports reveal that the rate of improvement appears to be slowing. An analysis of selected core measures, which cover data from 2000 to 2005, shows that quality improvement has slowed to an annual rate of 1.5 percent. Measures of patient safety showed an average annual improvement of just 1 percent.

However, the reports also show some notable gains. For example, the NHQR indicates that the portion of heart attack patients who received recommended tests, medications or counseling to quit smoking improved an average of 5.6 percent annually from 2002 to 2005. The NHDR showed that while Hispanics remain more likely than whites to get delayed care or no care at all for an illness, that disparity decreased between 2000 to 2001 and 2004 to 2005. In addition, while black children between 19 and 35 months old remain less likely than white children to receive all recommended vaccines, that disparity also decreased.

Other significant findings from the NHQR include:

• Between 1999 and 2005, the proportion of women age 40 and over who reported that they had a mammogram in the past 2 years decreased overall by 3.7 percent.
• Between 1999 and 2004, the rate of breast cancer deaths decreased from 26.6 to 24.4 per 100,000 female population. At 24.4 deaths per 100,000 females, the overall breast cancer death rate in 2004 was higher than the Healthy People 2010 target of 22.3. At the present rate of change, this target could be met by 2010.
• In 1999-2004, 48.7 percent of adults age 40 and over diagnosed with diabetes had their HbA1c level under optimal control. This percentage is statistically unchanged from the 1988-1994 time period.
• In 1999-2004, 48.2 percent of those age 40 and over diagnosed with diabetes had their total cholesterol under control. This is an improvement over the 1988-1994 rate of 29.9 percent.
• The percentage of women who received prenatal care in the first trimester of pregnancy increased gradually from 82.8 percent in 1998 to 83.9 percent in 2004. As of 2004, the percentage of women who received prenatal care in the first trimester of pregnancy had not yet achieved the Healthy People 2010 target of 90 percent.
• From 1998 to 2005, the percentage of children ages 19-35 months who received all recommended vaccines increased from 72.7 percent to 80.8 percent.

Findings from the 2007 NHDR show that some disparities have been eliminated:

• The disparity between Black and white hemodialysis patients with adequate dialysis was eliminated in 2005.
• The disparity between Asians and whites who had a usual primary care provider was eliminated in 2004.
• The disparity between Hispanic and non- Hispanic whites and between people living in poor communities and people living in high income communities for hospital admissions for perforated appendix was eliminated in 2004.

However, the NHDR also reports on the biggest disparities in quality where there has not been improvement:

• The rate of new AIDS cases for Blacks was 10 times higher than whites and Hispanics had a rate of new AIDS cases over 3.5 times higher than that of non-Hispanic whites.
• Asian adults age 65 and over were 50 percent more likely than whites to lack immunization against pneumonia.
• American Indians and Alaska Natives were twice as likely to lack prenatal care in the first trimester as whites.

NHQRnet/NHDRnet

In 2007, AHRQ launched NHQRnet and NHDRnet, a pair of new, interactive Web-based tools for searching AHRQ's storehouse of national health care data. These online search engines allow users to create spreadsheets and customize searches of information in the 2006 National Healthcare Quality Report and the 2006 National Healthcare Disparities Report.

NHQRnet allows access to data on dimensions of quality including effectiveness of care, safety, timeliness, patient centeredness, and overall measures. Clinical conditions include asthma, cancer, diabetes, depression, end stage renal disease, heart disease, HIV and AIDS, influenza and upper respiratory infections, and pneumonia. Access to data on care types/settings is also available for immunizations, maternal and child health, and nursing home and home health care. NHQRnet users can:

• Display estimates from national tables that are specific to particular subpopulations (e.g., particular age ranges).
• Track and display trends over time for national estimates of nearly 50 measures, including dimensions of health care quality, stages of health care, clinical conditions, settings of care, and access to health care.
• Access and download individual national and State data tables from the NHQR Tables Appendix.

NHDRnet content areas include quality of health care, access to health care, and priority populations. Clinical conditions include cancer, diabetes, heart disease, HIV/AIDS, and respiratory diseases. Dimensions of access include facilitators and barriers to health care and health care utilization. NHDRnet allows users to:

• Access data for quality of health care, access to health care, or for priority populations.
• Display estimates based on race, ethnicity, income, or education.
• Access and download individual tables from the NHDR Tables Appendix.

