NHQR/NHDR Dissemination of Information on State Data-Driven Strategic Efforts to Reduce Health Disparities

September 23, 2011

Summary Report

The National Academy for State Health Policy is pleased to provide this summary of the activities and accomplishments of NHQR/NHDR Dissemination of Information on State Data-Driven Strategic Efforts to Reduce Health Disparities. It summarizes activities, along with achievements and assessment of impact. These activities were conducted under a subcontract to Thomson Reuters (TR).

Background and Purpose

The National Academy for State Health Policy (NASHP) completed a report in February 2011 that analyzes leading state-produced disparities documents and their use of patient race/ethnicity data in improving health equity and reducing disparities in health and healthcare quality.¹

Relevant findings of interest were that states use a variety of data sources for initiatives to address healthcare disparities (including but not limited to discharge data); many states are in need of better data sources or better race/ethnicity data; and the importance of research partnerships and community engagement to the success of the disparities initiative. Notable data presentation techniques included disparity report cards by Georgia and New Mexico and county-level disparity maps by Maryland.

At AHRQ's request, TR and NASHP produced a dissemination plan to share this information with a variety of audiences, including State policymakers and HCUP partners and to implement recommendations.

The dissemination plan identified the overall goals of dissemination, the specific activities proposed to achieve those goals, the audience(s) for each activity, the messages to be conveyed, and the materials to be disseminated or otherwise developed to support the activity.

Overall goals of the dissemination activities were:

To provide stakeholders (e.g. state policymakers and data analysts, private sector partners, federal partners) with information on leading states activities related to collection, analysis and use of patient race/ethnicity data to improve health equity and reducing disparities in health and healthcare quality.
To enable stakeholders to obtain more in-depth information on the actions and lessons of leading states in collecting, analyzing, and using patient race/ethnicity data to improve health equity and reducing disparities in health and healthcare quality.
To enable leading states to dialogue with each other and federal partners to foster peer learning about successes, challenges, needs, actions, and plans related to collecting, analyzing, and using patient race/ethnicity data to improve health equity and reducing disparities in health and healthcare quality.

Activities

After discussion with NHQR/DR staff about report findings that would be of value to various audiences, and under the guidance of TR staff, NASHP completed the following activities:

Regular support and contact:
NASHP provided TR with biweekly task progress updates by e-mail and reported at least biweekly on progress by conference call.

HCUP Partner Webinar:
NASHP worked with TR and AHRQ to plan and conduct an HCUP Partner Webinar based on the final report; the webinar was provided as an extension of the HCUP Partner Workgroup on analyzing race/ethnicity data. NASHP identified and prepared state speakers and an HCUP Partner reactor, developed a brief summary to help promote the webinar among Partners, reviewed speaker slides, prepared an evaluation for the webinar, and facilitated the webinar. Additionally, NASHP presented an overview of report findings during the webinar, which was held March 14, 2011.

Publications and other documents:
NASHP completed the following documents with feedback from AHRQ and TR:

Final report summary: To help AHRQ highlight the final report on the HCUP table at general conferences, NASHP prepared a stand-alone summary of the report with lessons learned from states.
PowerPoint template: NASHP developed a template presentation about final report findings for AHRQ or others to use to highlight the report. The template includes notes for the speaker.
50-state environmental scan: NASHP created and formatted a brief summary of a spreadsheet of findings from the environmental scan of state publications documenting racial and ethnic health and healthcare disparities that informed the final report.
Four issue briefs: NASHP developed four new issue briefs on topics briefly introduced in the final report:

Assessing the Costs of Racial and Ethnic Health Disparities: State Experience
Reducing Racial and Ethnic Disparities through Health Care Reform: State Experience
Using Geographic Information to Target Health Disparities: State Experience
Using Report Cards to Measure Racial and Ethnic Health Disparities: State Experience

Electronic promotion of materials:
NASHP provided TR staff with the necessary information to link the final report and related documents to the HCUP-US page for topical reports on Race/Ethnicity Disparities and the HCUP Partner page on race/ethnicity data. NASHP also developed a summary paragraph for each document and posted them to the NASHP website.

