Identify Strategies to Improve Access, Foster Appropriate Use, and Reduce Unnecessary Expenditures

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Performance Budget Submission for Congressional Justification

Identify Strategies to Improve Access, Foster Appropriate Use, and Reduce Unnecessary Expenditures

Adequate access to health care services continues to be a challenge for many Americans. This is particularly true for the poor, the uninsured, members of minority groups, rural residents, and other vulnerable populations. In addition, the changing organization and financing of care has raised new questions about access to a range of health services, including emergency and specialty care. At the same time, examples of inappropriate care, including overutilization and misuse of services, continue to be documented. Through ongoing development of nationally representative and more specialized databases, the production of public-use data products, and research and analyses conducted by AHRQ staff and outside researchers, the Agency addresses critical policy issues pertaining to the access, cost and use of health care.

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Medical Expenditure Panel Survey (MEPS)

The Medical Expenditure Panel Survey (MEPS) is an ongoing, annual (1996 to present) nationally representative survey of health care use, expenditures, sources of payment, and insurance coverage for the U.S. civilian noninstitutionalized population. The 1996 MEPS also included a national survey of nursing homes and their residents. This survey is AHRQ's main source to collect and examine comprehensive data that estimate the level and distribution of health care use and expenditures, monitor the dynamics of the health care delivery and insurance systems, and assess health care policy implications. Select for more detail on MEPS.

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Healthcare Cost and Utilization Project (HCUP)

The Healthcare Cost and Utilization Project (HCUP) is a long-standing public-private partnership to build a multi-State health care data system. In Fiscal Year 1999, AHRQ redesigned HCUP based on input from key stakeholders and other sources, including State HCUP partners, hospital associations and other private data organizations, policymakers and researchers.

The following redesign efforts have been put in place for the HCUP project:

During l999, the number of HCUP State partners grew from l9 to 22 States. New State partners were selected for geographic diversity, population concentration, representation of important population subgroups (e.g., racial and ethnic minorities), and immediate availability of data.
Also in l999, the HCUP inpatient hospital data effort expanded to include other settings. Hospital-based ambulatory surgery data was collected from nine States on a pilot basis, along with emergency department data from one State. Data from these new sites is being evaluated for data-quality and policy relevance.
HCUPnet is now available for public access on the Agency's Web site. HCUPnet allows users to tailor an online query of HCUP's National Inpatient Sample (NIS), the largest all-payer inpatient database in the United States. HCUPnet is ideal for developing National estimates and analyzing national trends, including trends for hospitalizations that can only be analyzed with large sample databases (e.g. care patterns for rare conditions, frequency and distribution of uncommon procedures such as transplantation). In less than 2 months, the site received over 2,100 hits, an average of 51 per day.
Eleven of the 22 Statewide Inpatient Databases (SID) are now available from a single point of access, under the auspices of AHRQ. Before September l999, the only means to access SID data was to approach each HCUP partner State on an individual basis, determine if the data organizations released their SID, obtain information about State-specific application processes, and successfully complete the application processes. This method was time-consuming to researchers since each State had varied application requirements. AHRQ continues to work with the remaining States with the goal of making the SID universally available from a single point of access.
A feasibility study is under way to explore construction of a dataset specifically aimed at children's studies, in response to the growing interests of policymakers and researchers in studying pediatric hospitalizations. Children comprise about 16 percent of the HCUP Nationwide Inpatient Sample (which has 5.6 million observations). However, many pediatric conditions are relatively uncommon, which makes analysis difficult despite the large sample size of the NIS. The new children's database is in the early stages of development, and we are consulting with potential users (e.g. pediatric researchers and CDC staff involved in birth defects studies) to design the database to allow more reliable estimates for uncommon conditions and procedures.
Efforts are now under way to create a new database for minority studies called the Nationwide Inpatient Sample for Minority Studies (M-NIS). This dataset would enable the hospitalization experience of racial/ethnic groups to be studied, and in particular would facilitate disparities analysis. This dataset will be based on data from hospitals in the 16 HCUP States that provide data on race/ethnicity.

