2005 N a t i o n a l H e a l t h c a re D i s p a r i t i e s R e p o rt Agency for Healthcare Research and Quality Advancing Excellence in Health Care ? w w w. a h rq . g o v National Healthcare Disparities Report 2005 National Healthcare Disparities Report U.S. Department of Health and Human Services Agency for Healthcare Research and Quality 540 Gaither Road Rockville, MD 20850 AHRQ Publication No. 06-0017 December 2005 National Healthcare Disparities Report A c k n o w l e d g m e n t s A c k n o w l e d g m e n t s The National Healthcare Disparities Report (NHDR) is the product of collaboration among agencies across the Department of Health and Human Services (HHS). Many individuals guided and contributed to this r e p o rt. Without their magnanimous support, this report would not have been possible. S p e c i fi c a l ly, we thank: Primary AHRQ Staff: C a r o lyn Clancy, Bill Munier, Katherine Crosson, Ernest Moy, Elizabeth Day t o n , Dwight McNeill, James Burgdorf, Karen Ho, and Donna Rae Castillo. HHS Intera gency Wo rk Groups for the NHQR/NHDR: I rma Arispe (CDC-NCHS), Hakan Aykan (ASPE), A my Chanlongbutra (HRSA), Richard Conviser (HRSA), Martin Dannenfelser (ACF), Emily DeVoto (NIH), Agnes Davidson (OSOPHS), Brenda Eve lyn (FDA), Anita Everett (SAMHSA), Kay Felix-Aaron (HRSA), Suzanne Feetham (HRSA), Y vette Fryer (HRSA), Olinda Gonzalez (SAMHSA), Miryam Granthon (HRSA), Saadia Greenberg (AoA), Lein Han (CMS), Trent Hay wood (CMS), Tom Hertz (ASPE), Lisa Hines (CMS), Julia Holmes (CDC-NCHS), David Hunt (CMS), Deloris Hunter (NIH), Ruth Katz (ASPE), Richard Klein (CDC-NCHS), Lisa Koonin (CDC), Joel Levine (HRSA), Leopold Luberecki (ASL), Diane Makuc (CDC- ii NCHS), Ronald Manderscheid (SAMHSA), Saralyn Mark (OSOPHS), Marty McGeein (ASPE), Richard M c N a n ey (CMS), Rebecca Middendorf (ASPE), Leo Nolan (IHS), Karen Oliver (NIH), Suzanne Proctor (CDC-NCHS), Susan Queen (HRSA), Michael Rapp (CMS), William Robinson (HRSA), Beatrice Rouse (SAMHSA), Colleen Ryan Smith (IHS), Paul Seligman (FDA), Sam Shekar (HRSA), Adelle Simmons (ASPE), Sunil Sinha (CMS), Phillip Smith (IHS), Caroline Taplin (ASPE), Emmanuel Taylor (NIH), Benedict Truman (CDC), Nadarajen Vydelingum (NIH), Valerie Welsh (OSOPHS), Dinah Wi l ey (OCR), and Barbara Wi n gr ove (NIH). AHRQ Center for Quality Improvement and Patient Safety NHQR/NHDR Te a m : E rnest Moy, Nicole B e l a n g e r, James Burgdorf, Denise Burgess, Elizabeth Dayton, Tina Ding, Daryl Gray, Sonja Hall, Karen Ho, E d ward Ke l l ey, Dwight McNeill, Anna Po ke r, Kathy Rowan, Judy Sangl, David Stevens, Nancy Wi l s o n , Chunliu Zhan. HHS Data Expert s : S t even Cohen (AHRQ), Paul Eggers (NIH), Trena Ezzati-Rice (AHRQ), John Fleishman (AHRQ), Diane Fr a n ke n field (CMS), Reem Ghandour (HRSA), Joe Gfroerer (SAMHSA), Edwin Huff (CMS), Kenneth Keppel (CDC-NCHS), Doris Lefkowitz (AHRQ), Lynn Ries (NIH). Other AHRQ Contribu t o rs : R oxanne A n d r ews, Sepheen Byron, Fran Cheva r l ey, Rosaly Correa, Denise D o u g h e rt y, Pamela Owens, Larry Patton, Denise Remus, Mary Rolston, Scott Rowe, Randie Siegel, Marc Zodet, Phyllis Zucke r. Fi n a l ly, we would like to acknowledge the contributions of our colleague and friend, Daniel Strye r, who serve d as Director of A H R Q ?s Center for Quality Improvement and Patient Safety until his death earlier this ye a r. His commitment to this report and to applying health services research to improve the health care of all Americans continues to guide and inspire our wo r k . National Healthcare Disparities Report C o n t e n t s C o n t e n t s C h a p t e r Page H i g h l i g h t s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 1 . I n t roduction and Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 3 2 . Quality of Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 3 E ff e c t ive n e s s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 6 C a n c e r . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 6 D i a b e t e s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 0 End Stage Renal Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 3 H e a rt Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 5 HIV and A I D S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 9 Mental Health and Substance A bu s e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 2 R e s p i r a t o ry Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 6 Nursing Home and Home Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 0 Patient Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 4 iii Ti m e l i n e s s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 0 Patient Centeredness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 5 S u m m a ry Ta bl e s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 1 3 . Access to Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 7 Facilitators and Barriers to Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 9 Health Care Utilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 9 S u m m a ry Ta bl e s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 0 9 4 . Priority Po p u l a t i o n s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 1 7 Racial and Ethnic Minorities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 1 9 L ow Income Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 3 1 Wo m e n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 3 6 C h i l d r e n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 4 5 E l d e r ly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 5 3 Residents of Rural A r e a s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 5 9 I n d ividuals With Special Health Care Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 6 8 Ap p e n d i xe s : A . Data Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .w w w. q u a l i t y t o o l s . a h rq . g ov B. Detailed Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .w w w. q u a l i t y t o o l s . a h rq . g ov C . Measure Specifi c a t i o n s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .w w w. q u a l i t y t o o l s . a h rq . g ov D. Data Ta bl e s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .w w w. q u a l i t y t o o l s . a h rq . g ov iii National Healthcare Disparities Report National Healthcare Disparities Report H i g h l i g h t s Key Themes and Highlights From the National Healthcare Disparities Report Twenty years ago, the Department of Health and Human Services (HHS) released the Report of the S e c r e t a ry ?s Task Force on Black and Minority Health. That report documented many disparities in health and led to interventions to improve the health and health care of minorities. This ye a r, the A g e n cy for Healthcare Research and Quality (AHRQ) is pleased to release the third National Healthcare Disparities Report (NHDR). This annual report provides a comprehensive national ove rv i ew of disparities in health care among racial, ethnic, and socioeconomici groups in the general U.S. population and within priority populations and tracks the success of activities to reduce disparities. It is a companion report to the National Healthcare Quality Report (NHQR), a comprehensive ove rv i ew of quality of health care in America. A major advantage of an annual report series is its ability to track changes over time. This ye a r, data are presented that begin tracking trends across a broad arr ay of measures of health care quality and access for m a ny racial, ethnic, and socioeconomic groups. In addition, the 2005 report begins to examine the issue of whether the Nation is making progress toward eliminating health care disparities. 1 The NHDR tracks disparities in both quality of health care and access to health care. Measures of health care quality mirror those in the NHQR and encompass four dimensions of quality?eff e c t iveness, patient safety, timeliness, and patient centeredness. Measures of health care access are unique to this report and encompass t wo dimensions of access?facilitators and barriers to care and health care utilization. This ye a r ?s NHDR and NHQR focus on findings from a set of core report measures which represent the most i m p o rtant and scientifi c a l ly credible measures in the full measure sets. Core report measures were selected from the full measure sets by the HHS Interagency Work Groups that support the reports based on their clinical importance, policy relevance, and data reliability.i i The 2005 reports also introduce a number of new composite measures as well as improved methods for summarizing quality and disparities. In the 2005 NHDR, four key themes are highlighted for policy m a kers, clinicians, administrators, and community leaders who seek information to improve health care services for all A m e r i c a n s : ? Disparities still ex i s t . ? Some disparities are diminishing. ? O p p o rtunities for improvement remain. ? I n f o rmation about disparities is improv i n g . i Socioeconomic differences include differences in education and income levels. ii See Ta bles 2.1-2.3 in Chapter 2, Quality of Health Care, for data on core report measures of quality and Ta bles 3.1-3.2 in Chapter 3, Access to Health Care, for data on core report measures of access. Detailed tables for all measures as well as i n f o rmation on methods and measure specifications are ava i l a ble at www. q u a l i t y t o o l s . a h rq . g ov. National Healthcare Disparities Report H i g h l i g h t s Disparities Still Exist Consistent with ex t e n s ive research and findings in previous NHDRs, the 2005 report finds that disparitiesi i i related to race, ethnicity, and socioeconomic statusiv still pervade the American health care system. W h i l e va rying in magnitude by condition and population, disparities are observed in almost all aspects of health care, including: ? Across all dimensions of quality of health care including eff e c t iveness, patient safety, timeliness, and patient centeredness. ? Across all dimensions of access to care including facilitators and barriers to care and health care u t i l i z a t i o n . ? Across many levels and types of care including preve n t ive care, treatment of acute conditions, and management of chronic disease. ? Across many clinical conditions including cancer, diabetes, end stage renal disease, heart disease, HIV disease, mental health and substance abuse, and respiratory diseases. ? Across many care settings including primary care, dental care, home health care, emerg e n cy d e p a rtments, hospitals, and nursing homes. 2 ? Within many subpopulations including women, children, elderly, residents of rural areas, and indiv i d u a l s with disabilities and other special health care needs. To quantify the prevalence of disparities across the core report measures tracked in the 2005 report, racial, ethnic, and socioeconomic groups are compared with an appropriate comparison gr o u pv for each core report measure. Each group could receive care that is poorer than, about the same as, or better than the comparison group. iii Consistent with Healthy People 2010, the NHDR defines disparities as any differences among populations. In addition, all disparities discussed in the NHDR meet criteria based on statistical significance and size of difference described in Chapter 1, Introduction and Methods. iv Income and education are the primary measures of socioeconomic status used in the report . v For all measures, Blacks, Asians, and American Indians and Alaska Natives are compared with Whites; Hispanics are compared with non-Hispanic Whites; and poor individuals are compared with high income indiv i d u a l s . National Healthcare Disparities Report H i g h l i g h t s Figure H.1. Measures of quality for which members of selected groups experienced better, same, or poorer quality of care compared with reference group B e t t e r = Population received better quality of care than the comparison g ro u p . Same = Population and comparison group received about the same quality of care . Worse = Population received poorer quality of care than the comparison g ro u p . Key: AI/AN=American Indian or Alaska Native. Note: ?Asian? includes ?Asian or Pacific Islander? when information is not collected separately for each group. Data on all measures are not available 3 for all groups so totals differ among groups. Data presented are the most recent data available. Totals may not add to 100% due to ro u n d i n g . For sizable proportions of measures, minorities and the poor receive lower quality care. Of core report measures of quality, for ex a m p l e : ? Tog e t h e r, Blacks and American Indians and Alaska Natives (AI/ANs) received poorer quality care than Whites for about 40% (20/46 and 8/21, respective ly) of core report measures (Figure H.1). Blacks r e c e ived better quality care than Whites for 11% (5/46) of measures, and AI/ANs received better quality care for 14% (3/21) of measures. ? Asians received poorer quality care than Whites for 21% (7/32) of core report measures and better quality care for 38% (12/32) of measures. ? Hispanics received poorer quality of care than non-Hispanic Whites for over half of core report measures (20/38) and better quality care for 16% (6/38) of measures. ? Poor peoplev i r e c e ived lower quality of care than high income people for 85% (11/13) of core report measures and better quality care for 8% (1/13) of measures. v i ? Poor? is defined as having fa m i ly income less than 100% of the Federal pove rty level and ?high income? is defined as h aving fa m i ly income 400% or more of the Federal pove rty leve l . National Healthcare Disparities Report H i g h l i g h t s Figure