The overall health of the Americanpopulation has improved over the pastfew decades, but not all Americans havebenefitted equally from theseimprovements. Minority populations,in particular, continue to lag behindwhites in a number of areas, includingquality of care, access to care,timeliness, and outcomes. Other healthcare problems that disproportionatelyaffect minorities include providerbiases, poor provider-patientcommunication, and health literacyissues.

Improvements in preventive services,care for chronic conditions, and accessto care have led to a reduction and insome cases elimination of disparities inaccess to and receipt of care for someminority populations in areas such asreceipt of mammography, timing ofantibiotics, counseling for smokingcessation, and pediatric vision care. Onthe other hand, disparities in carecontinue to be a problem for someconditions and populations. Forexample, blacks, Asians, American

Indians/Alaska Natives, and Hispanicscontinue to lag behind whites in thepercentage of the population over 50who receive colon cancer screening, andthis gap has widened in recent years.

Minority Health:Recent Findings

P R O G R A M B R I E F

Advancing Excellence in Health Care • www.ahrq.govAgency for Healthcare Research and Quality

The mission of AHRQ is to improve the quality,safety, efficiency, and effectiveness of healthcare by:

• Using evidence to improve health care.

• Improving health care outcomes throughresearch.

• Transforming research into practice.

Look inside for:Cancer ......................................2Cardiovascular Disease ..............5Care for the Elderly/Long-TermCare ........................................6

Chronic Illness ..........................7Emergency Care/Hospitalization ........................10Health Care Access, Costs, andInsurance ..............................11

Mental/Behavioral Health ......14Preventive Services ..................16Quality of Care/Patient Safety ....................................16

Reproductive Health and BirthOutcomes..............................19

Additional Studies ..................21National Healthcare Quality andDisparities Reports ..................24

Disparities also have increased forblacks and Hispanics, compared withwhites, in the percentage of adultsdiagnosed with a major depressivedisorder who received treatment fortheir depression in the 12 monthsfollowing diagnosis.

Improving Health Care forMinority Populations

The Agency for Healthcare Researchand Quality supports extramural andintramural research on a broad range oftopics related to health care quality andsafety, effectiveness and outcomes,evidence-based medicine, health caredelivery, and the costs and financing ofhealth care. AHRQ also supportstargeted research on health care forspecific priority populations, includingminorities. Additional resources andmore detailed information can befound by visiting the AHRQ Web siteat www.ahrq.gov.

This program brief summarizes findingsfrom AHRQ-supported research onminority health reported in theliterature and/or published by AHRQfrom 2008 through mid-2012. Itemsmarked with an asterisk (*) are availablefrom AHRQ. See the last page of thisbrief for more information.

Cancer

• Researchers examine ways to increasebreast cancer screening among Latinas.

This study evaluated two interventionsto address the underuse ofmammography and breast self-examamong Latinas: (1) participation infocus groups to assess knowledge aboutbreast cancer and identify barriers toscreening and (2) participation indiscussion groups, including ananimated video on breast self-exam plustraining in the technique using latexmodels. Both interventions were cost

effective and successful in increasing thewomen's knowledge and screeningbehaviors. Calderon, Bazargan, andSangasubana, J Health Care PoorUnderserved 21:76-90, 2010 (AHRQgrant HS14022).

• Physicians often rely on untrainedindividuals to help them discuss breastcancer treatment with limited English-proficient women.

Researchers surveyed 348 physiciansabout their use and availability oftrained interpreters when counselinglimited English-proficient women withbreast cancer. Nearly all of thephysicians had treated patients withlimited English proficiency in thepreceding 12 months, and fewer thanhalf reported good availability oftrained medical interpreters ortelephone language interpretationservices. Instead, they used bilingualstaff not specifically trained in medicalinterpretation and patients' familymembers or friends. This wasparticularly true for physicians in solopractice or single-specialty medicalgroups. Rose, Tisnado, Malin, et al.,Health Serv Res 45(1):172-194, 2010(Interagency agreement AHRQ/NCI).

• Racial disparities seen in receipt ofchemotherapy among older womenwith breast cancer.

The researchers examined 2002 data on14,177 white women and 1,277 blackwomen aged 65 and older who werediagnosed with operable stage II or IIIAbreast cancer with positive lymphnodes. For the 65-69 age group, 66percent of white women receivedchemotherapy within 6 months ofdiagnosis, compared with 56 percent ofblack women. This racial disparitydiminished with advancing age; afterage 74, there were no differencesbetween white women and blackwomen in receipt of chemotherapy.

Bhargava and Du, Cancer115(13):2999-3008, 2009 (AHRQgrant HS16743).

• Geographic clustering of late-stagebreast cancer cases can help targetinterventions to increasemammography use.

A telephone survey conducted betweenMarch 2004 and June 2006 in the St.Louis, MO area revealed that moreblack than white women had obtainedmammograms during that time. St.Louis is an area known to have highrates of late-stage breast cancerdiagnosis. The researchers suggest thatsuch geographic clustering might beused to target specific populations andareas for interventions (e.g., travelingmammography vans, flexible clinichours) that could increasemammography use. Lian, Jeffe,Schootman, J Urban Health 85(5):677-692, 2008 (AHRQ grant HS14095).

• Less effective treatment and lowersocioeconomic status may account fordisparities in breast cancer survival.

Researchers studied more than 35,000Medicare-insured women with early-stage breast cancer for as long as 11years and found that black women weremore likely than white women to livein the poorest census tract quartiles.Also, more black women (15.7 percent)received breast-conserving surgerywithout followup radiation therapythan white women (12.4 percent),Hispanic women (11 percent), andAsian women (7.9 percent). Since therecommended therapy for early-stagebreast cancer is breast-conservingsurgery plus radiation, these treatmentdifferences could have contributed todisparities in survival, suggest theresearchers. Du, Fang, and Meyer, Am JClin Oncol 31(2):125-132, 2008(AHRQ grant HS16743).

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• Tracking system greatly reduces racialdisparities in receipt of adjuvanttherapies among women with breastcancer.

These researchers developed a trackingsystem to follow women with breastcancer who had seen a surgeon so thatthey could be contacted in the eventthey did not connect with anoncologist. The researchers comparedthe treatment of 639 women who wereseen at six New York City hospitalsbefore implementation of the trackingsystem with 300 women who were seenwhile the tracking system was in use.Rates of oncology consultations,chemotherapy use, and hormonaltherapy were higher for all women,particularly minority women, after thetracking system was in place. Forexample, underuse of radiotherapydeclined from 23 to 10 percent,underuse of chemotherapy decreasedfrom 26 to 6 percent, and underuse ofhormone therapy decreased from 27 to11 percent among black and Hispanicwomen. Bickell, Shastri, Fei, et al., JNatl Cancer Inst 100(23):1717-1723,2008 (AHRQ grant HS10859).

• Study finds disparities in receipt ofchemotherapy following ovarian cancersurgery.

Clinical guidelines have recommendedsince 1994 that all women diagnosedwith ovarian cancer stage IC-IV orhigher receive chemotherapy followingsurgery to remove the cancer. Thisstudy of more than 4,000 black andwhite women aged 65 or older whowere diagnosed with stage IC-IVovarian cancer found that white womenwere more likely than black women toreceive chemotherapy after surgery (65percent vs. 50 percent, respectively),although survival rates did not differbetween the two groups of women.Women with higher socioeconomicstatus (SES) had increased use of both

surgery and chemotherapy, and womenin the lowest quartile of SES were morelikely to die than those in the highestquartile of SES. Du, Sun, Milam, et al.,Int J Gynecol Cancer 18(4):660-669,2008 (AHRQ grant HS16743).

• Some Latinas have higher rates ofcervical cancer than white women.

According to this study, women ofMexican descent born in the UnitedStates are at higher risk for contractingthe human papillomavirus (HPV) thatcauses cervical cancer than whitewomen and foreign-born Latinas.Indeed, those who have acculturated—i.e., they think, speak, and read Englishat home or with friends—are morelikely than less acculturated Latinas tocontract HPV and cervical cancer.Kepka, Coronado, Rodriguez, andThompson, Prev Med 51(2):182-184,2010 (AHRQ HS13853).

• Several barriers to followup of anabnormal Pap smear may beencountered by Latinas.

In this study involving 40 Latinas whohad an abnormal Pap smear, researchersidentified four primary barriers tofollowup with colposcopy: anxiety orfear of the test, difficulty in schedulingthe test around work and/or child carecommitments, poorcommunication/language difficulties(30 women spoke Spanish only), andconcern about pain. Percac-Lima,Aldrich, Gamba, et al., J Gen InternMed 25(11):1198-1204, 2010 (AHRQHS19161). See also National HealthcareDisparities Report 2008, available atwww.ahrg.gov/qual/qrdr08.htm(Intramural).

• Elderly women, particularly black andHispanic women, feel lifelong cervicalcancer screening is important.

Researchers interviewed 199 womenaged 65 or older about their preferences

for cervical cancer screening. All of thewomen had received regular cervicalcancer screenings, and none hadundergone a hysterectomy. More thanhalf of the women (58 percent) felt thatlifelong screening was either importantor very important. Compared withAsian and white women, Latinas andblack women were more likely to holdstrongly to this belief. Only 20 percentof women said they had talked withtheir physicians about ending screening.Sawaya, Iwaoka-Scott, Kim, et al., Am JObstet Gynecol 200(1):40.el-40.e7, 2009(AHRQ grant HS10856).

• Lack of physician trust may partlyexplain black/white differences inprostate cancer mortality rates.

Prostate cancer mortality is more thantwice as high for black men as for whitemen in the United States, and lack ofphysician trust may play a role in thisdisparity. More than 1,300 interviewswere conducted with 474 men toexamine the relationship betweenphysician trust and health care accessamong black and white prostate cancerpatients. Results showed that black mengenerally had lower levels of trust intheir physicians than white men,particularly black men who reportedhaving failed to seek medicallynecessary care. Do, Carpenter, Spain, etal., Cancer Causes Control 21:31-40,2010 (AHRQ grant HS1085l).

• Researchers find that blacks havehigher rates of pituitary adenoma thanother ethnic groups.

An analysis of 2004-2007 data coveringnearly 26 percent of the U.S.population identified 8,276 cases ofpituitary adenoma (tumors on thepituitary gland that are usually benign).The highest age-adjusted incidence ofpituitary adenoma was found for blacks(4.4 cases per 100,000), and the lowestwas found for American Indians/Alaska

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Natives (1.9 cases per 100,000). Blackswere more likely than other groups tohave their pituitary adenomasdiagnosed through x-ray alone (nomicroscopic confirmation), and eventhough their tumors were slightly largerthan those found in whites, blacks hadlower rates of surgical treatment thanother groups. McDowell, Wallace,Carnahan, et al., Pituitary 14:23-30,2011 (AHRQ grant HS16094).

• Colorectal cancer survival rates vary byrace.

According to this study, blacks havelower colorectal cancer survival ratesthan whites, Asians, and Hispanics.Asians have a lower risk of dying thanwhites, while mortality rates forHispanics and whites are similar. Themortality differences between blacksand whites seen in this study wereassociated mostly with socioeconomicstatus (5 percent), tumor characteristics(3 percent), treatment (2 percent), andcoexisting illness (2 percent). Theresearchers note that poor survivalamong blacks may also be related tobiologic features that contribute toaggressive tumor behavior or to geneticabnormalities that may have an impacton response to therapy. White, Vernon,Franzini, and Du, Cancer 116:4622-4631, 2010. See also Du and Liu, JHealth Care Poor Underserved 21:913-930, 2010; White, Liu, Xia, et al.,Cancer 113(12):3400-3409, 2008(AHRQ grant HS16743); Bazargan,Ani, Bazargan-Hejazi, et al., PatientEduc Counsel 76:240-247, 2009; andAni, Bazargan, Bazargan-Hejazi, et al.,Ethn Dis 18(2 Suppl 2):105-111, 2008(AHRQ grant HS14022).