The latest report from HCUP shows that the most common reasons for hospital admission in the United States are births (3.8 million admissions), followed by coronary atherosclerosis (1.4 million admissions), pneumonia (1.2 million admissions), congestive heart failure (990,000 admissions) and heart attack (774,000 admissions) (select for Figure 4, 15 KB).

This information, based on 1996 data, is the latest in a series of statistical publications coming from the HCUP project. This data shows why Americans are hospitalized, how long they stay in the hospital, the procedures they undergo, and the charges for their stays. This in-depth profile of inpatient care answers many key questions about how specific conditions are treated in hospitals and the resulting outcomes. It contributes to the evidence base needed to develop effective strategies for improving the quality and value of health care. The estimates are based on the largest all-payer database in the U.S., the Nationwide Inpatient Sample, which is maintained by AHRQ. This sample consists of 7 million discharges from 1,000 hospitals (20 percent of U.S. hospitals).

The latest report also provides data about the most expensive conditions, or diagnoses, treated in U.S. hospitals in 1996 (select for Figure 5, 16 KB). The most expensive were as follows:

Spinal cord injury ($56,800)
Infant respiratory distress syndrome ($56,600)
Low birthweight ($50,300)
Leukemia ($46,700)
Heart valve disorders ($45,300)

The figures are average charges for the entire stay. Overall, patients stayed in the hospital an average of 5 days. But stays involving premature birth, with problems such as low birthweight and slow growth of the fetus, averaged 23 days. Stays because of infant respiratory distress syndrome average 22 days, and patients with spinal cord injuries remained hospitalized an average of 16 days.

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HIV Data Coordinating Center (DCC)

In Fiscal Year 1999 and 2000, AHRQ and sister agencies are providing support to develop the first phase of the HIV Resource Utilization Data Coordinating Center (DCC), which will pilot test data transmission from a small number of providers. The goal of this project is to provide timely and relevant information to policymakers about the resources utilized to treat persons with HIV disease. It is important to use timely data because quickly occurring therapeutic advances, the shifting epidemiology of HIV infection, and the rapid diffusion of managed care are having a major effect on patterns of health care resource utilization for HIV disease. The swiftness of change in HIV service delivery suggests that data collected as recently as three or four years ago do not necessarily reflect the current situation and may not be used dependably for policy and planning functions. Timely information is needed to assure that the more than $7 billion spent each year by Medicaid, Medicare, the Department of Veterans Affairs, and the Ryan White CARE Act to treat people with HIV disease is spent effectively and equitably. In particular, this information is needed by Federal and State policymakers to ensure that all persons with HIV disease (regardless of their gender, race, ethnicity, income or geographic location) have access to appropriate health care services.

The primary advantage of this project is that it will obtain reasonably complete medical and financial information from a large, nationally representative sample of 30,000 HIV-infected patients. A sample of this magnitude permits the study of differences in care among numerous categories of patients. The DCC will permit State-specific analyses of utilization, access, cost and quality for HIV-infected persons throughout the stages of HIV disease, including interstate comparisons of patterns of care for different racial and ethnic groups. DCC also will permit, for example, an analysis of the importance of factors such as insurance status, geographic location, gender and mode of transmission on the likelihood that persons in the early stages of HIV disease receive certain therapies.

This information is also needed by payers, including Medicare and Medicaid, who reimburse managed care organizations a fixed rate to treat their enrollees. In order to ensure that managed care organizations do not discriminate against persons with HIV disease, it is necessary that payments to managed care organizations for treating persons with HIV disease be adequate to provide the resources needed to treat these patients. The development of good risk adjustment mechanisms is predicated on the availability of current data on the utilization and cost of health services in this population. In view of the rapidity of change in HIV-related treatments and services, policy makers need an established, ongoing mechanism to collect relevant data and to provide relevant analyses of current resource utilization parameters in a timely manner.

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Research on Health Care Markets and Managed Care

We know that market dynamics and delivery-system organization affect outcomes, quality, access, cost and use. AHRQ continues to conduct and support studies, as well as develop databases and tools, that will enable decisionmakers to understand the key market and delivery-system variables and how changes in these variables affect health care.

