Chapter 5. Research on Health Care for Priority Populations

Not all Americans have full and equal access to the best quality health care. As a part of the Agency's overall research portfolio, AHRQ supports and conducts research and evaluations of health care for priority populations. Although emphasis is placed on disparities related to race, ethnicity, and socioeconomic status, research also focuses on the delivery of health care in inner-city and rural areas (including frontier areas) and on priority populations with unique health care needs or issues that require special attention.

AHRQ's priority populations include low-income groups, minority groups, women, children, the elderly, and individuals with special health care needs, including individuals with disabilities and those who need chronic care or end-of-life health care. Further, the Agency supports dissemination of health services research to promote broadening access to effective health care services and the elimination of health disparities.

Health Care for the Elderly, Minorities, Women, and Children

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

• An AHRQ-funded study indicates that African-American and Hispanic children in the United States who are 6 to 11 years of age are significantly more likely than non-Hispanic white children of the same age to be overweight.
• Moderately obese white women are 17 percent less likely to have had a mammogram than normal weight white women. Compared with normal weight black women, mammography use was similar or higher in overweight, mildly obese, and moderately obese black women.
• Over three-fourths of low-income black women in each of three age groups (65-74, 75-84, and 85 and older) underestimate their own risk of getting breast cancer. Women ages 85 and older are the least likely to have had a mammogram or clinical breast examination within the past year.
• Compared with men, women are less aggressively screened and treated for cholesterol problems, despite the fact that cardiovascular disease (CVD) is the leading cause of death among women. Studies that examine people with CVD indicate that men have cholesterol measured more often, are treated more aggressively (for example, with statin drugs), and have lower levels of low-density lipoprotein cholesterol (the so-called "bad" cholesterol), than women.

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Elderly Health

About one in every eight Americans is age 65 and over, representing an elderly population of over 35 million people. By the year 2030, the elderly population will more than double to 71.5 million. Most older people have at least one chronic condition and over half report a disability. AHRQ's support of research on the cost-effectiveness of care for the elderly helps inform health care discussions that may affect changes in health benefits and financing mechanisms, including those relating to the Medicare and Medicaid programs. Creating and translating new knowledge into practice, as well as improving the uptake of what is already known about high quality care for older people, continue to be key issues facing the health services research community and primary care providers.

Examples of Ongoing Research

• Researchers at Purdue University in Indianapolis are conducting a 4-year randomized controlled clinical trial designed to test the efficacy of an Integrated Program of Collaborative Care in improving the outcomes of care for older adults with Alzheimer Disease in a primary care setting. The study will also describe the prevalence of dementia disorders and associated comorbidity and will measure utilization, costs, use of community services, and the costs associated with the intervention.
• A project underway at the University of California in San Francisco will measure mortality, functional change, hospitalization, and quality of life in frail patients who continue to live in the community even though they are eligible to live in a nursing home. The study population is a group of patients at 12 national sites of the Program of All-Inclusive Care for the Elderly (PACE), a rapidly expanding program that provides care for patients in the community that have been certified as eligible for nursing homes. The products of this research represent a critical first step in developing methods to measure variations in outcomes and the quality of care, developing interventions to improve care of frail elders, and assessing the effectiveness of the rapidly growing PACE program.
• A study at Thomas Jefferson University is attempting to illuminate the decisionmaking processes underlying advance directives in order to enhance communication between health providers and patients and provide guidance for the construction and timing of advance directives. Researchers will test whether preferences for years of desired life and invasive medical treatments change as an individual's health and functioning deteriorate and if altering the description of advance-directive-style options (i.e., providing a description of palliative care vs. treatment) may influence preferences for treatments under various medical scenarios.
• A program developed at the University of Pittsburgh will attempt to address health disparities in minority adult Americans by better preparing researchers from minority and majority populations to conduct research on ways to eliminate disparities. Four projects are being conducted during the course of this program:
  1. Eliminating disparities in adult immunization.
  2. Patient-provider communication regarding cancer screening.
  3. An intervention evaluation study to control lipid disorders and hypertension in African-American males.
  4. Using oral histories to improve patient-provider interaction.

