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Women’s Health Issues 17 (2007) 334–337

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COMMENTARY

FRONTIERS IN GENDER-BASED RESEARCH: HEALTH CAREQUALITY DATA

Ernest Moy, MD, MPH* and Elizabeth Dayton, MA

Agency for Healthcare Research and Quality, Center for Quality Improvement and Patient Safety, Rockville, Maryland

Received 18 July 2007; accepted 13 August 2007

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ender-based research can play an important rolein improving our nation’s health and health care.

nderstanding the diverse health care needs andneven distribution of health services across subpopu-

ations can help to target interventions where they areost needed and likely to garner the greatest results.onsider the distinct health care needs of the Unitedtate’s 140 million females (Smith & Spraggins, 2001).lthough women have lower age-adjusted death rates

han men for 13 of the 15 leading causes of deathArias, Anderson, Kung, Murphy, & Kochanek, 2003),hey are more likely than men to report having arthri-is, asthma (Lethbridge-Cejku, Rose, & Vickerie, 2006),nd serious mental illness (National Center for Healthtatistics, 2005). Among Americans �85 years old,omen outnumber men by more than 2 to 1 (Hobbs &

toops, 2002), and in these later years they face aarticularly high likelihood of developing chroniconditions and serious disease. Additionally, givenhe adverse association between poverty and health,he disproportionate number of women (nearly 14%)iving in households with incomes below the Federaloverty level (US Census Bureau, 2005) confirms the

mportance of understanding how well women’sealth care needs are being met.Produced by the Agency for Healthcare Research

nd Quality (AHRQ), the National Healthcare Dispari-ies Report (NHDR; AHRQ, 2006) provides an annualnalysis of health care disparities trends across aomprehensive set of quality and access measures.eport text focuses on about 50 core measures and

* Correspondence to: Dr Ernest Moy, Agency for Healthcareesearch and Quality, Center for Quality Improvement and Patientafety, 540 Gaither Road, Rockville, MD 20850; Phone: 301-427-1329;ax: 301-427-1341.

gE-mail: ernest.moy@ahrq.hhs.gov.

opyright © 2007 by the Jacobs Institute of Women’s Health.ublished by Elsevier Inc.

resents disparities by race, ethnicity, socioeconomictatus, and for multiple congressionally designatedpriority populations,” including women. Report ap-endices track �250 measures across 34 databases,

ncluding data break-outs by gender for nearly alleasures. It should be read with its companion doc-

ment, the National Healthcare Quality Report (NHQR;HRQ, 2006), which examines and tracks the qualityf health care in the United States.The NHDR is a valuable tool for policy makers,

roviders, and patients alike. However, its breadthnd annual cycle preclude detailed examination ofany interesting findings. In particular, the NHDR

eports on only a handful of measures from the perspec-ive of gender-based research each year. We believe thathere is an opportunity to delve more deeply into manyf the data sources utilized in the NHDR to develop aore thorough and nuanced understanding of health

are by gender. This editorial aims to equip readersith knowledge of often underused data sources

ncluded in the NHDR appendices, many of which aresable and appropriate for gender-based analyses.

ata Sources for Future Research

ata in the NHDR come from numerous sources thatre appropriate to a wide range of disparities research.ources include surveys collected from samples ofivilian, noninstitutionalized populations, and datarom samples of health care facilities, surveillance andital statistics systems, and extracted from administra-ive data systems of health care. Table 1 presents all

HDR data sources. Multiple data sources in theHDR are rich with gender-relevant data and provide

ood opportunities for research on the intersection of

ender, race/ethnicity, and socioeconomic status.

1049-3867/07 $-See front matter.doi:10.1016/j.whi.2007.08.002

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E. Moy and E. Dayton / Women’s Health Issues 17 (2007) 334–337 335

Recent issues of Women’s Health Issues have ad-ressed gender disparities related to cancer, diabetes,eart disease, HIV, depression, substance abuse, andreventive services, and readers will likely be familiarith many of the databases used in these analyses.onsequently, we focus on some data sources thatave not been routinely used for gender-based analy-es, but are appropriate for research on topics relevanto health care quality, including kidney disease, asthma,ong-term care, and patient safety.