Research now underway will inform our understanding of how particular managed care policies and practices, such as protocols governing the referral of patients to medical specialists and arrangements for paying physicians, affect the quality of care for patients living with chronic illnesses. The studies will provide health plan executives and purchasers, including the government, with the first comprehensive findings regarding which practices can be adopted by managed care organizations to optimize effective health outcomes. The seven teams, drawn from scientists working at some of the top research institutions in the country, include, for example, these projects:

A project to study the care given to working-age members of seven United Health Care plans in different parts of the country for diabetic retinopathy and open-angle glaucoma, both of which are leading causes of blindness. (RAND, Santa Monica, CA) .
A project to study the quality of care for low-income children in Florida's Healthy Kids Program who suffer from asthma, diabetes or other problems. Participating groups include the Health Insurance Plan of Florida, Health Option/Blue Cross-Blue Shield of Florida, Humana, Florida Health Care Plans, Florida First, PCA Family (Physicians' Corporation of America-Family), JMH Health Plan of Florida (Jackson Memorial Trust Plan of Florida), Av-Med Health Plan and Physicians' Health Plan. (University of Florida)

Health care markets continue to grow in their complexity. Costs appear to be rising again, and some HMOs are withdrawing from Medicaid and Medicare programs. For-profit ownership is increasing, some hospital-health plan mergers from the past are being dissolved, and new consolidations are producing complex multi-product, multi-market health plans and diversified provider networks. Moreover, employers and health care coalitions are having greater impact on the shape of health care markets than before. But other aspects of health care are not changing: Access to health care continues to be a problem in rural markets, and racial and ethnic disparities in health outcomes and quality persist. Policymakers in both the public and private sectors need further information so they can forge sound policies and strategies in response to both market changes and persistent problems. In Fiscal Year 2000, AHRQ is awarding more than $2 million in grants to generate knowledge that policymakers can use to address these issues, with a special focus on rural markets and care to persons belonging to racial and ethnic minorities.

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Bioterrorism and Health Care

In Fiscal Year 2000, AHRQ received $5,000,000 from the Public Health and Social Services Emergency Fund for research related to bioterrorism. AHRQ's bioterrorism research agenda will include a combination of grants and contracts to elucidate the role of the health care system in detecting and treating the conditions resulting from bioterrorist acts. In Fiscal Year 2000, AHRQ will develop a multi-component initiative that complements current Federal efforts with the following activities:

Sponsoring a research initiative with Federal and private-sector partners to develop and evaluate information systems to detect sentinel events and provide rapid information to clinicians regarding appropriate management.
Supporting the development of a broader research agenda that identifies priority areas related to the role of clinicians, emergency departments, hospitals, private practices and professional societies.
Evaluating the current data capacity and needs of hospitals, clinical practices and emergency departments.
Convening regional and national stakeholder groups of clinicians, hospitals and emergency departments to inform current and future research agendas, with a specific focus on primary care practice networks.
Consulting with national experts in bioterrorism and clinical practice.
Assessing and improving the capacity of Integrated Delivery Systems and managed care organizations to detect and respond to bioterrorist attacks.

In addition, the Agency may support two evidence reports that provide clinically and programmatically useful syntheses of the world's literature on selected aspects of bioterrorism, such as diagnosis, treatment, and system response. An expert meeting of stakeholders also will be convened to identify gaps in knowledge and practice prior to developing the scope of work for these literature reviews to assure relevance to stakeholder needs and enhance the probability that the evidence will be adopted. The Agency will consult with other agencies and external organizations to gain their input concerning the appropriate focus of research in the area of bioterrorism.

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AHRQ's Commitment to Improved Health Care for Vulnerable Populations

Disparities in health have been documented repeatedly over the last few decades across a broad range of medical conditions and for a wide range of ethnic and racial groups. These differences have been noted in health outcomes such as quality of life and mortality, processes of care such as utilization rates of certain services, quality and appropriateness of care, and the prevalence of certain conditions or diseases. The documentation of these widespread disparities has been an important contribution of outcomes and effectiveness research and health services research. Nevertheless, these insights have infrequently led to significant improvements in racial and ethnic disparities, in part, because the causes of and contributing factors to these inequalities are inadequately understood.

