Key Themes and Highlights

Examining health care disparities is an integral part of improving health care quality. Health care disparities are the differences or gaps in care experienced by one population compared with another population. As the National Healthcare Quality Report (NHQR) shows, Americans too often do not receive care that they need or they receive care that causes harm.

The National Healthcare Disparities Report (NHDR) shows that some Americans receive worse care than other Americans. Within the scope of health care delivery, these disparities may be due to differences in access to care, provider biases, poor provider-patient communication, poor health literacy, or other factors.

The purpose of the NHDR, as mandated by Congress,ⁱ is to identify the differences or gaps where some populations receive poor or worse care than others and to track how these gaps are changing over time. Although the emphasis is on disparities related to race and socioeconomic status, the reporting mandate indicates an expectation that the Agency for Healthcare Research and Quality (AHRQ) will examine health care disparities across broadly defined "priority populations." These include ethnic minorities and other groups or categories of individuals experiencing disparate and inadequate health care.

The NHDR and NHQR use the same measures, which are categorized across four dimensions of quality: effectiveness, patient safety, timeliness, and patient centeredness. This year's report focuses on the state of health care disparities for a group of "core" measuresⁱⁱ that represent the most important and scientifically credible measures of health care quality for the Nation, as selected by the Department of Health and Human Services (HHS) Interagency Work Group.ⁱⁱⁱ By focusing on core measures, the 2009 report provides a more readily understandable summary and explanation of the key results derived from the data.^iv

Three key themes emerge in the 2009 NHDR:

• Disparities are common and uninsurance is an important contributor.
• Many disparities are not decreasing.
• Some disparities merit particular attention, especially care for cancer, heart failure, and pneumonia.

We also summarize efforts by AHRQ and HHS to accelerate the pace of improvement by:

• Training providers.
• Raising awareness.
• Forming partnerships to identify and test solutions.

Disparities Are Common and Uninsurance Is an Important Contributor

All population groups should receive equally high quality of care. Getting into the health care system (access to care) and receiving appropriate health care in time for the services to be effective (quality care) are key factors in ensuring good health outcomes.

Consistent with extensive research and findings in previous NHDRs, the 2009 report finds that disparities related to race, ethnicity, and socioeconomic status still pervade the American health care system. Although varying in magnitude by condition and population, disparities are observed in almost all aspects of health care, including:

• Across all dimensions of health care quality: effectiveness, patient safety, timeliness, and patient centeredness.
• Across all dimensions of access to care: facilitators and barriers to care and health care utilization.
• Across many levels and types of care: preventive care, treatment of acute conditions, and management of chronic diseases.
• Across many clinical conditions: cancer, diabetes, end stage renal disease, heart disease, HIV disease, mental health and substance abuse, and respiratory diseases.
• Across many care settings: primary care, home health care, hospice care, emergency departments, hospitals, and nursing homes.
• Within many subpopulations: women, children, older adults, residents of rural areas, and individuals with disabilities and other special health care needs.

To quantify the prevalence of disparities across the core measures tracked in the 2009 report, racial and ethnic minority groups and socioeconomic groups are compared with an appropriate reference group for each core measure. Each group could receive care that is poorer than, about the same as, or better than the reference group.

Figure H.1. Distribution of core quality measures for which members of selected group experienced better, same, or poorer quality of care compared with reference group

Better = Population received better quality of care than the reference group.
Same = Population and reference group received about the same quality of care.
Worse = Population received poorer quality of care than reference group.
Key: AI/AN = American Indian or Alaska Native.
Note:Asian includes Asian or Pacific Islander when information is not collected separately for each group. Data presented are the most recent data available. Measures presented here for racial and ethnic minority groups are a subset of the core measure set that has data for all groups. Some measures for poor populations are different from the measures used for racial and ethnic groups.