• Blacks have higher lung cancermortality rates than whites.

Lung cancer remains the leading causeof cancer-associated mortality, andblacks continue to have lower survival

rates than whites. This study found thatcompared with whites, blacks with non-small-cell lung cancer (NSCLC) had a22 percent greater overall risk of dyingfrom all causes during the various stagesof NSCLC, and blacks with stage III orIV NSCLC were 24 percent more likelyto die from lung cancer than whites.Receipt of standard stage-specifictreatment was significantly associatedwith longer survival, and poorsocioeconomic status was associatedwith a greater risk of dying. Hardy, Xia,Liu, et al., Cancer 115(20):4807-4818,2009. See also Hardy, Liu, Xia, et al.,Cancer 115:2199-2211, 2009 (AHRQgrant HS16743).

• More whites than blacks are diagnosedwith non-Hodgkin lymphoma, butblacks are more likely to die from it.

An estimated 63,000 elderly individualsare diagnosed with non-Hodgkinlymphoma (NHL) in the United Stateseach year. Whites are more likely thanother groups to be struck with thedisease, but compared with blacks, theyalso are more likely to receive life-prolonging chemotherapy. In this study,blacks were significantly less likely thanwhites to receive chemotherapy (43.2vs. 52.4 percent). Also, lowersocioeconomic status, more commonamong the black patients studied, wassignificantly associated with a higherrisk of dying. Wang, Burau, Fang, et al.,Cancer 113(11):3231-3241, 2008(AHRQ grant HS16743).

• Among American Indians, perceivedcancer risk is associated with self-reported family history of cancer.

A random survey of 182 AmericanIndian adults living on a Hopireservation in Northeastern Arizonafound that knowledge of cancer riskfactors and attitudes about cancerprevention were not associated with theparticipants' perceived risk of cancer.

Only a family history of cancer wassignificantly associated with perceivedrisk in this population. Gonzales, Ton,Garroutte, et al., Ethn Dis 20:458-462,2010 (AHRQ grant HS10854).

• Men and blacks often are not aware ofcancer screening benefits.

Characteristics like sex, race, andeducation level are associated with howwell patients understand the benefits ofcancer screening. For this study,researchers surveyed a diverse group of467 women and 257 men aged 50 andolder from seven primary care practicesin North Carolina to elicit their feelingsabout various cancer screening tests.About half of those surveyed wereunsure of what to do about cancerscreening, although most knew aboutits benefits. Men were only about halfas likely as women to know the benefitsof cancer screening, and blacks weremuch more likely than whites not toknow about the benefits. Gourlay,Lewis, Preisser, et al., Fam Med42(6):421-427, 2010 (AHRQ grantHS13521). See also Carpenter,Howard, Taylor, et al., Cancer CausesControl 21:1071-1080, 2010 (AHRQgrant HS13353) and Pagan, Su, Li, etal., Am J Prevent Med 37(6):524-530,2009 (AHRQ grant HS17003).

• Racial disparities in access tospecialized cancer care vary by place ofresidence.

Using 2000 census data, researcherscalculated the travel times to specializedcancer centers and oncologists for allZIP code areas and found that ruralblacks have the longest travel times toNational Cancer Institute centers ofcare. Rural blacks were only 42 percentas likely as rural whites to seek care atthese national centers. Onega, Duell,Shi, et al., J Rural Health 26:12-19,2010. See also Onega, Duell, Shi, et al.,Cancer 112(4):909-918, 2008 (AHRQ

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grant T32 HS00070); and Outcomes ofCommunity Health Worker Interventions,Evidence Report/Technology Assessment No. 181,available at www.ahrg.gov/downloads/pub/evidence/pdf/comhealthwork/comhwork.pdf.

• Among people with melanoma,neighborhood socioeconomic factorsaffect prognosis.

According to this study, melanomaprognosis is significantly associated withneighborhood racial heterogeneity,education, and income. Patients wholive in predominantly white, wealthy,and highly educated communities areless likely to have a poor prognosiscompared with those living in lessadvantaged communities. Eide,Weinstock, and Clark, J Health CarePoor Underserved 20:227-245, 2009(AHRQ grant T32 HS00011).

• Race influences participation ofcompanions in cancer consultations.

Companions can play an importantrole in meetings between newlydiagnosed cancer patients and theirclinicians. For this study involvingnewly diagnosed lung cancer patients,researchers recorded and analyzedconversations between clinicians from amedical center’s oncology or thoracicsurgery clinic and the patients and theircompanions (if applicable). They foundthat the companions of black patientswere less active participants in theconversation compared with thecompanions of white patients.Companions were more likely to beactive participants when the physician’scommunication emphasizedpartnership-building and supportivetalk and when the lung cancer diagnosishad been made before the visit. Streetand Gordon, Psychooncology 17:244-251, 2008 (AHRQ grant HS10876).

Cardiovascular Disease

• Blacks who receive heart transplantshave poorer survival than patients ofother races.

Researchers analyzed outcomes data fornearly 40,000 patients who underwentheart transplants over a 22-year period(1987-2009). Almost 5,000 of thepatients were black, and they had a 34percent higher risk of transplant-relateddeath than the nearly 31,000 whitepatients. Transplant recipients of otherraces (2,118 Hispanics, 967 Asians, andpatients from other non-black groups)did not differ from whites in adjustedrisk of transplant-related death. Liu,Bhattacharaya, Weill, et al., Circulation123(15):1642-1649 (AHRQ grantHS19181).

• Racial disparities found in the use ofstatins and/or aspirin to preventcardiovascular disease.

According to this study involving adultsat high risk of cardiovascular disease(CVD), blacks are less likely thanwhites to use statins (38 percent vs. 50percent, respectively) or aspirin (29percent vs. 44 percent) to preventCVD. The researchers note that thesedisparities in the use of CVDmedications may contribute to thedocumented disparities between blacksand whites in CVD outcomes. Statinuse did not differ between whites andHispanics, but Hispanics were lesslikely than whites to use aspirin. Qato,Lindau, Conti, et al.,Pharmacoepidemiol Drug Saf 19:834-842, 2010 (AHRQ grant HS13599).

• Increasing access to coronaryangiography led to a reduction inracial disparities in New Jersey.

Researchers examined the effects ofregulatory reforms in New Jerseybetween 1996 and 2003 and foundthat a doubling of angiography facilities

closed the gap between blacks andwhites in access to these services.Reducing this disparity was significant,since blacks are at higher risk for heartdisease and have higher cardiac deathrates than whites, note the researchers.Cantor, Delia, Tiedemann, et al.,Health Aff 28(5):1521-1531, 2009(AHRQ grant HS14191).

• Disparities persist in access to specialistsfor patients with cardiovasculardisease.

Researchers examined medical recordsfor 9,761 adults with coronary arterydisease (CAD) or congestive heartfailure (CHF) at primary care practicesaffiliated with two academic medicalcenters from 2000 to 2005. Theyfound that 79.6 percent of patientswith CAD and 90.3 percent of patientswith CHF had a cardiologyconsultation during that period. Menwere more likely than women to bereferred to a cardiologist, and patientsbeing treated at community healthcenters were less likely than those athospital-based practices to receive aconsultation. Blacks were more likelythan whites to obtain an initialconsultation, but those with CHF hadfewer followup consultations thanwhites, which may reflect weakerrelationships with their specialists, notethe researchers. Cook, Ayanian, Orav,and Hicks, Circulation 119:2463-2470,2009 (AHRQ grant T32 HS00020).

• Better short-term survival of blackswith heart failure correlates with lesssevere illness at hospital admission.

Researchers analyzed data on 1,408blacks and 7,260 whites who wereadmitted to the hospital from theemergency department (ED) during2003 and 2004 and discharged with adiagnosis of heart failure. Overall, blackpatients were younger than whitepatients (65.8 years vs. 77.4 years) and

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were much more likely than whitepatients to be assigned to the lowestrisk class using one of three predictionrules. Two possible explanations forthese findings are: (1) blacks are lesslikely than whites to have a usual sourceof care and may be more likely to seekinitial care for heart failure in the ED;and (2) better access to primary care forwhites may paradoxically result ingreater illness severity when they doarrive at the ED, since they are morelikely to visit the ED after failure ofinitial outpatient treatment. Auble,Hsieh, and Yealy, Am Heart J157(2):306-311, 2009 (AHRQ grantHS10888).

• Nurse-led disease management forheart failure is cost effective inethnically diverse urban areas.

Researchers randomized 406 low-income patients with heart failure toeither usual care or a nurse-led diseasemanagement program. All of thepatients were from the Harlemneighborhood of New York City, andmost were black or Hispanic. Duringthe year-long program, patients in theintervention group received regulartelephone calls and dietary instruction.Compared with patients in the usualcare group, the nurse-led patientsmaintained better physical functioningand had higher quality-of-life scores.The per-patient cost of the nurse-ledintervention was $2,177, which wasoffset by the $2,378 in lowerhospitalization costs per person.Hebert, Sisk, Wang, et al., Ann InternMed 149:540-548, 2008 (AHRQ grantHSI0402).

• Female and black stroke patients areless likely to receive preventive care toavoid further strokes.

One in three stroke survivors will sufferanother stroke within 5 years, but thereare measures clinicians can take toreduce the risk of another stroke.

According to this study of 501 patientshospitalized for acute ischemic stroke,54 percent of whites, 62 percent ofHispanics, and 77 percent of blacksreceived incomplete inpatientevaluations. Similarly, 66 percent ofwomen had incomplete inpatientevaluations, compared with 54 percentof men. In addition, 40 percent ofwhites, 43 percent of Hispanics, and 59percent of blacks received inadequatedischarge regimens of anticoagulant,antihypertensive, and lipid-loweringmedications. Blacks and Hispanics areat greater risk for recurrent strokes thanwhites. Improving delivery of theseeffective interventions will reducerecurrent stroke risk and may reducestroke risk disparities among minorities,conclude the researchers. Tuhrim,Cooperman, Rojas, et al., J StrokeCerebrovasc Dis 17(4):226-234, 2008(AHRQ grant HS10859).

Care for the Elderly/Long-TermCare

• Caring for older family members isespecially challenging for KoreanAmericans.

The researchers conducted eight focusgroups with first-generation KoreanAmerican adults who were living withand/or providing care to a KoreanAmerican relative or nonrelative aged60 or older. Focus group participantsexpressed a strong sense of duty to carefor ill or frail family members, therebyupholding the traditional value ofdaughter/son devotion. This duty oftencompeted with other life prioritieswithin immigrant life, such as workingextremely long hours andcommunication difficulties. All of thecaregivers were ambivalent about usingoutside, formal services, which theyviewed as a last resort. Han, Choi, Kim,et al., J Adv Nurs 63(5):517-526, 2008(AHRQ grant HS13779).

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• Greater functional disability amongolder blacks and Latinos may be duein part to disparities in treatment andcare quality.

This study of community-dwellingadults aged 50 and older found thatblacks and Latinos with physician visitsand hospitalizations were significantlyless able than same-aged whites to carryout activities of daily living. Inaddition, many of the blacks andLatinos in this survey had moremobility limitations than whites. Otherpredisposing factors (e.g., age and sex,chronic illness, and economic access tocare) did not account for the greaterdisability among blacks and Latinos.These findings suggest that improvingeconomic access to care may not beenough to guarantee equal access tohigh-quality care. Bowen and Gonzalez,Gerontologist 48(5):659-667, 2008(AHRQ grant HS13819).

• Racial disparities in care for the elderlypersisted and even worsened for someprocedures in the late 1990s.

Researchers analyzed discharge data forNew York and Pennsylvania hospitalsfor elderly patients undergoing threereferral-sensitive hospital proceduresduring 1997 and 2001—coronaryangiography, heart bypass surgery, andhip/joint replacement, all high-technology procedures that generallyrequire referral to a specialist. Elderlyblacks were 37 percent less likely thanelderly whites to have receivedangioplasty in 1997. This disparity hadwidened considerably by 2001, to 48percent. Disparities in hip/jointreplacement among other races alsoincreased over time relative to whites.Basu and Mobley, Med Care Res Rev65(5):617-637, 2008 (AHRQPublication No. 08-R074)*(Intramural).