Disparities persist despite improvements in health for the Nation as a whole. For example, mortality from ischemic heart disease decreased 20 percent for the overall population but decreased only 13 percent for blacks between 1987 and 1995. As minority populations continue to increase in size and proportion, the health of these groups will increasingly affect the health of the entire Nation. Also, lessons learned from understanding and eliminating disparities and improving the health care of underserved racial and ethnic groups will likely be applicable to the United States population as a whole. Minority children and chronically ill minority elderly are of particular interest because they may be especially vulnerable to a number of the causes of inequities and may be less able to safeguard their needs and interests adequately.

Some of the most glaring differences in outcomes are addressed by the President's Initiative to Eliminate Racial and Ethnic Disparities in Health. In 1996, the infant mortality rate was nearly 2½ times greater for blacks than whites. The incidence rate for cervical cancer is more than 5 times as high for Vietnamese women in the United States as for white women (47.3 vs. 8.7 cases per 100,000 women). And the prevalence of diabetes in Hispanics, Native Americans and Alaska Natives is approximately double that in whites.

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Minority Health

In Fiscal Year 1999, AHRQ made significant progress in the development of a portfolio of activities to address minority health. These included:

Convening a meeting of experts and stakeholders in minority health to understand the research needs and to receive input from users on future directions for Agency research.
Establishing a strategic plan for minority health.
Convening and cosponsoring several conferences addressing several issues in minority health, including a partnership meeting with Health Care Financing Administration (HCFA) and the Assistant Secretary of Planning and Evaluation (ASPE) on data needs for research on racial and ethnic disparities.
Funding 49 grants totaling more than $16.8 million in minority health.

Among the studies funded in Fiscal Year 1999 was one that received national media attention and reported that blacks and women with chest pain were much less likely than whites and men to receive a referral for cardiac catheterization. (Cardiac catheterization is the gold standard test for diagnosing coronary artery disease.) This disparity in testing was greatest for black women (odds ratio: 0.4).

Initiative to Eliminate Racial and Ethnic Disparities in Health

In Fiscal Year 1999, AHRQ directed a total of approximately $2 million within three RFAs—Quality Measurement for Vulnerable Populations, Assessment of Quality Improvement Strategies in Health Care, and Translating Research Into Practice—for research to develop new measures of quality, evaluate strategies for improving health care, and improve clinical practice in the areas of health status specified in the Race and Health Disparities Initiative (infant mortality, cardiovascular disease, cancer management, diabetes, HIV infection, and immunizations). (Select for a more detailed description of these RFAs.) In addition, five of six grants to study access and quality of care for low-income children focus on minority children.

In Fiscal Year 2000, AHRQ will direct nearly $8 million to support projects intended to achieve the goals of the Racial and Health Disparities Initiative. This includes:

Providing up to $4.35 million for "centers of excellence" that will identify practical tools and strategies to eliminate racial and ethnic disparities in the health care system. The centers will emphasize minority children and chronically ill elderly because these groups may be particularly vulnerable to the impact of disparities in health care treatment. Another research emphasis will be on clinical preventive services.
Providing approximately $3.5 million through the AHRQ initiative Translating Research into Practice II. The Agency will build partnerships between health care delivery sites, including providers who have traditionally served minority communities, and academic researchers, addressing the specific conditions of the Racial and Health Disparities Initiative, and supporting the design of systematic interventions to determine which approaches are most effective.
Setting aside additional funds to support the training of minority health services researchers to address the priority issues identified in the Race and Health Disparities Initiative.

One example of research funded in Fiscal Year 2000 that will improve health care for minorities is a grant to analyze the interpersonal processes between racially and ethnically diverse patients and their health care providers. This study, by the University of California at San Francisco, will survey African-American, Latino and white patients and will examine how interpersonal processes affect health care processes and clinical outcomes. Interventions arising from such studies will contribute to quality improvements in caring for diverse groups.

In 1996, Hispanic and black Americans were substantially less likely than other Americans to have a usual source of health care. Nearly 30 percent of Hispanics had no usual source of care, compared to 20 percent of blacks and 15.5 percent of whites. Blacks and Hispanics were also more likely than other Americans to have a hospital-based usual source of care.