For sizable proportions of measures, racial and ethnic minorities and poor people receive lower quality care:

• Blacks received worse care than Whites for 50% (10/20) of core measures (Figure H.1). Blacks received better care than Whites for 15% (3/20) of core measures.
• Asians received worse care than Whites for 30% (6/20) of core measures and better care for 40% (8/20) of core measures.
• American Indians and Alaska Natives (AI/ANs) received worse care than Whites for 45% (9/20) of core measures and better care for 25% (5/20) of core measures.
• Hispanics received worse care than non-Hispanic Whites for 70% (14/20) of core measures and better care for 20% (4/20) of core measures.
• Poor people received worse care than high-income people for 75% (15/20) of core measures and better care for 5% (1/20) of core measures.

Figure H.2. Distribution of core access measures for which members of selected group experienced better, same, or worse access to care compared with reference group

Better = Population had better access to care than the reference group.
Same = Population and reference group had about the same access to care.
Worse = Population had worse access to care than the reference group.
Key: AI/AN = American Indian or Alaska Native.
Note:Asian includes Asian or Pacific Islander when information is not collected separately for each group. Data presented are the most recent data available.

For many measures, racial and ethnic minorities and poor people have worse access to care:

• Blacks, Asians, and AI/ANs had worse access to care than Whites for one-third (2/6) of core measures (Figure H.2).
• Hispanics had worse access than non-Hispanic Whites for 83% (5/6) of core measures.
• Poor people had worse access to care than high-income people for all 6 core measures.

The growing rate of uninsurance in America has been the subject of considerable examination during the past 10 years in both the popular press and academic literature. A focus of this year's NHQR is the relationship between uninsurance and quality of care, and the findings demonstrate that uninsured people tend to get the worst care.

For the 2009 NHDR, we conducted multivariate analyses on a number of measures of quality of care to address the interrelationships among different demographic groups and socioeconomic factors, such as income and insurance. These analyses generated adjusted percentages that control for multiple factors simultaneously. In 9 of 12^v regression models that focused on children or adults under age 65, uninsurance was the single strongest predictor of quality of care, exceeding the effects of race, ethnicity, income, or education. However, uninsurance did not explain all differences in care related to race, ethnicity, and socioeconomic status, suggesting that mitigating uninsurance would greatly reduce but not completely eliminate disparities in care.

Many Disparities Are Not Decreasing

Both categories of measures, quality of care and access to care, show that disparities persist for all populations. Measures of quality include effectiveness (the percentage of patients with a disease or condition who get recommended care), patient safety, and timeliness. Measures of access to care include health insurance coverage, utilization of general health services, and barriers to care. The figures below illustrate how disparities in quality and access have changed for each population during the past 5 years.

Figure H.3. Distribution of changes over time in racial, ethnic, and socioeconomic disparities for selected core quality measures, 2000-2002 to 2005-2007

Improving = Population-reference group difference becoming smaller at an average annual rate of 1% or greater.
Same = Population-reference group difference changing at an average annual rate of less than 1%.
Worsening = Population-reference group difference becoming larger at an average annual rate of 1% or greater.
Key: AI/AN = American Indian or Alaska Native.
Note: Asian includes Asian or Pacific Islander when information is not collected separately for each group. Data presented are the most recent data available. Measures presented here for racial and ethnic minority groups are a subset of the core measure set that has data for all groups. Some measures for poor populations are different from the measures used for racial and ethnic groups.

• For Blacks, Asians, and Hispanics, at least two-thirds of measures of quality of care are not improving (gap either stayed the same or increased) (Figure H.3).
• For Blacks, only about 20% of measures of disparities in quality of care improved (gap decreased).
• For poor people, disparities are improving for almost half of the quality measures.
• For AI/ANs, more than 40% of disparities in quality improved.

Many Americans enjoy good access to primary and hospital care. For many populations, however, barriers exist to getting needed health care, such as having no health insurance or having trouble getting appointments. Reducing disparities in access to health care is an important step to improving overall quality. Figure H.4 is a summary of trends in the core measures of access.