H.2. Measures of access for which members of selected groups experienced better, same, or worse access to care compared with reference group B e t t e r = Population had better access to care than the comparison gro u p . Same = Population and comparison group had about the same access to c a re . Worse = Population had worse access to care than the comparison gro u p . K e y : AI/AN=American Indian or Alaska Native. N o t e : ?Asian? includes ?Asian or Pacific Islander? when information is not 4 collected separately for each group. Data on all measures are not available for all groups, so totals differ among groups. Data presented are the most recent data available. Totals may not add to 100% due to ro u n d i n g . For many measures, minorities and the poor have worse access to care. Of core report measures of access: ? Blacks and AI/ANs had worse access to care than Whites for half (4/8 and 3/6, respective ly) of core r e p o rt measures (Figure H.2) and better access to care for no measures. ? Asians had worse access to care than Whites for 43% (3/7) of core report measures and better access for 14% (1/7) of measures. ? Hispanics had worse access to care than non-Hispanic Whites for 88% (7/8) of core report measures. ? Poor people had worse access to care than high income people for all 8 core report measures. Some Disparities Are Diminishing The Department of Health and Human Services leads many initiatives aimed at reducing health care disparities and improving health care quality. These include the National Breast and Cervical Cancer Early Detection Program funded by the Centers for Disease Control and Prevention (CDC); the Hospital, Nursing Home, Home Health, and End Stage Renal Disease Quality Initiatives of the Centers for Medicare & Medicaid Services (CMS); and many activities coordinated by the HHS Disparities Council and Office of Minority Health. Many private organizations?such as the National Business Group on Health, A m e r i c a ?s Health Insurance Plans, and the A m bu l a t o ry Care Quality Alliance?also work to improve care and reduce disparities. To begin to quantify the success of such eff o rts to reduce disparities, the 2005 NHDR begins to track changes in the core report measures over time. For each core report measure, racial, ethnic, and socioeconomic gr o u p s National Healthcare Disparities Report H i g h l i g h t s are compared with a designated comparison group at different points in time. Both absolute and relative d i ff e r e n c e sv i i are compared using the most recent and the oldest years of data ava i l a ble. Core report measures for which both the absolute differences and the relative differences are becoming smaller over time are i d e n t i fied as improving disparities. Core report measures for which both the absolute differences and the r e l a t ive differences are becoming larger over time are identified as worsening disparities. Uncommonly, absolute and relative differences do not agree on direction of change. In these cases, direction of change is unclear and results for these measures are not presented. Figure H.3. Change in disparities in core report measures of quality over time for members of selected groups compared with reference group 5 I m p ro v i n g = Population-comparison group diff e rence becoming smaller. Wo r s e n i n g = Population-comparison group diff e rence becoming larg e r. K e y : AI/AN=American Indian or Alaska Native. N o t e : ?Asian? includes ?Asian or Pacific Islander? when information is not collected separately for each group. Data on all measures are not available for all groups, so totals differ among groups. The most recent and oldest years of data available are compare d . For racial minorities, more disparities in quality of care are becoming smaller than are becoming larger; for Hispanics, the reverse is true. Of core report measures of quality that could be tracked over time: ? Of disparities experienced by Blacks, 58% (23/40) were becoming smaller (Figure H.3); 42% we r e becoming larg e r. About half of disparities experienced by Asians (13/25) and AI/ANs (8/16) we r e becoming smaller while half were becoming larg e r. ? Of disparities experienced by Hispanics, 41% (14/34) were becoming smaller while 59% were become l a rg e r. ? Half of disparities experienced by poor people (5/10) were becoming smaller while half were becoming l a rg e r. vii Absolute differences are calculated by subtracting one rate from the comparison group rate. Relative differences are calculated by dividing one rate by the comparison group rate. National Healthcare Disparities Report H i g h l i g h t s Figure H.4. Change in disparities in core report measures of access over time for members of selected groups compared with reference group I m p ro v i n g = Population-comparison group diff e rence becoming smaller. Worsening = Population-comparison group diff e rence becoming larg e r. K e y : AI/AN=American Indian or Alaska Native. Note: ?Asian? includes ?Asian or Pacific Islander? when information is not collected separately for each group. Data on all measures are not available 6 for all groups, so totals differ among groups. Only two measures for Asiansand AI/ANs could be tracked over time due to changes in how Federal databases categorized race during the years studied. The most re c e n t and oldest years of data available are compare d . For racial minorities, all disparities in access to care that could be tracked are becoming smaller; for Hispanics and the poor, most disparities are becoming larg e r. Of core report measures of access that could be tracke d over time: ? All disparities experienced by Blacks (6/6), Asians (2/2), and AI/ANs (2/2) were becoming smaller ( Figure H.4). ? About 20% of disparities experienced by Hispanics (1/6) and by poor people (1/5) were becoming smaller and about 80% were becoming larg e r. Opportunities for Improvement Remain Rate Relative to Reference Gro u p Although many disparities are diminishing, opportunities for improvement can still be found for many gr o u p s . To quantify the size of specific disparities, the rate relative to its reference group was calculated for each group for each core report measure. For each group, the largest relative rates are shown in Ta ble H.1 and may help identify areas with greatest need for improve m e n t . ? All groups studied faced some disparities in quality of care. ? Some disparities in quality were prominent for multiple gr o u p s : N ew AIDS cases. P r o blems with timeliness of care (left emerg e n cy room without being seen, not getting care for illness or injury as soon as wa n t e d ) . P r o blems with patient-provider communication. National Healthcare Disparities Report H i g h l i g h t s Table H.1. Three largest disparities in quality of health care for selected groups: measure and rate relative to reference group G ro u p M e a s u re Relative rate* Black vs. White New AIDS cases 1 0 . 4 C h i l d ren with hospital admission for asthma 3 . 7 Left emergency department without being seen 1 . 9 Asian vs. White Mental health treatment for serious mental illness 1 . 6 Illness/injury care as soon as wanted 1 . 6 Elderly with pneumococcal vaccine 1 . 5 American Indian/ P renatal care in first trimester 2 . 1 Alaska Native vs. Adults with patient-provider communication pro b l e m s 1 . 8 W h i t e C h i l d ren with advice about physical activity 1 . 3 Hispanic vs. New AIDS cases 3 . 7 non-Hispanic White Illness/injury care as soon as wanted 2 . 0 C h i l d ren with patient-provider communication pro b l e m s 1 . 8 Poor vs. high income C h i l d ren with patient-provider communication pro b l e m s 3 . 3 Illness/injury care as soon as wanted 2 . 3 C h i l d ren with dental visit 2 . 0 7 * The relative rate is the rate for the stated group divided by the rate for the comparison group. It is one way to quantify the size of a d i s p a r i t y. For example, for the first measure listed, the rate of new AIDS cases for Blacks is 10.4 times the rate of new AIDS cases for Whites. To calculate relative rates, all measures were framed negatively as an adverse outcome. For example, for the first measure comparing Asians with Whites, Asians are 1.6 times more likely to lack mental health treatment for serious mental illness compared with Whites. Note: ?Asian? includes ?Asian or Pacific Islander? when information is not collected separately for each group. Data presented are the most recent data available. The 2005 NHDR also found that many groups faced similar disparities in access to care. The single larg e s t access problem faced by all groups, except Asians, was lack of health insurance. The largest problem report e d by Asians was lack of a primary care prov i d e r. National Healthcare Disparities Report H i g h l i g h t s I n c reasing Disparities Relative to Reference Group Measures for which a group received worse care than the reference group and for which this difference wa s getting worse rather than better are listed in Ta ble H.2. Table H.2. Disparities in quality of health care that are getting worse for selected groups G ro u p M e a s u re Black vs. White C h i l d ren with admission for asthma C h i l d ren with all recommended vaccines Elderly with pneumococcal vaccine Hospital treatment of pneumonia Asian vs. White Elderly with pneumococcal vaccine American Indian/Alaska Hospital treatment of heart attack Native vs. White High risk nursing home residents with pre s s u re sore s Home health care patients admitted to hospital Dialysis patients on waiting list for transplantation Hispanic vs. Needed and received substance abuse treatment non-Hispanic White Persons with diabetes with three recommended services 8 Mental health treatment for serious mental illness Adults with patient-provider communication pro b l e m s Illness/injury care as soon as wanted Tu b e rculosis patients who complete treatment within 12 months C h i l d ren with patient-provider communication pro b l e m s Hospitalized smokers with advice to quit Elderly with pneumococcal vaccine C h i l d ren with dental visit Hospital treatment of heart attack New AIDS cases Poor vs. high income Hospitalized smokers with advice to quit Illness/injury care as soon as wanted Persons with diabetes with three recommended services Adults with patient-provider communication pro b l e m s C h i l d ren with all recommended vaccines Note: ?Asian? includes ?Asian or Pacific Islander? when information is not collected separately for each group. The most recent and oldest years of data available are compare d . ? All groups had at least one area in which they received worse care and for which the difference wa s getting worse. Hispanics had many more measures that fell in this categ o ry than other groups. National Healthcare Disparities Report H i g h l i g h t s ? Some disparities in quality of care were unique to specific groups. Other disparities in quality of care were prominent for multiple groups; these disparities include: Va c c i n a t i o n s Hospital treatment of heart attack S e rvices for persons with diabetes P r o blems with timeliness Smoking cessation P r o blems with patient-provider communication The 2005 NHDR also found that only Hispanics and the poor faced disparities in access to care that were getting worse: ? For the poor, disparities in 4 of the 6 core report measures of access were getting worse. ? For Hispanics, all disparities in access were getting worse except being uninsured all ye a r. Information About Disparities Is Impro v i n g The 2005 NHDR provides more information about disparities than previous reports. In part, this is attribu t a bl e to improving data ava i l a ble for assessing disparities: ? A dditional data sourc e s?The 2005 NHQR and NHDR introduce these new data sources: Substance A buse and Mental Health Services Administration (SAMHSA) Treatment Episode 9 Data Set (TEDS). TEDS provides information on about 1.5 million substance abuse treatment admissions annually. C D C ?s National Program of Cancer Registries (NPCR). This program (45 States and the District of Columbia) together with data from the Surveillance, Epidemiology and End Results Progr a m (9 States and 6 metro areas) provides population-based cancer incidence data for the entire Nation. CMS and the Hospital Quality A l l i a n c e ?s Hospital Compare. Hospital Compare provides audited, near real-time information from 4,200 hospitals on care for heart attack, heart failure, and p n e u m o n i a . ? N ew measure s?The HHS Interagency Work Groups for the reports approved the addition of new measures of the quality of: HIV care. Mental health care. Substance abuse treatment. ? N ew cross-cutting va r i abl e s? N ew questions in A H R Q ?s 2002 Medical Expenditure Panel Survey (MEPS) allow examination of topics that are related to disparities including: Language spoken at home: English vs. another language. C o u n t ry of birth: United States vs. other country. ? Expanded capability of existing data sourc e s?More databases have completed transition to the 1997 Federal standards for racial and ethnic data and are able to provide: Estimates for Asians, Native Hawaiians or Other Pa c i fic Islanders, and people of more than one r a c e . R e l i a ble estimates for smaller groups due to refinements in sampling and ove r s a m p l i n g . National Healthcare Disparities Report H i g h l i g h t s Multiple years of data for almost all core report measures now allow more stable trending and assessments of disparities. Howeve r, gaps in information remain. For example, of the core report measures, statistically r e l i a ble estimates were not possible for: ? Most measures for Native Hawaiians and Other Pa c i fic Islanders. ? About half of quality measures for American Indians and Alaska Native s . ? About a third of quality measures for A s i a n s . Data collection that focuses on specific groups may be needed to yield reliable information about these p o p u l a t i o n s . Future reports will continue to benefit from continually improving data for examining and tracking disparities. Data from the National Center for Health Statistics (NCHS) 2004 National Nursing Home Survey are expected to be ava i l a ble for the 2006 reports; this should help to improve our understanding of disparities in the quality of nursing home care. NCHS? National Health Interv i ew Survey data will begin to include oversamples of Asians in the near future. A working group convened by AHRQ that includes representation from the Departments of Commerce, Education, Health and Human Services, and Veterans A ffairs is curr e n t ly working to create a standard definition of disability that can be applied across multiple extant databases; this d e finition should allow expanded analyses related to persons with disabilities in future report s . 