Chronic Illness

• Viewing patient stories seems to helpblack patients with hypertensionmanage their blood pressure.

This study found that watching storysegments of patients talking about highblood pressure helped black men andwomen with hypertension makesubstantial improvements in their ownblood pressure readings. The studyinvolved 299 blacks with hypertensionwho were recruited from an inner cityclinic in the South; 147 of the patientswere assigned to the storytellingintervention, and the other 152 wereassigned to the usual-care group. Thosein the intervention group showed areduction in blood pressure thatpersisted through the 9-monthfollowup period. Houston, Allison,Sussman, et al., Ann Intern Med154(2):77-84, 2011 (AHRQ grantHS19353).

• Control of high blood pressure can bedifficult for blacks and MexicanAmericans.

Despite adherence to treatment andlifestyle changes, high blood pressurecontrol is often elusive for blacks andMexican Americans, according to thisstudy of nearly 5,400 adults withhypertension. Blacks and MexicanAmericans were twice as likely as whitesto report following advice to exercise,quit smoking, restrict alcohol, andreduce stress. Also, blacks were muchmore likely to report salt restriction andattempts to lose weight. Despiteadherence to medication (which wassimilar for all three groups) and lifestylemodification, both blacks and MexicanAmericans were 40 percent and 50percent, respectively, more likely thanwhites to continue to suffer fromuncontrolled hypertension. Natarajan,Santa Ana, Liao, et al., Ann Epidemiol

19:172-179, 2009 (AHRQ grantHS10871).

• Knowledge test validated for KoreanAmericans with hypertension.

Researchers developed the High BloodPressure Knowledge Test and assessedits utility, reliability, and validity in agroup of Korean Americans. Resultsshowed that the test is sensitive todifferences in blood pressure controlstatus and should provide a reliable,standardized measure of high bloodpressure with wide relevance. Han,Chan, Song, et al., J Clin Hypertension13(10):750-757, 2011. See also Lee,Han, Song, et al., Int J Nurs Stud47(4):411-417, 2010; Han, Kim, Kim,et al., Patient Educ Counsel 80:130-134,2010; and Kim, Han, Song. et al., JClin Hypertension 12(4):253-260, 2010(AHRQ grant HS13160).

• Study finds low rates of racial/ethnicdiscrimination by health care providerscaring for diabetes patients.

Discrimination has been suggested asone potential explanation forracial/ethnic disparities in health andhealth care. However, this study of18,000 patients receiving care in a largegroup plan in northern Californiafound that just 3 percent of membershad reported discrimination fromdoctors or other providers, comparedwith 20 percent who reported suchdiscrimination in everyday life. Allracial/ethnic minority groups reporteddiscrimination more frequently thanwhites, with blacks reporting generaldiscrimination most frequently, andFilipinos reporting health care providerdiscrimination most often. Lyles,Karter, Young, et al., J Health Care PoorUnderserved 22:211-225, 2011 (AHRQgrant HS13853).

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• Diabetes testing is declining amongpoor, minority, and inner-city adults.

According to data presented in the2010 National Healthcare DisparitiesReport, the proportion of poor adultsaged 40 and older with diabetes thathad their blood sugar, eyes, and feetexamined at least once a year droppedfrom 39 percent to 23 percent between2002 and 2007. Blacks experienced an11 percent drop in testing, from 43 to32 percent, while the proportion ofHispanics who had all three exams fellfrom 34 to 27 percent over the sameperiod. The decline was smallest amongwhites at 4 percent (from 43 to 39percent). Available atwww.ahrg.gov/qual/qrdr10.htm(Intramural).

• Health information. technology maybe instrumental in decreasingdisparities among people with diabetes.

This literature review included 18articles published between 2006 and2009 on the effectiveness of health careinterventions using health informationtechnology to improve diabetes processof care and intermediate diabetesoutcomes in black and Hispanicpatients in underresourced settings.Baig, Wilkes, Davis, et al., Med Care ResRev 67(5 Suppl):163S-197S, 2010. Seealso Lu, Kotelchuck, Hogan, et al., MedCare Res Rev 67(5):1985-2305, 2010(AHRQ contract P233200900421P).

• Few diabetes education programsserving American Indians and AlaskaNatives meet national standards.

American Indians and Alaska Nativeshave diabetes rates that are two to threetimes as high as the general population,and they are four times as likely to diefrom the disease. Thus, diabeteseducation is particularly important forthese individuals to help them learn to

self-manage their disease. According tothis study, few diabetes educationprograms funded by the Indian HealthService met national standards in 2001.Programs were assessed against threelevels of care, and only 9 of 86programs achieved level 2 recognition.Since that time, with increased fundingtoward staff and training, the numberof recognized programs grew to 37 in2009. Roubideaux, Noonan, Goldberg,et al., Am J Public Health 98(11):2079-2084, 2008 (AHRQ grant HS10854).

• Use of a uniform treatment algorithmeliminates racial disparities in bloodsugar control.

According to this study, differencesbetween blacks and whites in glycemiclevels disappear in care settings wheretreatment is uniform, immediate care isfacilitated, and medication isaggressively managed. Patients withtype 2 diabetes (3,324 blacks, 218whites) all made initial and 1-yearfollowup visits; a subset of patients hadan additional followup visit at 2 years.Patient adherence to treatment, numberof visits, and provider behavior weresimilar for both groups. Initially,glycemic levels were higher in blackpatients than in white patients; at 1year, the difference in glycemic levelshad narrowed but remained significant.Among those who returned for a 2-yearvisit, (1,691 blacks, 114 whites),glycemic levels were no longer different.Rhee, Ziemer, Caudle, et al., DiabetesEduc 34(8):655-663, 2008 (AHRQgrant HS07922).

• Low-income city-dwelling adults withhigh blood pressure are reasonablyknowledgeable about their condition.

This study of predominantly low-income black women withhypertension found that nearly two-

thirds (65 percent) of them were fairlyknowledgeable about their condition.Those with less knowledge tended to beat least 60 years of age, have less than ahigh school education, or be recentlydiagnosed with the condition.Individuals who were uncomfortableasking questions of their doctors alsowere less knowledgeable. Nearly one-fourth of the patients did not knowthat high blood pressure can causekidney problems, despite the prevalenceof kidney problems among blacks withhypertension. The study involved 296adults being cared for at one urbanclinic. Sanne, Muntner, Kawasaki, etal., Ethn Dis 18:42-47, 2008 (AHRQgrant HS11834).

• Underresourced clinics that treatmedically complex patients may partlyexplain poor chronic disease outcomesamong minorities.

Primary care clinics that serve minoritypatients have less access to medicalresources, a chaotic work environment,and more medically challengingpatients, compared with clinics thatserve predominantly white patients,according to this study. The researcherscompared data from 27 clinics with atleast 30 percent minority patients withdata from 69 clinics with less than 30percent minority patients. Varkey,Manwell, Williams, et al., Arch InternMed 169(3):243-250, 2009 (AHRQgrant HS11955).

• Low health literacy and culturaldifferences affect screening andmanagement of chronic disease.

The researchers examined the impact ofcultural differences and low healthliteracy on chronic disease outcomesand the use of preventive screening testsand found that many racial/ethnicgroups lack an understanding of the

idea of chronic disease. For example,the stigma associated with non-normative sexual behavior may keepunmarried Latinas from seeking outPap smears. The researchers call forprograms to address cultural andlinguistic barriers in primary care andprevention settings. Shaw, Huebner,Armin, et al., J Immigr Minor Health11:460-467, 2009 (AHRQ grantHS14086). See also Schillinger,Hammer, Wang, et al., Health EducBehav 35:664-682, 2008 (AHRQ grantHS14864).

• New program helps physicians teachpatients how to correctly use asthmainhalers.

Asthma is a chronic illness thatdisproportionately affects minoritiesliving in major urban areas. Critical toasthma self-management is patients'ability to use inhalers properly, butfactors such as low patient healthliteracy and poor clinician knowledge ofnew inhalers and their use can makepatient education difficult. TheChicago Breathe Project is anintervention designed to improveeducation for resident physicians onnew inhalers and inhaler techniquesand ways to assess their use duringpatient encounters. According to theresearchers, the Chicago Breathe Projectcan be easily replicated in other urbanareas to benefit minority communitiesaffected by asthma. Press, Pincavage,Pappalardo, et al., J Natl Med Assoc102(7):548-555, 2010 (AHRQ grantHS16967).

• More stress means worse asthma ininner-city adults.

This study found a direct link betweenan individual's level of stress and theseverity of their asthma. Those whoperceived higher stress levels were morelikely to have increased asthma-relatedproblems compared with those who

reported lower stress levels. The study'sfindings are based on encounters with326 inner-city residents with asthma;most were either black or Hispanic andof low socioeconomic status. They alsohad various conditions in addition toasthma, including hypertension (47percent) and diabetes (25 percent).Wisnivesky, Lorenzo, Feldman, et al., JAsthma 47:100-104, 2010. See alsoPonieman, Wisnivesky, Leventhal, etal., Ann Allergy Asthma Immunol103:38-42, 2009; Wisnivesky, Kaltan,Evans, et al., Med Care 47(2):243-249,2009; and Wisnivesky, Lorenzo, Lyn-Cook, et al., Ann Allergy AsthmaImmunol 101:264-270, 2008 (AHRQgrant HS13312).

• Study finds racial/ethnic variation inparental perceptions of their children’sasthma.

Researchers interviewed parents of 739children with persistent asthma in aMedicaid health plan in Massachusetts.Overall, 75 percent of parents believedtheir children could be symptom-freemost of the time (75 percent Latino, 84percent black, and 89 percent white).Also, 43 percent of Latino parents, 44percent of black parents, and 55percent of white parents said theirchildren should have no emergencyroom visits or hospitalizations forasthma. Black (18 percent) and Latino(23 percent) parents were more likelythan white parents (8 percent) to havecompeting family priorities “all of thetime” or “most of the time” in additionto their child’s asthma, even afteradjusting for income, education,insurance, and other factors. Wu,Smith, Bokhour, et al., Ambul Pediatr8(2):89-97, 2008 (AHRQ grant T32HS00063).

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• Many patients with sickle cell diseaseself-discharge from the hospital.

This study found that many patientswith sickle cell disease leave the hospitalagainst medical advice, which canjeopardize their health. Those who weremore distrustful of clinicians and thosewho reported difficulty in persuadingmedical staff about sickle cell pain weremore likely to self-discharge from thehospital. Haywood, Lanzkron,Ratanawongsa, et al., J Hosp Med5:289-294, 2010 (AHRQ grantHS13903). See also Tanabe, Porter,Creary, et al., J Natl Med Assoc102(11):1033-1041, 2010 (AHRQgrant T32 HS00078); Sobota, Graham,Heeney, et al., Am J HematoI 85(1):24-28, 2010 (AHRQ grant T32HS00063); and Brousseau, Owens,Mosso, et al., JAMA 303(13):1288-1294, 2010 (AHRQ Publication No.10-R060)* (Intramural).

• Certain socioeconomic factors increaseparental nonadherence torecommendations for managing sicklecell disease.

Infants with sickle cell disease are atgreatly increased risk for pneumococcalinfection. Treatment with penicillin hasbeen shown to reduce the risk ofinfection by 64 percent, but this studyfound that 60 percent of Medicaid-enrolled infants with sickle cell diseasedid not receive an antibioticprescription by the age of 12 weeks.Having one or more risk factors—beinga single mother, maternal age youngerthan 20 years, maternal education lessthan 12 years, very low income, andurban residence—significantly increasednonadherence to recommendedtreatment. Warren, Arbogast, Dudley,et al., Arch Pediatr Adolesc Med164(3):298-299, 2010 (AHRQ grantHS16974).

• Adult drug for sickle cell anemia maybe safe for children.