To access AHRQ's NHQRnet, go to http://nhqrnet.ahrq.gov. For NHDRnet, go to http://nhdrnet.ahrq.gov.

State Snapshots

AHRQ's State Snapshots Web tool was launched in 2005, and has been updated annually. Based on data drawn from more than 30 sources, including government surveys, health care facilities and health care organizations, the State Snapshots is an application that helps State health leaders, researchers, consumers, and others more easily access information about the status of health care quality in individual States, including each State's strengths and weaknesses. The 51 State Snapshots—every State plus Washington, D.C.—are based on 149 quality measures. Each measure provides information about a different aspect of health care performance including:

• Summary measures that provide an overall picture of health care quality in three different contexts: by types of care (such as preventive, acute, or chronic care), by settings of care (such as nursing homes or hospitals), and care by clinical area (such as care for patients with cancer or respiratory diseases).
• The 149 individual measures range from preventing bed sores to screening for diabetes-related foot problems to providing antibiotics quickly to hospitalized pneumonia patients.
• The State Snapshots also allow users to compare a State's performance against other States in the same region, plus how a State compares against "best performing States."

The State Snapshots Web site also offers these options for data searches:

• Strongest and Weakest Measures: This section summarizes areas in which a State has performed well compared to other States, plus areas in which a State's scores are comparatively low.
• Focus on Diabetes: Underscoring the need to confront a disease now afflicting more than 18 million Americans, this section illustrates how States compare in quality of care, treatment variations, and health care spending for diabetes.
• All-State Data Table for All Measures: With more than 5,000 entries, this downloadable spreadsheet includes all 149 individual performance measures for each State.

To access this year's State Snapshots tool, go to http://statesnapshots.ahrq.gov.

Recent research findings on disparities and minority health

• Education, income, and net worth explain more racial/ethnic disparities than either health behaviors or insurance coverage. Researchers found that crude mortality rates over a 6-year period for late middle-aged whites, blacks, English-speaking Hispanics and Spanish-speaking Hispanics were 5.8 percent, 10.6 percent, 5.8 percent, and 4.4 percent, respectively. Higher mortality rates for black versus white people were mostly explained by worse baseline health. However, accounting for education, income, and net worth reduced disparities in declining self-reported overall health for blacks and English-speaking Hispanics (but not Spanish-speaking Hispanics) to nonsignificance. In contrast, health insurance and health behaviors (for example, smoking, alcohol use, and body mass index) explained little of the racial/ethnic differences in health outcomes.
• Although mortality rates from cardiovascular disease (CVD) in the United States continue to decrease, rates are rising among Native American Indians. CVD is the leading cause of death in American Indians beginning at age 45 compared with age 65 for the U.S. general population. Prevalence of hypertension in a rural group of 4,549 American Indians aged 45 to 74 increased from 42.2 percent in 1989-1991 to 61.3 percent among men 8 years later and from 36.4 percent to 60.3 percent among women. Prevalence of diabetes increased from 41.4 to 47.4 percent among men and from 48.4 to 55.8 percent among women during the study period—three times higher than the 16.4 percent of people with diabetes among a similar age group in the 1994 National Health and Nutrition Examination Survey.

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Getting Value for Money Spent on Health Care

According to data from the Medical Expenditure Panel Survey (MEPS), Americans spent $1.02 trillion in health care expenses for hospital inpatient and outpatient care, emergency room services, office-based health care providers, dental services, home health care, prescription medicines, and other medical services in 2005. Nearly 85 percent of the U.S. population had some medical expense with an average annual expense per person of approximately $4,000. The average expense for a person age 65 and over was more than $9,000, three times the average for a person under age 65 ($3,200). Despite this level of health care spending, health care quality in this Nation still needs improvement.