idney diseasehe NHDR includes data on dialysis from the End-tage Renal Disease Clinical Performance MeasuresCPM) Project and on renal transplantation from thenited States Renal Data System (USRDS). Sponsoredy the Centers for Medicare & Medicaid Services (CMS),he CPM Project (www.cms.hhs.gov/CPMProject/) ab-tracts clinical information contained in the medical

able 1. Databases utilized in the National Healthcare Disparities

urveys collected from populationsAHRQ, Medical Expenditure Panel Survey (MEPS), 1999–2003CAHPS Hospital Survey, 2005CDC, Behavioral Risk Factor Surveillance System (BRFSS), 2001–CDC-NCHS, National Asthma Survey, 2003CDC-NCHS, National Health and Nutrition Examination SurveyCDC-NCHS, National Health Interview Survey (NHIS), 1998–200CDC-NCHS/National Immunization Program, National ImmuniCMS, Medicare Current Beneficiary Survey (MCBS), 1998–2002Health Resources and Services Administration, Healthy SchoolsNational Hospice and Palliative Care Organization, Family EvaluSubstance Abuse and Mental Health Services Administration (SA

2002–2004US Census Bureau, US Census of Population, 2000ata collected from samples of health care facilities and providersCenter for Studying Health System Change, Community TrackinCDC-NCHS, National Ambulatory Medical Care Survey (NAMCCDC-NCHS, National Hospital Ambulatory Medical Care SurveyCDC-NCHS, National Hospital Ambulatory Medical Care SurveyCDC-NCHS, National Hospital Discharge Survey (NHDS), 1998–CMS, End Stage Renal Disease Clinical Performance Measures Pata extracted from data systems of health care organizationsAHRQ, Healthcare Cost and Utilization Project (HCUP) State InpCMS, Hospital Compare, 2005CMS, Medicare Patient Safety Monitoring System, 2002–2004CMS, Home Health Outcomes and Assessment Information Set (CMS, Nursing Home Minimum Data Set, 2002–2004CMS, Quality Improvement Organization (QIO) program, HospiHIV Research Network data (HIVRN), 2001–2003Indian Health Service, National Patient Information Reporting SyNational committee for Quality Assurance, Health Plan EmployeNational Institutes of Health, United States Renal Data System (USAMHSA, Treatment Episode Data Set (TEDS), 2002–2003ata from surveillance and vital statistics systemsCDC, National Program of Cancer Registries (NPCR), 2002–2003CDC-National Center for HIV, STD, and TB Prevention, HIV/AICDC-National Center for HIV, STD, and TB Prevention, TB SurvCDC-NCHS, National Vital Statistics System (NVSS), 1999–2003NIH, Surveillance, Epidemiology, and End Results (SEER) progr

ecords of a national random sample of adult in-center A

emodialysis patients. NHDR findings from the CPMroject are that women on dialysis are significantly

ess likely than men to have an arteriovenous fistula,he preferred modality for vascular access. However,

omen are more likely than men to receive adequateialysis as measured by urea reduction ratios.Sponsored by the National Institutes of Health and

MS, the USRDS (www.usrds.org) compiles a wideariety of data from administrative, surveillance, andedical record systems related to kidney disease, treat-ent, survival, and costs. NHDR findings from theSRDS are that women on dialysis are less likely thanen to be registered on a waiting list for renal

ransplantation and to receive a transplant within 3ears of kidney failure. Gender differences in care foridney disease deserve further study.

sthmahe 2006 NHDR includes data from the 2003 National

NES), 1999–2002

Survey (NIS), 1998–2004

y Communities User Visit Survey, 2003of Hospice Care, 2005

), National Survey on Drug Use and Health (NSDUH),

y Physician Survey, 1998–20057–2003patient Department (NHAMCS-OPD), 1997–2003gency Department (NHAMCS-ED), 1997–2003

ESRD CPMP), 2001–2004

Databases disparities analysis file, 2001–2003

), 2002–2004

lity Alliance (HQA) measures, 2000–2004

NPIRS), 2002–2004and Information Set (HEDIS), 2001–2005

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E. Moy and E. Dayton / Women’s Health Issues 17 (2007) 334–337336

laits/nas.htm). Sponsored by the Centers for Diseaseontrol and Prevention’s National Center for Environ-ental Health and conducted by the National Center

or Health Statistics, this survey is the most compre-ensive national data set on asthma prevalence andare. It can be used to examine health, socioeconomic,ehavioral, and environmental predictors of asthmaontrol. Topics include the 4 essential components ofsthma management critical for effective long-termontrol: assessment and monitoring, controlling envi-onmental factors, pharmacotherapy, and patient ed-cation. NHDR findings are that only 67% of womenith asthma were taught to recognize early signs of an

sthma attack, 48% were told how to change theirnvironment to control their asthma, 40% used con-roller medications, and 25% had an asthma manage-

ent plan. Opportunities to improve asthma care foromen merit further investigation.