This review of published studies foundthat the medication hydroxyurea—which is approved for use in adults withsickle cell disease to prevent sudden,painful episodes—may also be usefuland safe when taken by children withthe disease. A panel of experts foundthat hydroxyurea did not cause growthdelay in children ages 5 to 15, butbecause the drug affects thereproductive system of male mice, itmay have an adverse effect on spermproduction after puberty. Strouse,Lanzkron, Beach, et al., Pediatrics122(6):1332-1342, 2008 (AHRQcontract 290-02-0018).

• Formal and informal social supportnetworks enhance management of HIVdisease.

The advent of improved treatment forHIV infection has changed the natureof the disease from an acute illness to achronic condition. This has increasedthe importance of HIV diseasemanagement, including regular medicalappointments and consistentmedication use. Through interviewswith HIV-positive adults, this studyfound that formal support networks(professional support organizations) arecritical for engagement in HIV-specificmedical care, while informal networks(family, friends) are instrumental inemotional, household-related, andfinancial support. George, Garth,Wohl, et al., J Health Care PoorUnderserved 20:1012-1032, 2009(AHRQ grant HS14022).

• Treatment of hepatitis C virusinfection is less likely for blacks andthose coinfected with HIV.

This study compared treatment of 241patients with hepatitis C virus (HCV)infection and 158 patients with HCV

and HIV coinfection and found thatHIV coinfection was an independentpredictor of not receiving treatment forHCV. Blacks also were less likely thanwhites to receive treatment for HCV,most likely because of their reducedlikelihood of achieving good treatmentresponses to HCV medicationscompared with whites. Butt, Tsevat,Leonard, et al., Int J Infect Dis 513:449-455, 2009 (AHRQ grant HS13220).

• Sociodemographic factors may predictearly discontinuation of HIV therapy.

Antiretroviral therapy (ART) used totreat HIV infection can have severe anddebilitating side effects (e.g., nausea,vomiting. diarrhea, dizziness, andintense dreams), yet long-termadherence is critical to halting diseaseprogression. This study found thatblacks and young people are more likelythan others to stop taking their HIVmedication early, and women are morelikely than men to stop taking someART drugs. These use patterns may bedue to greater and more severe sideeffects related to genetic differencesamong blacks and/or greatersusceptibility to drug side effects amongwomen, according to the researchers.Asad, Hulgan, Raffanti, et al., J NatlMed Assoc 100(12):1417-1424, 2008(AHRQ grant HS10384).

Emergency Care/Hospitalization

• Researchers examine trends inhospitalization for children withKawasaki syndrome.

Kawasaki syndrome (KS) is a rarechildhood disease affecting the bloodvessels that occurs most often amongchildren aged 5 or younger of Japaneseor other Asian ancestry living in Hawaiiand the continental United States. Thisstudy found that children younger thanage 5 accounted for more than 83

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percent of all Kawasaki-relatedhospitalizations, and that higherhospitalization rates were observed forboys, children from higher incomefamilies, and children with privateinsurance. Japanese children had thehighest incidence per 100,000population (210.5), followed by NativeHawaiian children (86.9), other Asianchildren (84.9), and Chinese children(83.2). Homan, Christensen, Belay, etal., Hawaii Med J 69:194-197, 2010.(AHRQ ·Publication No. 11-R004).*See also Holman, Belay, Christensen, etal., Pediatr Inject Dis J 29(6):483-488(AHRQ Publication No. 11-R074)*(Intramural).

• Minority children with asthma oftenuse emergency departments (EDs) forcare.

Researchers analyzed 1996-2000 dataon 982 children with asthma andfound that black and Hispanic childrenreceived asthma care in the ED moreoften than white children, which isconsistent with findings from earlierstudies. The authors suggest thatadditional ED visits occur because thesechildren often lack a usual source ofcare and do not have a plan in place tomanage asthma at home when anattack occurs. Thus, improving careaccess and offering programs to teachcaregiver skills to manage asthma mayreduce ED visits. Kim, Kieckhefer,Greek, et al., Prev Chronic Dis,6(1):Epub, 2009 (AHRQ grantHS13110).

• Black children are more likely thanwhite children to be hospitalized for aruptured appendix.

According to an analysis of data fromAHRQ, the hospital admission rate ofblack children for a ruptured appendixin 2006 was 365 per 1,000 admissions,compared with 276 per 1,000admissions for white children. Hispanic

children had the second highest rate,344.5 per 1,000 admissions, followedby Asian and Pacific Island children at329 per 1,000 admissions. See the 2009National Healthcare Disparities Report,available at www.ahrq.gov/qual/nhdr09/nhdr09.pdf (Intramural).

• Blacks are less likely than whites tohave surgery performed by high-volume surgeons and hospitals.

Researchers examined data from NewYork City hospitals for 10 surgicalprocedures that have shown a directrelationship between volume andreduced short-term mortality. Examplesinclude heart bypass surgery, total hipreplacement, and certain cancersurgeries. For 9 of the 10 procedures,black patients were significantly lesslikely than whites to have their surgeryperformed by a high-volume surgeon orin a high-volume hospital. Asian andHispanic patients also were more likelyto have a less-experienced surgeonperform the procedure at a low-volumehospital. Epstein, Gray, and Schlesinger,Arch Surg 145(2):179-180, 2010. Seealso Gray, Schlesinger, Siegfried, andHorwitz, Inquiry 46:322-338 (AHRQgrant HS14074).

• Researchers call for increased use ofprofessional interpreters in hospitals.

This study examined the correlationbetween limited English proficiencyand hospital readmission rates andfound that Chinese and Spanishspeakers were more likely to bereadmitted to the hospital than Englishspeakers. When compared directly withEnglish-speaking Asians and Latinos,the higher readmission rates persistedfor those who spoke only Chinese andSpanish. Among English speakers,blacks had the highest and Latinos thelowest readmission rates. Since only 14percent of the non-English-speakingpatients used professional staff

interpreters, the researchers cite theneed to create a culture of professionalinterpreter use in hospitals. Karliner,Kim, Meltzer, and Auerbach, J HospMed 5:276-282, 2010 (AHRQ grantsHS10597 and HS11416).

• Hospitalization rates for HIV infectionhave declined, but disparities still exist.

The annual rate of hospitalizations forHIV infection has declined consistentlyover the past few years, yet blacks,women, those infected with HIVthrough IV drug use, and olderindividuals are still hospitalized moreoften than other patients with HIV.Patients covered by Medicare,Medicaid, or a combination of the twowere much more likely to behospitalized than patients with privateinsurance. Yehia, Fleishman, Hicks, etal., J Acquir Immune Defic Syndr53(3):397-404, 2010 (AHRQPublication No. 10-R046)*(Intramural).

Health Care Access, Costs, andInsurance

• Being foreign-born negatively affectsaccess to care.

Using data on more than 6,000 non-elderly adults in the United States andCanada, researchers found that foreign-born adults in the United States were48 percent less likely than native-bornadults to have seen a health professionalin the preceding 12 months. Whenthey looked at the joint effects ofnativity and race/ethnicity on access tocare, the disparities were even greater.For example, foreign-born Hispanicshad 55 percent lower odds of having aregular medical doctor than native-bornnon-Hispanic whites. LeBrun and Shi,J Health Care Poor Underserved22(3):1075-1100, 2011 (AHRQ grantT32 HS00029). See also Gresenz,Rogowski, and Escarce, Health Serv Res

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44(5):1542-1562, 2009 (AHRQ grantHS10770).

• Many U.S.-Mexico border residents“cross over” to obtain health careservices.

Researchers conducted a survey amongU.S. border residents living in Texasabout seeking out health care services inMexico. More than half of the 1,405survey respondents said they crossed theborder to use one of four types ofservices in Mexico: visits to doctors,medications, dental visits, and hospitaladmissions. Factors associated withcrossing the border to obtain healthcare services included no healthinsurance, dissatisfaction with thequality of care in the United States, andself-reported poor health status. Nearlyhalf of those participating in the surveydid not have health insurance. Su,Richardson, Wen, and Pagan, HealthServ Res 46(3):859-876, 2011 (AHRQgrant HS17003).

• Enrollment in Medicare Advantageplans reduces disparities in primarycare quality in three States.

According to this analysis of 2004hospital discharge data from AHRQ'sHealthcare Cost and UtilizationProject, patients enrolled in MedicareAdvantage managed care plans inCalifornia, Florida, and New York hada lower incidence of preventablehospitalizations across all racial/ethnicgroups, compared with those enrolledin fee-for-service Medicare. Accordingto the study’s author, better carecoordination and use of primary andpreventive care may be especiallybeneficial for minorities, since theyoften are vulnerable and need suchsupport. Basu, Health Care Manag Sci15(1):15-28, 2012 (AHRQ PublicationNo. 12-R014)* (Intramural).

• Americans, especially blacks, spendsubstantial periods of time uninsured.

Researchers used mortality data fromthe National Center for HealthStatistics and data on health and healthinsurance status on 34,403 individualsparticipating in AHRQ's MedicalExpenditure Panel Survey (MEPS) in2004 to examine the risk of beinguninsured. They found that amongthose aged 20-24, blacks wereuninsured 43 percent of the time,compared with 36 percent of the timefor same-age whites. Differencesbetween blacks and whites wereparticularly large between the ages of 50and 60, when health begins to declineand Medicare coverage has yet to begin.Kirby and Kaneda, Demography47(4):1035-1051, 2010 (AHRQPublication No. 11-R037)*(Intramural).

• Some minority patients have difficultyaccessing care provided by communityhealth centers.

Researchers studied access to careprovided by four community healthcenters (CHCs) located in States with ahigher-than-average percentage of AsianAmerican, Native Hawaiian, and otherPacific Islander patients. They foundthat while the CHCs served as safetynets for some of the most vulnerablepatients, many patients were unable toaccess or use the CHC care unlessenabling services (e.g., languageinterpretation, health education, andfinancial or insurance eligibilityassistance) were provided. Comparedwith nonusers, users of enablingservices were more likely to be older,female, and uninsured. Weir, Emerson,Tsent, et al., Am J Public Health100(11):2199-2205, 2010 (AHRQgrant HS13401).

• Asian Americans enrolled intraditional fee-for-service Medicarereceive fewer needed services thanwhite patients.

Researchers examined the association ofrace/ethnicity and socioeconomic statuswith the use of two Medicare-coveredcancer screening services (colorectalcancer screening and mammography)and three diabetes-related care services(blood sugar measurement, eye exams,and self-care instructions) amongelderly whites and Asian Americans.The study focused on the metropolitanstatistical areas (MSAs) with the largestnumber of elderly Asians in 2000,including Los Angeles, New York City,and Washington, DC. Asians were lesslikely than whites to receive colorectalcancer screening and mammography,while Asian-white disparities in diabetescare were less consistent and variedaccording to geographic region.Outside of the nine MSAs studied,Asian-white differences were significantacross both cancer screening servicesand all three diabetes services. Cancer isthe leading cause of death amongAsians, and diabetes-related conditionsrank fifth. Moy, Greenberg, and Borsky,Health Aff 27(2):538-549, 2008(AHRQ Publication No. 08-R064)*(Intramural).

• HIV care sites serving a largeproportion of blacks and Hispanicsmay be difficult to access for allpatients.

Researchers surveyed 915 HIV-infectedadults receiving care at 14 U.S. HIVclinics and found that, on average,blacks and Hispanics spent more timetraveling to the care site than whites (36and 37 vs. 29 minutes). Further, traveltime to the HIV care site lengthened asthe proportion of black and Hispanicpatients increased at a given site.Finally, waiting times at care sites werelonger for Hispanics and blacks than

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whites (36 and 31 vs. 27 minutes).Korthuis, Saha, Fleishman, et al., J GenIntern Med 23(12):2046-2052, 2008(AHRQ Publication No. 09-R032)*(Intramural). See also Ford, Daniel,Earp, et al., Am J Public Health99(S1):5137-5143, 2009 (AHRQ grantT32 HS00032).