Additionally, NASHP helped to disseminate the HCUP documents and promote the AHRQ websites electronically by: including them in NASHP e-newsletters sent to approximately 10,000 unduplicated individuals (state officials, researchers, funders, advocates); sending targeted e-mail announcements to state Office of Minority Health staff and directors, governors' health policy advisors, and public health directors; and disseminating document summaries and weblinks to relevant organizations (Kaiser, Families USA) that regularly post and distribute new documents about healthcare disparities.

AHRQ conference session:
NASHP helped to coordinate a session for AHRQ's 2011 Annual Conference that was based on findings from the final report. The session, "State Initiatives to Measure and Reduce Disparities in Health Care," was held on September 21, 2011. NASHP identified and worked with AHRQ and TR to prepare state speakers; NASHP worked with AHRQ and conference staff to coordinate session logistics, including the session agenda, room layout, and timely submission of final speaker materials. Finally, NASHP moderated the session and presented a brief overview of report findings during the session.

The session was well attended (approximately 50 AHRQ meeting participants). The session also provided a dissemination vehicle for documents prepared as part of the project. The final report summary and a resource list with information about each related document and a link to the HCUP-US website were available for participants.

AHRQ ancillary meeting:
NASHP planned a small, invitation-only meeting that was held in conjunction with AHRQ's 2011 Annual Conference. "Measuring Progress in Health Care Disparities Reduction: A State-Federal Discussion" was held September 21, 2011, directly after the AHRQ conference session. With guidance from AHRQ and TR, NASHP invited state and federal officials, identified and prepared speakers, created the meeting agenda (see attached agenda), evaluation, and packets, and facilitated the meeting.

Specific objectives were:

Identify leading states' lessons for using data to track and evaluate their efforts to reduce racial and ethnic disparities in health and healthcare.
Identify leading states' biggest challenges to assessing the impact of their racial/ethnic disparities reduction activities.
Identify potential ways the federal government can assist states in their use of data to inform, advance, track, or evaluate disparities reduction activities.
Identify opportunities for improved state-to-state learning on the use of data to reduce racial and ethnic disparities in health and healthcare.

Through this meeting, federal officials and representatives from leading states discussed challenges and lessons associated with using data to inform, advance, track, or evaluate efforts to reduce racial and ethnic disparities in health and healthcare. The 27 participants included 11 state officials (representatives of six State Offices of Minority Health; four epidemiologists from State Departments of Health, one Medicaid official); ten representatives from federal agencies (AHRQ, HRSA, SAMHSA, AoA, CDC, CMS, HHS); two private sector partners (academic institution and NCQA), and AHRQ contractor staff (see attached list). Observers were also present.

Discussion at the meeting focused on linking data to health system and population health improvement initiatives, state efforts to track progress and evaluate impact of disparities reduction activities, putting state and federal pieces together to track disparities reduction, and lessons and opportunities.

According to evaluation results, participants found the meeting to be quite useful. More than 90% of returned evaluations (n=21) rated the meeting overall as excellent or very good. Some of the highlights of the meeting for participants were the open dialogue and exchange, the expertise of participants, representation of federal agencies and states, and "excellent balance between much sharing of specific state and federal programs, measurement, lessons, vision, future plans..."

In terms of what participants liked least about the meeting, several participants noted the difficulty in attempting to cover a lot of information in a short meeting: "Overall great for a one day meeting. Still felt rushed."

The meeting reinforced that disparities reduction activities need to be driven by states and communities at the local level. Suggestions for ways that the federal government can assist states in their use of data to inform, advance, track, or evaluate disparities reduction activities fell into several themes:

Identify and share best practices (e.g., model state disparities reports, "success stories," use of advisory groups) and facilitate state-to-state sharing through webinars and meetings.
Improve the consistency of implementing data standards across agencies.
Provide training and technical assistance, particularly in the area of using data and making data analysis relevant to users/decision makers, including how to get communities and policymakers involved in the data analysis agenda sooner.
Communicate about available resources

Participants greatly appreciated the opportunity to network. Over 95% of respondents rated audience participation as excellent or very good. Over 90% of respondents rated as excellent or very good the value of the meeting for making new professional contacts and enabling informal professional exchanges.