Examples of Recent Findings

• One in five (21 percent) of elderly individuals has filled a prescription for a drug that in general should be avoided in patients aged 65 and older. In addition, nearly half (44 percent) of these prescriptions were for drugs that carry a substantial risk of adverse effects in elderly patients.
• Although people older than 75 years have a slower rate of physical recovery from coronary artery bypass graft surgery than elderly patients who are younger, they gain similar health benefits from the procedure. An AHRQ-funded study showed that the older group's physical function scores were significantly lower than the younger group until 1 year, confirming a slower recovery of physical function. However, recovery speed for angina relief and quality of life improvement did not differ by age.
• Through 2001, only 63 to 65 percent of elderly individuals in the United States had been vaccinated against influenza and pneumonia. Practices that allot more time for acute care visits and use more immunization promotion activities have higher vaccination rates:
  • Practices that allotted 16-20 minutes versus 10-15 minutes for acute care visits had influenza vaccination rates that were more than twice as high.
  • Practices that did not have a source of free vaccines had 57 percent fewer influenza vaccinations.
  • Practices that were urban/suburban and had a source of free flu vaccines had four times as many influenza vaccinations.
  • Practices that had three or more immunization promotion strategies—such as designated vaccination clinics, computerized immunization tracking systems, prompts on patient charts, and a source of free or reduced-cost vaccinations—had twice as many pneumonia vaccinations.

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Minority Health

Although the overall health of Americans has improved dramatically over the last century, racial and ethnic minorities continue to face challenges in accessing high quality care. Racial and ethnic minorities are more likely than non-Hispanic whites to be poor or near poor, and they often experience worse access to care and lower quality of preventive, primary, and specialty care. Closing the gap for minority populations is a major priority for the Department of Health and Human Services and for AHRQ. AHRQ has been funding and conducting research on topics relevant to minority health for many decades.

Examples of Ongoing Research

• Research at the Morehouse School of Medicine emphasizes the identification of health care intervention opportunities and best intervention strategies for low-income children and chronically ill African Americans who primarily receive care from community providers in inner-city and rural communities. The overall longterm objectives of this research are to assess, inform, and expose clinical faculty, health care consumers, community health care providers, and health agency partners to an extensive knowledge base of intervention opportunities and intervention strategies for improving health care access and quality of services for vulnerable African Americans.
• Researchers at the Medical University of South Carolina are developing collaborative management of Type 2 diabetes in black Americans and investigating how culturally sensitive collaboration is crucial to changing the poor outcomes of Type 2 diabetes in blacks. The three specific aims are to identify the knowledge, beliefs, and attitudes of black patients that impact their diabetes outcomes, identify impediments to improved diabetes outcomes in blacks that are attributable to health care providers, and to identify external factors that impact on diabetes outcomes in blacks.
• Training medical interpreters for Navajo patients with diabetes through a project at the University of New Mexico at Albuquerque may improve diabetes outcomes and health care utilization patterns. The State of New Mexico includes a significant portion of the Navajo Nation, which is the second largest American Indian tribe. Navajo people have 2.5 times the rate of diabetes compared with the general population. Researchers hope to improve patients' diabetes knowledge, and selfcare practices.
• Researchers at the Mount Sinai School of Medicine in New York are conducting a randomized controlled trial to test the effectiveness of a nurse case management intervention to improve hypertension control among blacks and Hispanics living in East and Central Harlem and evaluate the effectiveness of a nurse-managed computerized physician reminder system coupled with improved patient education. The project will also assess the effectiveness of a computerized reminder system with feedback on improving underuse of effective local and systemic adjuvant treatments for breast cancer as well as the magnitude of underuse of treatments for managing premature births.