• Black and Hispanic Medicare patientsoften wait longer than white patientsfor surgery after hip fracture.

According to this study, black andHispanic Medicare patients with hipfractures had approximately a half-daydelay in receiving hip stabilizationsurgery compared with white patients.Most often, the delay in surgery wasdue to the need to evaluate and stabilizeother medical problems, such as chestpain. Other possible explanationsinclude the higher prevalence in blacksand Hispanics of undiagnosed anduncontrolled medical conditions suchas diabetes and hypertension or delayedtransportation to the hospital leading toan afternoon admission and surgerydeferral until the next day. Nguyen-Oghalai, Kuo, Wu, et al., South Med J103(5):414-418, 2010. See alsoNguyen-Oghalai, Ottenbacher, Kuo, etal., Arch Physical Med Rehab 90:560-563, 2009 (AHRQ grant HS11618).

• Disparities in outpatient care andexpenditures have widened forHispanics but not for blacks.

To explore trends in care disparities,researchers analyzed data on office-based or outpatient visits for two timeperiods: 1996-1997 and 2004-2005.They found that medical care spendingfor whites and blacks increasedsignificantly (over $1,500) over thoseyears, but there was a much smallerincrease (about $400) in spending forHispanics. Hispanic-white disparities inoutpatient care visits increased between1996 and 2005, while black-white

differences remained relatively constant.Le Cook, McGuire, and Zuvekas, MedCare Res Rev 66(1):23-48, 2009(AHRQ Publication No. 09-R019)*(Intramural).

• Minority children are half as likely aswhite children to receive specializedtherapies.

This study found that 3.8 percent ofchildren aged 18 or younger obtainspecialized therapies from the healthcare system, including physical,occupational, and speech therapy andhome health care services. Childrenmost likely to use specialized therapiestend to be male (59.7 percent), white(80.6 percent), and have a chroniccondition (38.8 percent). Blackchildren, Hispanic children, andchildren of other races were much lesslikely than white children to receivespecial therapies. These findings suggestthat either minority children areunderusing therapies or white childrenare overusing them, according to theresearchers. Kuhlthau, Hill, Fluet, et al.,Dev Neurorehabil 11(2):115-123, 2008(AHRQ grant HS13757).

• More blacks than whites have troubleaffording their prescription medicines.

Researchers recruited elderly black andwhite patients from 48 primary carepractices in Alabama. Patients wereasked about their ability to pay forprescriptions, their insurance coverage,coexisting medical conditions, andsocioeconomic status. Blacks were twiceas likely as whites to not fill aprescription (50 vs. 25 percent) andwere far more likely to reportinadequate income to meet basic needs(61 vs. 17 percent). Of 399participating patients, 53 percent hadan annual household income of lessthan $15,000. Cobaugh, Angner, Kiefe,et al., Am J Health Syst Pharm 65:2137-2143, 2008 (AHRQ grant HS10389).

• Immigrants use fewer preventiveservices than U.S. natives.

Researchers compared use of preventivecare services by immigrants and native-born residents and found that U.S.natives had more medical and dentalvisits, received more flu shots, and werescreened more often for highcholesterol levels and cervical, breast,and prostate cancers. Althoughimmigrants’ use of preventive servicesincreases the longer they stay in theUnited States, their use never matchesthat of U.S. natives. Immigrants arelikely to be uninsured when they arrivein the United States, but even after theyobtain continuous coverage, they stillare less likely than U.S. natives to usepreventive care. Pylypchuk andHudson, Health Econ; E-pub August2008 (AHRQ Publication No. 09-R025)* (Intramural).

• Hispanics enrolled in Medicaremanaged care plans are less positivethan whites about their careexperiences.

More than half of Hispanics insuredthrough Medicare were enrolled inmanaged care programs in 2002. A2002 survey included 125,369respondents enrolled in 181 Medicaremanaged care programs nationally.Responses from white enrollees werecompared with responses fromHispanic enrollees; also, responses fromHispanics who completed the survey inEnglish were compared with those whocompleted the survey in Spanish.English-speaking Hispanics viewed allaspects of their care—except providercommunications—worse than whitesdid. Spanish-speaking respondentsreported more negative care experienceswith timeliness of care, providercommunications, and office staffhelpfulness but were more satisfied withgetting needed care. Weech-Maldonado, Fongwa, Gutierrez, and

13

Hays, Health Serv Res 43(2):552-568,2008 (AHRQ grant HS16980).

• Researchers examine the effects ofvarious factors on children’s healthinsurance coverage.

Children of different racial and ethnicgroups vary substantially with respect tohealth insurance coverage. Theseresearchers explored how much a givencharacteristic contributes to coveragedifferences, using a recently developedstatistical technique—decompositionanalysis. They found that observablecharacteristics such as poverty, parenteducational level, family structure (forblack children), and immigration-related factors (for Hispanic children)account for 70 percent or more of thecoverage differences among white,black, and Hispanic children. Theyconclude that the lower coverage levelsamong ethnic and racial minorities aredue to the fact that uninsurance isconcentrated among socioeconomicallydisadvantaged children who happen tobe minorities. Pylypchuk and Selden, JHealth Econ 27(4):1109-1128, 2008(AHRQ Publication No. 08-R068)*(Intramural).

• Geographic information system maypinpoint areas where increased primarycare is needed.

Using the Multiple Attribute PrimaryCare Targeting Strategy (MAPCATS),researchers were able to identifygeographic regions where increasingaccess to primary care services for theHispanic community would have thegreatest potential impact on healthoutcomes. They used MAPCATS toanalyze five key attributes of theHispanic population in Charlotte, NC:socioeconomic status, populationdensity, insurance status, patterns ofemergency department use, and use ofthe primary care safety net. Theattributes were combined with input

from health providers and communitymembers to create a composite mapthat showed the community's overallprimary care needs. Dulin, Ludden,Tapp, et al., Am Board Family Med23(1):109-120, 2010 (AHRQ grantHS16023).

• Some minority patients voice concernsabout using telemedicine to expandaccess to care.

Telemedicine holds promise as a way tocompensate for physician shortages andovercrowding in inner city healthfacilities. This study found that innercity blacks and Hispanics view thebenefits of the technology similarly, butblacks tend to be more wary oftelemedicine. Their concerns centeredmostly on the inability to check adoctor's qualifications and uncertaintyabout the telemedicine equipment'sability to protect privacy andconfidentiality. George, Hamilton, andBaker, Telemed J E Health 15(6):1-6,2009 (HS14022).

Mental/Behavioral Health

• Research finds a link between PTSDand elevated blood sugar in lowincome minorities.

Researchers studied 103 low incomeminority patients with type 2 diabeteswho were being treated at one of fourcommunity-based primary care clinicsin Harlem. They found that 12 percentof these men and women had fullposttraumatic stress disorder (PTSD),and another 12 percent had sub-threshold PTSD. The most commonsources of trauma were childhoodphysical abuse (22 percent) and thedeath of a child (18 percent). Thosewho had full PTSD were significantlymore likely to have an elevated HBA1Clevel. Patients with PTSD also weremore likely to suffer from depressivesymptoms and to be taking a

14

psychiatric medication. Miller,Mancuso, Boutin-Foster, et al., GenHosp Psychiatry 33:116-122, 2011(AHRQ grant T32 HS00066).

• Among adolescents, whites are muchmore likely than blacks or Hispanics touse antidepressants.

According to this analysis of data fromAHRQ's Medical Expenditure PanelSurvey, white adolescents are more thantwice as likely as Hispanic adolescentsand almost five times as likely as blackadolescents to use antidepressants. Theresearchers note that much of theHispanic/white gap may be explainedby two-parent families, family income,education, health insurance, and havinga usual source of care. On the otherhand, the black/white gap may be duein part to the way minorities perceivemental health difficulties and the use ofantidepressants by adolescents. Kirby,Hudson, and Miller, Med Care Res Rev67(3):342-363, 2010 (AHRQPublication No. 10-R072).* See alsoHudson, Miller, and Kirby, Med Care45(11):1068-1075, 2007 (AHRQPublication No. 08-R044)*(lntramural).

• Less-accultured Latinos use fewermental health services than others.

An analysis of data on use of mentalhealth services by the three largestLatino groups in the Nation (Mexicans,Cubans, and Puerto Ricans) revealedthat those who were less accultured andmore medically self-reliant used fewermental health services than others.Mexicans (4.5 percent) and Cubans(5.7 percent) were less likely thanwhites (9.3 percent) to use any mentalhealth service, but use by Puerto Ricans(8.3 percent) was not significantlydifferent from that of whites. LowerEnglish language proficiency and lesstime spent in the United States wereassociated with the lowest use of mental

health services. Berdahl and TorresStone, Community Ment Health J45:393-403, 2009 (AHRQ PublicationNo. 10-R006)* (Intramural).

• Blacks and whites spend about thesame amount of time in office visitswith psychiatrists.

From 2001 to 2003, black patients hadoffice-based visits with psychiatrists thatwere an average of 4.4 minutes shorterthan visits by white patients (28.3 vs.32.7 minutes). By 2004-2006, the timespent with a psychiatrist was about thesame for black and white patients.Between these periods of time, therewere longer visits by black patientsrather than shorter visits by whitepatients, suggesting that the change wasnot mediated by treatment patterns.Olfson, Cherry, and Lewis-Fernandez,Arch Gen Psychiatr 66(2):214-221, 2009(AHRQ grant HS16097).

• Intervention may improve access todepression care for minority youths.

These researchers studied the impact ofa quality improvement interventiondesigned to improve access to evidence-based depression care for minorityyouths. Results showed a significantreduction in depression symptomsamong blacks in the interventiongroup. Among Latinos, the onlyimprovement was in care satisfaction,while there were no intervention effectsfor white youths. Ngo, Asarnow, Lange,et al., Psychiatr Serv 60(10):1357-1364,2009 (AHRQ grant HS09908).

• Asian Americans resist using mentalhealth services.

According to this study, AsianAmericans may resist using Westernmental health services for manyreasons, including stigma, fear ofinstitutionalization, and lack of faith inthe benefits of psychotherapy. Thosewho do seek mental health care areamong the most severely disturbed.

This analysis of New York City datafound that schizophrenic disorders werethe most frequent diagnoses amongAsians, with a rate twice as high forAsians as for other groups. They alsostayed in the hospital longer than otherpatients: 2.59 additional days forAsians, compared with 1.67 additionaldays for other groups. Shin, Issues MentHealth Nurs 30:112-121, 2009 (AHRQgrant HS00149).

• Blacks and Hispanics are less likelythan whites to seek treatment formental health problems.

Researchers used 2001-2004 MedicalExpenditure Panel Survey data toexplore why minorities seek mentalhealth services less frequently thanwhites. Just 7 percent of those surveyedreported fair or poor mental health, andwhites were more likely than blacks toassociate their mental symptoms withtheir mental health status. According tothe authors, this finding suggests thatthe gap between whites, blacks, andHispanics using mental health serviceslikely reflects underuse by minoritiesand not overuse by whites. Zuvekas andFleishman, Medical Care, 46(9):915-923, 2008 (AHRQ Publication No. 09-R007)* (Intramural).

• Racial disparities affect physician-patient communication about mentalhealth problems.

This study involved primary care visitsmade by 46 white and 62 blacknonelderly adults with symptoms ofdepression who were seen by physiciansin urban community-based practices.Communication about depressionoccurred in only about one-third of thevisits (43 percent of white visits and 27percent of black visits). Black patientswere less likely than white patients totalk about their depression (11 vs. 38statements, respectively). Also,physicians made fewer rapport-building

15

statements during visits with blackpatients (21 statements) than duringvisits with white patients (30statements). Even in visits wherecommunication about depressionoccurred, physicians considered fewerblack (67 percent) than white (93percent) patients as suffering significantemotional distress. Ghods, Roter, Ford,et al., J Gen Intern Med 23(5):600-606,2008 (AHRQ grant HS13645).

• Certain types of therapy are moreeffective for minority youth withpsychosocial problems.