Themes from the meeting include the following:

Improving data to measure efforts to reduce racial and ethnic disparities in health and healthcare

Currently, there is great momentum to standardize and improve methods of tracking and evaluating efforts to reduce racial and ethnic (R/E) disparities in health and healthcare. Provisions of the Affordable Care Act, national measurement initiatives (i.e., National Quality Forum reports and measures) and private sector support (private foundations) are propelling these efforts forward.
There is a critical need for standardization and uniformity in measurement to enable comparisons across geographic areas, progress over time, and aggregation of data from a variety of sources. HHS is currently working on new standards for federal collection of R/E data, as required by the health reform law.
More granular data are needed in a number of areas. These include: the ability to drill down to community-level data, data on racial and ethnic subpopulations, and measures of social determinants of health. Small population samples pose a challenge in this area.
As new disparities measures are developed and standardized, more attention should focus on measures of assets in addition to deficits. Data sources and analyses on multiple chronic conditions and more contemporary delivery system issues are also needed.

Using data to reduce racial and ethnic disparities in health and healthcare

Successful measurement and documentation of disparities and disparity reduction activity requires partnership in order to determine the measurement agenda and make the data relevant for the audience. Partnership must be considered early in the process.
In attempting to leverage new partnerships, states should consider examining the costs and costs savings of health and healthcare disparities, especially given the difficult fiscal climate (i.e., payers such as Medicaid may be interested in learning how reductions in disparities can reduce overall costs). In addition, stratifying Medicaid quality measures by race at the state level may be illuminating. CMS is releasing an ACA-mandated report on R/E data collection this week.
Successful strategies for sharing health disparities data include focusing on stories in addition to quantitative data, and linking problems to solutions.
Data stewards must consider the goals of sharing the data. (i.e., should the comparison group be the population with the best health indicators? The White population? Is the focus on reducing the disparity between rates or on improving rates that are substandard or moving in the wrong direction?)

Opportunities for promoting state-to-state and state/federal assistance

Federal agencies are aligning forces and creating new tools that will assist states in their efforts to measure and track disparities. These include changes to federal grant applications to require documentation of community partners and disparities impact of projects, new data collection standards, a new resource to enable analysis of data from small populations, and new tools for community-level engagement (CDC's Winnable Battles). Other resources identified include CDC's community data initiative/dashboard and new survey data from SAMHSA for state and sub-state reports on mental health and substance abuse.
States seek more opportunities to share best practices and lessons with each other. Regional meetings of state Offices of Minority Health provide one example of state efforts to share with each other. The Medicaid Directors Learning Collaborative and ASTHO may also be relevant given their recent work with R/E data collecting and sharing). Federal government agencies can support this type of brainstorming, problem solving, and sharing of best practices.

The session also provided a dissemination vehicle for documents prepared as part of the project. The final report executive summary and a resource list with information about each document and a link to the HCUP Website was available for participants.

Achievements and Assessment of Impact

The task achieved its intended goals: project staff created information that has been used, and will continue to be used, to reach a variety of stakeholders with information about leading states activities related to collection, analysis and use of patient race/ethnicity data to improve health equity and reducing disparities in health and healthcare quality. The products built on the original report and provided more in-depth information on the actions and lessons of leading states. Finally, leading states had an opportunity through the AHRQ ancillary meeting to dialogue with each other and federal partners to foster peer learning about successes, challenges, needs, actions, and plans related to collecting, analyzing, and using patient race/ethnicity data to improve health equity and reducing disparities in health and healthcare quality.

States are very proud to have been included in this project and mentioned in the related documents. For example, the Connecticut Department of Public Health's webpage on disparities includes a link to the final report on the HCUP webpage with a note that the report cites the state as a leader in documenting and analyzing disparities (http://www.ct.gov/dph/cwp/view.asp?a=3132&q=388116).

