# Presentation: 534968

## Evidence-Based Research to Reduce  Healthcare Disparities

- Helen Burstin, MD, MPH
- Director, Center for Primary Care, Prevention and Clinical Partnerships
- Health Disparities: Progress, Challenges and Opportunities
- March 1, 2005

## Mission Statement:  AHRQ

*        *

- The mission of the Agency for Healthcare Research and Quality is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans.

## Outline

- AHRQ: Advancing Excellence in Health Care
- The State of Health Care Disparities and Quality: Update on the 2004 Reports
- Reducing disparities: opportunities in prevention and chronic illness management
- The role of health information technology
- The road ahead

## Slide 4

## AHRQ RESEARCH FOCUS:HOW IT DIFFERS 

- Patient-centered, not disease-specific
- Dual Focus -- Services + Delivery Systems Effectiveness research focuses on actual daily practice, not ideal situations (“efficacy”)
- _AHRQ mission includes production __***and***__ use of evidence-based information_

## Diffusion of knowledge

- Balas EA, Boren SA., Managing Clinical Knowledge for Health Care Improvement. Yearbook of Medical Informatics 2000.

## Bridging the Quality Chasm

**Bridging the Quality Chasm**

**Where                                                   Where We**
**We Are                                                  Want To Be**

**TRIP**

**Implementation**

**Diffusion**

**Adoption**

**Innovation**

**Health IT**

## How Does AHRQ Bridge the Chasm?

- Supporting and conducting user-driven research that meets the needs of its customers
- Translating research and evidence into tools that can be used to improve health care
- Working with users to ensure that research results in measurable improvements
- Mechanisms: grants and data development

## Outline

- AHRQ: Advancing Excellence in Health Care
- The State of Health Care Disparities and Quality: Update on the 2004 Reports
- Reducing disparities: opportunities in prevention and chronic illness management
- The role of health information technology
- The road ahead

## Two Annual Reports Mandated

- Mandated by Congress in the Healthcare
- Research and Quality Act (PL. 106-129)
- “National trends in the quality of health care provided to the American people”
- “Prevailing disparities in health care delivery as it relates to racial factors and socioeconomic factors in priority populations”

## How the Reports are Related 

| NHQR | NHDR |
| --- | --- |
| Snapshot of quality of health care in America | Snapshot of disparities in health care in American |
| Quality | Quality + Access |
| Variation across states | Variation across populations |

## Goals of the Reports

- National Level
- Provide assessment of disparities and quality
- Provide baselines to track progress
- Identify information gaps
- Emphasize interdependence of disparities and quality
- Promote awareness and change
- State / Local / Provider Level
- Provide tools for self-assessment
- Provide national benchmarks
- Promote awareness and change

## Measurement Topics 

**Quality of Health Care**
- Effectiveness
- Cancer, Diabetes, ESRD, Heart Disease, HIV/AIDS, Maternal and Child Health, Mental Disease, Respiratory Disease, Nursing Home and Home Health Care
- Safety
- Timeliness
- Patient centeredness

**Access to Health Care**
- Getting into the system
- Insurance, Usual Source of Care, Perceptions of Need
- Getting care within the system
- Perceptions of care
- Patient-provider communication, relationship
- Health care use

## Slide 14

## Key Findings from the 2004 Reports

**Disparities are pervasive.**
- Improvement is possible, but change takes time.
- Gaps in information exist, especially for specific conditions and populations.

- The gap between the best possible care and actual care remains large.
- Quality is improving in many areas, but change takes time.
- Further improvement in health care is possible.

## Disparities are pervasive.

## Gaps in information exist.

## Linking Disparities and Quality

- Actual Care
- for the
- Disadvantaged

- Actual Care
- for the
- Advantaged

**Disparity Chasm**

- Inequitable:
- Uninsurance,
- Poverty,
- Language,
- Culture,
- Bias

- Actual Care

- High Quality
- Care

**Quality Chasm**

- Ineffective,
- Unsafe,
- Untimely,
- Not Patient
- Centered,
- Inefficient

- Actual Care
- for the
- Disadvantaged

- High Quality Care

- Ineffective,
- Unsafe,
- Untimely,
- Not Patient
- Centered,
- Inefficient,
- Inequitable

**+**

**=****  Quality Improvement**
**for the Disadvantaged**

**Linking Disparities and Quality**

## Linking Disparities and Quality

- Is it fair to compare the health care of
- Uninsured and privately insured patients
- Publicly insured and privately insured patients
- Poor and high income patients
- Blacks and whites
- Implications for
- Benchmarking
- Public reporting
- Pay for performance
- Data collection

