The Centers for Disease Control and Prevention (CDC) defines health equity as “the state in which everyone has a fair and just opportunity to attain their highest level of health.”39 Back in 2001, the Institute of Medicine (now the National Academy of Medicine) report Crossing the Quality Chasm: A New Health System of the 21st Century, called for making health care equitable in addition to being safe, effective, person-centered, timely, and efficient. Unfortunately, more than 20 years later, inequitable health outcomes persist across racial/ethnic and socioeconomic groups in the United States.40
In 2021, the National Academy of Sciences, Engineering, and Medicine (NASEM) observed that “primary care is the only health care component where an increased supply is associated with better population health and more equitable outcomes.”27 Given this, efforts to increase access to primary care (through locating practices in the communities where patients live, expanded hours and telehealth options, and transformations in healthcare payment models) have the potential to improve health equity.41 However, careful research, monitoring, and evaluation are needed to ensure that these efforts are effective and are not introducing new and unintended consequences.
For twenty years, AHRQ has published the National Healthcare Quality and Disparities Report, which shows trends in health care disparities by race, ethnicity, and social determinants of heath.42 AHRQ has also invested in a small number of primary care research grants focused on examining and addressing health inequities. This section of the report includes a summary of AHRQ’s primary care grants and resources with a main focus on advancing health equity.
Grants with a focus on health equity can be found throughout the report, and are indicated with this icon.
Grants
Seven AHRQ primary care grants actively funded during FYs 2021 and 2022 focused mainly on examining or addressing health inequities, including four R01s (Research Projects), two K01s (Research Career Programs), and one K08 (Clinical
Investigator Award). Another 25 grants had at least some focus on health equity and are described elsewhere in this report, including in Healthcare Systems and Infrastructure (6), Practice and Quality Improvement (4), Digital Healthcare (3), Behavioral Health and Substance Use Disorders (3), Person-Centered Care (3), Primary Care Workforce (1), Public Health and Community Integration (1), and COVID-19 (1).
Federally Qualified Health Centers and Care for Vulnerable Populations (R01) |
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PI: Vicki Fung Organization: Massachusetts General Hospital; Independent Hospital Examines whether the Patient Protection and Affordable Care Act (ACA)-related funding increases for federally qualified health centers are associated with improvements in outpatient care; downstream clinical effects including emergency department visits, hospitalizations, and mortality; and total spending for Medicaid patients. |
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PI: Sarah Beal Organization: Cincinnati Children’s Hospital Medical Center; Independent Hospital Evaluates the impact of different delivery models on health outcomes for children in foster care and examines the factors that contribute to variations in healthcare use and health outcomes for these youth. The findings can be used to implement health delivery practice changes, often in primary care, to improve the health outcomes of these vulnerable youth. |
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PIs: Barbara Wells Trautner; Larisa Grigoryan Organization: Baylor College of Medicine; School of Medicine; Internal Medicine Examines how factors at the patient, healthcare system, and clinician encounter levels predict use of non- prescribed antibiotics by patients seen in safety net primary care clinics who are predominantly uninsured and often have low incomes. This work will result in the development of a communication tool designed to help clinics guide their patients toward safer antibiotic use. |
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PI: Jessica N Sanders Organization: University of Utah Uses a matched-control design to evaluate the impacts of a county-level contraceptive initiative on unintended pregnancies and birth outcomes at a population-level. The study will also use linked all-payer claims, electronic medical records, geospatial markers, demographic profiles, and birth certificates to identify regional disparities in family planning access and outcomes. |
The Effect of Rurality and the COVID-19 Pandemic on Telemedicine and Preventive Healthcare Use (K01) |
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PI: Annie Elizabeth Larson Organization: OCHIN, INC Investigates the role of telemedicine in improving access to primary care for rural patients. The research team is looking at the frequency and type of preventive care visits, differences between urban and rural patients on uptake of telemedicine, and the effect of telemedicine on the quality and equity of care for chronic health conditions among rural and urban patients. Learn more about this study in a recent NCEPCR webinar: Using Large Datasets in Primary Care Research. |
The Cost of Illness: The Impact of COVID-19 on Patient Financial Outcomes (K08) |
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PI: Nora V Becker Organization: University of Michigan at Ann Arbor; School of Medicine; Internal Medicine Examines "financial toxicity," or the financial consequences of illness. The grant first investigates which patient subgroups are at the highest risk of financial burden; then estimates the objective financial burden of a COVID-19 infection; and assess patients’ subjective financial distress related to their illness. This study is focused on a topic integral to primary care. |
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PI: Karen M Clements Organization: University of Massachusetts Medical School, Worcester Uses claims analyses to examine uptake of newer and more effective direct-acting antiviral (DAA) treatment for hepatitis C virus among Medicaid populations across multiple states. The research team will also identify the patient, provider, and contextual factors that predict DAA treatment. |
Initiatives and Resources
Since 2003, AHRQ has annually published the National Healthcare Quality and Disparities Report (NHQDR) to summarize the status of health and healthcare delivery in the US, identifying areas of strength, weakness, and disparities for access to and quality of healthcare. Quality is described in six categories in the report: patient safety, patient-centered care, care coordination, effective treatment, healthy living, and care affordability. The 2021 and 2022 NHQDRs are described in the tables below, along with some key findings.
2021 National Healthcare Quality and Disparities Report
The data reported in the 2021 NHQDR were collected in 2019 or earlier, prior to the start of the COVID-19 public health emergency. This report serves as a defining “snapshot” of where the US healthcare system stood prior to the start of the COVID-19 pandemic response.
Areas of improvement documented between the early 2000s and 2018 include:
- decreased death rates for HIV, heart disease, and colon cancer;
- more people under age 65 have health insurance coverage;
- decreased personal spending on health insurance and healthcare services for people under age 65 with public insurance;
- improvements in healthcare quality for Black, Hispanic, and American Indian and Alaska Native communities, although significant disparities still exist.
Areas of ongoing challenge include the following:
- Despite decreases in HIV death rates, including among Black people, the HIV death rate for Black people is still more than six times the rate for White people.
- Poor access to dental care and oral healthcare services are ongoing, particularly among people who have a low income or who live in rural areas.
- The opioid and mental health crisis have continued to worsen, including worsening suicide death rates between 2008 and 2018 and increased opioid-related emergency department visits between 2005 and 2018.
2022 National Healthcare Quality and Disparities Report
The data reported in the 2022 NHQDR were collected in 2020 and prior, and therefore include information on the first year of the COVID-19 public health emergency.
Some findings reported in the 2022 NHQDR include the following:
- While the percentage of people with health insurance coverage has increased overall, Hispanic groups, non-Hispanic American Indians, and Alaskan Natives are significantly less likely to have health insurance than other groups
- Life expectancy in the US decreased for the first time in 2020, because of the COVID-19 pandemic. This decline was worse for Hispanic and non-Hispanic Black groups than for non-Hispanic White groups, continuing to exacerbate health disparities between these groups. The leading cause of death in 2020 in the US was heart disease, cancer, COVID-19, and unintentional injuries. The most common unintentional injury was drug overdose, accidental falls, and motor vehicle accidents.
- While the number of workers in ambulatory healthcare settings significantly declined at the start of the COVID-19 public health emergency, employment in those settings has recovered. However, the number of healthcare workers continues to decrease in hospitals and nursing and residential care settings, particularly for the roles that require less educational attainment.
The 2022 NHQDR highlights four Special Emphasis topics that are priority issues for the Biden-Harris Administration, including maternal health, child and adolescent mental health, substance use disorders, and oral health.
