Chapter 5. Research on Health Care for Priority Populations

As part of the Agency's overall research portfolio, AHRQ supports and conducts research and evaluations of health care delivery for priority populations. These include individuals who live in inner city and rural areas (including frontier areas), low-income groups, minorities, women, children, elderly individuals, and people with special health care needs, including those with disabilities and those who need chronic or end-of-life care. Further, the Agency supports the generation and dissemination of health services research to promote equitable access to health care services for all Americans and the elimination of health disparities among racial and ethnic minority populations. This section of the report is focused on AHRQ's activities with regard to three of these priority populations: minorities, women, and children.

Health Care for Minorities, Women, and Children

AHRQ's research emphasizes the needs of priority populations, who generally are underserved by the health care system and underrepresented in research. Disparities in health care for minorities, women, and children have been well-documented in recent years. These disparities span a broad range of medical conditions and health care delivery issues. For example:

• In 2001, more than one-third of Hispanics and one-fifth of blacks were uninsured during the first half of the year, compared with about 15 percent of white non-Hispanics.
• One AHRQ-supported study of mortality following heart attack found an 11 percent, 2-year mortality rate for women before age 60, compared with 7 percent for men in the same age group.
• Uninsured pregnant women are less likely than those who have insurance to receive timely prenatal care.
• Elderly black and Hispanic women are screened less frequently for breast and cervical cancer than their younger counterparts.
• Adolescents who live outside two-parent families are significantly more likely to be uninsured than those who live in two-parent families, and adolescents living in households headed by grandparents are most likely to be uninsured.

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Minority Health

Although the overall health of Americans has improved dramatically over the last century, racial and ethnic minorities have in the past experienced poor health and challenges in accessing high quality care. Findings from the 2000 Census indicate continued diversification of the U.S. population and growth in some groups considered to be at high risk for missing the benefits of health care.

This will become even more problematic, since some racial and ethnic minority populations are growing at a much more rapid pace than the majority white population. By the year 2050, it is estimated that nearly one in two Americans will be a member of a racial or ethnic minority group—that is, black, Hispanic, Asian, or American Indian.

Despite the high quality of care available, research has suggested that a gap exists between ideal health care and the actual care that Americans sometimes receive. For example:

• Blacks have a 10 percent higher cancer incidence rate and a 30 percent higher cancer death rate than whites. Although cancer death rates are declining more quickly for blacks compared with whites, cancer survival is lower among blacks for almost all cancers regardless of age or site.
• Hispanics and American Indians or Alaska Natives are less likely than whites to have their cholesterol checked.
• Black, Hispanic, and people of lower socioeconomic status are less likely than whites and people who are more affluent to have their blood pressure checked or to receive counseling and treatment for some cardiac risk factors.
• Compared with whites, blacks and Hispanics have higher rates of hospitalization for complications of diabetes.

AHRQ Focus on Minority Health

Closing the gap for minority populations is a major priority for the Department of Health and Human Services and for AHRQ. Indeed, AHRQ has been funding and conducting research on topics relevant to minority health for many decades.

In FY 2003 alone, AHRQ funded about $42 million in research with a major emphasis on minority health. This commitment includes continued funding of the Excellence Centers to Eliminate Ethnic/Racial Disparities (EXCEED) grants, a major research effort to improve our understanding of the factors that contribute to ethnic and racial inequities in health care, and the Minority Research Infrastructure Support Program (M-RISP), which was established to increase the capacity of institutions that serve racial and ethnic minorities to conduct rigorous health services research.