10 Other eff o rts will improve data quality for the reports in the long term. For ex a m p l e : ? The Health Research and Educational Trust continues to improve collection of racial and ethnic data by hospitals. ? A m e r i c a ?s Health Insurance Plans (AHIP) has developed a toolkit to help health plans collect data to address disparities and is conducting regional workshops in cities where data collection could be enhanced. ? The National Health Plan Learning Collaborative to Reduce Disparities and Improve Quality is spearheading the analysis and use of disparities data by health plans. ? The recently enacted Patient Safety and Quality Improvement Act of 2005 creates a network of patient safety databases that will supply information for the reports. Fi n a l ly, the revolution in health information technologies allows data needed to assess disparities to be collected and processed more quickly, effi c i e n t ly, securely, and economically each ye a r. Looking Forward The NHDR continues to be the broadest annual examination of disparities in health care ever undert a ken in the United States. As support for reducing disparities continues to gr ow, the ability to monitor and track i m p r ovements in disparities is becoming critical. In this 2005 report, the information infrastructure built in p r evious reports to track the Nation?s progress toward the elimination of disparities in health care is reaching m a t u r i t y. For the first time, multiple years of data are ava i l a ble to assess the direction of change across a larg e number of measures of health care quality and access. The NHDR finds that many racial disparities are i m p r oving but that many disparities affecting Hispanics and the poor are getting larg e r. Potential opport u n i t i e s for improvement exist, notably in timeliness and patient-provider communication, where many gr o u p s encounter problems and disparities are often getting wo r s e . National Healthcare Disparities Report H i g h l i g h t s The NHDR concentrates on the national view of health care disparities. It is descriptive and not prescriptive about how to eliminate disparities. Because causes of disparities and priorities for addressing them va ry across the country, successfully addressing disparities often requires focused community-based projects that are supported by detailed local data. Prevention and elimination of health care disparities for the wh o l e Nation will result from coordinated actions at Federal, State, and local levels to extend the benefits of reg i o n a l and local successes nationwide. The methods and measures used in the reports are made ava i l a ble online in hopes that communities and providers will apply them to their own data. Communities that make this i nvestment may use NHDR findings as annual national benchmarks against which to compare their progr e s s . Working tog e t h e r, using the NHDR as a guide, A m e r i c a ?s patients, providers, purchasers, and policy m a ke r s can make full access to high quality health care a reality for all. 11 National Healthcare Disparities Report 12 National Healthcare Disparities Report I n t roduction and Methods Chapter 1. Introduction and Methods In 1999, Congress directed the A g e n cy for Healthcare Research and Quality (AHRQ) to produce an annual r e p o rt, starting in 2003, to track ?prevailing disparities in health care delive ry as it relates to racial factors and socioeconomic factors in priority populations.? Although the emphasis is on disparities related to race, e t h n i c i t y, and socioeconomic status (SES), this directive includes a charge to examine disparities in ?priority p o p u l a t i o n s ? ? groups with unique health care needs or issues that require special focus. The first National Healthcare Disparities Report (NHDR), released in 2003, was a comprehensive national ove rv i ew of disparities in health care among racial, ethnic, and socioeconomic groups in the general U. S . population and within priority populations. The second NHDR initiated a second critical goal of the report series?tracking the Nation?s progress towards the elimination of health care disparities. This third NHDR meets these goals more completely and rigorously. New databases and measures have been added to provide a more comprehensive assessment of disparities in the Nation. Methods have been d eveloped for tracking change in disparities in a standardized fashion that allows identification of specifi c disparities that are improving and disparities that are worsening. While the 2005 report aims to include more data, eff o rts have also been made to make this gr owing body of i n f o rmation more understandable. To this end, the most important and scientifi c a l ly supported measures? 13 i d e n t i fied as core report measures?have been selected from the full NHDR measure set and are the focus of the report. This ye a r ?s report begins annual tracking of these core report measures. Another approach to making large amounts of information easier to comprehend is to create composite or summary measures. This ye a r ?s report introduces several new composite measures of quality. As in previous years, the 2005 NHDR was planned and written by AHRQ staff with the support of A H R Q ?s National A d v i s o ry Council and the Interagency Work Group for the NHDR. The work group includes r e p r e s e n t a t ives from eve ry operating division of the Department of Health and Human Services (HHS). In addition, to guide the development of new composite measures and new methods for summarizing report i n f o rmation, a Technical Expert Panel was convened. This panel included health statisticians and health p o l i cy m a kers from the Federal and private sectors. How This Report Is Organized The basic structure of the report is unchanged from last year and consists of the following: ? H i g h l i g h t s summarizes key themes from the 2005 report . ? Chapter 1: I n t roduction and Methods documents the organization, data sources, and methods used in the 2005 report and describes major changes from previous report s . ? Chapter 2: Quality of Health Care examines disparities in quality of health care in the general U. S . population. Measures of quality of health care used in this chapter are identical to measures used in the National Healthcare Quality Report (NHQR) except when data to examine disparities are unava i l a bl e . Sections cover four components of health care quality: eff e c t iveness, patient safety, timeliness, and patient centeredness. National Healthcare Disparities Report I n t roduction and Methods ? Chapter 3: Access to Health Care examines disparities in access to health care in the general U. S . population. Sections cover two components of health care access: barriers and facilitators to health care and health care utilization. ? Chapter 4: Priority Po p u l a t i o n s examines disparities in quality of and access to health care among A H R Q ?s priority populations including: Racial and ethnic minorities E l d e r ly L ow income gr o u p s Residents of rural areas Wo m e n I n d ividuals with special health care needs C h i l d r e n A p p e n d i xes are ava i l a ble online (www. q u a l i t y t o o l s . a h rq . g ov) and include: ? Appendix A : Data Sourc e s p r ovides information about each database analyzed for the NHDR including data type, sample design, and primary content. ? Appendix B: Detailed Methods p r ovides detailed methods for select databases analyzed for the NHDR. ? Appendix C: M e a s u re Specifi c a t i o n s p r ovides information about how to generate each measure a n a lyzed for the NHDR. It includes both measures highlighted in the report text as well as other 14 measures that were examined but not included in the text. It also includes information about the s u m m a ry measures used in the report . ? Appendix D: Data Tables p r ovides detailed tables for most measures analyzed for the NHDR, including both measures highlighted in the report text and measures examined but not included in the text. A few measures cannot support detailed tables and are not included in the appendix. When data are ava i l a ble: Race tables and ethnicity tables are stratified by age, gender, residence location, and one or more socioeconomic va r i a bles (i.e., household income, education, insurance, and/or area income). Socioeconomic tables are stratified by age, gender, residence location, race, and ethnicity. S u m m a ry data tables organized by topic are presented first followed by detailed data tables for each measure. New in This Report Consistent with the goal of improving quality of and access to health care for all Americans, a number of i m p r ovements in the quality and accessibility of the NHDR are made each ye a r. Improvements include changes to report format, changes to the measure set, addition of new data sources, expanded analyses, and s u m m a ry of disparities. Changes to Report Format With broad support across HHS, the 2004 NHDR and its companion NHQR were restructured as chart b o o k s . For the 2005 reports, additional modifications have been made to make the information in the reports easier to understand. Although needed to assess health care in America comprehensive ly, the large number of measures t r a c ked in the reports may sometimes be confusing and ove r whelming for users. Hence, changes in report National Healthcare Disparities Report I n t roduction and Methods f o rmat have been implemented to help focus attention on the most significant issues and trends, including the selection of core report measures and the development of new composite measures. C o re re p o rt measure s . For the 2005 reports, the Interagency Work Groups were convened to select a gr o u p of measures from the full measure sets on which the reports would present findings each ye a r. Focus on tracking these core report measures allows more detailed discussion of this subset of measures, which, as noted above, represent the most important and scientifi c a l ly sound measures in the full measure sets. In addition, readers will be able to more readily observe changes in the same measures each ye a r. Measures in the full measure sets must have met criteria for inclusion based on importance, scientifi c soundness, and feasibility. The Interagency Work Groups established additional criteria for selecting the core r e p o rt measures. Many of these criteria were based on criteria used to select the Healthy People 2010 Leading Health Indicators as well as criteria used to select measures to highlight in the 2004 reports. Primary, s e c o n d a ry, and balancing criteria are listed in Ta ble 1.1. Primary criteria were given greater weight than s e c o n d a ry criteria. Balancing criteria were included to ensure that core report measures covered all conditions and sites of care included in the full measure sets. This process yielded 46 core report measures of quality of health care and 13 core report measures of access to health care.i These core report measures are generally representative of the full measure set when testing 15 disparities and trends over time. The distributions of disparities are generally comparable in the two measure sets. In addition, the medians of the average annual percentage change for the full measure set and for the core measure set were consistent for the four components of care and overall. i For a list of these measures, see Ta bles 2.1- 2.3 in Chapter 2, Quality of Health Care, and Ta bles 3.1-3.2 in Chapter 3, Access to Health Care. National Healthcare Disparities Report I n t roduction and Methods Table 1.1. Criteria for selecting core report measures Primary criteria Importance/clinical significance/pre v a l e n c e Reliability of data Ability to track multiple disparities groups at multiple levels/number of comparisons possible Sensitivity to change (evidence-based process measures favored over outcomes) Ease of interpretation and understanding/methodological simplicity High utility for directing public policy Secondary criteria Applicability to the general U.S. population Availability of data regularly and recently Ability to link to established indicator sets (i.e., Healthy People 2010 objectives) Ability to support multivariate modeling Balancing criteria Balance across health conditions a c ross core re p o r t Balance across sites of care m e a s u re s