MEPS Data and Racial and Ethnic Differences in Health

In February 1999, AHRQ released a chartbook presenting estimates of health insurance coverage, access to health care, and health status for blacks, Hispanics and whites in America. The chartbook, "Racial and Ethnic Differences in Health, 1996," features findings from AHRQ's 1996 Medical Expenditure Panel Survey (MEPS). This chartbook identifies important differences in health insurance, access to care, and health status for minorities in this country (select for Figure 6, 3 KB).

Significant findings include:

More than one-third of Hispanics had no health insurance coverage. While Hispanics represent only 11.6 percent of the U.S. population under age 65, they make up more than 21 percent of the uninsured population.
Hispanic and black Americans were more likely than white Americans to lack private, job-related health insurance coverage.
Blacks were the group most likely to have only public insurance: more than one-fourth of blacks, compared with one-fifth of Hispanics and one-tenth of whites.
Families headed by Hispanics were the most likely to report barriers to obtaining the health care they needed and were the least likely to have a usual source of health care.
Blacks and Hispanics were more likely than whites to be in fair or poor health.

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Children's Health

In Fiscal Year 1999, AHRQ significantly enhanced its child health activities by funding a substantial amount of new research, conducting research syntheses, and partnering with private-sector organizations and foundations. In Fiscal Year 1999, AHRQ distributed funding for 30 grants totaling over $9 million focusing exclusively on kids. AHRQ expanded its portfolio in child health care research by focusing on a broader range of health conditions and settings for health care, and placed a greater emphasis on quality improvement research. As a result of new projects funded in Fiscal Year 1999, outcomes researchers are examining the effects of differing organizations of care and new technologies on the health outcomes of children with asthma, depression and other mental health problems, and other disorders. Differing strategies in quality improvement are being evaluated for preterm newborns with respiratory distress, children with asthma, and adolescents at risk of chlamydia. Quality measures are being developed and tested for school-aged children, hospitalized children, high-risk infants, children with diabetes and children with severe and persistent mental illness.

AHRQ also added to the quality improvement toolbox with the publication of evidence reports for the diagnosis and treatment of attention deficit hyperactivity disorder (ADHD) and traumatic brain injury (TBI) in children and adolescents. The ADHD reports are being used by the American Academy of Pediatrics to develop guidelines for use by providers of children's health care. The Evidence-based Practice Center at Oregon Health Sciences University that produced the evidence report on TBI is conducting extensive follow up to reduce the amount of inappropriate care being delivered, and to encourage research to determine what works for TBI in children.

Because 80 percent of prescription drug use in children is estimated to be "off label"—that is, not tested with this population—AHRQ is also supporting a CERTs program at the University of North Carolina that is focusing on children's issues in pharmacotherapy and medical devices.

AHRQ again continued its efforts to support the implementation of the State Children's Health Insurance Program (SCHIP) and Medicaid for children by working cooperatively with the many Federal and State agencies involved in SCHIP and Medicaid operations, by publishing new analyses from MEPS, and by supporting cooperative-agreement grants that will build the evidence base on the impacts of public insurance for low-income children.

Research on Health Care and Health Insurance for Children. Recent policy changes have attempted to increase children's health insurance coverage and access to care so that children can obtain health care that is appropriate to their developmental needs. However, many children still lack health insurance (11 million in 1996) and adequate access to health care. These children risk health problems associated with not being immunized, not receiving appropriate well-child care, and not receiving timely treatment for acute health problems.

In Fiscal Year 1999, as part of our continuing focus on children's health, AHRQ, along with The David and Lucile Packard Foundation and the Health Resources and Services Administration (HRSA), funded nine research projects totaling $9.1 million over three years to help public health insurance programs and health care delivery systems improve the quality of and access to health care for low-income children. These studies will seek to uncover which health insurance and delivery features work best for low-income children—particularly minority children and those with special health care needs. The studies should benefit SCHIP as well as other public insurance programs and delivery systems, including Medicaid and other State and locally subsidized health insurance.