Current and Recently Completed Research on Minority Health

Examples of other current and recently completed research projects focused on minority health include:

• In a project underway at the University of Rochester, researchers are examining the impact of HMOs on disparities. They are comparing the scope and magnitude of disparities between managed care and traditional fee-for-service insurance plans in several areas, including prevention, health status change, use of highly technological procedures, avoidable complications, and mortality.
• Researchers at the University of Florida are assessing the effectiveness of a culturally sensitive model of care for hypertension applied at the patient, provider, and organizational levels in a primary care clinic serving an ethnically diverse population.
• Use of preventive asthma care among black children is the focus of a project underway at the University of North Carolina, Chapel Hill. Researchers are investigating how race—when defined explicitly as social class, culturally derived health beliefs, and exposure to racism and other structural forces—mediates use of preventive asthma care by black children.
• Researchers at the Children's Hospital Research Center in San Diego are using focus groups, cognitive interviews, and field testing of an existing sample of children with special health care needs to develop and test a questionnaire on barriers to care. The questionnaire is being fielded in both English and Spanish.

Recent Research Findings Related to Minority Health

Examples of recent findings from AHRQ-supported research on minority health include:

• When black and Hispanic patients suffering from depression were provided with recommended medications or psychotherapy by culturally competent providers, as well as language translation when needed, they were substantially less likely than similar patients receiving usual care to be depressed 6 or 12 months later. The study involved 398 Hispanics, 93 blacks, and 778 whites from 46 primary care practices in six U.S. managed care organizations.
• The Program of All-Inclusive Care for the Elderly (PACE) was carried out at 12 demonstration sites around the country from 1990 to 1996. The demonstrations involved 2,861 patients (859 blacks and 2,002 whites). PACE provides comprehensive medical and long-term care services—ranging from physical therapy and durable medical equipment to medications and transportation—for nursing home-eligible older people who live in the community. A greater proportion of black elders enrolled in PACE survived compared with white elders, according to the researchers who conducted the study. Survival for black and white patients was 88 percent and 86 percent, respectively, at 1 year, 67 percent and 61 percent at 3 years, and 51 percent and 42 percent at 5 years. After adjusting for coexisting medical conditions and other factors, elderly black PACE patients still had a 23 percent lower mortality rate than white patients.
• Expanding insurance coverage by itself will not eliminate racial/ethnic disparities in access to high quality health care services, according to a recent study by AHRQ researchers. They found that other factors—including income, local area demographic and economic indicators, and individual patient characteristics—also play a role. The researchers used data from the 1996-1999 Medical Expenditure Panel Survey, county-level health care system data, and data from other sources to examine the roles that insurance coverage, the health care delivery system, and other external factors play in explaining racial/ethnic disparities in access to outpatient care among patients of all ages.
• Problems with doctor/patient communication may be at least partly to blame for racial/ethnic disparities in use of health care. Researchers from Baylor College of Medicine found that blacks and Latinos are hospitalized and undergo surgery or other invasive procedures that require a doctor's order at lower rates than white patients, even when they have the same access to care, diagnosis, and severity of illness. This suggests that at least some disparities in health care use emerge after the patient gets to the doctor, in the context of the doctor-patient interaction, not from problems in getting to the doctor in the first place. This may be because patients from different ethnic groups may be more or less inclined to provide a health narrative to the doctor, may use different terms to describe the same symptoms, and may screen out views that they think the doctor will find unacceptable (for example, non-Western beliefs about illness). Also, ethnic and cultural norms influence a patients' willingness to ask questions, express concerns, and be assertive during a medical interaction.

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Women's Health

The life expectancy of U.S. women has nearly doubled in the past 100 years, from 48 years in 1900 to nearly 80 years in 2000, compared with an average of 74 years for men in 2000. Although women have a longer life expectancy than men, they do not necessarily live those extra years in good physical and mental health. On average, women experience 3.1 years of disability at the end of life.

AHRQ supports research on all aspects of health care provided to women, including quality, access, outcomes, and cost. AHRQ is particularly interested in studies that examine ways to enhance active life expectancy for older women.

AHRQ's women's health research agenda supports studies that are designed to:

• Enhance care for women with chronic illnesses and disabilities.
• Identify and reduce differences in health care received by minority women.
• Address the health care needs of women living in rural areas.