Figure H.4. Distribution of changes over time in racial, ethnic, and socioeconomic disparities for selected core access measures, 2000-2002 to 2005-2007

 Improving = Population-reference group difference becoming smaller at an average annual rate of 1% or greater.
Same = Population-reference group difference changing at an average annual rate of less than 1%.
Worsening = Population-reference group difference becoming larger at an average annual rate of 1% or greater.
Key:AI/AN = American Indian or Alaska Native.
Note:Asian includes Asian or Pacific Islander when information is not collected separately for each group. Data presented are the most recent data available.

• For Asians and AI/ANs, an equal number of core measures of access improved and worsened (Figure H.4).
• For Blacks, more than 80% of the core measures used to track access remained unchanged (gap stayed the same) or got worse (gap increased). However, the one measure that improved is notable. Over time, the Black-White difference in health insurance coverage among people under age 65 decreased. By 2007, the gap was not statistically significant.
• For Hispanics, two-thirds of core access measures improved (gap decreased).
• For poor populations, more than 60% of core access measures improved (gap decreased).

Some Disparities Merit Particular Attention

As previous reports have shown, large disparities exist in many areas of health care. Although some improvement has been seen in quality of care, closing the gap between groups remains a challenge. Often, quality of care may improve for all groups, but gaps between groups may remain if interventions do not specifically address disparities. The NHDR can be used to identify the most significant gaps that merit particular attention. Two approaches for identifying important gaps are presented. One focuses on individual populations and one examines patterns of disparities across populations.

An analysis of health care for each population allows targeting of resources and efforts to improve care and narrow the gaps in care for racial and ethnic minorities and poor populations. Table H.1 presents an analysis of the largest disparities or "biggest gaps" for each population. The biggest gaps are defined as those quality measures with the largest relative rates between Whites and racial and ethnic minorities and between high-income and poor individuals. The relative rate quantifies how large the gap is compared with the reference group. For example, a relative rate of 1.9 means that this population was almost twice as likely as the White population to report that children did not receive advice about physical activity.

The annual change shows the rate at which the gap is changing over time. A gap that is getting smaller with time is considered evidence that the disparity is improving, while a gap that is getting larger is considered evidence that the disparity is worsening. The time period used to calculate annual change varies by measure (refer to the Data Tables appendix for available data years). Measures that have the largest disparities and are worsening over time should be targeted for improvement.

Table H.1. Largest disparities for each population, relative rate compared with reference group and annual percentage change

Note: Largest disparity and improving over time = Measures that had one of the three highest relative rates (largest gap) and a decrease in the size of the gap over time. Largest disparities and worsening over time = Measures that had one of the three highest relative rates and an increase in the size of the gap over time.

Some of the largest disparities were also areas where the most improvement has been achieved over time.

• The largest disparities for Blacks, AI/ANs, and Hispanics included the rate of new AIDS cases. The rate for Blacks was almost 10 times as high as the rate for Whites, for Hispanics more than 3 times as high, and for AI/ANs 1.4 times as high. However, from 2000 to 2007, for Blacks, AI/ANs, and Hispanics, this measure was among those with the greatest reduction in disparities for each group (10.2% per year, 2.7% per year, and 4.2% per year, respectively; Table H.1).
• The largest disparities for Asians and poor populations included a measure related to timeliness of care. Asians were 1.5 times as likely as Whites to report they sometimes or never get care for illness or injury as soon as wanted. Poor people were more than twice as likely as high-income people to report this problem. However, from 2002 to 2006, this measure had one of the greatest reductions in disparities over time in both groups (2.9% percent per year for Asians and 2.8% per year for poor people).
• Provider-patient communication reported for children was among those measures with the largest disparities for Hispanics and poor populations. Hispanics were 1.7 times as likely as Whites and poor people were 3 times as likely as high-income people to report poor provider-patient communication. However, from 2001 to 2006, these groups also experienced large reductions in disparities for this measure (5.5% improvement per year for Hispanics and 10.2% improvement per year for poor populations).

Measures worth targeting for improvement include the following.