Examples of Recent Findings

• Black men in the United States have a much higher cancer incidence than white men because of occupational exposure to known carcinogens. An AHRQ study that analyzed clinical data on men with non-Hodgkin's lymphoma, Hodgkin's disease, and soft-tissue sarcoma found:
  • Among black men, exposure to chromium dust—a known carcinogen often encountered in the metal, printing, paint, textile, and other industries—was associated with nearly four times the risk of non-Hodgkin's lymphoma.
  • Wood dust exposure was associated with nearly five times the risk of Hodgkin's disease and nearly four times the risk of soft-tissue sarcoma.
  • Black men who were exposed to pesticides and who reported working at a sawmill, pulp mill, or planing mill had nearly three-fold increases in their risk of soft-tissue sarcoma, although this risk did not reach statistical significance.
  • No significant occupational risk factors for cancer among white men were identified, suggesting that black men have greater exposure to carcinogens on the job than white men.
• Quality improvement programs that encouraged depressed patients to undergo standard treatments for depression (psychotherapy or antidepressant medication) and gave them and their doctors up-to-date information and resources to increase access to treatments reduced depression rates among black and Hispanic patients.
• White patients are twice as likely as black patients to receive coronary angiography (CA), an imaging procedure to diagnose heart problems, and revascularization procedures to correct these problems (coronary bypass surgery or coronary angioplasty). Fewer angiographies among black heart disease patients may be due in part to less access of black patients to cardiologists, who are more likely to recommend coronary angiography. Compared with white patients, black patients had 2.4 times greater odds than white patients of not obtaining a referral for CA, and 1.89 times greater odds of not receiving the procedure. However, this difference in receipt of CA was reduced to 1.4 among patients who received a referral for CA.
• Black patients undergo amputation of a lower extremity two to three times as often as white patients. A study funded by AHRQ suggests that greater severity and progression of peripheral arterial disease (PAD) or diabetes among blacks could account for these racial disparities independent of any access problems to hospitals for vascular surgery. Blacks were 1.7 times as likely as other patients to be admitted for a primary amputation, that is, a major amputation without any previous attempt at revascularization. However, after adjusting for age, sex, and diabetes mellitus prevalence, white and black patients were equally likely to undergo primary amputation. Repeat amputees were 2.5 times as likely to be black as white, but these patients had more advanced and aggressive PAD.

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Women's Health

In 1900, the leading causes of mortality among U.S. women included infectious diseases and complications of pregnancy and childbirth. Today, the chronic conditions of heart disease, cancer, and stroke account for 63 percent of American women's deaths and are the leading causes of mortality for both women and men. Women have a longer life expectancy than men, but 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.

Findings from the 2004 National Healthcare Quality and Disparities Reports indicate:

• Between 1998 and 2002, prenatal care for women in their first trimester improved; however, current rates are still below the Healthy People 2010 goal of 90 percent.
• For services unique to women, when compared with white women, both blacks and Hispanics receive poorer quality care for 75 percent of quality measures.
• Poor, near poor, and middle-income women had lower rates of both Pap tests and mammography than high-income women.
• Women tend to receive better preventive care for cancer and cardiovascular disease than men, while men tend to receive better treatment for end-stage renal disease and heart disease.
• Women were less likely than men to receive either a beta-blocker or aspirin on arrival at the hospital for a heart attack.

AHRQ supports research on all aspects of health care provided to women:

• Understanding differences between the health care needs of women and men.
• Understanding and eliminating disparities in health care.
• Empowering women to make better health care decisions.
• Enhancing the response of the health system to women's needs.