Value-Driven Health Care Initiative

AHRQ is working closely with the Department of Health and Human Services to fulfill the goals of HHS Secretary Mike Leavitt's Value-Driven Health Care Initiative. The goal of the Initiative is to create a health care system where patients can get better information about the quality and cost of their care that includes competition to provide them with the best value. The Initiative was launched on August 22, 2006, when President Bush signed an executive order to help increase the transparency of health care by requiring Federal agencies that administer or support health insurance programs to provide information on the cost and quality of health care. Under the Executive Order, all health care programs administered or sponsored by the Federal government are required to pursue collaborative efforts to promote four cornerstones for health care improvement:

• Connecting the system through the adoption of interoperable health information technology.
• Measuring and making available results on the quality of health care delivery.
• Measuring and making available price information on the costs of health care items and services.
• Aligning incentives so that payers, providers, and patients benefit when care delivery is focused on achieving the best value of health care at the lowest cost.

Chartered Value Exchange

In 2007, working with AHRQ, HHS designated more than 100 Community Leaders that are encouraging the growth of community-based, multi-stakeholder collaboratives working to drive health care reform. These groups were the first eligible to apply to be a Chartered Value Exchange. As Chartered Value Exchanges, communities will have access to information from Medicare that gauges the quality of care physicians provide to patients. These performance measurement results can be combined with similar private-sector data to produce a comprehensive consumer guide on the quality of care available. The Chartered Value Exchanges are:

• Wisconsin Healthcare Value Exchange, Madison, Wisconsin.
• Healthy Memphis Common Table, Germantown, Tennessee.
• Greater Detroit Area Health Council, Detroit, Michigan.
• Niagara Health Quality Coalition, Williamsville, New York.
• Oregon Health Care Quality Corporation, Portland, Oregon.
• Pittsburgh Regional Health Initiative, Pittsburgh, Pennsylvania.
• Puget Sound Health Alliance, Seattle, Washington.
• Utah Partnership for Value-driven Health Care, Salt Lake City, Utah.
• Louisiana Health Care Quality Forum, Baton Rouge, Louisana.
• Maine Chartered Value Exchange Alliance, Scarborough, Maine.
• Minnesota Healthcare Value Exchange, St. Paul, Minnesota.
• Massachusetts Chartered Value Exchange, Watertown, Massachusetts.
• Alliance for Health, Grand Rapids, Michigan.
• New York Quality Alliance, Albany, New York.

These communities will join a nationwide Learning Network sponsored by AHRQ. This network will provide peer-to-peer learning experiences through facilitated meetings, both face-to-face and on the Web and access to HHS experts and new tools, including an ongoing private Web-based knowledge management system.

AHRQ launches a new series of advice columns AHRQ director Carolyn Clancy, M.D., presents a series of brief, easy-to-understand advice columns for consumers to help navigate the health care system. The columns are designed to help consumers navigate the health care system, make decisions about their health care, recognize high-quality health care, be an informed health care consumer; and choose a hospital, doctor, and health plan. In 2007, subjects included: Where Medical Errors Occur and Steps You Can Take to Avoid Them. Facing the Facts Get Involved to Get Better Care. Health Care Quality: Take A Closer Look. Becoming an Involved Health Care Consumer. Recognizing High-Quality Health Care. The advice columns are on the AHRQ Web site at www.ahrq.gov/consumer/cc.htm.

Recent research findings on health care costs and improving performance

• Educational outreach to individual physicians (individual academic detailing) to improve recommended prescribing of antihypertensive medications can reduce drug costs. Researchers at the HMO Research Network Center for Education and Research in Therapeutics found that the estimated annual drug cost savings (after the cost of the program) for individual detailing was $21,711 or $289 in savings per physician. Extrapolating these results to the plan level (7,600 newly diagnosed and treated hypertensive patients in a typical year) would result in an estimated $155,000 savings in the cost of antihypertensive medications with universal adoption of the individual detailing intervention.
• From 1996 to 2003, the financial burden of health care in the United States for people less than 65 years of age increased, especially among the poor and those with job-related and public insurance coverage, according to an analysis of MEPS data from 1996 and 2003. People with nongroup plans were nearly three times as likely to bear high total burdens as individuals in any other insurance category. Others at higher-than-average risk of incurring financial burdens were poor and low-income people, people under age 65, those in fair or poor health, those with a limitation in functioning, people suffering from a chronic medical condition, or those living in a nonmetropolitan area. High out-of-pocket burdens were associated with delaying or foregoing medical care for financial reasons.

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