New project documents also attracted attention from other organizations. In July 2011, the HCUP issue brief on costs of disparities was selected as one of the month's "Health Policy Picks" by KaiserEDU.org and the New York Academy of Medicine Library's Grey Literature Collection. The issue brief on disparities and healthcare reform was highlighted in the Association of State and Territorial Health Officials' September 2, 2011 "Primary Care and Prevention Network News" e-newsletter. The message went to all state health officials. The brief was also highlighted in a September 7, 2011 SHADAC/SHARE (State Health Access Data Assistance Center/State Health Access Reform Evaluation) e-newsletter, and it was selected as a September 2011 "Health Policy Pick" by KaiserEDU.org and the New York Academy of Medicine Library's Grey Literature Collection.

The dissemination activities have provided mechanisms for additional states to use the examples, experiences, and lessons of leading states as they develop their plans to collect, analyze, and use patient race/ethnicity data. The documents can inform state officials as they look for ways to improve health system performance and implement the Affordable Care Act. NASHP will continue to disseminate these products in future work with state officials related to reducing health and healthcare disparities and achieving health equity.

AGENDA

AHRQ Ancillary Meeting:

Measuring Progress in Health Care Disparities Reduction: A State-Federal Discussion

Through this meeting, federal officials and representatives from leading states will discuss challenges and lessons associated with using data to inform, advance, track, or evaluate efforts to reduce racial and ethnic disparities in health and healthcare.

Specific objectives:

Identify leading states' lessons for using data to track and evaluate their efforts to reduce racial and ethnic disparities in health and healthcare.
Identify leading states' biggest challenges to assessing the impact of their racial/ethnic disparities reduction activities.
Identify potential ways the federal government can assist states in their use of data to inform, advance, track, or evaluate disparities reduction activities.
Identify opportunities for improved state-to-state learning on the use of data to reduce racial and ethnic disparities in health and healthcare.