Examples of current AHRQ-supported research on women's health include:

• In a study led by researchers at the Medical College of Wisconsin, the goal is to determine the impact of false-positive mammograms. Women will be categorized as false-positive or true-negative mammogram status, and researchers will compare both groups according to days of work missed, perceived health status, physician visits, and medical expenditures. Outcomes and associations with race, age, socioeconomic status, and comorbidity also will be compared.
• Researchers at Montefiore Medical Center in New York are focusing on the effectiveness of various domestic violence interventions. An important goal is to establish a methodology to define outcome measures. In addition, they will determine the feasibility of monitoring outcomes through a prospective cohort study and create a methodology for a cost-benefit analysis.
• Researchers at Rutgers University are using nationally representative data to estimate the out-of-pocket prescription drug burden on female Medicare beneficiaries over age 65. The researchers will estimate the proportion of elderly women with high out-of-pocket expenditures and determine how health care access problems exacerbate the burden for these drugs for subgroups of elderly women.

In addition to these projects, other studies underway focus on:

• Cardiovascular disease.
• Breast and cervical cancer screening and treatment.
• Hysterectomy and alternative treatments for benign gynecological conditions.
• Urinary incontinence.
• Access to care.
• Quality of care.
• Intimate partner violence.
• Clinical preventive services.
• Reproductive health.
• Other topics important to women.

Recent Findings From AHRQ Research on Women's Health Insurance status does not explain male/female differences in heart attack treatments and outcomes. This study involved more than 327,000 men and women who suffered heart attacks between 1994 and 1997. Women received fewer cardiac treatments and procedures and had worse outcomes than men, but insurance status was not the reason. Lumpectomy followed by radiation and mastectomy are equally effective for treating early-stage breast cancer. Two studies from Georgetown University examined the cost-effectiveness of surgical treatments for early-stage breast cancer and patients' quality of life after surgery. They found that giving older women with early-stage breast cancer a choice between breast-conserving surgery and radiation and mastectomy is cost effective. They also found that how older women are treated during their care, not the therapy itself, is the most important determinant of long-term quality of life. Telecolposcopy can enhance diagnostic accuracy for women with abnormal Pap smears or other indications for colposcopy who are examined at rural clinics. The study was carried out by researchers at the Medical College of Georgia. Researchers at the University of Maryland, Baltimore, interviewed 1,300 women to assess urinary incontinence before and after hysterectomy and found that UI improves for the first 2 years after surgery for most women who have moderate or severe incontinence.

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Children's Health

Childhood is a unique developmental stage of life, childhood health may affect adult health, and the child health care system is distinctive. For these and other reasons, children's health has been a research and policy priority in the United States for many years.

The following four distinguishing characteristics have important implications for policymakers, clinicians, and others who are involved in health care for children:

• Developmental change. Children develop at a rapid rate, and their health depends in large measure on the success of their cognitive, emotional, and physical growth and development.
• Dependency. Children depend on parents and other adults for financing and accessing health care.
• Differential epidemiology. Children experience a unique pattern of health, illness, and disability, and a different pattern of health care use.
• Demographic patterns. These include the high rate of children living in poverty, family size, and family composition.

A unique set of health care financing and organizational arrangements has evolved for U.S. children. Poor children have been a mandatory population for the Medicaid program from the beginning, and adolescents were added gradually over time to the program. In 1997, the State Children's Health Insurance Program (SCHIP) was created to provide coverage to certain uninsured low-income children who are not eligible for Medicaid. Other health care financing mechanisms for children include the Maternal and Child Health Block Grants and Social Security, which provides cash benefits to eligible families to help pay for health care for some disabled children.

AHRQ's Child Health Research Agenda

A special research focus is necessary to improve the delivery of health care services to children and adolescents. AHRQ's child health research agenda is focused on finding ways to improve outcomes, quality, and access to health care for America's 70 million children and adolescents. The goal is to improve the quality and safety of care provided to children, enhance their access to care, and improve the delivery of care to children with special needs, those living in rural and underserved areas, and children from poor or near poor families.