Inclusion of at least some State data Inclusion of at least some multivariate models 16 Composite measure s . Composite measures can be used to facilitate understanding of information from many i n d ividual measures. Composite measures used in previous reports include the percentage of persons with diabetes who receive a number of recommended serv i c e si i and the percentage of children who receive all recommended vaccines. Because these composite measures were reported to be useful by a variety of p o l i cy m a kers, an eff o rt was made to identify new composite measures for the 2005 and future reports. A Technical Expert Panel consisting of health statisticians and health policy m a kers from the Federal and priva t e sectors was convened to provide guidance. This panel made recommendations about the selection of appropriate models for different types of composite measures as well as for specific composite measures that could be crafted from the current report measure sets. A number of these recommended composite measures were developed for the 2005 reports. Three new composite measures build upon an opportunities model developed by Qualidigm1 and used in the Centers for Medicare & Medicaid Services (CMS) Premier Hospital Quality Incentive Demonstration2 and for publ i c r e p o rting by the Rhode Island Department of Health.3 The model assumes that each patient needs and has the o p p o rtunity to receive one or more processes of care but that not all patients need the same care. T h e denominator for an opportunities model composite is the sum of these opportunities to receive appropriate care across a panel of process measures. The numerator is the sum of the appropriate care that is actually delive r e d . The composite measure is typically presented as the proportion of appropriate care that is delivered. In addition, a composite measure of patient-provider communication developed for the CAHPS? (form e r ly k n own as Consumer Assessment of Health Plans4) survey is included in this report. The composite measure averages four measures of patient centeredness used in previous NHDRs. The composite measure is typically presented as the proportion of respondents who reported that their doctors sometimes or neve r, usually, or a lways communicated we l l . i i This composite measure was modified between the 2004 and 2005 reports. The current composite measure of diabetes care focuses on receipt of the three processes for which the best data are ava i l a ble: HbA1c testing, retinal eye examination, and foot examination in the past ye a r. National Healthcare Disparities Report I n t roduction and Methods N ew composite measures included in the 2005 reports and the individual measures they aggr egate are show n in Ta ble 1.2. Future reports will include even more composite measures. Table 1.2. New composite measures in the 2005 NHQR and NHDR Composite measure Individual measures forming composite Recommended hospital Receipt of aspirin within 24 hours of hospitalization c a re for heart attack Receipt of aspirin upon discharg e Receipt of beta-blocker within 24 hours of hospitalization Receipt of beta-blocker upon discharg e Receipt of ACE inhibitor for left ventricular systolic dysfunction Receipt of counseling about smoking cessation among smokers Recommended hospital Receipt of evaluation of left ventricular ejection fraction c a re for heart failure Receipt of ACE inhibitor for left ventricular systolic dysfunction Recommended hospital Receipt of initial antibiotics within 4 hours c a re for pneumonia Receipt of appropriate antibiotics Receipt of culture before antibiotics Receipt of influenza screening or vaccination Receipt of pneumococcal screening or vaccination 17 P a t i e n t - p ro v i d e r P rovider sometimes or never listened carefully to them c o m m u n i c a t i o n P rovider sometimes or never explained things clearly P rovider sometimes or never showed respect for what they had to say P rovider sometimes or never spent enough time with them P re s e n t a t i o n . Each section in the 2005 report begins with a description of the importance of the section?s topic. Where possible, this introduction is now provided in a more standardized format. Then, chart fi g u r e s and accompanying findings highlight a small number of measures relevant to this topic. When data are ava i l a ble, these charts typically show contrasts by : ? Race?Blacks, A s i a n s ,i i i N a t ive Hawaiians or Other Pa c i fic Islanders (NHOPIs), American Indians or Alaska Natives (AI/ANs), and people of more than one race compared with W h i t e s . ? Ethnicity?Hispanics compared with non-Hispanic W h i t e s . ? I n c o m e ? Po o r, near poor, and middle income people compared with high income people.iv ? E d u c a t i o n ? People with less than a high school education and high school graduates compared with people with any college education. Almost all core report measures and composite measures have multiple years of data, so figures typically illustrate trends over time. When data support stratified analyses, a figure showing racial and ethnic d i fferences stratified by SES is included. When data support multivariate analyses, regressions were run and used to help interpret bivariate and stratified results. Multivariate analyses were performed for 10 of the core r e p o rt measures for quality of care and 9 of the core report measures of access to care, though they are not presented within the report. As in last ye a r ?s report, findings presented in the text meet report criteria for iii ?Asian? includes ?Asian or Pa c i fic Islander? (API) when information is not collected separately for each gr o u p . iv Throughout this report, ?poor? is defined as having fa m i ly incomes less than 100% of the Federal pove rty level; ?near p o o r,? between 100% and 199%; ?middle income,? between 200% and 399%; and ?high income,? 400% or more of the Federal pove rty leve l . National Healthcare Disparities Report I n t roduction and Methods i m p o rt a n c ev; comparisons not discussed in text do not meet these criteria. Howeve r, absence of diff e r e n c e s that meet criteria for importance should not be interpreted as absence of disparities. Often, large diff e r e n c e s b e t ween groups did not meet criteria for statistical significance because of small sample sizes and limited p owe r. In addition, significance testing used in this report does not take into account multiple comparisons. Changes to the Measure Set The measure sets used in the 2005 NHDR and NHQR have been improved in several ways. First, a handful of measures were modified to reflect more current standards of care. Second, age adjustmentv i for a number of measures was updated. Fi n a l ly, a number of new measures were added to fill identified gaps, including: ? Two measures of quality of HIV care from the HIV Research Netwo r k : HIV patients with CD4 cell count <200 who received P n e u m o c y s t i s pneumonia (PCP) prophy l a x i s . HIV patients with CD4 cell count <50 who received disseminated Mycobacterium avium c o m p l ex ( M AC) prophy l a x i s . ? One measure of quality of mental health care from the Substance A buse and Mental Health Serv i c e s A d m i n i s t r a t i o n ?s (SAMHSA?s) National Survey on Drug Use and Health: Adults with serious psychological distress receiving treatment who get better. 18 ? One measure of quality of substance abuse treatment from SAMHSA?s Treatment Episode Data Set ( T E D S ) : Patients receiving substance abuse treatment who complete treatment. Measure revisions were proposed and rev i ewed in meetings of the Interagency Work Group for the NHDR, which includes representation from across HHS. Addition of New Data Sourc e s As in previous years, new sources of data were identified and added to help fill these gaps (Ta ble 1.3). Standardized suppression criteria were applied to all databases to support reliable estimates.vii N ew data added this year come from: ? S A M H S A?s Treatment Episode Data Set. This database provides information on about 1.5 million substance abuse treatment admissions annually. ? Centers for Disease Control and Prevention (CDC) National Program of Cancer Registries (NPCR). T h i s p r ogram (45 States and the District of Columbia) together with data from the National Cancer Institute?s S u rveillance, Epidemiology and End Results (SEER) program (9 States and 6 metro areas) prov i d e s population-based cancer incidence data for the entire Nation. ? Centers for Medicare & Medicaid Services and Hospital Quality A l l i a n c e ?s Hospital Compare. T h i s database provides audited, near real-time information from 4,200 hospitals on care for heart attack, heart failure, and pneumonia. v Criteria for importance are that the difference is statistically significant at the alpha=0.05 level, two-tailed test and that the r e l a t ive difference is at least 10% different from the reference group when framed positive ly as a favo r a ble outcome or n ega t ive ly as an adverse outcome. v i Age-adjusted measures are labeled as such. All other measures are not age adjusted. v i i Estimates based on sample size fewer than 30 or with relative standard error greater than 30% were considered unreliabl e and suppressed. Databases with more conserva t ive suppression criteria were allowed to retain them. National Healthcare Disparities Report I n t roduction and Methods Expanded Analyses Trends in health care quality and access. In previous NHDRs and NHQRs, many measures were report e d for only 2 years, gr e a t ly limiting the ability to detect trends. In the 2005 reports, 3 or more years of data are n ow reported for most measures in the measure sets. In addition, methods for assessing temporal change have been improved and standardized. In the 2005 reports, the oldest and most recent estimates for each measure are used to calculate average annual rate of change for the general U.S. population and for each racial, ethnic, and socioeconomic gr o u p . Consistent with Health, United States, the geometric rate of change, which assumes the same rate each ye a r b e t ween the two time periods, has been calculated for the 2005 NHDR and NHQR. Two criteria are applied to determine whether a significant trend exists: ? First, the difference between the oldest and most recent estimates must be statistically significant with p<0.05. ? S e c o n d, the magnitude of average annual rate of change must be at least 1% per ye a r, when the measures are framed as a favo r a ble outcome or as an adverse outcome. O n ly changes over time that meet these two criteria are discussed in the 2005 report s . One additional constraint relates to trends among specific racial and ethnic groups. Some Federal databases 19 completed transition to the 1997 Federal standards for racial and ethnic data during years covered by the NHDR. These new standards created two separate racial categories: ?Asian? and ?Native Hawaiian or Other Pa c i fic Islander.? In addition, individuals could report more than one race, which signifi c a n t ly affected estimates for the ?American Indian or Alaska Native? categ o ry. In contrast, effects on estimates for Whites, Blacks, and Hispanics were proport i o n a t e ly much smaller. The 2005 NHDR does not show trends for groups directly or s i g n i fi c a n t ly affected by the new standards. Howeve r, trends for Whites, Blacks, and Hispanics that span this transition are shown because effects are small. L a n g u a ge spoken at home and country of birt h . Language and country of birth are important determ i n a n t s of health care, especially for racial and ethnic minorities. In the 2003 NHDR, data from the Commonwe a l t h Fund Health Care Quality Survey were used to examine these effects on disparities, but no new data cove r i n g these issues were ava i l a ble for the 2004 NHDR. For the 2005 NHDR, A H R Q ?s Medical Expenditure Pa n e l S u rvey (MEPS) added questions about language spoken at home and country of birth. Findings that compare people who speak English at home with people who speak another language at home and people born in the United States with people born in a foreign country are shown in Chapter 4, Priority Populations. In addition, MEPS tables in the NHDR appendixes now include these comparisons. Summary of Disparities In the 2005 NHDR, eff o rts to summarize disparities have been further refined. In the Highlights and in Chapter 4, Priority Populations, the extent of disparities across the core report measures are summarized for Blacks, Hispanics, Asians, NHOPIs, AI/ANs, and the poor. Racial, ethnic, and socioeconomic groups are compared with a designated comparison group for each core report measure; each group could receive care that is worse than, about the same as, or better than the comparison group. For each group, the percentages of National Healthcare Disparities Report I n t roduction and Methods measures for which the group received worse care, similar care, or better care were calculated. All core report measures of quality of care were used when summarizing disparities in quality. Health care utilization measures are difficult to interpret and were excluded when summarizing disparities in access to care. N ew methods of summarizing disparities and identifying areas for improvement are also included in this r e p o rt : Rate re l a t ive to re f e rence gro u p . To begin to quantify the magnitude of disparities and to identify the larg e s t disparities faced by specific groups, rates relative to designated comparison groups were examined. For each group, the group rate was