Seven of the projects focus exclusively on or have separate analyses of children with special health care needs, and five explore disparities between minority and non-minority children. A key feature of this set of projects is that the principal investigators will participate in a national Coordinating Committee that will undertake activities to strengthen individual studies and to make it possible for the results to be applied across locations, populations, and insurance design and organizational delivery system features. The Coordinating Committee will receive guidance from a user group, consisting of Federal, State and local government representatives. Summaries of selected grants follow.

Improving Health Care for Low-Income Children

Provider Participation and Access in Alabama and Georgia. This study will examine the effect of SCHIP and Medicaid changes and expansions in Alabama and Georgia on provider availability and on low-income children's subsequent access to, utilization of, and satisfaction with health services. Two sub-studies, one of African-American children and one of children with special health care needs, will be undertaken. (University of Alabama)

Impact of Publicly Funded Programs on Child Safety Nets. The purpose of this national study is to look at the impact of Medicaid managed care and SCHIP on the survival and financial viability of pediatric safety net providers. (Northwestern University)

Medicaid vs. Premium Subsidy: Oregon's SCHIP Alternatives. This study will compare the access to, satisfaction with, and quality of health care of Oregon children who choose to enroll in the SCHIP Medicaid-look-alike program, those who choose to enroll in the premium subsidy program, and those who remain uninsured. There will be a focus on Hispanics, who are disproportionately represented among the uninsured. Researchers will also investigate continuity of enrollment and the reasons why some fail to re-enroll in the SCHIP program. (Center for Health Economics Research, Waltham, Massachusetts)

Special Health Care Need Children: SCHIP Responsiveness. This study will explore how States exercise their flexibility in SCHIP program design by describing eligibility criteria in freestanding SCHIP programs and all managed care design features in SCHIP programs nationwide. Researchers also will analyze the data from the National Health Interview Survey, the Medical Expenditure Panel Survey, and the Area Resource File to model the impact of key benefit features on low-income children's access to and utilization of health care. (George Washington University)

Access and Quality of Care for Low-Income Adolescents. This is a study of the impact of the organizational features of Florida's SCHIP plans and providers on adolescents' access to and quality of care, health and functioning, and expenditures, including a comparative analysis of minority and non-minority youths. (University of Florida)

New York's SCHIP: What Works for Vulnerable Children. The purpose of this study is to assess the impact of New York's SCHIP health plan features on enrollees' access, utilization and quality of care, including sub-studies of children with asthma and minority children. In addition, investigators will examine continuity of enrollment, the magnitude and reasons for loss of commercial insurance, the impact of SCHIP on uncompensated inpatient care, and the factors that cause some eligible families not to enroll. (Rochester University School of Medicine)

AHRQ Data and Children's Health

Three AHRQ databases provide important information about children's health care experiences. A recent study on hospital care for children and adolescents using HCUP found that asthma, injuries, and mental health problems account for more hospitalizations of children over five years of age than any other conditions, while preschoolers and infants need hospital care mostly for infections and birth-related problems. The National CAHPS® Benchmarking Database (NCBD), begun in Fiscal Year 1999, includes data from 41 States on families' experiences and satisfaction with care provided to their children.

In a study published in March 1999, AHRQ researchers using MEPS found that between 1977 and 1996, the percentage of children who were uninsured increased substantially, but the increase occurred almost exclusively among children living with only one parent. In addition, the percentage of children in single-parent families with private health insurance increased over this period. However, they were still much less likely to have private insurance and more likely to be uninsured than children in two-parent households. This study shows that information on family structure can provide an additional gauge for determining which children are at increased risk of lacking health insurance. This knowledge can help in developing public policies that are targeted to reduce these gaps and improve the quality of health care services. Select for Figure 7 (3 KB), which compares insurance status for children in single-parent families and in two-parent families.

Other findings include:

Over this period, the percentage of children covered by private insurance declined, and the percentage of children with public coverage increased.
In 1996, more than 20 percent of privately insured children whose single parent previously had been married received their coverage from a policyholder who did not live with them, most likely the children's other parent. This compares with a 1987 rate of only 5 percent.
Children whose single parents never married were far more likely to be publicly insured in 1987 and 1996 than those whose parents had been married at some point (65.4 percent versus 29.4 percent in 1987; 62.9 percent versus 30.3 percent in 1996).
The percentage of children in two-parent families with public coverage more than doubled between 1987 and 1996, from 6.1 percent to 12.7 percent. This increase was primarily among poor families and those with only one working parent, and was consistent with the expansions in the Medicaid program during this period.