This review of the evidence found thatpsychotherapy is moderately effectivefor many mental health problemsexperienced by minority youth,although some treatments seem to workbetter than others. For example,multisystemic therapy is the onlytherapy shown to reduce criminaloffending among black delinquentyouths. It is delivered in the youngperson’s home or school by speciallytrained therapists. Cognitive behavioraltherapy and individual psychotherapyare preferable when treating depressionin Latino adolescents. Ethnic minorityyouths seem to respond best totreatments that are highly structured,time-limited, pragmatic, and goal-oriented, note the researchers. Hueyand Polo, J Clin Child Adolesc Psychol37(1):262-301, 2008 (AHRQ grantHS10870).

• Underserved blacks and Hispanicswith depression often use alternativemedicine for their symptoms.

This study involved data on 315patients with depression from twooutpatient primary care clinics in LosAngeles; 66 percent of the patients wereHispanic, and 20 percent were black.Nearly 60 percent of the patientsreported using complementary and

alternative medicine (CAM) to managetheir symptoms sometimes, and 24percent used it often. Lack of healthinsurance was one of the strongestpredictors of CAM use. These findingssuggest that CAM use amongunderserved minority individuals mayserve as a substitute for conventionalcare when access to care is limited orunavailable, note the researchers.Bazargan, Ani, Hindman, et al., J AlternComplement Med 14(5):537-544, 2008.

Preventive Services

• Study finds lower flu vaccination ratesfor black nursing home residents insame facilities.

The average flu vaccination rate amongnursing home residents nationwide was72 percent during the 2005-2006 fluseason, but the odds of beingvaccinated were 14-16 percent lower forblacks than for whites within the samefacility. Also, nursing homes with highproportions of black residents hadlower vaccination rates for both blackand white residents compared withhomes that had a lower proportion ofblack residents. The researchers notethat blacks are consistently more likelythan whites to refuse flu vaccinationswhen offered; they also suggest that lowrevenue, insufficient staffing, and poor-quality care may contribute to the lowervaccination rates in these facilities. Cai,Feng, Fennell, and Mor, Health Aff30(10):1939-1946, 2011 (AHRQ grantHS16094).

• Culturally appropriate interventionsraise flu and pneumonia vaccinationrates at inner-city health centers.

Researchers undertook a 4-year trialinvolving predominantly minority andeconomically disadvantaged patientsolder than age 50 using proven,culturally appropriate interventions at

four inner-city health centers andcompared the results with anothercenter that received no intervention(the control). Over the 4-year trial,annual flu vaccination rates increasedfrom 27 percent to 49 percent at theintervention sites, while the control sitecontinued to have low rates ofvaccination (20 percent). Interventionsites also increased use of pneumoniavaccinations, from 48 percent to 81percent in patients aged 65 and older.Increases in vaccination rates wereobserved among white and Hispanicpatients. Nowalk, Zimmerman, Lin, etal., J Am Geriatr Soc 56(7):1177-1182,2008 (AHRQ grant HS10864).

Quality of Care/Patient Safety

• Efforts to improve quality may notalways reduce racial/ethnic disparities.

These authors provide a brief overviewof how efforts to reduce racial andethnic disparities came to focus onquality improvement activities. Theyhighlight five challenges to reducingdisparities through qualityimprovement and describe specificanalyses that should be incorporatedinto such activities. Weinick andHasnain-Wynia, Health Aff30(10):1837-1842, 2011 (AHRQ grantto the Harvard Interfaculty Program forHealth System Improvement).

• Many black mothers are skepticalabout the relationship between infantsleep position and SIDS.

Black infants are twice as likely as whiteinfants to die from SIDS, and they arealso twice as likely to be placed on theirstomachs to sleep, despite AmericanAcademy of Pediatricsrecommendations that infants sleep ontheir backs to reduce the risk of suddeninfant death syndrome. Researchersconducted 13 focus groups with 73

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black mothers of infants, as well as 10individual interviews, to examineperceptions about SIDS among blackparents. They found that the mothersperceived the link between sleepposition and SIDS to be implausible,SIDS to be random and unpreventable,and parental vigilance to be the key toSIDS prevention. Moon, Oden, Joyner,and Ajao, J Pediatr 157:92-97, 2010.See also Oden, Joyner, Ajao, andMoon, J Natl Med Assoc 102(10):870-880, 2010, and Joyner, Oden, Ajao,and Moon, J Natl Med Assoc102(10):881-889 (AHRQ grantHS16892).

• Having a strong social network plays acritical role in health status.

Researchers administered a 22-itemsurvey to 1,074 women to examinewhether a multidimensional, socialsupport instrument originallydeveloped for older Chinese andKoreans could be used for meaningfulcomparisons across four ethnic groupsof women (black, white, Hispanic, andChinese). Social support items in thesurvey were divided among threecategories: tangible support,informational support, and financialsupport. Using the survey results, theresearchers derived a valid and reliableeight-item social support instrumentthat is available in English, Spanish,and Chinese. Wong, Mordstokke,Gregorich, and Perez-Stable, J CrossCult Gerontol 25:45-58, 2010 (AHRQgrant HS10856).

• Certain hospitalized patients are atincreased risk for an adverse event.

In this study of Medicare patientshospitalized in 3,648 hospitals,researchers found that blacks had ahigher risk than whites of sufferingfrom a health care-associated infectionor adverse drug event. In addition,patients of all races treated in hospitals

with the highest percentage of blackpatients had a significantly higher riskof hospital-acquired infection or adversedrug event than patients dischargedfrom hospitals with the lowestpercentage of black patients. Metersky,Hunt, Kilman, et al., Med Care49(5):504-510, 2011 (AHRQPublication No. 11-R050)*(Intramural).

• Black Medicare enrollees have moreproblems accessing care than whiteenrollees.

A review of survey results from 101,189white and 8,791 black Medicareenrollees revealed that blacks have farworse experiences than whites withgetting care quickly, getting neededcare, office staff helpfulness, and healthplan customer services. Blacks also ratedtheir specialist care and health plansmore negatively than whites. On theother hand, blacks did report betterprovider communication than whitesand rated their personal doctors andnurses more positively. Fongwa,Cunningham, Weech-Maldonado, etal., J Health Care Poor Underserved19(4):1136-1147, 2008 (AHRQ grantsHS09204 and HS16980).

• Study compares trends in disparitiesover time.

These researchers used 1996-2005 datafrom AHRQ's Medical ExpenditurePanel Survey (MEPS) to examinetrends in disparities and assess theinfluence of changes in socioeconomicstatus among racial/ethnic minoritieson disparity trends. They found thatblack-white disparities in having anoutpatient visit were roughly constantbetween 1997 and 2005, whileHispanic-white disparities increased foroutpatient visits and for medicalexpenditures during the same period.Le Cook, McGuire, and Zuvekas, MedCare Res Rev 66(1):23-48, 2009

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(AHRQ Publication No. 09-R019)*(Intramural).

• Payers and policymakers canincorporate disparity reduction goalsinto pay-for-performance strategies.

One concern about pay-for-performance strategies is their potentialto have a negative impact onracial/ethnic disparities in care. Theseresearchers suggest ways that payers andpolicymakers can incorporate disparityreduction goals into existing pay-for-performance programs. Such strategiesshould include performance measuresthat target disparities, and they shouldreward performance improvement inaddition to achievement. Also, payersand health care organizations should tiepay-for-performance incentives todisparity reduction by stratifyingquality of care data according toracial/ethnic groups. Chien and Chin, JGen Intern Med 24(1):135-136, 2009(AHRQ grant HS17146).

• AHRQ tool helps English- andSpanish-speaking consumers reducemedication errors.

As a group, Hispanics tend to rely onfriends and coworkers for health care-related advice before turning to theexpertise of medical professionals.AHRQ has published a new guide andmedication tracking tool (available inEnglish and Spanish) in conjunctionwith the National Council on PatientInformation and Education to helpconsumers reduce medication errors.The guide can be personalized, and itincludes a detachable, wallet-sized cardthat can be used by patients to keeptrack of all their medicines, includingvitamins and other supplements. Sumedicamento: Informese. Evite riesgos(Your Medicine: Be Smart, Be Safe)(AHRQ Publication No. 11-0049-A,English and 11-0049-B, Spanish)*(Intramural).

• Blacks are more likely than members ofother racial/ethnic groups to take partin medical decisionmaking.

This survey of 924 diabetes patientsbeing treated at 34 community healthcenters revealed that black patients aremore likely than whites or otherminority patients to initiate discussionswith their physicians about four of sixareas of diabetes care. Researchers askedsurvey participants about theirbehaviors related to making medicaldecisions and assessed their preferencesfor shared decisionmaking (agendasetting, information sharing, anddecisionmaking). There was noassociation between race and the threepreferences. Peek, Tang, Cargill, andChin, Med Decis Making 31:422-431,2011 (AHRQ grant HS10479). Seealso Garcia-Gonzalez, Gonzalez-Lopez,Gamez-Nava, et al., J Clin Rheumatlol15(3):120-123, 2009 (AHRQ grantHS16093).

• Medication adherence improves whenpatients are treated by providers of thesame race.

This study of 131,277 adults withdiabetes found that receiving treatmentfrom a doctor of the same race—or onewho speaks the same language—as thepatient may improve medicationadherence rates among blacks andHispanics who lack proficiency inEnglish. For example, when blacks hadblack doctors, adherence rates rose to53.2 percent compared with 49.8percent for blacks who did not haveblack doctors. Among Hispanics,adherence rates improved for thosewhose doctors spoke Spanish (50.6percent) compared with those who didnot (44.8 percent). Traylor, Schmittdiel,Uratsu, et al., J Gen Intern Med25(11):1172-1177, 2010 (AHRQ grantHS13902). See also Gerber, Cho,Arozullah, et al., Am J Geriatr

Pharmacother 8(2):136-145, 2010(AHRQ grant HS13004); Rathore,Ketcham, Alexander, et al., J Gen InternMed 24(11):1183-1191, 2009 (AHRQgrant HS15699); and Kim, Howard,Kaufman, and Holmes, J Natl MedAssoc 100(10):1386-1393, 2008(AHRQ grant HS13353).

• Doctor/patient communication stylediffers between white and HispanicHIV patients.

According to this study of HIV patientsand physicians in New York City andPortland, OR, Hispanics are much lesslikely than whites to engage in patient-centered conversations with theirproviders. Even Hispanics who werefluent in English were less likely thanwhites to talk with their providersabout psychosocial issues. Becausediscussions about HIV care are oftencomplex and emotionally charged, theresearchers suggest that health careproviders pay particular attention topsychosocial issues during encounterswith all patients. Beach, Saha, Korthuis,et al., J Gen Intern Med 25(7):682-687,2010 (AHRQ contract 290-01-0012).

• Report examines the effects ofrace/ethnicity and insurancestatus/income on quality of care forchildren.

The authors of this report describe thejoint effects of race and insurancestatus/income on children's health carequality across a set of 23 qualityindicators. Racial and ethnic disparitiesvaried by income level and type ofinsurance. A key finding is that for thesame income level or type of insurance,some racial/ethnic groups had morepronounced differences in quality ofcare than others. Berdahl, Owens,Dougherty, et al., Acad Pediatr10(2):95-118, 2010 (AHRQPublication No. 10-R057)*(Intramural).

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• Pediatricians show less implicit racebias than others.

Researchers surveyed academicpediatricians about their implicit andexplicit racial attitudes and stereotypesand found that pediatricians are lesslikely to harbor attitudes that favorwhite Americans than other physiciansand individuals. Most of the surveyedpediatricians were white (82 percent),and 93 percent were American-born.The researchers found no link betweenpediatricians’ implicit racial attitudesand stereotypes and quality of pediatriccare. Sabin, Rivara, and Greenwald,Med Care 46(7):678-685, 2008(AHRQ grant HS15760).

• Hispanics tend to give more positiveratings of care than whites.

