December 16, 1998: Richard S. Baker, Charles R. Drew University

This letter addresses AHCPR's request for topics for research on therapeutic effectiveness to be undertaken by Centers for Education and Research on Therapeutics (CERTs), published in the Federal Register November 3, 1998.

Introduction

Recently, there has been a great deal of attention devoted to examining variations in health care and health outcomes (see Health, United States; 1998). Disparities in health outcomes exist between high and low socioeconomic groups and across racial/ethnic groups in the United States including Whites (non-Hispanic), Blacks (non-Hispanic), Asians (non-Hispanic) and Hispanics.

For example, in 1995 the chronic disease death rate for men with a high school education or less was 2.3-2.5 times that for men with more than a high school education; less educated women had death rates 1.9-2.2 times the death rate for women with education beyond high school (Health, United States; 1998). Similar disparities exist by race/ethnicity (1). Diabetes, the seventh leading cause of death among Americans, accounted for 153 years of potential 1ife lost among White males, 357 years among Black males, and 204 years among Hispanic males. Similar disparities exist among White, Black, and Hispanic females (Health, United States; 1998). A recent report by Norris documents large disparities in the incidence of end stage renal disease among Southern California Whites (164 cases per million); Blacks (552 cases per million); Asians (254 cases per million); and Hispanics (490 cases per million) (2).

Less is known about health outcomes among Asian and Pacific Islander Americans. A recent review of chronic disease prevalence among Asian and Pacific Islander Americans showed considerable variability among sub-groups. For example, a study conducted in California found Filipino men and women age 50+ have prevalence rates of hypertension of 60 percent and 65 percent while Japanese American men and women had rates of 32 percent and 18 percent. Similarly, studies have found twice the rate of Type II diabetes among Japanese Americans compared with White Americans and four times the rate compared with Japanese in Japan (Minorities, Aging, and Health, Sage; 1997).

It is commonly believed that these disparities are accounted for in large part by the differential effectiveness of medical therapeutics in low-income and culturally and linguistically diverse patient populations. That is, the technologies exist that can reduce the disparities in health we observe, but we fail to effectively implement them, particularly among low-income and culturally and linguistically diverse patient populations. However, evidence documenting the relatively poor effectiveness of interventions for underserved and disadvantaged populations is circumscribed. Moreover, less is known about ways to improve the delivery of efficacious interventions for these groups.

We propose a center that will conduct state-of-the-art research on the effectiveness of medical therapeutics among urban, low-income and culturally and linguistically diverse patient populations with the principal goal of reducing disparities in health among economic and racial/ethnic groups in the United States.

Center Goals and Research Topics

1. To conduct research on the effect of drugs, biological products, and devices (medical therapeutics) on the health outcomes of urban, low income, and culturally and linguistically diverse patient populations with a) diabetes and its complications such as retinopathy; b) cardiovascular disease; c) pediatric asthma and other adult chronic pulmonary disease; and d) end stage renal disease.
2. To conduct research on the effect of prevention and detection technologies on disease outcomes of urban, low income, a culturally and linguistically diverse patient populations with respect to cancer including prostate, breast, and colon cancers.
3. To develop optimal (balancing effectiveness, cost, and ethical concerns) therapeutic implementation strategies for improving the health of urban, low income, and culturally and linguistically diverse patient populations.
4. To create a center with a national and international research and educational mission focusing on the treatment of disease among urban, low income, and culturally and linguistically diverse patient populations.

Significance to Federal Health Programs and Vulnerable Population

Medicaid and other direct and indirect federal programs have the goal of improving the health of vulnerable populations. The results of research and education conducted by this center will target vulnerable, urban populations in the United States and therefore directly support the goals of these programs.

The Charles R. Drew University of Medicine and Science, located in South Central Los Angeles, is dedicated to providing care to a poor, culturally and linguistically diverse population. The racial/ethnic make-up of Drew University's service area is 60 percent Hispanic, 23 percent African American, 12 percent non-Hispanic White, and 5 percent Asian American. In addition to the largely Hispanic and African American composition of the Drew service area, the immediately adjacent communities of Gardena (30 percent Asian American) and Wilshire Center (32 percent Asian American) provide immediate access to largely Japanese and Korean populations as well. Nearly 32 percent of the patient population lives below the Federal poverty level and nearly 46 percent have less than a high school education. Compared to the average for Los Angeles County, the South Central Los Angeles region has significant fewer physicians and hospital beds per capita and a significantly greater overall age-adjusted mortality rate.

Organization of Center

The proposed CERTs center represents a collaboration between Drew University and the University of California Los Angeles (UCLA). The research center, to be based at Drew University, will draw upon the clinical expertise of Drew University in caring for vulnerable patient populations and in research areas such as areas as cross-cultural health. Similarly, the center will draw upon the research expertise of UCLA in health services research including health-related quality of life, health economics, statistics, and cost-effectiveness analysis.

Several examples of successful collaborations between Drew University and UCLA exist. These include the UCLA-Drew Clinical Research Unit, Drew-RAND Center on Health and Aging, and the UCLA-Drew Oral Health Center. Drew and UCLA also have a long-standing joint medical education program that has graduated 310 physicians since it was founded in 1966. These successful collaborations will serve as models for the proposed Drew-UCLA Center for Education and Research on Therapeutics.

The proposed collaboration draws upon the strengths of both institutions and promises to greatly benefit both institutions. On the one hand, Drew University provides care to a large urban underserved population and has as its mission, "To conduct medical education and research... to this and other underserved populations." Drew University is currently enhancing and expanding its own research and educational agenda on urban health—The Urban Health Initiative. On the other hand, UCLA has broad expertise in health services research and is interested in expanding its research agenda on disparities in health and health care.

We thank you for giving our letter your consideration and look forward to the outcome of your deliberations.

Richard S. Baker
Associate Professor
Charles R. Drew University

David M. Carlisle
Associate Professor
University of California Los Angeles

1. Years lost before age 75 per 100,000 population under 75 years of age.

2. Personal communication provided by Keith Norris, M.D., Drew University, 1731 East 120th Street, Los Angeles, California 90059; Telephone: (323) 563-5911; Fax: (323) 563-4889.

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