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Women's Health

The life expectancy of U.S. women has increased dramatically since the turn of the century, from 47 in 1900 to nearly 79 in 1993. The average life expectancy for a man in 1993 was about 72. Although women have a longer life expectancy than men, they do not necessarily live those extra years in good physical and mental health (select for Figure 8, 3 KB).

In 1900, the leading causes of mortality among U.S. women included infectious diseases and pregnancy and childbirth. Today, the chronic conditions of heart disease, cancer, and stroke account for 65 percent of American women's deaths and are the leading causes of mortality for both women and men. AHRQ has a vigorous intramural and extramural research program, focused principally on health care quality and the outcomes of health care services.

The AHRQ women's health program assists the Agency in developing and disseminating research that can be used to understand and improve health care services provided to women. The Agency's current research portfolio related to women, which is estimated to be $50.0 million in Fiscal Year 2000, is evenly spread through the pipeline of research. Highlights include:

Health care outcomes and quality. This area includes clinical studies on heart disease, breast cancer, reproductive health (including hysterectomy), Alzheimer's disease, depression, osteoporosis, and diabetes. In work underway, the USPSTF is assessing what is known about the effectiveness of selected clinical preventive care services for women, including screening and diagnostic tests for ovarian and cervical cancers, breast diseases, ultrasound, and hormone replacement therapy.
Access and cost of services. Ongoing research includes studies of how changes in the organization and delivery of care are affecting access to and cost of services of particular interest to women. The Medical Expenditure Panel Survey provides critical information necessary to track and understand issues related to insurance coverage for women. Data on the use of acute care and nursing home services are available by gender and by age, race, and ethnicity.

Research related to women's health is currently under way in the following areas:

Assessing the differences in access to quality care by sex, age and race.
Examining the differences by race in prenatal care and infant morbidity and mortality.
Promoting quality assurance in mammography.
Examining the cost-effectiveness of various treatments for early stage breast cancer.
Studying the rates of hysterectomy and its relative effectiveness for various conditions.
Training primary care providers to recognize and treat domestic violence.
Exploring the cost-effectiveness of clinical preventive services.
Assessing the needs of and care provided to minority women infected with HIV.

Fiscal Year 1999—A Selection of New Grants Related to Women

Outcomes of Legislated Increases in Maternity Stays. This project will evaluate the effects of two successive policies regarding hospital care for childbirth: Harvard Pilgrim Health Care's program to reduce inpatient length of stay and Massachusetts legislation mandating that health insurance cover at least 48-hour stays after normal deliveries. This grant will also examine whether or not these policies had differential effects on certain vulnerable populations and on mothers or infants with complications during pregnancy or at birth. (Harvard Pilgrim Healthcare)

Physician/patient Preference in Hysterectomy. This research will study physician and patient preferences in hysterectomy. The project has two components, which will focus on helping consumers (patients) make more informed choices regarding the decision to have hysterectomy and assisting clinicians to decide what works best in clinical practice. (Women and Infants Hospital of Rhode Island)

Coordination of Outpatient Early-Breast Cancer Care. This project will study the coordination of care in the treatment of early breast cancer at six New York hospitals. Coordination of care has not been studied in the outpatient setting, and breast cancer, a disease that involves multiple medical specialities and treatments, is a good model to assess care coordination. (Mount Sinai School of Medicine)

Mammography and Detection Controlled Estimation. Mammography is the dominant method of initial screening for breast cancer in women, saving both lives and medical costs. However, the chances that women who receive regular mammograms will obtain a false positive are significant—up to 10 percent. Given these costs, the medical profession has considered reducing its recommendations for the use of mammograms. This may limit the effectiveness of mammograms in reducing breast cancer. This research project proposes to examine the incidence of false negative mammograms using detection controlled estimation (DCE), an advanced econometric technique. (Pennsylvania State University)

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