• From 2000 to 2005, disparities in colorectal cancer screening for AI/ANs have been worsening. The gap between AI/ANs and Whites is increasing at a rate of 7.7% per year.
• From 2005 to 2007, disparities in hospital care for heart failure for AI/ANs have been worsening at a rate of 12.4% per year.
• From 2000 to 2007, disparities in pneumococcal vaccination have been worsening for Asians and Hispanics at a rate of 4.7% per year and 2.4% per year, respectively.
• In addition to the disparities evident across individual priority populations, in some cases several different populations experience the same gaps in care, perhaps reflecting similar barriers to quality care. Table H.2 shows the measures worsening for multiple groups.

Table H.2. Core measures that are getting worse for more than one racial and ethnic group compared with reference group

Note: A complete table of the disparities that worsened for specific populations can be found in Chapter 4, Priority Populations.

• Blacks, Asians, AI/ANs, and Hispanics all experienced disparities in the percentage of adults age 50 and over who received a colonoscopy, sigmoidoscopy, proctoscopy, or fecal occult blood test and in recommended hospital care for pneumonia (Table H.2).
• Blacks and Hispanics both had worsening disparities in colorectal cancer mortality from 2000 to 2006.
• AI/ANs and Hispanics had worsening disparities in the recommended hospital care for heart failure from 2005 to 2007.
• Asians and Hispanics both had worsening disparities in pneumococcal vaccination for adults age 65 and over from 2000 to 2007.

Findings from the 2009 NHDR show that disparities in care for cancer, heart failure, and pneumonia exist across populations. Although quality of hospital care for heart failure and pneumonia has improved overall, care for Whites continues to improve at a higher rate than for minority populations. Thus, quality improvement has not necessarily translated to disparities reduction, which is critical for high-quality care.

Low rates of colorectal cancer screening and other cancer screenings may be due to cultural attitudes and patient perceptions, such as the belief that screening is not necessary. In addition, patients may have problems paying for followup visits to complete screening and may have logistical problems getting to appointments. Similarly, pneumococcal vaccination rates may be lower for Blacks and Asians because of distrust in the effectiveness of vaccines and perceptions that vaccines are not necessary.

Efforts Are Needed To Accelerate Improvement

This 2009 report summarizes the areas where health care disparities have improved and where they have not. But national reports will not eliminate disparities by themselves. Building on information contained in the NHDR and NHQR, HHS organizations are implementing an exciting range of programs that seek to reduce disparities and accelerate the pace of health care quality improvement for all Americans. As individual, community, social, and health system factors contribute to health care disparities, multiple strategies exist to address these factors. Efforts have focused on training health care professionals; raising awareness among health care professionals and patients; and changing health systems at the hospital, provider, and community levels.

Train Providers

Cultural expectations, assumptions, and language affect the quality of care patients receive. Some efforts have focused on training health care personnel to deliver culturally and linguistically competent care for diverse populations:

• The Think Cultural Health Web site (http://www.thinkculturalhealth.org ) is sponsored by the Office of Minority Health (OMH). This site offers the latest resources and tools to promote cultural competency in health care. Users can access free online courses accredited for continuing education credit, such as "A Physician's Practical Guide to Culturally Competent Care" and "Culturally Competent Nursing Care." The site also provides supplementary tools, including the "Health Care Language Services Implementation Guide," to help providers and organizations promote respectful, understandable, and effective care to an increasingly diverse patient population.
• The Unified Health Communication Web-Based Training Program is sponsored by the Health Resources and Services Administration (HRSA). This interactive training course introduces a unified health communication concept called "Unified Health Communication (UHC) 100/101: Addressing Health Literacy, Cultural Competency, and Limited English Proficiency." The UHC 100/101 course explores three crucial areas that can affect provider-patient communication: health literacy, cultural competency, and limited English proficiency. Each of these three components can influence various aspects of health communication. In combination, they can have an even greater impact on improving health care delivery, reducing health disparities, and empowering patients to become more involved in their own health management to enhance their quality of life. This course is currently used across a variety of health care delivery venues. Its use underscores the importance of clear health communication through the discussion of innovative approaches by health care providers.
• The Office for Civil Rights (OCR)^vi is the sole HHS agency with the authority to enforce Title VI of the Civil Rights Act of 1964, 42 U.S.C. 2000d. This law prohibits discrimination based on race, color, or national origin in programs and activities that receive Federal financial assistance. OCR enforces Title VI by providing technical assistance and training to health care providers and human service agencies; investigating race, color, and national origin discrimination complaints filed by individuals and advocacy groups; and resolving those complaints through corrective action and voluntary compliance agreements OCR, for example, recently collaborated with Medco, the nation's largest mail-order pharmacy, in its development of a multifaceted plan to improve services to limited-English-proficient consumers. In addition, OCR, in partnership with the National Consortium for Multicultural Education, funded by the National Institutes of Health's National Heart, Lung, and Blood Institute, recently published a curriculum on cultural competency in medicine that incorporates Title VI compliance. The OCR curriculum, "Stopping Discrimination Before It Starts: The Impact of Civil Rights Laws on Health Care Disparities—A Medical School Curriculum," was published in the Association of American Medical College's MedEdPORTAL (http://www.aamc.org/mededportal ). This portal is a Web-based tool that facilitates the nationwide exchange of high-quality, peer-reviewed educational materials.