10:00 - 11:00 a.m.	Welcome, Overview and Introductions This section will include welcome remarks from AHRQ and an overview of the meeting purpose and agenda. Participants will share their name and agency/organization. Introductions will be followed by opening remarks from a national expert. Ernest Moy, Medical Officer, Center for Quality Improvement and Patient Safety, Agency for Healthcare Research and Quality (AHRQ) Jill Rosenthal, Program Director, National Academy for State Health Policy (NASHP) Presenter: (15 mins) Dennis Andrulis, Senior Research Scientist, Texas Health Institute and Associate Professor, University of Texas School of Public Health
11:00 a.m. - 12:10 p.m.	Linking Data to Health System and Population Health Improvement Initiatives This session is intended to focus on how race/ethnicity data and health equity fit within the context of population health, quality improvement, cost containment and healthcare reform initiatives in states. Speakers from two states will discuss their use of race/ethnicity data to support these initiatives. The two state presentations will be followed by group discussion of the following questions: How do (or might) states use race/ethnicity data to target improvement efforts to geographic areas or populations of greatest need? Or in payment reform, health insurance exchange, health information technology, or other aspects of federal healthcare reform? How do (or might) Offices of Minority Health and Public Health collaborate with other state agencies such as Medicaid to support new uses of race/ethnicity data? What challenges do states face in using data these ways? What type of cross-state collaboration and learning would facilitate your state's efforts? What type of assistance from the federal government or activity at the federal level would facilitate these state efforts? Presenters: (10 mins per state) Carlessia Hussein, Director, Maryland Office of Minority Health and Health Disparities Rilwan Feyisitan, Chief Administrator, Office of Minority Health, Rhode Island Department of Health Samara Viner-Brown, Chief, Center for Health Data and Analysis, Rhode Island Department of Health Reactor: (2-3 mins) Larke Huang, Senior Advisor, Substance Abuse and Mental Health Services Administration (SAMHSA) Facilitated Discussion
12:10 - 12:50 p.m.	Lunch (Box lunches will be available in the room for participants)
12:50 -2:00 p.m.	State Efforts to Track Progress and Evaluate Impact of Disparities Reduction Activities
11:00 a.m. - 12:10 p.m.	Linking Data to Health System and Population Health Improvement Initiatives States take a variety of approaches to assessing progress and impact of their disparities reduction activities. These approaches include surveys of state agencies to gauge internal familiarity and use of data as well as reports to explicitly compare data across years. During this session, a state speaker will discuss how Utah currently assesses progress and impact of disparities reduction activities and data reports. The presentation will be followed by group discussion of the following questions: How does your state define "progress" and "impact"? How did your state select an approach to assess progress and impact? What are the strengths and limitations of your state's approach? Has your approach changed over time? How and why? How will we know we've made improvements and how will we know the activities or interventions to which those improvements should be attributed? What opportunities for information sharing and peer learning with other states would be useful? Presenter: (10 mins) April Young Bennett, Multicultural Health Specialist, Center for Multicultural Health/Office of Minority Health, Utah Department of Health Reactor: (2-3 mins each) Ahmed Calvo, Senior Medical Officer, Health Resources & Services Administration (HRSA) Cecilia Rivera Casale, Senior Advisor for Minority Health, AHRQ Facilitated Discussion
2:00 - 2:30 p.m.	Putting State and Federal Pieces Together to Track Disparities Reduction, Part 1 During this session three representatives from federal agencies will describe how race/ethnicity data fit into their agency activities and their efforts to track progress in disparities reduction. They will comment on how state input and collaboration could inform these activities. Presenters: (5-10 mins each) Leandris Liburd, Director, Office of Minority Health and Health Equity, Centers for Disease Control and Prevention (CDC) Mary Roary, Data Lead, Office of Minority Health, Office of the Secretary, Department of Health and Human Services Megan Thomas, Health Insurance Specialist, Centers for Medicare and Medicaid Services (CMS)
2:30 - 2:45 p.m.	Break (Coincides with part of AHRQ Conference break)
2:45 - 3:30 p.m.	Putting State and Federal Pieces Together to Track Disparities Reduction, Part 2 This continuation of the previous session will begin with brief remarks from a state reactor to kick off discussion about the presentations from the pre-break session. State and federal officials will then weigh in on questions such as: What needs, challenges, and opportunities exist for state/federal collaboration to create a national picture of the impact of disparities reduction activities? In what areas could state/federal coordination and communication yield better data collection, analysis? Reactor: (2-3 mins) R. Mauricio Palacio, Director, Office of Health Disparities, Colorado Department of Public Health and Environment Facilitated Discussion
3:30 - 4:00 p.m.	Lessons Learned, Opportunities and Adjournment This section will highlight themes from the meeting regarding lessons learned and potential opportunities for greater progress. Discussion questions include: What are the take-away messages from the meeting? What types of federal activity, tools, or support would help states measure progress in reducing disparities in healthcare? Ernest Moy, AHRQ Jill Rosenthal, NASHP Facilitated Discussion

AHRQ Ancillary Meeting
Measuring Progress in Health Care Disparities Reduction: A State-Federal Discussion

September 21, 2011

PARTICIPANT LIST

Dennis Andrulis
Senior Research Scientist
Texas Health Institute
Email: dandrulis@texashealthinstitute.org

April Young Bennett
Multicultural Health Specialist
Center for Multicultural Health/Office of Minority Health
Utah Department of Health
Email: aybennett@utah.gov

Ahmed Calvo
Senior Medical Officer
Health Resources & Services Administration
Email: AHMED.CALVO@hrsa.hhs.gov

Cecilia Rivera Casale
Senior Advisor for Minority Health
Agency for Healthcare Research and Quality
Email: cecilia.casale@ahrq.hhs.gov

Paul Cotton
Director of Federal Affairs
National Committee for Quality Assurance
Email: cotton@ncqa.org

Denise Dougherty
Senior Advisor
Children's Health and Quality Improvement
Agency for Healthcare Research and Quality
Email: Denise.Dougherty@ahrq.hhs.gov