## Disparities: Relationship of Race/Ethnicity to Income

## AHRQ Research Study: Cost- Related Medication Underuse 

_**Major Finding:**_  About 2/3 of chronically ill adults don’t tell their clinicians that they don’t take their medications because of high cost
- Clinicians should take a more proactive                       role in identifying and assisting patients                     who have problems paying for                            prescription drugs
- Patients were most likely to find clinicians helpful if they provided free samples, asked about problems paying for prescriptions, and offered advice about how to pay for current regimens

- J. Piette, M. Heisler, T. Wagner, Cost-Related Medication Underuse, *Archives of Internal *
*Medicine*, September 13, 2004

## Racial and Ethnic Disparities Exist Among High Income Individuals

## Outline

- AHRQ: Advancing Excellence in Health Care
- The State of Health Care Disparities and Quality: Update on the 2004 Reports
- Reducing disparities: opportunities in prevention and chronic illness management
- The role of health information technology
- The road ahead

## Rollout Strategy: Reports Products

**qualitytools.gov**

**NHQR/DR-net**

**Workbooks**
**Knowledge**
**Packs**
**Patient**
**Guides**

**QI Clearinghouse**

**Working papers****	**** Articles****	****       Supplements**

**April Summit**

**Webcasts**

**Rollout Strategy: Reports Products**

## Further Improvement is Possible: Examples of Excellence  

**Further Improvement is Possible: Examples of Excellence  **

- Maryland – Biggest improvement in State rank for administering beta blockers

- Alabama –
- Only State to significantly increase rates of colorectal cancer screening

**North Dakota –**
- Best overall performance for adult diabetic HbA1c testing

**Minnesota –**
- Biggest improvement in State rank for mammogram testing rates

- Source:  National Healthcare Quality Report, 2003, 2004

**2003 NHQR vs. 2004 NHQR**

**Notes:**
Here are four examples of states with significant improvements in healthcare quality.
Minnesota showed the biggest improvmeent for mammogram testing
North Dakota has the best performance for adult diabetic hbaic testing.
Maryland had the biggest improvement in the administration of beta blockers following a heart attack.
Alabama only state to significantly increase the rate of colorectal cancer screening.
This is a demonstration that states are making change in health care quality, that improvement is possible, and that understanding the experience of these states can help other states implement similar programs.

## Making the case 

**Making the case **
**What’s the data**
**Turning data into information **
**Learning from others**
**Developing a QI plan**
**Moving the agenda forward**

## Disparities in Quality of Care for Medicare Enrollees

- Schneider et al. JAMA 2002

**Notes:**
I will now show you a few examples of clinically significant disparities in care. This slide show that for medicare patients enrolled in managed care. Blacks with are significantly less likely to have an eye exam, receive a beta blocker after a heart attack, and get up medical visit after hospitalization for mental diseases than white.

## National Health Plan Learning Collaborative to Reduce Disparities

- Public/private partnership to reduce disparities in health care for people with diabetes and other conditions (AHRQ and RWJ)
- Over next 3 years, collaborative will test ways to improve collection and analysis of data on race and ethnicity and match data to existing quality measures to close gap in care
- 9 National Health Plans Sponsored by nine of Nation’s largest health insurance plans, and other organizations (serving commercial, Medicare, and Medicaid).

## Participating Health Plans

- AETNA
- *Anthem BCBS
- Cigna HealthCare
- Harvard Pilgrim
- Health Partners
- Highmark Blue Cross Blue Shield
- Kaiser Permanente

- Molina Healthcare
- United Healthcare (UnitedHealth Group and Ovations, Senior and Retiree Services)
- *Wellpoint

**TOTAL ENROLLEES  = 76,748,227**

*******Anthem and Wellpoint have merged to form Wellpoint, Inc.**

## Improving Health. Improving Business.

**Improving Health. Improving Business.**
**A 4-Part Guide to Implementing Employee Health**
**Improvement and Preventive Services**
**1. Assessing Preventive Care Needs and Selecting Services**
**2. Developing/Purchasing High-Quality Preventive Services**
**3. Communicating Your Preventive Care Program**
**4. Measuring the Success of Preventive Services**
**Center for Prevention and Health Services**
**National Business Group on Health**