In FY 2004, AHRQ supported the following activities in women's health:

• With support from AHRQ, a research team at Brown University and Rhode Island Hospital developed the Women's Interactive System for Decisions on Menopause, or WISDOM©. During the course of development, AHRQ collaborated with leaders in the fields of women's health, evidence-based medicine, risk modeling, risk communication, medical informatics, Web design, and decision support aids. The tool can be found at http://www.medwisdom.org. Among the unique design features of the Web site are:
  • Comprehensive evidence-based information on menopausal treatments—The Web tool is an interactive matrix that can be manipulated to show the most effective treatments for the user's menopausal symptoms. The database includes herbal remedies as well as prescription medicines and can be sorted according to efficacy, treatment type, and symptom concerns.
  • Personalized risk assessment—Women can assess their 10-year and lifetime risks for cardiovascular disease (CVD), breast cancer, and osteoporotic hip fracture based on information they enter into the content database. The results are presented with bar graphs and text.
  • Prevention options—Women can view their personal risk for CVD, breast cancer, and hip fracture with and without treatment as well as the impact of those treatments on menopausal symptoms and life expectancy.
  • Contraindications—Women are informed if they have contraindications to any specific treatments.
  • Clinician summary—Women can print a summary of their information and results so they can discuss these results with their clinicians.
• AHRQ awarded a contract to the National Committee for Quality Assurance to conduct analyses of HEDIS data investigating differences between women and men in quality of care (prevention and treatment) related to cardiovascular disease and its risk factors as measured through HEDIS performance measures in a national sample of managed care plans. This information will be used to inform the development of recommendations for improving quality of care and eliminating sex-based differences in cardiovascular care.
• In April 2004, AHRQ convened a 2-day expert panel meeting to discuss issues related to "Improving the Use and Safety of Medications in Women Through Sex/Gender and Race/Ethnicity Analysis." The meeting brought together a multidisciplinary team of 35 science, clinical, and pharmacological experts to discuss and exchange information on the pharmacological dynamics of medications, how they differ between men and women, the impact of age, sex/gender, race, and ethnicity on dosing variances and how pharmacodynamics impact drug use and safety.

Examples of Ongoing Research

• Researchers at the Oregon Health & Science University are developing an evidence-based childbirth decision support tool to weigh the consequences for various childbirth methods. They will test its effectiveness to improve patients' shared decisionmaking and satisfaction, and reduce feelings of failure, anxiety, and postpartum depression. This Web-based tool will be widely accessible, providing an opportunity to overcome the economic, racial, linguistic, and ethnic disparities that currently exist in prenatal education and health outcomes.
• A randomized controlled study at the University of Arizona will assess the efficacy and effectiveness of acupuncture treatment of depression during pregnancy. Few medically acceptable treatments are available for the treatment of depression during pregnancy and preliminary work provides evidence that acupuncture may be a safe and acceptable treatment option for depression.
• Researchers at the Montefiore Medical Center in the Bronx, NY, are investigating the effectiveness of a domestic violence intervention and defining outcome measures for domestic violence interventions that incorporate patient, community, and expert viewpoints. This project will also explore the feasibility of monitoring these outcomes measures in this population and create a methodology for a cost-benefit analysis of domestic violence interventions.
• A project at the Medical College of Wisconsin is investigating the adverse psychological and social effects that false-positive mammograms can have on women. Researchers will compare two groups of women, those with false-positive mammograms and those with true-negative mammograms, with regard to days off work, perceived health status, physician visits, and medical expenditures. They will also evaluate associations with race, age, socioeconomic status, and comorbidity.