AHRQ's work helps to fill the major gap that exists in evidence-based information on the health care needs of children and adolescents. In FY 2003, AHRQ committed nearly $10 million in total support for new child health services research projects and training grants, contracts, and interagency agreements relating directly to health care issues affecting children and adolescents.

Examples of Ongoing Research and Recent Findings

Examples of current AHRQ-supported research on health care for children and adolescents include:

• Researchers at the University of Washington in Seattle are examining whether providing evidence at the point of outpatient pediatric care will improve antibiotic use for childhood illnesses, reduce duration of therapy for acute sinusitis, reduce use of bronchodilators, and increase the use of intranasal steroids for allergic rhinitis.
• A study underway at West Virginia University is assessing the usefulness of a motivational tobacco intervention for rural smokers ages 14 to 18 who seek emergency care for an illness or injury.
• Using evidence-based asthma management strategies, researchers at Arkansas Children's Hospital in Little Rock are assessing the effectiveness of a case management intervention implemented by Head Start personnel. The goal is to identify and describe the factors associated with poor asthma management in 1,000 enrollees and estimate the cost of the intervention.
• Researchers at the Medical College of Wisconsin, Milwaukee, are developing a triage instrument for use by ER clinicians to help them triage pediatric patients to the appropriate level of care.

Child Health Insurance Research Initiative (CHIRI™) Studies In 1999, AHRQ—in partnership with the Health Resources and Services Administration and the David and Lucile Packard Foundation—funded nine 3-year projects for more than $9 million to examine ways to improve health care for low-income children receiving care through publicly funded programs, including SCHIP. The projects were dispersed around the country and focused on identifying which features work best for low-income, minority, and special-needs children. Five of the projects have been completed; the following four projects are still in progress: Evaluation of Kansas Healthwave, Kansas Health Institute. Medicaid versus Premium Subsidy: Oregon's CHIP Alternatives, Center for Health Economics Research, Waltham, MA. New York's SCHIP: What Works for Vulnerable Children, University of Rochester. Provider Participation and Access in Alabama and Georgia, University of Alabama at Birmingham.

Examples of findings from recently completed AHRQ-funded studies on health care for children and adolescents include:

• Children experienced a substantial number of potentially preventable patient safety problems during hospital stays in 1997, according to a study conducted by AHRQ staff researchers. They found that the rates of such problems ranged from 0.2 (foreign body left during a procedure) to 154.0 (birth trauma) problems per 10,000 hospital discharge records. They also found that children who experienced a patient safety problem in the hospital also faced a 2-18 times greater risk of death than children who did not have such a problem.
• Researchers at Montefiore Medical Center, Bronx, NY, found that the availability of a school-based health center measurably improved the health and school performance of 949 inner-city children with asthma. They conclude that such centers may offer a practical response to the limited access that poor and uninsured children have to health care.
• According to researchers at the Vanderbilt University Center for Education and Research on Therapeutics in Nashville, erythromycin therapy in newborns increases the risk of gastric outlet obstruction. Using Tennessee Medicaid files from 1985 to 1997, they found that infants who received erythromycin between 3 and 13 days after birth were at substantially increased risk for developing infantile hypertrophic pyloric stenosis, which results in gastric outlet obstruction requiring surgery.
• Increasing use of preventive medications may reduce disparities in asthma burden, according to researchers at Harvard Pilgrim Healthcare in Boston. They analyzed data on Medicaid-insured children with asthma in five managed care organizations and interviewed parents to gauge asthma status and evaluate racial/ethnic variations in the processes of asthma care. Despite having worse asthma than white children, black children (31 percent) and Hispanic children (42 percent) were much less likely than white children to be using inhaled antiinflammatory medication. Subsequent research found that racial and ethnic minority parents' concerns about using the medication may contribute to the differences in care.

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