## Closing the Quality and Disparity Gaps

- 2003 IOM report *Priority Areas for National Action*
- 20 clinical topics with evidence supporting “best practices”
- AHRQ’s *National Healthcare Quality Report *and *National Healthcare Disparities Report*
- AHRQ commissioned Stanford-UCSF to identify evidence supporting quality improvement interventions in priority areas
- Goal is to increase the delivery of effective healthcare

## Outline

- AHRQ: Advancing Excellence in Health Care
- The State of Health Care Disparities and Quality: Update on the 2004 Reports
- Reducing disparities: opportunities in prevention and chronic illness management
- The role of health information technology
- The road ahead

## HIT + Systems approach Can Make a Difference

**Lapp&eacute;, J. M. et. al. Ann Intern Med 2004;141:446-453**

**Proportions of patients receiving the appropriate discharge prescriptions**

**HIT + Systems approach**** Can Make a Difference**

- Intermountain Health Care QI effort on CVD
- Results:
- 90% prescription rates
- 27% decrease in unadjusted absolute death rates

## AHRQ Research: Knowledge Management in Diabetes 

- Systematic review of RCTs of computer-assisted interventions in diabetes care
- significantly improved HbA1C  and glucose levels
- substantially improved physician compliance with diabetes care guidelines in six of eight studies
**Compliance with recommended diabetes care procedures was 71% to 227% higher among doctors prompted by computer systems to perform the procedures compared with doctors who did not receive the prompts**

- Balas, Krishna, Kretschmer, et al., Computerized knowledge management in diabetes care (2004). *Medical Care* 42(6), pp. 610-621.

## Grants and Contracts to Improve Patient Safety and Quality of Care Awarded

- $139 million in grants and contracts awarded to promote the use of health information technology (HIT)
_**Promoting access to HIT:**_  Over 100 grants with a special focus on small and rural hospitals and communities
_**Developing statewide and regional networks:**_  Five-year contracts to five States (CO, IN, RI, TN, UT); participants include major purchasers of health care, public and private payers, hospitals, ambulatory care facilities, home health care providers, and long-term care providers
_**Encouraging adoption of HIT by sharing knowledge:**_  Creation of National Health Information Technology Resource Center to aid grantees and other Federal partners

## Santa Cruz County, CA Diabetes Mellitus Registry
Expands an established Web-based, interactive Diabetes Mellitus Registry
provides patient histories and needed tests at the point of care among public, private, and not-for-profit health care providers
tracks the diabetes population to identify trends in key indicators of care 

- Expands an established Web-based, interactive Diabetes Mellitus Registry
- provides patient histories and needed tests at the point of care among public, private, and not-for-profit health care providers
- tracks the diabetes population to identify trends in key indicators of care

**Health IT Grants to Improve Quality of Diabetes Care**

## New Mexico Health Information Collaborative 
Develops a community-wide HIE collaborative in a rural area
gives patients and providers access to comprehensive clinical data on the Internet
develops disease-management prototypes on diabetes, pediatric asthma, depression, and low back pain
evaluates the development, implementation, and outcomes of the collaborative 

- Develops a community-wide HIE collaborative in a rural area
- gives patients and providers access to comprehensive clinical data on the Internet
- develops disease-management prototypes on diabetes, pediatric asthma, depression, and low back pain
- evaluates the development, implementation, and outcomes of the collaborative

**Health IT Grants to Improve Quality of Diabetes Care**

## Outline

- AHRQ: Advancing Excellence in Health Care
- The State of Health Care Disparities and Quality: Update on the 2004 Reports
- Reducing disparities: opportunities in prevention and chronic illness management
- The role of health information technology
- The road ahead

## Improving Quality and Safety

- “We need to make the right thing
- the easy thing...”
- Mark Chassin, MD
- October 12, 2000

## Getting to Improvement

- Making research findings usable – now: _[www.qualitytools.ahrq.gov](http://www.qualitytools.ahrq.gov/)_
- Partnerships with professional organizations, communities and patients
- Focus on learning (if this were easy ....)
- Identifying champions

## What We Don’t Know

***WHY*** and ***HOW**** *disparities occur in the healthcare system
- What proportion of observed disparities are amenable to improvements in the health care system?
***HOW*** to collect relevant data respectfully -- and when
- How to link evidence of a problem to possible solutions

## Sir Michael Marmot

- Putting an appropriate monitoring system in place should act as a suitable conscience to determine the degree to which goals are met...
**	****	****	**

**Sir Michael Marmot**

- _For additional questions, please contact:_
- Dr. Helen Burstin  _hburstin__[@ahrq.gov](mailto:cclancy@ahrq.gov)_