Raise Awareness

Other efforts to address health care disparities leverage key partnerships to raise awareness of disparities by using data and research:

• The Health Disparities Roundtable was convened in 2006 under cosponsorship by OMH and AHRQ and in partnership with the Institute of Medicine. The roundtable generates action and engages interested parties from academia, industry, government, philanthropy, the corporate sector, and the community to reduce racial and ethnic health disparities. It fills an important role as a focus for public-private research partnerships and policy discussions to address various topics. These include: (1) ways to bring together health-care focused and broader community-based approaches to address disparities more effectively; (2) strategies to expand and strengthen research to develop effective treatments for those diseases that disproportionately affect minority populations, as well as research that focuses on the complex interactions of biologic and social factors as determinants of health; (3) effective cultural competency techniques and cross-cultural education in health care settings; (4) educational strategies to end health disparities; (5) development and promotion of effective strategies to increase minority representation in medicine and health professions; and (6) understanding of the causes of health and health care disparities and best solutions.
• The Federal Collaboration on Health Disparities Research (FCHDR) was developed by the Centers for Disease Control and Prevention (CDC) in collaboration with OMH and cosponsored by AHRQ. FCHDR identifies and supports research priorities for cross-agency collaboration to hasten the elimination of health disparities. This collaboration is led by the HHS Health Disparities Council and the Interagency Committee on Disability Research of the Department of Education. Through FCHDR, Federal partners have formed subject matter expert workgroups around four initial research topic areas for collaboration: obesity, built environment (homes, schools, workplaces, parks and recreation areas, business areas, transportation systems, etc.), mental health care, and comorbidities. These priorities represent opportunities for Federal agencies and other partners to collaborate on innovative research.
• The Disparity Reducing Advances Project is a multiyear, multistakeholder project cosponsored by AHRQ and others, including CDC, the National Cancer Institute, the American Cancer Society, Central Florida Family Health Center, the Robert Wood Johnson Foundation, and the University of Texas Medical Branch. This project identifies the most promising strategies for bringing health gains to poor and underserved populations and accelerating the development and deployment of these strategies to reduce health care disparities.
• The Centers for Medicare & Medicaid Services (CMS) Health Disparities Programallows CMS to develop a health care forum that encompasses public and private partnerships to address health disparities nationwide through a common message. The focus of this program is to improve health literacy and outcomes through three overarching functions: (1) align CMS and Federal resources to provide a solid foundation for messaging on health disparities activities and projects, (2) standardize elements throughout the Quality Improvement Organization 9th Scope of Work themes for the health disparities program, and (3) work with internal and external stakeholders to advance health disparities planning objectives. The Health Disparities Program is achieving these goals by using several methods, such as grants to Historically Black Colleges and Universities and Hispanic Serving Institutions, health disparities forums, newsletters throughout statewide programs, plenary sessions at conferences, and collaborations with national organizations, such as the Administration on Aging, OMH, and National Institutes of Health.
• Healthy People 2020 is a comprehensive health promotion and disease prevention agenda. It has four overarching goals: (1) eliminate preventable disease, disability, injury, and premature death; (2) achieve health equity, eliminate disparities, and improve the health of all groups; (3) create social and physical environments that promote good health for all; and (4) promote healthy development and healthy behaviors across every stage of life. Through a national consensus process, HHS is identifying specific objectives for improving the health of the Nation, establishing baseline values for the objectives, and setting specific targets to be achieved by 2020. Agencies across HHS and in other Federal departments are involved in pursuing this agenda. Progress toward the achievement of these goals and objectives is monitored by CDC's National Center for Health Statistics.
• The Health Disparities Calculator (HD*Calc) is a statistical software program that generates multiple summary measures for evaluating and monitoring health disparities. Data such as cancer rates, survival, and stage at diagnosis, which are categorized by groups such as ethnicity, race, socioeconomic status, and geographic areas, can be used with HD*Calc to generate 11 absolute and relative summary measures of disparity. It can be used either as an extension of SEER*Stat, which allows users to import Surveillance, Epidemiology, and End Results (SEER) data, or on its own with other population-based health data, such as from the National Health Interview Survey, California Health Interview Survey, Tobacco Use Supplement to the Current Population Survey, and National Health and Nutrition Examination Survey. HD*Calc is located on the SEER Web site at http://seer.cancer.gov/hdcalc/. This work is supported by the Surveillance Research Program and Applied Research Program within the Division of Cancer Control and Population Sciences at the National Cancer Institute.