Examples of Recent Findings

• Colorectal cancer is the second leading cause of cancer death in the United States, yet AHRQ research indicates that morbidly obese women are nearly 6 percent less likely than others to be screened for colorectal cancer than normal weight women.
• Only 46 percent of older women with osteoporosis-related fractures receive treatment in the 6 months following a fracture to prevent further fractures as called for by clinical guidelines. Fewer than 12 percent of women are diagnosed with osteoporosis prior to a fracture, even though nearly 11 percent have conditions—such hyperthyroidism or chronic renal failure or take medications like steroids or anticonvulsants—that would put them at risk for developing osteoporosis. In addition, more than one-third (39 percent) of these women are already at increased risk for falling due to medical problems like stroke and dementia or medications such as long-acting benzodiazepines or tricyclic antidepressants.
• Women with abnormal uterine bleeding who undergo hysterectomies experience greater improvement in their symptoms and express higher satisfaction with their overall health 6 months after treatment than women who are prescribed an alternate regimen of oral medication for the same condition. The women who had hysterectomies experienced greater improvements in mental health, sexual desire and functioning, sleep, and overall satisfaction with health.
• Out-of-pocket costs for oral contraceptive pills (OCPs) and the inconvenience of making monthly pharmacy visits may be barriers to women's consistent use of OCPs. AHRQ research shows that privately insured women pay, on average, 60 percent of the total expenditures for OCPs, which cost about $14 per monthly pack. Women who have no prescription drug coverage, are uninsured, or are privately insured but not in managed care plans have higher out-of-pocket expenditures for oral contraceptives.

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Children's Health

Finding ways to improve outcomes, quality, and access to health care for America's 70 million children and adolescents is a critical goal of health services research and a continuing priority for AHRQ. Children and adolescents are growing and developing, and their health care needs, use of services, and outcomes are very different from those of adults. Unlike adults, children and adolescents usually are dependent on parents and others for access to care and evaluations of the quality of that care.

Furthermore, adolescents differ from younger children; they are moving from childhood to adulthood and have their own unique health care needs, preferences, and patterns of use.

For these and many other reasons, a special research focus is needed to increase understanding of the issues involved in improving the delivery of health care to children and adolescents. AHRQ has a commitment to build the infrastructure and capacity for child health services research and ensure that practitioners and policymakers have the knowledge and tools they need to:

• Improve child health outcomes.
• Enhance the quality of care children receive.
• Address access, use, and costs.
• Translate evidence-based research into improved clinical practice.

AHRQ's Children's Health Advisory Group (CHAG), under the leadership of the Agency's Senior Advisor for Child Health, is the principal source of policy advice and coordination of child health activities for the Agency as a whole. The purpose is to:

• Develop and promote the Agency's strategic plan for child health.
• Foster and support child health research, development of datasets and tools, and other child health activities in AHRQ Offices and Centers (O/Cs).
• Facilitate communication among the Senior Advisor, for Child Health and the O/Cs, as well as among the O/Cs, on child health issues.

AHRQ's Child Health Research Agenda

In 2004, AHRQ committed over $22 million of total support over the lives of the projects for new intramural and extramural research activities focused on child health, including grants, contracts, and interagency agreements. The goals of these projects are to support improvements in health outcomes, improve quality and patient safety, and identify strategies to improve access, foster appropriate use, and reduce unnecessary expenditures.

Examples of Ongoing Research

• Researchers at Children's Hospital in Los Angeles, CA are conducting a randomized controlled trial to assess the effects of preoperative gait analysis on surgical outcomes in ambulatory children with cerebral palsy. The study population includes a large number of Hispanic children and a small sample of African-American, Asian, and Native Hawaiian or other Pacific Islander children.
• Using a telehealth model, researchers at the University of Rochester in New York will evaluate children in schools and child care programs to examine the impact of telehealth on utilization and cost, continuity of care, adherence to well-child visit schedules, and immunization rates.
• Using a patient-centered health technology called ParentLink, researchers at Children's Hospital Corporation in Boston, will evaluate the completeness and accuracy of information provided by parents on symptoms, conditions, medications, and allergies compared with information documented by emergency department physicians and nurses. They also will assess ParentLink's impact on patient safety and quality.
• Researchers at Massachusetts General Hospital in Boston will assess changes in patient experience of care using a modified CAHPS® survey on the impact of medication dosing based on weight has on pediatric adverse drug events, a test result tracking system on appropriate followup of ordered tests, and automated reminders on symptom monitoring medications for children with asthma and attention deficit disorder.
• Investigators at the University of Tennessee Health Science Center will develop a database to include diagnosis, health record, and educational information on children with special health care needs.
• A research project at Yale University will implement and evaluate a community-wide electronic health record for use by clinicians in pediatric primary care, school health, specialty care, and emergency medicine who provide care for inner city children with asthma.
• Researchers at the University of Rochester Medical Center in New York will examine the prevalence of complementary and alternative medicine use among older adolescents, especially Hispanic adolescents.