divided by the comparison group rate to calculate the relative rate for each core r e p o rt measure. For each group, the relative rates were then sorted. The median relative rate across core r e p o rt measures is presented in Chapter 4 as another way of summarizing the magnitude of disparities in quality and access. The relative rates are also used to identify potential areas for improvement in the Highlights and Chapter 4, Priority Po p u l a t i o n s . Trends in disparities. A new method for summarizing trends in disparities is introduced in this report. Fo r each core report measure, racial, ethnic, and socioeconomic groups are compared with a designated comparison group at different points in time. Both absolute and relative diff e r e n c e sv i i i are compared using the most recent and oldest years of data ava i l a ble. Core report measures for which both the absolute diff e r e n c e s 20 and the relative differences are becoming smaller over time are identified as improving disparities. Core r e p o rt measures for which both the absolute differences and the relative differences are becoming larger ove r time are identified as worsening disparities. Uncommonly, absolute and relative differences do not agree on direction of change. In these cases, direction of change is unclear and results for these measures are not presented. For each group, the percentage of core report measures with trend data that were improving or worsening was calculated; these percentages are presented in the Highlights and in Chapter 4, Priority Populations. Note that data on all core report measures were not ava i l a ble for all groups. Hence, summary measures should only be used to quantify differences between a specific group and its comparison group. v i i i Absolute differences are calculated by subtracting one rate from the comparison group rate. Relative differences are calculated by dividing one rate by the comparison group rate National Healthcare Disparities Report I n t roduction and Methods Table 1.3. Databases used in the 2005 reports (new databases in italics) Surveys collected from samples of civilian populations: ? AHRQ, Medical Expenditure Panel Survey (MEPS), 1999-2002 ? CDC-NCHS, National Health Interview Survey (NHIS), 1998-2003 ? CDC-NCHS/National Immunization Program, National Immunization Survey (NIS), 1998-2003 ? CMS, Medicare Current Beneficiary Survey (MCBS), 1998-2002 ? HRSA, Community Health Center User Survey, 2002 ? SAMHSA, National Survey on Drug Use and Health (NSDUH), 2002-2003 Data collected from samples of health care facilities and pro v i d e r s : ? CDC-NCHS, National Ambulatory Medical Care Survey (NAMCS), 1997-2002 ? CDC-NCHS, National Hospital Ambulatory Medical Care Survey-Outpatient Department (NHAMCS-OPD), 1 9 9 7 - 2 0 0 2 ? CDC-NCHS, National Hospital Ambulatory Medical Care Survey-Emergency Department (NHAMCS-ED), 1 9 9 7 - 2 0 0 2 ? CDC-NCHS, National Hospital Discharge Survey (NHDS), 1998-2003 ? CMS, End Stage Renal Disease Clinical Performance Measures Project (ESRD CPMP), 2001-2003 21 Data extracted from data systems of health care organizations: ? AHRQ, Healthcare Cost and Utilization Project State Inpatient Databases disparities analysis filei ( H C U P SID), 2001-2002 ? CMS, Hospital Compare, 2004 ? CMS, Medicare Patient Safety Monitoring System, 2002-2003 ? CMS, Nursing Home Minimum Data Set, 2002-2003 ? CMS, Quality Improvement Organization (QIO) program, 2000-2003 ? HIV Research Network data (HIVRN), 2001-2002 ? IHS, National Patient Information Reporting System (NPIRS), 2002-2003 ? NCQA, Health Plan Employer Data and Information Set (HEDIS), 2001-2004 ? NIH, United States Renal Data System (USRDS), 1998-2002 ? SAMHSA, Treatment Episode Data Set (TEDS), 2002 Data from surveillance and vital statistics systems: ? CDC, National Nosocomial Infections Surveillance, 1998-2003 ? CDC, National Program of Cancer Registries (NPCR), 2002 ? CDC-National Center for HIV, STD, and TB Prevention, HIV/AIDS Surveillance System, 2000-2003 ? CDC-National Center for HIV, STD, and TB Prevention, TB Surveillance System, 1999-2001 ? CDC-NCHS, National Vital Statistics System (NVSS), 1999-2002 ? NIH, Surveillance, Epidemiology, and End Results (SEER) program, 1992-2002 i This file is designed to provide national estimates of disparities in the AHRQ Quality Indicators using weighted records from a sample of hospitals from the following 22 States: AZ, CA, CO, CT, FL, GA, HI, KS, MD, MA, MI, MO, NJ, NY, PA , RI, SC, T N, TX, VA, V T, and WI. For details, see Appendix A, Data Sources, and Appendix C, Measure Specifi c a t i o n s . National Healthcare Disparities Report I n t roduction and Methods R e f e re n c e s 1. Scinto JD, Galusha DH, Krumholz HM, Meehan T P. The case for comprehensive quality indicator reliability assessment. J Clin Epi. 2001; 54:1103-11. 2. Rewarding Superior Quality Care: The Premier Hospital Quality Incentive Demonstration. Centers for Medicare & Medicaid Services Fact Sheet. March 2005. 3. Rhode Island Department of Health. Hospital Pe r f o rmance in Rhode Island. Technical Report. July 2003. < h t t p : / / w w w. h e a l t h . r i . g ov / c h i c / p e r f o rm a n c e / q u a l i t y / q u a l i t y 1 7 t e c h . p d f > 4. Hargr aves J, Hays RD, Cleary PD. Psychometric properties of the Consumer Assessment of Health Plans Study (CAHPS) 2.0 adults core survey. Health Serv Res 2003 Dec;38(6 Pt 1):1509-27. 22 National Healthcare Disparities Report Quality of Health Care Chapter 2. Quality of Health Care As better understanding of health and sickness has led to superior ways of preventing, diagnosing, and treating diseases, the health of most Americans has improved dramatically. Howeve r, ample evidence indicates that some Americans do not receive the full benefits of high quality care. Specifi c a l ly, ex t e n s ive disparities in health care related to race, ethnicity, and socioeconomic status have been demonstrated by much research and c o n fi rmed by previous releases of the National Healthcare Disparities Report . Components of Health Care Quality Quality health care means doing the right thing, at the right time, in the right way, for the right people?and h aving the best possible results.1 Quality health care is care that is: ? E ff e c t ive ? P r oviding services based on scientific knowledge to all who could benefit and refraining from p r oviding services to those not like ly to benefi t . ? S a f e ? Avoiding injuries to patients from the care that is intended to help them. ? Ti m e ly?Reducing waits and sometimes harmful delays for both those who receive and those who give c a r e . 23 ? Patient centered?Providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions. ? E q u i t a bl e ? P r oviding care that does not va ry in quality because of personal characteristics such as g e n d e r, ethnicity, geographic location, and socioeconomic status. ? E ffi c i e n t ? Avoiding waste, including waste of equipment, supplies, ideas, and energ y.2 Health care quality is measured in several ways including: ? Clinical performance measures of how well providers deliver specific services needed by specifi c patients, such as whether children get the immunizations that they need. ? Assessments by patients of how well providers meet health care needs from the patient?s perspective, such as whether providers communicate clearly. ? Outcome measures?such as death rates from cancers preve n t a ble by screening?that may be affected by the quality of health care receive d . How This Chapter Is Organized This chapter presents new information about disparities in quality of health care in America. The measures used here are the same as those used in the National Healthcare Quality Report, and this chapter is c o n s t ructed to mirror sections in the NHQR?eff e c t iveness, patient safety, timeliness, and patient centeredness. Eff e c t iveness of care is presented under eight clinical condition or care setting areas: cancer, diabetes, end stage renal disease (ESRD), heart disease, HIV and AIDS, mental health and substance abu s e , r e s p i r a t o ry diseases, and nursing home and home health care. Maternal and child health is discussed in Chapter 4, Priority Po p u l a t i o n s . As in previous NHDRs, this chapter?s discussion on quality of care focuses on disparities in quality related to race, ethnicity, and socioeconomic status in the general U.S. population. Disparities in quality of care within National Healthcare Disparities Report Quality of Health Care s p e c i fic priority populations are presented in Chapter 4. This chapter also presents analyses of changes ove r time, as well as some stratified analyses. A d d i t i o n a l ly, this year the NHDR focuses on a narr ower set of measures than the full set of measures tracke d in previous reports. With guidance from the Interagency Work Groups advising the NHDR and NHQR, this n a rr ower set of core report measures was established. The core report measures aim to be representative of the overall NHDR measure set; but, because they are fewer in number, they are more manageable for p o l i cy m a kers and others to understand and apply when utilizing the NHDR. For details on the process used to e s t a blish core report measures, see Chapter 1, Introduction and Methods. It is primarily core report measures that are presented in the 2005 NHDR and that will be tracked in future iterations of the NHDR. Howeve r, the entire NHDR measure set will continue to appear in the appendixe s ; and from year to ye a r, supplemental measures (those from the overall NHDR measure set that are not core r e p o rt measures) will be presented in the text of the NHDR as well. This ye a r ?s report includes a small amount of supplemental measures. Fi n a l ly, new composite measures are introduced in this ye a r ?s NHDR, including composites for appropriate hospital care for heart attack and pneumonia. T h ey are presented in this chapter in the sections on heart disease and respiratory diseases, respective ly. For composite details, see Chapter 1, Introduction and Methods. 24 Categorization of Effectiveness Measures by Health Care Need To facilitate identifying the measures discussed in this section as related to the patient?s need for preve n t ive care, treatment of acute illness, and chronic disease managment, the eff e c t iveness section of this chapter c a t egorizes measures as follows: P re v e n t i o n The majority of health care resources are invested in caring for the unhealthy. Howeve r, caring for healthy people is another important component of health care. Educating people about healthy behaviors can help to postpone and avoid illness and disease. A d d i t i o n a l ly, detecting health problems at an early stage increases the chances of eff e c t ive ly treating them, often reducing suffering and expenditures. Tre a t m e n t E ven when preve n t ive care is ideally implemented, it cannot entirely ave rt the need for acute care. Delive r i n g optimal treatments for acute illness can help reduce the consequences of illness and promote the best recove ry p o s s i ble. M a n a g e m e n t Some diseases, such as diabetes and end stage renal disease, are chronic, which means they cannot simply be treated once; they must be managed across a lifetime. Management of chronic disease often invo l ves lifestyle changes and regular contact with a provider to monitor the status of the disease. For patients, eff e c t ive management of chronic disease can mean the difference between normal, healthy living and frequent medical p r o blems. Note that findings for women and children, which parallel those presented in the NHQR for maternal and child health, are presented in the sections on women and children in Chapter 4, Priority Populations, bu t a p p l i c a ble measures are included in the list below. National Healthcare Disparities Report Quality of Health Care Measures presented in eff e c t iveness fall within the three components of health care need as listed below. (Fo r findings related to all core report measures of eff e c t iveness, see Ta bles 2.1a and 2.1b. ) S e c t i o n M e a s u re P reve n t i o n : Cancer (breast) M a m m ogr a p hy Cancer (breast) A d vanced stage breast cancer H e a rt disease Cholesterol screening* R e s p i r a t o ry diseases Pneumococcal vaccination M a t e rnal and child health (wo m e n ) Osteoporosis screening* M a t e rnal and child health (wo m e n ) Prenatal care M a t e rnal and child health (wo m e n ) Dental care M a t e rnal and child health (children) Dental carei* M a t e rnal and child health (children) Counseling about physical activ i t y Tre a t m e n t : H e a rt disease Recommended hospital care for heart attack R e s p i r a t o ry diseases Recommended hospital care for pneumonia 25 Nursing home and home health care I m p r oved walking or mov i n g Nursing home and home health care Hospital admission for home care patients M a t e rnal and child health (wo m e n ) Recommended hospital care for heart attack M a t e rnal and child health (children) Hospital admissions for ga s t r o e n t e r i t i s Mental health and substance abu s e R e p o rted help from mental disorder treatment Mental health and substance abu s e Completion of substance abuse treatment Mental health and substance abu s e Receipt of needed substance abuse treatment M a n a ge m e n t : Diabetes H e m oglobin, cholesterol, blood pressure Diabetes Receipt of recommended services for diabetes End stage renal disease (ESRD) A d e q u a cy of hemodialysis End stage renal disease (ESRD) R egistration for transplantation H e a rt disease Blood pressure under control* HIV and AIDS HIV patients with PCP and MAC prophy l a x i s * HIV and AIDS N ew AIDS cases Nursing home and home health care Use of physical restraints Nursing home and home health care P r evalence of pressure sores M a t e rnal and child health (wo m e n ) Receipt of recommended services for diabetes M a t e rnal and child health (children) Pediatric asthma admissions *Supplemental measure. i Includes 1 core measure?dental visits?and 1 supplemental measure?untreated dental carries. National Healthcare Disparities Report Quality of Health Care E ff e c t i v e n e s s C a n c e r Number of deaths (2003) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 5 4 , 6 4 34 Estimated deaths for 2005 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 7 0 , 2 8 03 Cause of death rank (2003) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 n d4 Number of Americans that have been diagnosed with cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 , 8 0 0 , 0 0 03 N ew cases (2005 est.