Rilwan Feyisitan, Jr.
Chief Administrator
Office of Minority Health
Rhode Island Department of Health
Email: Rilwan.Feyisitan@health.ri.gov

Lori Gerhard
Director
Office for Program Innovation & Demonstration
U.S. Administration on Aging
Email: Lori.Gerhard@AoA.hhs.gov

Carrie Hanlon
Policy Specialist
National Academy for State Health Policy
Email: chanlon@nashp.org

Larry Hinkle
Research Assistant
National Academy for State Health Policy
Email: lhinkle@nashp.org

Karen Ho
Health Science Administrator
Agency for Healthcare Research and Quality
Email: Karen.Ho@ahrq.hhs.gov

Vicky Howell
Epidemiologist
Office of Policy and Performance
New Mexico Department of Health
Email: vicky.howell@state.nm.us

Larke Huang
Senior Advisor
Substance Abuse and Mental Health Services Administration
Email: larke.huang@samhsa.hhs.gov

Carlessia Hussein
Director
Maryland Office of Minority Health and Health Disparities
Email: husseinc@dhmh.state.md.us

Margaret Hynes
Senior Epidemiologist
Health Information Systems and Reporting Division
Connecticut Department of Public Health
Email: Margaret.Hynes@ct.gov

Angela Jimenez
Administrator
Office of Multicultural Health
Connecticut Department of Public Health
Email: Angela.Jimenez@ct.gov

Leandris Liburd
Director, Office of Minority Health and Health Equity
Centers for Disease Control and Prevention
Email: LEL1@cdc.gov

David Mann
Epidemiologist
Maryland Office of Minority Health and Health Disparities
Email: dmann@dhmh.state.md.us

Ernest Moy
Medical Officer
Agency for Healthcare Research and Quality
Email: ernest.moy@ahrq.hhs.gov

R. Mauricio Palacio
Director, Office of Health Disparities
Colorado Department of Public Health and Environment
Email: palaciom@smtpgate.dphe.state.co.us

Susan Raetzman
Senior Research Leader
Thomson Reuters
Email: susan.raetzman@thomsonreuters.com

Mary Roary
Data Lead
Office of the Secretary, Office of Minority Health
Email: mary.roary@hhs.gov

Cheryl Roberts
Deputy Director for Programs
Virginia Department of Medical Services
Email: cheryl.roberts@dmas.virginia.gov

Jill Rosenthal
Program Director
National Academy for State Health Policy
Email: jrosenthal@nashp.org

LouAnn Sanchez
Director, Office of Health Equity
New Mexico Department of Health
Email: LouAnn.Sanchez@state.nm.us

Megan Thomas
Health Insurance Specialist
Centers for Medicare and Medicaid Services
Email: megan.thomas@cms.hhs.gov

Samara Viner-Brown
Chief, Center for Health Data and Analysis
Rhode Island Department of Health
Email: Samara.Viner-Brown@health.ri.gov

Observers

Diane Justice
Senior Program Director
National Academy for State Health Policy
Email: djustice@nashp.org

Kien Lee
Principal Associate/Vice President
Community Science
Email: Kien@communityscience.com

Amanda Richardson
Policy Analyst
National Academy for State Health Policy
Email: arichardson@nashp.org

Margaret Trinity
Project Director, AHRQ CVE Learning Network
Lewin Group
Email: margaret.trinity@starpower.net

Jacquelyn Williams
Project Officer, State Partnership Grants to Improve Minority Health
Division of Program Operations
Office of Minority Health
Email: jacquelyn.williams@hhs.gov

¹ Hanlon C, Rosenthal J, and Hinkle L. State Documentation of Racial and Ethnic Disparities to Inform Strategic Action. Online September 22, 2011, p 23. U.S. Agency for Healthcare Research and Quality (AHRQ). Available: http://www.hcup-us.ahrq.gov/reports.jsp.

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NHQR/NHDR Dissemination of Information on State Data-Driven Strategic Efforts to Reduce Health Disparities