Form Partnerships To Identify and Test Solutions

Other partnerships leverage both public and private partners to address health care disparities at the community and provider level:

• The AHRQ National Health Plan Collaborative (NHPC), which has 11 participating health plans with a total of 87 million enrollees, is cofunded by the Robert Wood Johnson Foundation. NHPC identifies and implements approaches to reducing racial and ethnic disparities and to improving quality among health plan enrollees. In Phase II of the collaborative, three task forces addressed primary data collection and language access and are building the business case for reducing disparities. The collaborative builds on the continued interest of health plans in reducing disparities and improving health care for minorities. Members of the collaborative have developed a toolkit that will serve as the core vehicle to share NHPC's findings and recommendations. The toolkit will be a Web-based searchable database of tools, research, statistics, case studies, and lessons learned. Users will be able to search the tool according to their needs, resulting in a personalized page of information and resources. The toolkit will enable other health plans or stakeholders to implement interventions or methods to address disparities and will provide lessons learned and best practices for reducing disparities.
• An HHS pilot project, Improving Hispanic Elders' Health: Community Partnerships for Evidence-Based Solutions, is bringing together teams of local leaders from communities with large numbers of Hispanic elders to develop local plans for addressing health disparities. Teams cut across organizational boundaries and include representatives from the local area agency on aging, Hispanic community organizations, the local public health agency, aging services providers, the medical community, and health service research organizations. AHRQ, the Administration on Aging, CDC, CMS, and HRSA are assisting teams to develop coordinated strategies for improving the health and well-being of Hispanic elders. Eight communities with sizable disparities participate in this pilot project: Chicago, Illinois; Houston, Texas; Los Angeles, California; McAllen, Texas; Miami, Florida; New York, New York; San Antonio, Texas; and San Diego, California. Information from the NHDR and customized data created by AHRQ for each community have helped target interventions to specific neighborhoods in greatest need of particular services.
• The National Partnership for Action (NPA) To End Health Disparities (http://minorityhealth.hhs.gov/npa/), launched by the Office of Minority Health, is a multifaceted effort to mobilize and connect individuals and organizations across the country to create a Nation free of health disparities, with quality health outcomes for all people. The NPA is composed of three components: (1) the National Plan for Action; (2) 10 Regional Blueprints for Action, which are aligned with the National Plan for Action and include strategies and actions most pertinent to communities in each region; and (3) targeted initiatives that will be undertaken by partners across the public and private sectors in support of the NPA. An example of an NPA initiative is the National Business Group on Health Racial and Ethnic Health Disparities Advisory Board. This advisory board facilitates alliances between business, medicine, and public health organizations to improve the quality of health care for racial and ethnic minority populations while promoting beneficiary health and employee productivity. Some employers have already developed initiatives to reduce health disparities. Products include issue briefs on topics such as why companies are making health disparities their business and how health plans view health disparities. The board holds several Web conferences featuring best practices by a wide range of employers.