ong-term carehe NHDR includes long-term care data from theome Health Outcome and Assessment Information

et (OASIS) and the Nursing Home Minimum Dataet (MDS), both maintained by CMS. OASIS (www.ms.hhs.gov/oasis/) is a comprehensive assessmentf adult, nonmaternity, home care patients who areeceiving skilled services. Data are recorded by homeealth agency personnel on respondents’ demograph-

cs and patient history, living arrangements, support-ve assistance, sensory status, skin status, respiratorytatus, elimination status, neurologic/emotional/be-avioral status, activities of daily living, medications,quipment management, and information collected atnpatient facility admission or agency discharge. NHDRindings from the OASIS are that women receivingome health care are significantly less likely than men

o improve in physical functioning, such as walking oroving around. However, women receiving home

ealth care are also less likely to be admitted to theospital and more likely to be able to stay at homefter home health care ends.MDS (www.cms.hhs.gov/NursingHomeQualityInits/)

s a standardized, primary screening and assessmentool of health status, completed by facility personnel.t measures physical, medical, psychological, and so-ial functioning of nursing home residents, includingemographics and patient history, psychosocial well-eing, physical functioning, continence, disease diag-oses, health conditions, medications, nutritional andental status, skin condition, activity patterns, special

reatments and procedures, discharge potential, andognitive, communication/hearing, vision, and mood/ehavior patterns. NHDR findings from the MDS arehat women in nursing homes, both those receivingong-term chronic care and those receiving short-termare after a hospitalization, are significantly more

ikely than men to experience moderate to severe pain. o

owever, women in nursing homes are less likely toave pressure sores, even after adjusting for risk.hus, gender differences in long-term care are preva-

ent and deserve further examination using thesenderutilized data sources.

atient safetyatient safety, defined as freedom from accidental

njury due to medical care, is a component of healthare quality increasingly under examination, yet lim-ted research to date has examined gender differences.he NHDR includes patient safety data from 2 CMSrograms, the Medicare Patient Safety Monitoringystem (MPSMS) and the Medicare Quality Improve-ent Organization (QIO) program, and 2 AHRQ

atabases, the Healthcare Cost and Utilization ProjectHCUP), and the Medical Expenditure Panel SurveyMEPS).

The MPSMS (www.qualidigm.org/Professionals/opic/PatientSafety/Monitoring.aspx) uses an elec-

ronic data collection tool to abstract medical charts for aandom sample of all Medicare hospital discharges.dverse events tracked by MPSMS include those asso-

iated with the use of central vascular catheters, surgicalrocedures, joint revisions and replacements; ventilator-ssociated pneumonia and blood stream infections ac-uired in hospitals; and adverse drug events that areospital associated or the cause of hospital admission.atient risk factor information is also collected, includ-

ng demographics, principal diagnosis and its sever-ty, and comorbid conditions and treatments. NHDRindings from the MPSMS include gender differencesn postoperative complications: Women are moreikely to have postoperative urinary tract infections,

hereas men are more likely to have postoperativeneumonia.The Medicare QIO program (www.cms.hhs.gov/ualityImprovementOrgs/) consists of a national net-ork of QIOs responsible for each state. Employing an

nnovative health care improvement approach, QIOsork with consumers, physicians, hospitals, and other

aregivers to refine care delivery systems to make sureatients get the right care at the right time, particu-

arly among underserved populations. The target pop-lation is Medicare beneficiaries, and current settingsf care include nursing homes, home health agencies,ospitals, and physician offices. Data include abstractsf medical records from a systematic random samplef Medicare beneficiaries. NHDR findings from QIOata are that the timing of prophylactic antibioticsiven to Medicare patients undergoing surgery doesot vary by gender.Much of the NHDR’s patient safety data are fromCUP (www.ahrq.gov/data/hcup/). HCUP data are

rought together annually from state governmentata organizations, hospital associations, private data

rganizations, and the federal government, creating a

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E. Moy and E. Dayton / Women’s Health Issues 17 (2007) 334–337 337

ational information resource of discharge-level hos-ital data. Because of variations in the quality ofoding of race and ethnicity across states and hospi-als, a special Disparities Analysis File (http://www.hrq.gov/qual/nhdr06/methods/HCUP.htm) is cre-ted each year for the NHDR based on informationrom states and hospitals with the best data.1 NHDRatient safety measures from HCUP include inpatientomplications following surgeries, other procedures,nd childbirth. In general, women undergoing sur-ery have lower rates than men of postoperativeomplications including postoperative sepsis, respira-ory failure, metabolic derangement, and dehiscencef abdominal incisions. However, women have higherates of iatrogenic pneumothorax and technical diffi-ulty during a procedure.

