In an era of managed care, researchers are increasingly casting a critical eye on how we use health services. Looking specifically at whether health care is delivered effectively and appropriately to minority populations is the charge of the Medical Effectiveness Research Center (MERC) for Diverse Populations, a research center established within the UCSF School of Medicine in 1993. Funded by the federal Agency for Health Care Policy and Research, MERC (pronounced "mercy") is one of several such research centers around the country.

A major component of MERC's work is conducting outcomes research on health services and procedures provided to minorities. MERC researchers tease from mounds of complex data evidence that may point the way to better health care delivery for minority populations. The core staff of MERC, which is directed by Eugene Washington, MD, chair of the department of obstetrics, gynecology and reproductive sciences, includes a diverse group of 24 investigators from the schools of medicine and nursing.

Eugene Washington, director of MERC

MERC studies are looking at health care delivery in areas that include reproductive health, perinatal medicine, heart disease and cancer. A recent study headed by Miriam Kuppermann, PhD, MPH, for example, examined utilization of prenatal diagnostic testing in California in different racial-ethnic groups. All pregnant women aged 35 and over at the time of delivery are currently offered prenatal diagnostic testing in the form of either amniocentesis or chorionic villus sampling (CVS) to determine whether their baby has Down syndrome or other genetic defects with known chromosomal markers. CVS can be performed earlier in the pregnancy (between 10-12 weeks gestation) and yields more information than amniocentesis, but it has a slightly higher association with spontaneous abortion than does amniocentesis, which must be performed between the 15th and 18th weeks of pregnancy.

"We looked at what factors determine the procedure women choose," says Washington. "What we found was that African-American and Latina women were only a third as likely to avail themselves of either prenatal diagnostic test as white or Asian women, even though these tests are universally available and paid for," says Washington.

The study showed that socioeconomic factors were partly responsible, but did not entirely account for the disparity. The researchers also found that this lack of utilization of prenatal testing was reflected in state of California statistics on the prevalence of Down syndrome-affected births in Latina and African-American women in this age group. Researchers now hope to find out if the relative under-utilization of prenatal diagnostic testing in these groups is a preference on the part of these women or an educational issue that needs to be better addressed.

Another intriguing MERC study, headed by Mark Alexander, PhD, looked at rates of hospitalization of African-Americans and whites for congestive heart failure, a disease that is a leading cause of death in the United States and one of the most costly diseases to treat.

Hospitalization rates for congestive heart failure are known to be much higher for African-Americans than whites, but the prevalence of risk factors for the disease, such as high blood pressure, diabetes, and obesity, is also higher in African-Americans. The study, conducted in a sample of patients from Northern California Kaiser Permanente, was designed to determine whether the higher hospitalization rate could be explained by racial differences in the prevalence of risk factors, or whether other factors, such as access to outpatient care, might account for the difference.

The study found no significant differences in hospitalization rates among males when the increased prevalence of risk factors in African Americans was considered, but did find a significant difference among African American and white women. Now MERC researchers are exploring whether the much lower use of hormone replacement therapy in African-American women might account for the discrepancy. "There may be missed opportunities for preventing heart disease in this group," says Washington.

In addition to outcomes studies, MERC researchers are involved in important methodological research that addresses racial-ethnic differences.

"One question we've asked is how do patients from different socioeconomic and racial/ethnic backgrounds define quality care," says Washington. One MERC study, which looked at patients who received mammograms and Pap smears, indicated that women consider not only the technical components of the procedures but interpersonal aspects of care.

"Things like their perception of how they were treated, and whether providers seem to care about them and convey information effectively were very important," says Washington, and preliminary data suggest that there are indeed differences in how various groups define the components of quality care.

In addition to conducting research, MERC also provides education and training in health services research, technical assistance to policy makers and other groups, and disseminates its research findings to providers and consumers.

By Leslie Lingaas

1st appeared - 6/02/97