Conclusion

Reducing disparities in health care requires measurement and reporting, but these are not the ultimate goals. The fundamental purpose of examining disparities is to ensure that health care improves the lives of all patients and their families, regardless of race, ethnicity, or socioeconomic status. The NHDR concentrates on tracking disparities in health care at the national level, but the statistics reported in the NHDR and NHQR reflect the aggregated everyday experiences of patients and their doctors and nurses across the Nation. It makes a difference in people's lives when breast cancer is diagnosed early with timely mammography; when a patient suffering from a heart attack is given the correct lifesaving treatment in a timely fashion; when medications are correctly administered; and when doctors listen to their patients and their families, show them respect, and answer their questions.

Since its initial publication in 2003, the NHDR has provided a broad and detailed examination of disparities for at-risk priority populations in U.S. health care. The ability to monitor and track changes in disparities is critical. Growing interest in public reporting for quality improvement activities continues to be an impetus to improve not only the quality of data but also the quality of care provided.

This 2009 report summarizes the many areas where little to no progress has been achieved in reducing disparities. However, it also highlights progress that is being made in key conditions that disproportionately affect priority populations. Many factors contribute to disparities in health care quality and access, and it is a major challenge to address them. Yet a number of promising programs at HHS, such as those described here, are doing just that. The activities described are only a few of the many efforts of HHS organizations that address the challenges in reducing health care disparities. Other HHS agencies are contributing in many other ways to address disparities in health service delivery, health care finance, and clinical research in addition to both Federal and State efforts to expand access. What they have in common are the focus on multiple stakeholders and the need for tailored solutions depending on the particular disparities and populations involved.

With the publication of this seventh NHDR, AHRQ stands ready to contribute to efforts such as those above to encourage and support the development of national, State, Tribal, and neighborhood solutions using national data and benchmarks in disparities. We hope that the progress and gaps outlined in this NHDR will help policymakers ensure that all patients receive the health care they need to make their lives better

ⁱ This 2009 report is the seventh National Healthcare Disparities Report (NHDR) mandated by the U.S. Congress in 42 U.S.C. 299a-1(a)(6). It is produced by the Agency for Healthcare Research and Quality (AHRQ) on behalf of the U.S. Department of Health and Human Services (HHS) and in collaboration with an HHS-wide Interagency Work Group.
ⁱⁱ Not all core measures have data for all subgroups for analysis.
ⁱⁱⁱ The HHS Interagency Work Group, which represents HHS agencies and offices, was formed to provide advice and support to AHRQ and the National Reports team.
^iv Data on all NHDR measures are available in the Data Tables appendix.
^v Multivariate analyses were conducted for the following measures for which data were available: breast cancer screening, children who did not have patient-centered care, children who received advice about healthy eating, children who sometimes or never got care for illness or injury as soon as wanted, children ages 3-6 who ever had a vision check, adults with a dental visit in the past year, diabetes patients who received recommended care, adults ages 18-64 uninsured all year, adults who did not have patient-centered care, adults with a usual primary care provider, adult smokers with advice to quit smoking, and adults who sometimes or never got care for illness or injury as soon as wanted. Uninsurance was not a predictor of quality for children who reported a lack of patient-centered care, children who sometimes or never got care for illness or injury as soon as wanted, and adult smokers with advice to quit smoking.
^vi For technical assistance or more information on filing a complaint, the HHS Office for Civil Rights may be contacted at (202) 619-0403, OCRmail@hhs.gov, or http://www.hhs.gov/ocr/civilrights/complaints/index.html.

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