Examples of Recent Findings

• Experienced pediatricians who relied on their clinical judgment more than existing clinical guidelines were able to minimize hospitalizations and avoid unnecessary lab testing for infants with fevers without a negative impact on the outcomes of care. The researchers found that clinicians followed clinical practice guidelines to treat infants with fevers 42 percent of the time. In the first month of life, 40 percent fewer infants were hospitalized when clinicians did not follow guidelines. Rather than hospitalization, the clinicians saw many infants in repeated office visits and had frequent telephone followup.
• Children who participated in the Federal Supplemental Nutrition Program for Women, Infants, and Children (WIC) for a full year were about 1.7 times as likely to have two or more dental visits per year, 1.5 times as likely to have one dental visit, and nearly 2 times more likely to have a preventative visit and a restorative visit as children who never participated in WIC. In addition, WIC participants were 32 percent less likely than non-participants to have an emergency visit related to oral problems.

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Child Health Insurance Research Initiative (CHIRI™)

In 1999, AHRQ—in partnership with the David and Lucile Packard Foundation and the Health Resources and Services Administration—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 the State Children's Health Insurance Programs (SCHIP). The projects were dispersed around the country and focused on identifying which features work best for low-income, minority, and special needs children. Although seven of the nine grants ended in FY2003, the projects continue to produce useful information for policymakers.

Examples of recent findings from CHIRI™ projects include:

• SCHIP increased access to and satisfaction with health care among enrolled low-income children, according to a study of three State's SCHIP programs in three States (Florida, Kansas, and New York). The study showed that vulnerable children-minorities, children, and adolescents with special health care needs, and children uninsured for long periods of time-shared in these gains. It also highlighted areas to target for future improvement.
• Increases in SCHIP enrollment were associated with a decline in office-based physician participation in Medicaid in urban areas in Georgia, where the same provider network serves both Medicaid and SCHIP. However, increases in SCHIP enrollment had little effect on physician participation in Alabama, which uses an open health care provider panel. Researchers concluded that an adequate provider system is critical to assuring improvements in access to care for children enrolled in public insurance programs.
• Thirty-eight percent of children with special health care needs had a behavioral or mental health problem, but only 26 percent of caregivers perceived the need for treatment or counseling, according to an Indiana study. The researchers concluded that because caregivers do not always recognize behavior and mental health problems, children with special health care needs should be assessed for these problems during routine health care visits and referred to appropriate services.
• Recent findings from the CHIRI™ project in New York indicate that enrollment improved enrollees' access, continuity, and quality of health care. Enrollment in SCHIP:
  • Decreased the proportion of enrollees who did not have a usual source of care (from 14 percent to 3 percent).
  • Decreased the proportion of enrollees with any unmet health care needs (31 percent to 19 percent).
  • Reduced unmet need for specific types of care (specialty care, 16 percent), acute and preventive care (10 percent each), and dental and vision care (13 percent each).
  • Increased the proportion of children with a preventive visit (74 percent to 82 percent) with no significant changes in the number of emergency, specialty, and acute care visits.
  • Improved children's continuity of care: the proportion of children who used their usual source of care for most or all visits nearly doubled (from 47 percent to 89 percent).
  • Increased quality of care: families gave a higher rating to the benefits and medical care that they received after SCHIP enrollment compared with before enrollment.

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