Researchers examined how Hispanicethnicity and insurance status(Medicaid vs. commercial managedcare) affect the use of the 0-10 ratingscales in the Consumer Assessment ofHealthcare Providers and Systems(CAHPS) survey. Previous studies haveshown that Hispanics report care that issimilar to or less positive than non-Hispanic whites but give more positiveratings of care, and that blacks andHispanics are more likely than whitesto use the extreme responses in a ratingscale. In this study, Hispanics weremore likely than whites in commercialplans to give the highest rating of “10,”but they often gave ratings of 4 orbelow relative to an omitted category of“5” to “8.” The researchers call this“extreme response tendency,” which is atendency to respond systematically toquestionnaire items on some basis otherthan what the items were intended tomeasure. They suggest poolingresponses at the top (9 and 10) andbottom (0 to 6) of a 10-point scalewhen making racial/ethniccomparisons. Weech-Maldonado,Elliott, Oluwole, et al., Med Care

46(9):963-968, 2008 (AHRQ grantHS11386).

• Enhancing cultural competence ofclinicians and clinics may reduce caredisparities.

Culturally competent clinicians aremore likely to understand the language,values, and beliefs of the racial andethnic groups they serve and to havethe attitudes and skills to convey theirrespect and understanding in the carethey provide. This study is the first tolink provider cultural competence withthe cultural competence of the clinicsin which they work. Researchers foundthat culturally competent clinicians aremore likely to work in clinics that havea higher percentage of minority staff,offer cultural diversity training, andprovide culturally adapted patienteducation materials. Enhancing thecultural competence of both cliniciansand clinics may be a synergisticapproach to reducing health caredisparities, according to the researchers.They surveyed 49 providers from 23clinics in Baltimore, MD andWilmington, DE. Paez, Allen, Carson,and Cooper, Social Sci Med 66:1204-1216, 2008 (AHRQ grant HS13645).

Reproductive Health and BirthOutcomes

• Perceived lower social standing islinked to unplanned pregnancies.

More than one-third of the 1,000pregnant women in the San Franciscoarea who responded to a surveyreported that their pregnancies wereunplanned. Black women reported thehighest rate of unintended pregnancy(62 percent), and white womenreported the lowest rate (23 percent).Although just 18 percent of thosesurveyed were black, they accounted for33 percent of the unintendedpregnancies. The researchers also found

that a woman's subjective socialstanding was associated withunintended pregnancy; the lower thewoman's level of self-perceived socialstanding, the more likely her pregnancywas unplanned. Bryant, Nakagawa,Gregorich, and Kuppermann, JWomen's Health 19(6):1195-1200, 2010(AHRQ grant HS10856).

• Researchers find a link betweenrace/ethnicity and risk for gestationaldiabetes.

According to this analysis of data onnearly 140,000 women who developedgestational diabetes, women who areAsian, Hispanic, or American Indianare more likely than white or blackwomen to develop the condition. Asianwomen had the highest rate (6.8percent) of gestational diabetes,followed by American Indian (5.6percent) and Hispanic (4.9 percent)women; 3.4 percent of white womenand 3.2 percent of black womendeveloped gestational diabetes. The ratewas even higher when the father wasAsian (65 percent), Hispanic (4.6percent), or American Indian (4.5percent), compared with white (3.9percent) or black (3.3 percent) fathers.The researchers suggest that becausethese racial/ethnic groups originated inAsia, they may share a common geneticrisk for developing gestational diabetes.Caughey, Cheng, Stotland, et al., Am JObstet Gynecol 202(6):616.el-616.e5,2010 (AHRQ grant HS10856).

• Study identifies ways to enhanceprenatal care in underresourcedsettings.

Based on a literature review and keyinformant interviews, these researchersidentified 17 innovative strategiesinvolving health informationtechnology that have been or could beused to improve prenatal care intraditionally underresourced settings

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that serve black, Hispanic, and AsianAmerican patients, as well as lowincome children. The strategies couldbe used to improve the content ofprenatal care, increase access to timelyprenatal care, and enhance theorganization and delivery of prenatalcare. Lu, Kotelchuck, Hogan, et al.,Med Care Res Rev 67(5 Suppl):198-230,2010 (AHRQ contractP233200900421P).

• One-fifth of mothers do not receiverecommended corticosteroids beforedelivery of premature infants.

Strong evidence shows thatadministration of antenatalcorticosteroids during preterm laborreduces the incidence of respiratorydistress syndrome and othercomplications associated withprematurity. This study of prematurebirths at three New York City hospitalsfound that 20 percent of eligiblemothers did not receive indicatedantenatal corticosteroid therapy. Thefailure to administer recommendedsteroids was related strongly to howlong after admission the delivery tookplace, as well as lack of prenatal care,longer gestation, advanced cervicalexam, and intact membranes atadmission. The study included 515women eligible for corticosteroidtherapy; 70 percent of the women wereblack or Hispanic, and most wereinsured through Medicaid or aMedicaid HMO. Howell, Stone,Kleinman, et al., Matern Child Health J14:430-436, 2010 (AHRQ grantHS10859).

• Stress and anxiety in pregnant blackwomen contribute to low birthweightbabies.

This study of 554 pregnant women(mostly poor, black, and unmarried)seen in the early 1990s at obstetricclinics in Memphis, TN, found that

just over 15 percent delivered lowbirthweight babies. Those whoexperienced either verbal or physicalabuse during their pregnancies deliveredbabies that were, on average, 3.5 ozlighter than the average-weight babiesdelivered by mothers who did not sufferabuse. Also, anxious mothers deliveredbabies that were 2.5 oz lighter thanaverage, and those who experiencedneighborhood stress delivered babiesthat were 2.28 oz lighter. Holland,Kitzman, and Veazie, Women's HealthIssues 19(6):390-397, 2009 (AHRQgrant T32 HS00044).

• Black women’s choice of hospital to givebirth may contribute to racialdisparities in neonatal deaths.

Black infants in the United States aremore than twice as likely to die as whiteinfants during the first month of life(neonatal period). According to thisstudy of records for all live births anddeaths of very low birthweight (VLBW)infants born in 45 hospitals in NewYork City over a 6-year period (1996-2001), choice of birth hospital had asignificant effect on the survival of thesefragile newborns. Neonatal mortalityrates for infants in this study rangedfrom 9.6 to 27.2 deaths per 1,000births. VLBW white infants were morelikely to be born in hospitals ranked inthe lowest third for neonatal mortality(49 percent), compared with VLBWblack infants (29 percent). If blackwomen had delivered in these lowerrisk hospitals, mortality rates wouldhave been reduced by 6.7 deaths per1,000 VLBW births, eliminating morethan one-third of the black/whitedisparity in VLBW neonatal mortalityrates in New York City. Howell,Hebert, Chatterjee, et al., Pediatrics121(3):e407-e415, 2008 (AHRQ grantHS10859).

• Most pregnant Latinas do not receiverecommended screening for intimatepartner violence.

Researchers surveyed 210 pregnantLatinas in the Los Angeles, CA, areaand found that almost two-thirds of thewomen had never been asked aboutbeing abused. Routine screening ofpregnant women for intimate partnerviolence is recommended by theAmerican College of Obstetrics andGynecology. Rodriguez, Shoultz, andRichardson, Violence Victims 24(4):520-532, 2009 (AHRQ grant HS11104).

• Pregnant Latinas who experienceintimate partner violence often sufferfrom depression.

Researchers surveyed 210 Hispanicwomen who were pregnant aboutintimate partner violence, strength (e.g.,social support, coping strategies),adverse social behavior (e.g., alcoholand/or tobacco use), depression, andpost-traumatic stress disorder (PTSD).More than 40 percent of the womenreported intimate partner abuse,including physical, emotional, or sexualabuse. All of the women reportedsimilar levels of mastery (being incontrol of their lives), but socialsupport was lower for the 92 womenwho reported abuse, as well as socialundermining by their partner (anger,criticism, insults) and stress. Womenwho were abused were more likely thanwomen who were not to be depressedor have PTSD. Rodriguez, Heilemann,Fielder, et al., Ann Fam Med 6(1):44-52, 2008 (AHRQ grant HS11104).

• Gene-environment interactions mayexplain the black/white disparities inpreterm birth and infant mortality.

The authors of this commentarypropose that now is the time totranslate what has been learned aboutepigenetic mechanisms in animalstudies to the realm of human studies

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to examine the role of gene-environment interactions (e.g., dietarydifferences, toxins). Such interactionsmay contribute to preterm birth andinfant mortality, whichdisproportionately affect black families.Burris and Collins, Ethn Dis 20:296-299, 2010 (AHRQ grant T32HS00063).

• Requiring proof of citizenship cutparticipation in Oregon's Medicaidfamily planning program.

Proof of citizenship has been arequirement for Medicaid eligibilitysince implementation of the FederalDeficit Reduction Act in November2006. Since that time, family planningvisits have declined by one-third underthe Medicaid-funded Oregon FamilyPlanning Expansion Project. However,the decline in accessing these serviceswas seen in both whites and Hispanics,casting doubt on the need for proof ofcitizenship to combat Medicaid fraudby noncitizens, according to theresearchers. Angus and DeVoe, HealthAff 29(4):690-698, 2010 (AHRQ grantHS16181).

• Advantage of high survival ratesamong Iow-weight black infants hasdiminished.

Using California birthweight data from1989 to 2004 for black and whiteinfants who weighed 3.3 pounds or lessat birth, researchers found that aboutone-fourth of all babies born with verylow birthweights did not survive 30days after birth. Although black babieshad lower mortality rates in 1989 and1990, this advantage disappeared after1991. Beginning in 2002, the mortalityrate for very low birthweight infantsdecreased for white babies but rose forblack babies. The researchers suggestthat the advantage black infants oncehad may have been eliminated oncebetter access to high-quality prenatal

care and therapeutic innovationsbecame more prevalent. Bruckner,Saxton, Anderson, et al., J Pediatr155(4):482-487, 2009 (AHRQ grantT32 HS00086).

Additional Studies

• Using pedometers to set activity goalsincreases physical activity amongnative elders.

Researchers studied the use ofpedometers to increase walking,physical activity, and fitness levels overa 6-week period among AmericanIndian and Alaska Native primary carepatients. Participants achievedsignificant improvements on mostoutcomes, which included step counts,self-reported physical activity and well-being, and a 6-minute walk test.Sawchuk, Russo, Charles, et al., AmIndian Alsk Native Ment Health Res18(1):23-41, 2011. See also Sawchuk,Russo, Bogart, et al., Prev Chronic Dis8(3):1-9, 2011; Sawchuk, Charles,Wen, et al., Prev Med 47:89-94, 2008;and Sawchuk, Bogart, Charles, et al,Am Indian Alsk Native Ment Health Res15(1):1-17, 2008 (AHRQ grantHS108S4).

• Study compares treatments to overcomephobia in Asian Americans.

Researchers compared a standard invivo exposure treatment for phobia,including catastrophic thinking andgeneral fear, in Asian Americans with aculturally adapted similar treatment.They found that Asian Americans withlow acculturation benefitted more fromthe culturally adapted treatment, butthe two treatments were equallyeffective for Asian Americans with highacculturation. Pan, Huey, andHernandez, Cultur Divers Ethnic MinorPsychol 17(1):11-22, 2011 (AHRQgrant HS10870).

• Twenty-seven percent of elementaryschool children living in Puerto Ricoare obese.

According to this 2008 study,elementary school children in PuertoRico have higher rates of obesity (27percent) than same-age Hispanicchildren (25 percent) and non-Hispanicwhite or black children (19 percent)living in the United States. Another 11percent of Puerto Rican elementaryschool children met the criteria forbeing overweight. Rivera-Soto,Rodriguez-Figueroa, and Calderon,Puerto Rico Health Sci J 29(4):357-363,2010 (AHRQ grant HS14060).

• Race is one of several factors in theNation’s epidemic of childhood obesity.