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 , 3 7 2 , 9 1 03 Total cost . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$209.9 billion5 Direct medical costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$74 billion5 Incidence, mort a l i t y, screening, and treatment va ry by . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .r a c e6 7 e t h n i c i t y6 7 S E S8 9 P revention: Mammography 26 Ensuring that all populations have access to appropriate cancer screening services is a core element of reducing cancer health disparities.1 0 This year the NHDR focuses on breast cancer; findings for colorectal cancer are found in the 2004 NHDR. Screening mammogr a p hy is an eff e c t ive way to discover breast cancer before a patient has symptoms and to reduce new cases of late stage disease and mortality caused by this c a n c e r.1 1 Figure 2.1. Women age 40 and over who report they had a mammogram within the past 2 years, by race, ethnicity, income, and education, 2000 and 2003 S o u rc e : National Health Interview Survey, 2000, 2003. R e f e rence population: Women age 40 and over in the civilian noninstitutionalized population. National Healthcare Disparities Report Quality of Health Care ? In both 2000 and 2003, the proportion of women age 40 and over who had a mammogram in the past 2 years was lower among Asian compared with White women; among Hispanic compared with non- Hispanic White women; and among poor, near poor, and middle income women compared with high income women (Figure 2.1). ? In 2000, the proportion of women age 40 and over who had a mammogram in the past 2 years was lowe r among Black women compared with White women, but this disparity was not evident in 2003. ? From 2000 to 2003, the proportion of women age 40 and over who had a mammogram within the past 2 years fell signifi c a n t ly among high income women by 4.1%. ? In 2003, the only groups to achieve the Healthy People 2010 target of 70% of women age 40 and ove r r e c e iving a mammogram within the past 2 years were non-Hispanic White women, women with middle or high incomes, and women with at least some college education. Racial and ethnic minorities are disproport i o n a t e ly of lower socioeconomic status. To distinguish the eff e c t s of race, ethnicity, income, and education on cancer screening, this measure is stratified by income and education level. Figure 2.2. Women age 40 and over who report they had a mammogram within the past 2 years by race (left) and ethnicity (right) stratified by income, 2003 27 S o u rc e : National Health Interview Survey, 2003. R e f e rence population: Women age 40 and over in the civilian noninstitutionalized population. National Healthcare Disparities Report Quality of Health Care Figure 2.3. Women age 40 and over who report they had a mammogram within the past 2 years by race (left) and ethnicity (right) stratified by education, 2003 28 S o u rce: National Health Interview Survey, 2003. R e f e rence population: Women age 40 and over in the civilian noninstitutionalized population. ? Racial and ethnic differences in recent mammogr a p hy use differ with income and education level. ? After controlling for income, near poor Blacks are more like ly to receive mammogr a p hy than near poor Whites. Poor and near poor Hispanics are more like ly to receive mammogr a p hy than respective non- Hispanic Whites (Figure 2.2). ? After controlling for education, Black high school graduates are more like ly to receive mammogr a p hy than White high school graduates (Figure 2.3). National Healthcare Disparities Report Quality of Health Care P revention: Advanced Stage Breast Cancer Cancers can be diagnosed at different stages. Monitoring the rate of cancers that are diagnosed at adva n c e d stages is a measure of the eff e c t iveness of cancer screening eff o rts. Figure 2.4. Age-adjusted rate of advanced stage (stage II or higher) breast cancer per 100,000 women age 40 and older by race (left) and ethnicity (right), 1992-2002 29 K e y : AI/AN=American Indian or Alaska Native; API=Asian or Pacific Islander. S o u rc e : Surveillance, Epidemiology, and End Results program, 1992-2002. R e f e rence population: Women age 40 and older. ? In all years, rates of advanced stage breast cancer were lower among API and AI/AN women compared with White women and among Hispanic women compared with non-Hispanic White women. Black women had higher rates than White women in 1992, 1993, and 2002 (Figure 2.4). ? B e t ween 1992 and 2002, rates of advanced stage breast cancer decreased among AI/AN wo m e n . National Healthcare Disparities Report Quality of Health Care D i a b e t e s Number of deaths (2003) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 3 , 9 6 54 Cause of death rank (2003) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 t h4 Total number of Americans with diabetes (2002) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 8 , 2 0 0 , 0 0 01 2 N ew cases (age 20 and ove r, 2002) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 , 3 0 0 , 0 0 01 2 Total cost . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$132 billion1 2 Direct medical costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$92 billion1 2 Groups more like ly to have or die from diabetes13 14 15 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B l a c k s H i s p a n i c s A I / A N s Management: Receipt of Recommended Services for Diabetes E ff e c t ive management of diabetes includes HbA1c testing, eye examination, and foot examination in the past ye a r, as well as appropriate influenza immunization and lipid management.16 17 Figure 2.5. Adults with diagnosed diabetes who had three recommended services for diabetes in the past 30 year, by race (this page, left), ethnicity (this page, right), and family income (next page) 2000-2002 National Healthcare Disparities Report Quality of Health Care S o u rce: Medical Expenditure Panel Survey, 2000-2002. R e f e rence population: Civilian, noninstitutionalized population with diabetes age 18 and older. 31 Note: Recommended services for diabetes are 1) HBA1c testing, 2) retinal eye examination, and 3) foot examination in past year. ? In 2001 and 2002, the proportion of adults with diagnosed diabetes who had three recommended serv i c e s for diabetes was lower among Hispanics compared with non-Hispanic Whites (Figure 2.5).i i ? In all 3 years, the proportion of adults with diagnosed diabetes who had these services was lower among poor compared with high income adults. In 2002, near poor and middle income adults were also less l i ke ly to receive these services than high income adults. ? From 2000 to 2002, the proportion of adults with diagnosed diabetes who had these services did not change signifi c a n t ly for any racial, ethnic, or income group. i i For diabetes care findings for AI/ANs, see text on the focus on Indian Health Service facilities in Chapter 4, Priority Populations. National Healthcare Disparities Report Quality of Health Care Management: Hemoglobin, Cholesterol, and Blood Pre s s u re Under Contro l Persons with diagnosed diabetes often have other cardiovascular risk factors such as high blood pressure and high cholesterol. The combination of these conditions with diabetes increases the likelihood of complications from diabetes, such as heart disease and stroke. Therefore, in addition to controlling blood sugar levels, diabetes management often includes treating high blood pressure and high cholesterol. HbA1c testing determines the average blood sugar level over 2-3 months and provides information about control of blood sugar leve l s . Checking blood pressure and cholesterol levels is also needed to assess control of these risk fa c t o r s . Figure 2.6. Adults with diagnosed diabetes with HbA1c, total cholesterol, and blood pressure under control, by race/ethnicity, 1999-2002 32 S o u rc e : National Health and Nutrition Examination Survey, 1999- 2 0 0 2 . R e f e rence population: Civilian noninstitutionalized population with diabetes age 18 and over. ? O p p o rtunities for improving the outcomes of diabetes management exist. Only 40% of those diagnosed with diabetes have their HbA1c under optimal control (<7.0%). Significant racial/ethnic disparities are not observed (Figure 2.6). ? O n ly half of those diagnosed with diabetes have their total cholesterol under control (<200 mg/dL). Blacks with diabetes are more like ly than Whites to have their total cholesterol under control. ? O n ly 70% of those diagnosed with diabetes have their blood pressure under control (<140/90). S i g n i ficant racial/ethnic disparities are not observe d . National Healthcare Disparities Report Quality of Health Care End Stage Renal Disease (ESRD) Total ESRD deaths (2003). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 2 , 5 8 81 8 Cause of death rank (2003) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . > 1 5 t h4 Total cases (2003) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 5 2 , 9 5 71 8 N ew cases (2003). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 0 2 , 5 6 71 8 Total ESRD program expenditures (2003) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $27.3 billion1 8 Total patients returning to dialysis or re-transplantation due to graft fa i l u r e . . . . . . . . . . . . . . . . . . > 4 , 7 0 01 8 Since 1995, rates of transplantation for patients under 50 have . . . . . . . . . . . . . . . . . . . . . . . . . . . d e c l i n e d1 8 Since 1995, rates of transplantation for patients over 50 have . . . . . . . . . . . . . . . . . . . . . . . . . . . i n c r e a s e d1 8 Groups more like ly to develop ESRD and less like ly to be treated . . . . . . . . . . . . . . . . . . . . . m i n o r i t i e s19 20 Management: Adequacy of Hemodialysis A d e q u a cy of dialysis is important to the 70% of ESRD patients on dialysis, as it reflects sufficient removal of waste from the body. Racial differences in adequacy of dialysis (urea reduction ratio 65% or higher) have p r ev i o u s ly been report e d .2 1 33 Figure 2.7. Hemodialysis patients with adequate dialysis (urea reduction ratio 65% or higher), by race (left) and ethnicity (right), 2001-2003 Key: AI/AN=American Indian or Alaska Native. S o u rc e : ESRD Clinical Performance Measures Project, 2001-2003. R e f e rence population: ESRD hemodialysis patients and peritoneal dialysis patients. ? In all 3 years, the proportion of hemodialysis patients who received adequate dialysis was lower among Blacks and higher among Asians compared with Whites. (Figure 2.7). National Healthcare Disparities Report Quality of Health Care ? In 2003, the proportion of adult hemodialysis patients who received adequate dialysis was higher among Hispanics compared with non-Hispanic W h i t e s . ? The proportion of adult hemodialysis patients who received adequate dialysis improved signifi c a n t ly from 2001 to 2003 for Whites, Blacks, non-Hispanic Whites, and Hispanics. Management: Registration for Transplantation It is important that persons with ESRD are registered on the waiting list for kidney transplantation to ensure earliest possible transplantation. Racial and ethnic differences in registration on the waiting list for kidney transplantations have been observe d .2 2 Figure 2.8. Dialysis patients under age 70 registered on the waiting list for transplantation by race (left) and ethnicity (right), 1998-2002 34 Key: AI/AN=American Indian or Alaska Native. S o u rc e : ESRD Clinical Performance Measures Project, 1998-2002. R e f e rence population: ESRD hemodialysis patients under age 70 and peritoneal dialysis patients. ? In all 5 years, the proportion of dialysis patients registered for transplantation was lower among Blacks and AI/ANs and higher among Asians compared with Whites (Figure 2.8). ? In all 5 years, the proportion of dialysis patients registered for transplantation was lower among Hispanics compared with non-Hispanic W h i t e s . ? From 1998 to 2002, the proportion of dialysis patients registered for transplantation improved among Whites, Blacks, Asians, non-Hispanic Whites, and Hispanics, but no group achieved the Healthy Pe o p l e 2010 target of 66%. National Healthcare Disparities Report Quality of Health Care Heart Disease Number of deaths (2003) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 8 4 , 4 6 24 Cause of death rank (2003) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 s t4 Number of cases of coronary heart disease (2004) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 3 , 0 0 0 , 0 0 02 3 Number of cases of congestive heart fa i l u r e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 , 9 0 0 , 0 0 02 3 Number of Americans with high blood pressure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 5 , 0 0 0 , 0 0 02 3 Number of heart attacks each ye a r . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 , 1 0 0 , 0 0 02 3 Number of new cases of heart failure each ye a r . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 5 0 , 0 0 02 3 Total cost (cardiovascular disease) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$393.4 billion4 Direct medical costs (cardiovascular disease) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$241.8 billion4 P r evalence and death rate of hy p e rtension and heart disease higher among . . . . . . . . . . . . . . . . . . . .B l a c k s Cardiac care differs by . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .r a c e e t h n i c i t y S E S P revention: Cholesterol Scre e n i n g 35 High cholesterol is a major risk factor for heart disease. Awareness and control of blood cholesterol can help reduce the risk of heart attack. Figure 2.9. Adults with blood cholesterol screening in past 5 years by race (this page, left), ethnicity (this page, right), income (next page, left ), and education (next page, right), 1998 and 2003 National Healthcare Disparities Report Quality of Health Care 36 K e y : AI/AN=American Indian or Alaska Native. S o u rc e : National Health Interview Survey, 1998, 2003. R e f e rence population: Civilian noninstitutionalized population age 18 and over. ? In both 1998 and 2003, the proportion of adults who had their blood cholesterol checked was lowe r among Hispanics compared with non-Hispanic Whites; among poor, near poor, and middle income adults compared with high income adults; and among adults with a high school education or less compared with adults with any college education (Figure 2.9). ? In 1998, AI/ANs were less like ly to receive cholesterol screening compared with Whites. In 2003, Blacks were more like ly to receive cholesterol screening compared with W h i t e s . ? From 1998 to 2003, rates of blood cholesterol screening improved from 67% to 73% for all adults. ? S i g n i ficant improvements in screening were observed within all racial, ethnic, income, and education groups except AI/ANs, for which the change did not reach statistical significance. National Healthcare Disparities Report Quality of Health Care Treatment: Recommended Hospital Care for Heart Attack For heart attack patients who reach the hospital in time, eff e c t ive acute treatment is essential for saving live s and preventing further cardiac damage.2 4 This ye a r, the NHDR introduces a new composite measure for acute care for heart attack, which incorporates the following six measures from previous NHDRs: 1) receipt of aspirin within 24 hours of hospitalization, 2) receipt of aspirin upon discharge, 3) receipt of beta-bl o c ke r within 24 hours of hospitalization, 4) receipt of beta-bl o c ker prescription upon discharge, 5) receipt of AC E inhibitor for left ventricular systolic dysfunction, and 6) counseling about smoking cessation among smokers. Figure 2.10. Recommended hospital care (incorporates six measures as described above) received by Medicare patients with heart attack, by race/ethnicity, 2002-2003 37 K e y : AI/AN=American Indian or Alaska Native. S o u rce: M e d i c a re Quality Improvement Organization Pro g r a m , 2002-2003. R e f e rence population: M e d i c a re beneficiaries hospitalized for heart attack. N o t e s : Whites, Blacks, AI/ANs, and Asians are non-Hispanic g roups. Composite is calculated by averaging the percent of the population that received each of the six incorporated components of c a re. For further details on composite measures, see Chapter 1, I n t roduction and Methods. ? In 2002, Medicare patients with heart attack received recommended hospital care 80% of the time; in 2003 this population received recommended care 82% of the time (Figure 2.10). ? In both years, these percentages were lower among Blacks and Hispanics compared with Whites. ? From 2002 to 2003, the percentages increased for Whites and Blacks but did not change signifi c a n t ly for other groups. National Healthcare Disparities Report Quality of Health Care Management: Blood Pre s s u re Under Control (Among Adults With Hypertension) An important advance in the management of chronic cardiovascular disease has been the development of better medications to help control high blood pressure and to prevent damage to the heart, kidney, and eyes. Figure 2.11. Adults with hypertension whose blood pressure is under control, 1988-1994 and 1999-2002 S o u rce: National Health and Nutrition Examination Survey, 1988- 1994 and 1999-2002. R e f e rence population: Civilian noninstitutionalized population with hypertension, age 18 and over. N o t e : H y p e r t e n s i o n is defined as either having elevated blood 38 p re s s u re (average systolic pre s s u re > 140 mm Hg or average diastolic p re s s u re >90 mm Hg) or taking antihypertensive medication. B l o o d p re s s u re under control is defined as average systolic blood pre s s u re < 140 mm Hg and average diastolic blood pre s s u re <90 mm Hg. P e rcentages are age adjusted to the 2000 standard population These data were estimated for Mexican Americans rather than all Hispanics. ? During both time periods, the proportion of adults with hy p e rtension whose blood pressure is under control was lower among Mexican Americans compared with non-Hispanic Whites (Figure 2.11). ? Compared with 1988-1994, the proportion of adults with blood pressure under control in 1999-2002 increased from 23% to 29%. Improvements were observed among non-Hispanic Whites and non- Hispanic Blacks. National Healthcare Disparities Report Quality of Health Care HIV and AIDS Number of AIDS deaths (2003) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 8 , 0 1 72 5 Cause of death rank (2003) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .> 1 5 t h4 Rank for persons ages 15-24; 25-44; 45-64, respective ly . . . . . . . . . . . . . . . . . . . . . . . . . . .10th; 6th; 9th Number of Americans living with HIV (2003 est.) . . . . . . . . . . . . . . . . . . . . . . . . . . .1 , 0 3 9 , 0 0 0 - 1 , 1 8 5 , 0 0 02 6 Number of persons living with AIDS (2003 est.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 0 5 , 9 2 62 7 N ew cases of HIV annually (2003 est.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .a p p r ox i m a t e ly 40,0002 6 N ew AIDS cases (2003 est.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 3 , 1 7 12 7 Combined Federal and State Medicaid expenditures for AIDS (2003) . . . . . . . . . . . . . . . . . . .$8.5 billion2 8 HIV prevalence and treatment rates va ry by . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .r a c e e t h n i c i t y g e n d e r S E S Management: PCP and MAC Pro p h y l a x i s Management of chronic HIV disease includes outpatient and inpatient services. Because national data on HIV care are not routinely collected, HIV measures tracked in the NHDR come from the HIV Research Netwo r k , 39 which consists of 18 medical practices across the United States that treat large numbers of HIV patients. Although program data are collected from all Ryan White CARE Act grantees, the aggr egate nature of the data make it difficult to assess the quality of care provided by Ryan White CARE Act providers. As HIV disease progresses, CD4 cell counts fall and patients become increasingly susceptible to opport u n i s t i c infections. When CD4 cell counts fall below 200, medicine to prevent development of P n e u m o c y s t i s pneumonia (PCP) is routinely recommended; when CD4 cell counts fall below 50, medicine to preve n t d evelopment of disseminated Mycobacterium avium c o m p l ex (MAC) infection is routinely recommended.2 9 National Healthcare Disparities Report Quality of Health Care Figure 2.12. HIV patients with CD4 cell count <200 who received PCP prophylaxis in the past year, by race/ethnicity, 2002 S o u rc e : HIV Research Network, 2002. R e f e rence population: HIV patients age 18 and older receiving care from HIV R e s e a rch Network providers. N o t e : Whites and Blacks are non-Hispanic populations. 40 ? The proportion of HIV patients with CD4 cell count <200 who received PCP prophylaxis did not differ s i g n i fi c a n t ly by race/ethnicity (Figure 2.12). Figure 2.13. HIV patients with CD4 cell count <50 who received MAC prophylaxis in the past year, by race/ethnicity, 2002 S o u rce: HIV Research Network, 2002. R e f e rence population: HIV patients age 18 and older receiving care from HIV R e s e a rch Network providers. N o t e : Whites and Blacks are non-Hispanic populations. ? The proportion of HIV patients with CD4 cell count <50 who received MAC prophylaxis did not diff e r s i g n i fi c a n t ly by race/ethnicity (Figure 2.13). National Healthcare Disparities Report Quality of Health Care Management: New AIDS Cases Although differences in developing AIDS does not necessarily translate into differences in quality of care, e a r ly, appropriate treatment of HIV disease can delay progression to AIDS. Improved management of chronic HIV disease has like ly contributed to declines in new AIDS cases. For example, as the use of highly active a n t i r e t r oviral therapy (HAART) to treat HIV infection became widespread in the mid-1990s, rates of new AIDS cases declined., Figure 2.14. New AIDS cases per 100,000 population age 13 and over, by race/ethnicity, 1998-2003 41 Key: API=Asian or Pacific Islander; AI/AN=American Indian or Alaska N a t i v e . S o u rce: HIV/AIDS Reporting System, 1998-2003. R e f e rence population: U.S. population age 13 years and over. Note: This source categorizes race/ethnicity as a single item; i.e., White=non-Hispanic White; Black=non-Hispanic Black ? After declining from 18.0 to17.0 cases per 100,000 persons between 1998 and 2001, the overall rate of n ew AIDS cases then rose to 17.7 cases per 100,000 persons by 2003. ? In 2003, the rate of new AIDS cases among non-Hispanic Blacks was more than 10 times higher (75.3 per 100,000) than the rate among non-Hispanic Whites (7.2 per 100,000). The rate among Hispanics (26.8 per 100,000) was over 3 times as high as the rate among non-Hispanic Whites (Figure 2.14). ? From 1998 to 2003, the rate of new AIDS cases fell from 80.7 to 75.3 per 100,000 among non-Hispanic Blacks, from 31.3 to 26.8 per 100,000 among Hispanics, and from 8.2 to 7.2 per 100,000 among non- Hispanic W h i t e s . ? No race, ethnic group, or gender has yet reached the Healthy People 2010 goal of 1.0 new AIDS case per 100,000 population. National Healthcare Disparities Report Quality of Health Care Mental Health and Substance Abuse Americans with mental disorders including substance abuse in past year (2001-2003) . . . . . . . . . . 2 6 . 4 %3 2 Persons age 18-64 receiving care in year of onset for: major depressive episode (2001-2003) . . . . . 3 7 %3 3 bipolar disorder. . . . . . . . . . . . . . . . . . . . . . . . 3 9 %3 3 d y s t hy m i a . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 2 %3 3 Median delay among those who eve n t u a l ly get mental health treatment (2001-2003) . . . . . . . . . . 8 ye a r s3 3 Persons age 12 and over with alcohol and/or illicit drug dependence/abuse (2003) . . . . . . . . . 22 million3 4 Persons with alcohol dependence with treatment in the onset year (2001-2003). . . . . . . . . . . . . . . . . 2 1 %3 3 Persons with drug dependence with treatment in the onset year (2001-2003) . . . . . . . . . . . . . . . . . . . 2 6 %3 3 Median delay among substance abusers who eve n t u a l ly get treatment (2001-2003). . . . . . . . . . . . 