MEPS (www.meps.ahrq.gov) is commonly used forender-based research so we will not describe thisurvey of the civilian, noninstitutionalized US popu-ation. The NHDR relies on MEPS to provide the onlynformation in the report on medication error in thembulatory setting. Using MEPS data, the NHDRinds that elderly women are 1.7 times more likely toeceive medications that could be inappropriate forlders and 2.5 times more likely to receive medicationshat generally should be avoided by elders. A betternderstanding of gender differences in patient safetyould facilitate efforts to reduce medical error.

onclusion

isparities research helps to improve understandingf where health care is exemplar, where it falls farhort of its potential, and where interventions areikely to bear the greatest impact. The NHDR bringsogether a breadth of data sources, many of which haveeen underutilized to date but which could valuably bexamined to better understand gender disparities inare, especially with regard to some components of caref particular importance for women. The editorial hasescribed some sources that the authors of the NHDRelieve have great possibilities for future research, whiche hope to have inspired. These include areas in whichomen receive suboptimal care or care that differs in

uality from care received by men. Links to data sourcesre provided to facilitate access to this information.

1HCUP is designed to provide national estimates of disparitiessing weighted records from a sample of hospitals with reasonableata on race and ethnicity from 22 states: AZ, CA, CO, CT, FL, GA,I, KS, MD, MA, MI, MO, NJ, NY, PA, RI, SC, TN, TX, VA, VT,

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n addition, the AHRQ web site provides links tohe NHDR (www.ahrq.gov/qual/nhdr06/nhdr06.htm),he NHQR (www.ahrq.gov/qual/nhqr06/nhqr06.htm),

HDR and NHQR detailed tables which typicallyupport analyses by gender (www.ahrq.gov/qual/hdr06/index.html and www.ahrq.gov/qual/nhqr06/

ndex.html), and interactive tools for generating cus-omized tables which typically also support analysesy gender (http://nhdrnet.ahrq.gov/nhdr/jsp/nhdr.jspnd http://nhqrnet.ahrq.gov/nhqr/jsp/nhqr.jsp). It isoped that these resources enable gender researchers toxplore new frontiers in health care quality.

eferencesmith, D.I., & Spraggins R.E. (2001). Gender: 2000. Census 2000 Brief.

Washington, DC: U.S. Census Bureau. Available: www.census.gov/prod/2001pubs/c2kbr01-9.pdf. Accessed July 13, 2007.

rias, E., Anderson, R.N., Kung, H.C., Murphy, S.L., & Kochanek,K.D. (2003). Deaths: Final data for 2001. National Vital StatisticsReports, 52 (3), 1–115.

ethbridge-Cejku, M., Rose, D., & Vickerie, J. (2006). Summaryhealth statistics for U.S. adults: National Health Interview Sur-vey, 2004. Vital and Health Statistics, 10 (228), 1–154.

ational Center for Health Statistics. (2005). Health, United States,2005 with chartbook on trends in the health of Americans. Hyattsville,MD: Centers for Disease Control and Prevention, National Cen-ter for Health Statistics.

obbs, F., & Stoops, N. (2002). Demographic trends in the 20th century.Census 2000 Special Reports. Washington, DC: U.S. CensusBureau. Available: www.census.gov/prod/2002pubs/censr-4.pdf. Retrieved July 13, 2007.

.S. Census Bureau. (2005). Current population survey. Annualsocial and economic supplement. Table POV01: Age and sex ofall people, family members and unrelated individuals iterated byincome-to-poverty ratio and race: 2004. Below 100% of poverty—all races. Available: http://jpubdb3.census.gov/macro/032005/pov/new01_100_01.htm. Retrieved July 13, 2007.

gency for Healthcare Research and Quality (AHRQ). (2006).National healthcare disparities report, 2006. Rockville, MD: Agencyfor Healthcare Research and Quality. Available: www.ahrq.gov/qual/nhdr06/nhdr06.htm. Retrieved July 13, 2007.

gency for Healthcare Research and Quality (AHRQ). (2006).National healthcare quality report, 2006. Rockville, MD: Agency forHealthcare Research and Quality. Available: www.ahrq.gov/qual/nhqr06/nhqr06.htm. Retrieved July 13, 2007.

uthor DescriptionsErnest Moy’s research focuses on the measurement

f quality and disparities in health care and thepplication of measurement to improving quality andatient safety.Elizabeth Dayton’s research focuses on social and

nvironmental causes for disparities in health status

nd receipt of health care.