According to this study, 2.7 millionU.S. children are severely obese, anincrease of more than 300 percent since1976. Researchers examined datarepresenting 71 million U.S. childrenand found that black and MexicanAmerican boys aged 12 to 19 are mostlikely to be severely obese, and childrenfrom poor families are also at increasedrisk for severe obesity. As in adults,severe obesity in children andadolescents can lead to chronic healthproblems, such as diabetes andcardiovascular disease. Skelton, Cook,Auinger, et al., Acad Pediatr 9(5):322-329, 2009 (AHRQ grant HS13901).

• Extrapulmonary TB occurs most oftenin black men.

Although tuberculosis most oftenaffects the lungs, it can also infect otherparts of the body such as the lymphnodes and various organs. Thisextrapulmonary type of TB most oftensignals a compromised immune system,such as from HIV disease. Theresearchers compiled data on all 2,142TB cases reported in the State ofTennessee from 2000 to 2006 andfound that more than one-fourth (26.1

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percent) were extrapulmonary innature. The rate of extrapulmonary TBwas highest in black men (5.93 per100,000, compared with black women(3.21), men of other races (1.01), andwomen of other races (0.58). Fiske,Griffin, Erin, et al., BMC Infect Dis10(16):1-8, 2010 (AHRQ grantHS13833).

• MRSA infections have increasedamong American Indian/AlaskaNative individuals.

Researchers examined outbreaks ofmethicillin-resistant Staphylococcusaureus (MRSA) infections amongAmerican Indians and Alaska Natives(AI/ANs) and found that nationwidehospitalization rates for MRSAinfection in AI/ANs increased between1996 and 2005 (from 4.6 to 50.6 per100,000). Hospitalization rates werehighest for young AI/AN children andnonelderly adults, and skin and softtissue infections were the mostcommonly diagnosed. The highestprevalence of MRSA infections were inthe Indian Health Service regions ofAlaska and the Southwest. Byrd,Holman, Bruce, et al., Clin Infect Dis49(7):1009-1015, 2009 (AHRQPublication No. 10-R016)*(Intramural).

• Poor blacks have the worst long-termoutcomes from work-related back pain.

This review of outcomes amongworkmen's compensation (WC)claimants in Missouri found that morethan 6 years after settlement of WCclaims, lower socioeconomic status,black race, and poor early adjustmentwere associated with poorer long-termadjustment among claimants with lowback pain. These individuals werefound to have higher levels of pain,pain-related disability, and catastrophicthinking while in pain. Black claimantsalso had higher rates of occupationaldisability than other claimants, as

evidenced by long-term unemploymentand receipt of Social Security disability.Chibnall and Tait, Pain Med10(8):1378-1388, 2009 (AHRQ grantsHS13087 and HS14007). See alsoBernstein, Gallagher, Cabral, and Bijur,Pain Med 10(1):106-110, 2009 (AHRQgrant HS13924).

• Differences in socioeconomic status inchildhood correlate with racialdifferences in disability in adulthood.

This researcher analyzed 1998-2006data on community-dwelling blacksand whites, beginning at age 65 andcontinuing every 2 years. She looked athealth conditions, behaviors, anddisability at baseline in 1998 andcompared adult socioeconomic status(SES) with childhood SES. Comparedwith white parents, black parents ofstudy participants had fewer years ofeducation, and black fathers were lesslikely to work in certain occupations,such as professional and sales jobs.Black fathers also were more likely to beabsent or deceased when blackparticipants were growing up. As adults,black participants had lowereducational levels, income, and wealthcompared with whites. Over the courseof the study, blacks reported moredisabilities than whites, and theirdisabilities increased over time. Bowen,Soc Sci Med 69:433-441, 2009 (AHRQgrant HS13819).

• Perceived racism among black womenis linked to socioeconomic position.

This study of 1,249 women, aged 40 to79, living in Connecticut found thatboth individual and neighborhoodsocioeconomic position (SEP) may playa role in understanding how racialdiscrimination is perceived, measured,and processed. Black women who hadhigher levels of education reportedmore racial discrimination than thosewith less than 12 years of education.Interestingly, income and occupation

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were not associated with perceivedracial discrimination among the womenin this study. Dailey, Kasl, Holford, etal., Ethn Health 15(2):145-163, 2010(AHRQ grant HS15686).

• Older Mexican American men aremore accepting than others ofphysician-assisted suicide.

In this study, Mexican Americans aged60 to 89 reported stronger agreementwith legalizing physician-assistedsuicide (52.7 percent) than non-Hispanic whites (33.7 percent), andMexican American men were morethan twice as likely as MexicanAmerican women to agree with it. Highreligiosity was not a predictor ofopposition to legalizing physician-assisted suicide among MexicanAmericans, but among non-Hispanicwhites, those who were highly religiouswere much less likely to support itslegalization. Espino, Macias, Wood, etal., J Am Geriatr Soc 58(7):1370-1375,2010 (AHRQ grant HSl4064).

• Minority pediatricians are more likelythan white pediatricians to care forminority children.

This study found that minoritypediatricians treated an average of 20percent more minority children thanwhite pediatricians; the percentage ofminority patients was highest forHispanic pediatricians (57.9 percent)and black pediatricians (57.6 percent),compared with 33.4 percent for whitepediatricians and 40.6 percent for Asianpediatricians. Minority pediatriciansalso took care of many more publiclyinsured or uninsured patients thanwhite pediatricians. Basco, Cull,O'Connor, and Shipman, Pediatrics125(3):460-467, 2010 (AHRQ grantHS15679). See also Sabin, Nosek,Greenwald, and Rivara, J Health CarePoor Underserved 20:896-913, 2009(AHRQ grant HS1S676).

• Researchers examine patients’ generalattitudes toward doctors’ race andethnicity.

Using a telephone survey, researchersasked 695 whites and 510 blacks inHamilton County, OH, how they feltabout two dimensions of technicalcompetence and interpersonal skills.They found that black patients weremore likely than white patients tobelieve that same-race doctors wouldbetter understand their health problems(7 percent vs. 12 percent), and theyexpected to be more at ease with samerace doctors than white patients (27percent vs. 20 percent). Blacks alsowere more likely than whites to feel thesame way about physicians born in theUnited States. Malat, van Ryan, andPurcell, J Natl Med Assoc 101(8):800-807, 2009 (AHRQ grant HS13280).

• Health literacy test found valid forboth English- and Spanish-speakingindividuals.

These researchers developed andvalidated the Short Assessment ofHealth Literacy—Spanish and Englishand in a test with 201 Spanish-speakingand 202 English-speaking individuals,found it to have good reliability andvalidity. Lee, Stucky, Lee, et al., HealthServ Res 45(4):1105-1120, 2010(AHRQ grant HS13233).

• CAHPS survey instrument developedin collaboration with Choctaw NationHealth Services program.

Working together, representatives fromAHRQ’s Consumer Assessment ofHealthcare Providers and Systems(CAHPS) program and the ChoctawNational Health Services program havedeveloped the CAHPS AmericanIndian Survey for use in evaluatingChoctaw patient experiences at thetribe’s various Indian Health Service(IHS) clinics in Oklahoma. The surveyhas been field-tested and found to be

valid; it will be used as the basis fordeveloping additional surveyinstruments for the IHS to measurequality of care across various health careprograms serving tribes in other parts ofthe country. Weidmer-Ocampo,Johansson, Dalpoas, et al., J HealthCare Poor Underserved 20(3):695-712,2009 (AHRQ grants HS09204 andHS16980).

• Using a list of common surnames canhelp improve estimates of race/ethnicityin patient data.

According to this study, using a list ofrelatively common surnames from the2000 Census can yield more accurateestimates of racial/ethnic disparities incare. The 151,671 surnames listed by atleast 100 individuals represent nearly90 percent of all individuals capturedby the census. Using the self-reportedracial/ethnic affiliations for eachsurname, together with geographicalinformation, researchers can calculate aset of likelihoods for someone with aspecific surname being white, black,Hispanic, or so on. Elliott, Morrison,Fremont, et al., Health Serv OutcomesRes Methodol 9:69-83, 2009 (AHRQcontract 282-00-0005).

• Researchers can safely omit race andethnicity from cesarean rate risk-adjustment models.

Perinatal outcomes such as infant andmaternal death, prematurity, andcesarean delivery are used as a measureof the quality of obstetric care. Theseless desirable outcomes are known to behigher in the black population than inthe white population. The objective ofthis study was to see if adding race andethnicity to an otherwise identicalmodel would improve the predictiveimpact of the model. Researchers testedtwo risk-adjustment models for primarycesarean rates and found that the twomodels did not differ substantially in

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predictive discrimination or in modelcalibration. They suggest that race andethnicity can safely be left out ofcesarean rate risk-adjustment models.Bailit and Love, Am J Obstet Gynecol69:e1-e5, 2008 (AHRQ grantHS14352).

• Researchers examine risk of workplaceinjury and how racial/ethnicdisparities in risk change over time.

The researcher estimated individualworkplace injury and illness risk overtime for a group of American workerswho participated in a 10-year study(1988-1998) and found that white menhad a high risk of injury relative toother groups (white women, black menand women, and Latino men andwomen). Among women, black womenhad the highest risk of injury. Berdahl, JPublic Health 98(12):2258-2263, 2008(AHRQ Publication No. 09-R020)*(Intramural).

• Study results in culturally appropriatesurvey instruments for use withHmong Americans.

Because of its history of refugee status,low proportion of English speakers, andcultural beliefs, the Asian Hmongpopulation in central California has lowinvolvement with health careinstitutions. The researchers workedwith Hmong community leaders todevelop and focus-group test alinguistically and culturally sensitivesurvey that can be used to assessknowledge about hypertension care inthis population. Wong, Mouanoutoua,and Chen, J Cult Divers 15(1):30-36,2008 (AHRQ grant HS10276).

National Healthcare Quality andDisparities Reports

Each year since 2001, AHRQ haspublished two national reports thatpresent detailed information, including

charts and updated trend information,on the quality of health care servicesand disparities (by race and income) inhealth care in the United States. Copiesof the most recent reports are availablefrom AHRQ.

National Healthcare Disparities Report,2011 (AHRQ Publication No. 12-0006).*

National Healthcare Quality Report,2011 (AHRQ Publication No. 12-0005).*

For More Information

AHRQ’s State Snapshots, an interactiveWeb-based tool, show how each State isdoing on specific health care qualitymeasures, including trendinginformation on whether States haveshown improved or worsened care forracial/ethnic minorities and otherpopulations. AHRQ’s 2011 StateSnapshots are available athttp://statesnapshots.ahrq.gov.

Spanish-Language Resources

AHRQ is partnering with Hispanic-serving organizations to promote theAgency’s Spanish-language resourcesand to encourage consumers to becomemore active partners in their healthcare. The Agency now offers more than30 publications in Spanish thatcompare treatments for heart andvascular system conditions, diabetes,cancer, bone and joint-relatedconditions, pregnancy, digestive systemailments, depression, and otherconditions. These and their English-language companion guides wereproduced by AHRQ's Effective HealthCare Program, which conducts patient-centered outcomes research and makesresearch results available to consumers,clinicians, policymakers, and others.

To learn more about these guides andother resources, visit the Agency's Website at http://www.ahrg.gov/consumer/espanoix.htm.

Other Minority Health Intitiatives

To find out more about other initiativesrelated to minority health, includingthe Agency's minority health researchagenda, visithttp://www.ahrg.gov/research/minorix.htm.

Copies of items in this brief that aremarked with an asterisk (*) are availablefrom the AHRQ PublicationsClearinghouse. To order a copy, call theclearinghouse toll-free at 1-800-358-9295 or send an e-mail toAHRQpubs@ahrq.gov. Please use theAHRQ publication number whenordering.

Contact AHRQ

For additional information aboutAHRQ’s activities, funding for research,or other topics, please visit the AHRQWeb site at www.ahrq.gov.

For questions and comments regardingAHRQ’s priority populations researchprogram, you may contact us atPrioritypops@ahrq.hhs.gov

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AHRQ Pub. No. 12(13)-P005-EF(Replaces AHRQ Pub. No. 09--P002)

February 2013