6 ye a r s3 3 Costs for health care services related to the diagnosis and treatment of substance a buse and mental disorders (2001) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $104 billion3 5 Mental health carei i i and substance abuse treatment differ by . . . . . . . . . . . . . . . . . . . . . . . r a c e34 36 37 38 39 40 e t h n i c i t y34 36 37 S E S3 4 42 In a cross-national survey among adults in 14 countries conducted from 2001-2003, the United States had the highest rate with any mental disorders including substance abuse (26%), severity of mental disorders (8%), anxiety disorders (18%), mood disorders (10%), and impulse-control disorders (7%) in the past ye a r.3 2 I n response to the need for mental health and substance abuse treatment in the United States, guidelines have been developed to improve the quality of mental health and substance abuse treatment, 41 42 43 44 45 46 a n d quality improvement programs have been shown to improve outcomes and reduce costs.47 48 iii Differences in care are observed, though prevalence of mental disorders for racial/ethnic minorities in the United States is similar to that for Whites. Differences in care may in part reflect variation in preferences/cultural attitudes towards mental health. National Healthcare Disparities Report Quality of Health Care Treatment: Reported Help From Mental Disorder Tre a t m e n t S e l f - r e p o rting of help from treatment for mental disorders is a good measure of the eff e c t iveness of treatment. Figure 2.15. Adults reporting great help from treatment for their mental disorder, by race, ethnicity, and education, 2002 S o u rce: SAMHSA, National Survey on Drug Use and Health, 2002. R e f e rence population: U.S. population age 18 and older who re c e i v e d mental health tre a t m e n t . Notes: Mental health treatment is defined as having counseling, inpatient c a re, outpatient care, or prescription medications for problems with emotions, nerves, or mental health and does not include alcohol or drug t reatment. Great help from mental health treatment is defined as respondents answering ?a lot? and/or ?a great deal? to the following question asked of those who received mental health treatment: ?How much did the counseling or medicine improve your ability to manage daily 43 activities like those asked about in the previous questions?? Daily activities included controlling emotions around people, thinking clearly, being able to concentrate on something important, going out of the house and getting a round on your own, and taking care of your daily responsibilities at work, school, or at home as well as washing, dressing and feeding yourself on your own. ? Of the 27 million people in 2002 who received treatment for mental disorders, 59% reported that their treatment provided great help (Figure 2.15). ? Adults who did not complete their high school education are less like ly to report receiving great help from their mental disorder treatment than adults with any college education. Racial and ethnic d i fferences were not signifi c a n t . National Healthcare Disparities Report Quality of Health Care Treatment: Completion of Substance Abuse Tre a t m e n t Completing all parts of a substance abuse treatment plan has been shown to increase the likelihood of health i m p r ove m e n t . Figure 2.16. Discharges from substance abuse treatment facilities in which the patient completed substance abuse treatment by demographics, 2002 S o u rc e : SAMHSA, Treatment Episode Data Set (TEDS) discharge data, 2 0 0 2 . R e f e rence population: D i s c h a rges age 12 and older from publicly funded substance abuse treatment facilities. N o t e s : Completed tre a t m e n t is defined as admissions that completed all parts of their treatment plan or program and does not include those t r a n s f e r red for further treatment. In 2002, 23 States submitted complete 44 data on about 800,000 discharges to SAMHSA?s recently establishedd i s c h a rge component of the Treatment Episode Data Set. Analyses of the demographic characteristics, service types, and primary substance of abuse found that the admissions in these States did not differ significantly f rom States not reporting discharge data. The following States pro v i d e d complete discharge data: California, Colorado, Georgia, Hawaii, Illinois, Iowa, Kansas, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Montana, Nebraska, New Jersey, Ohio, Oklahoma, Rhode Island, South Carolina, Texas, Utah, and Wyoming. ? Of the 748,000 discharges from specialty substance abuse treatment in 2002 reported to SAMHSA?s Treatment Episode Data Set (TEDS) discharge system, nearly 42% completed treatment (Figure 2.16). ? Blacks were less like ly to complete treatment compared with non-Hispanic Whites. Individuals with less than a high school education were less like ly to complete treatment compared with individuals with any c o l l ege education. National Healthcare Disparities Report Quality of Health Care Treatment: Receipt of Needed Substance Abuse Tre a t m e n t Need for treatment was defined as meeting at least one of three criteria in the past year: (1) dependent on any illicit drug; (2) abuse of any illicit drug; or (3) received treatment for an illicit drug problem as an inpatient at a hospital or as an inpatient or outpatient at a mental health center or substance abuse rehabilitation or treatment fa c i l i t y. Receiving needed substance abuse treatment is important for a variety of reasons. Untreated substance abuse can have a direct toxic effect on a number of body organs as well as ex a c e r b a t e numerous health and mental health conditions. Untreated substance abuse results in incapacity to engage in h e a l t hy societal roles such as work and school. A d d i t i o n a l ly, active substance abuse is often associated with p hysical and domestic violence as well as increased risk-taking behavior such as unsafe driv i n g . Figure 2.17. Persons age 12 and over who needed substance abuse treatment and received such treatment, by race, ethnicity, income, and education, 2003 45 S o u rc e : SAMHSA, National Survey on Drug Use and Health, 2003. R e f e rence population: U.S. population age 12 and older who needed substance abuse tre a t m e n t . ? O verall, only 15% of those who met criteria for needing substance abuse treatment actually received it ( Figure 2.17). ? Hispanics were less like ly than non-Hispanic Whites to receive needed substance abuse treatment. ? Poor persons were more like ly than high income persons to receive needed substance abuse treatment. ? D i fferences related to race and education were not significant due to small sample sizes. National Healthcare Disparities Report Quality of Health Care Respiratory Diseases Number of deaths, influenza and pneumonia combined (2003) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 4 , 8 4 74 Cause of death rank, influenza and pneumonia combined (2003) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 t h4 Americans 18 and over with an asthma attack in past 12 months (2003) . . . . . . . . . . . . . . . . 1 3 , 6 2 3 , 0 0 04 9 Americans under 18 with an asthma attack in past 12 months (2003) . . . . . . . . . . . . . . . . . . . . . 3 , 9 7 5 , 0 0 05 0 Annual number of pneumonia cases (1996). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 , 8 0 0 , 0 0 05 1 Total cost of lung diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $139.6 billion5 Total direct medical costs of lung diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $80.7 billion5 Total cost of upper respiratory infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $40 billion5 1 Total cost of asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $11.3 billion-$14 billion5 2 R e s p i r a t o ry care differs by . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . r a c e53 54 55 P revention: Pneumococcal Vaccination Vaccination is an eff e c t ive strategy for reducing illness, death, and disparities associated with pneumococcal disease and influenza.56 57 46 Figure 2.18. Adults age 65 and over who ever had pneumococcal vaccination, by race (this page, left), ethnicity (this page, right), income (next page, left), and education (next page, right), 1999-2003 National Healthcare Disparities Report Quality of Health Care S o u rc e : National Health Interview Survey, 1999-2003. 47 R e f e rence population: Civilian noninstitutionalized population age 65 and over. ? In all 5 years, the proportion of adults age 65 and over who ever had pneumococcal vaccine was lowe r among Blacks compared with Whites; Hispanics compared with non-Hispanic Whites; poor compared with high income elderly; and elderly with less than a high school education compared with elderly with a ny college education (Figure 2.18). ? In 4 of the 5 years, rates were also lower among Asians compared with Whites; near poor compared with high income elderly; and high school graduates compared with elderly who had any college education. ? From 1999 to 2003, the overall proportion of adults age 65 and over with pneumococcal va c c i n e i m p r oved from 49.9% to 55.7%. Improvements were observed among Whites, non-Hispanic W h i t e s , l ower income groups, and lower education gr o u p s . Racial and ethnic minorities are disproport i o n a t e ly of lower socioeconomic status. To distinguish the eff e c t s of race, ethnicity, income, and education on pneumococcal vaccination, this measure is stratified by income and education level. National Healthcare Disparities Report Quality of Health Care Figure 2.19. Adults age 65 and over who ever had pneumococcal vaccination, by race (left) and ethnicity (right) stratified by income, 2003 S o u rce: National Health Interview Survey, 2003. R e f e rence population: Civilian noninstitutionalized population age 65 and older. Note: Estimates not 48 available for high income Blacks and Hispanics. Figure 2.20. Adults age 65 and over who ever had pneumococcal vaccination, by race (left) and ethnicity (right) stratified by education, 2003 S o u rce: National Health Interview Survey, 2003. R e f e rence population: C i v i l i a n n o n i n s t i t u t i o n a l i z e d population age 65 and o l d e r. National Healthcare Disparities Report Quality of Health Care ? Blacks of eve ry income and education level were less like ly than Whites to report pneumococcal vaccination (Figures 2.19 and 2.20). ? Hispanics of eve ry income and education level were less like ly than respective non-Hispanic Whites to r e p o rt pneumococcal va c c i n a t i o n . Treatment: Recommended Hospital Care for Pneumonia A p p r ox i m a t e ly 5 million cases of pneumonia occur annually and result in nearly 55 million days of restricted a c t iv i t y, 31.5 million bed days, and 1.3 million hospitalizations each ye a r.5 8 The Centers for Medicare & Medicaid Services tracks a set of measures for quality of pneumonia care for hospitalized adults age 65 and older through the CMS Quality Improvement Organization (QIO) program. This ye a r, the NHDR introduces a n ew composite measure for hospital care for pneumonia, which incorporates the following five measures from p r evious NHDRs: 1) receipt of antibiotics within 4 hours, 2) receipt of appropriate antibiotics, 3) receipt of blood culture before antibiotics, 4) receipt of influenza screeningiv or vaccination, and 5) receipt of pneumococcal screeningv or vaccination. Figure 2.21. Recommended hospital care (incorporates five measures as described above) received by Medicare patients with pneumonia, by race/ethnicity, 2002-2003 49 Key: AI/AN=American Indian or Alaska Native. S o u rce: Quality Improvement Organization Program, 2002-2003. R e f e rence population: M e d i c a re beneficiaries with pneumonia who are hospitalized. Note: Whites, Blacks, Asians, and AI/ANs are non-Hispanic populations. Composite is calculated by averaging the percent of the population that received each of the five incorporated components of care. For further details on composite measures, see Chapter 1, Introduction and Methods. ? From 2002 to 2003, the overall percentage of Medicare patients with pneumonia who receive d recommended hospital care improved from 54% to 59% (Figure 2.21). ? In both years, this percentage was lower among non-Hispanic Blacks compared with non-Hispanic Whites. In 2002, the percentage was also lower among Hispanics. ? From 2002 to 2003, the percentage of Medicare patients with pneumonia who received recommended hospital care increased for non-Hispanic Whites, non-Hispanic Blacks, and Hispanics but did not change s i g n i fi c a n t ly for other groups. iv Person is assessed as to whether he or she would be a good candidate for va c c i n a t i o n . v I b i d . National Healthcare Disparities Report Quality of Health Care Nursing Home and Home Health Care Number of nursing home residents (1999) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 , 6 0 0 , 0 0 05 9 Number of home health patients (2000). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 , 4 6 0 , 0 0 06 0 D i s c h a rges from nursing homes (1998-1999) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 , 5 0 0 , 0 0 05 9 D i s c h a rges from home health agencies (2000) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 , 8 0 0 , 0 0 06 0 Causes of nursing home discharg e s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . r e c ove ry and stabilization (33%) admission to hospital (29%) death (24%) Total cost of nursing home serv i c e s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $110.8 billion6 1 Total cost of home health serv i c e s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $40 billion6 1 Po rtion of nursing home expenditures paid by Medicaid and Medicare . . . . . . . . . . . . . . . . . . . . . . . . . 6 0 % Po rtion of nursing home residents supported by Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 0 %6 2 Nursing home care differs by . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . r a c e6 3 e t h n i c i t y6 3 S E S6 3 Groups more like ly to live in nursing homes with limited resources. . . . . . . . . . . . . . . . . . . . . . . . . B l a c k s6 4 50 This section highlights two core measures of nursing home quality of care?use of physical restraints and presence of pressure sores?and two measures of home health care quality?improvement in walking or m oving around and episodes with acute care hospitalization. Management: Use of Physical Restraints Among Nursing Home Residents Nursing home residents who are restrained daily can become weak, lose their ability to go to the bathroom by t h e m s e l ves, and develop pressure sores or other medical complications. Restraints should only be used wh e n t h ey are necessary as part of the medical treatment. T h ey should never be used to punish a resident or to make things easier for the staff. Only a doctor can order a restraint. Nursing homes are not allowed to use restraints based solely on a fa m i ly ?s request, unless there is a documented medical need and a doctor?s order. Figure 2.22. Long-stay nursing home residents who were physically restrained, 2002-2003 Key: API=Asian or Pacific Islander; AI/AN=American Indian or Alaska N a t i v e . S o u rc e : CMS Minimum Data Set, 2002-2003. Data are from the third quarter of each calendar year. R e f e rence population: Long-stay nursing home re s i d e n t s . Note: Long-stay residents are persons in an extended/permanent nursing home stay. Short-stay residents are persons needing skilled nursing care or rehabilitation services following a hospital stay but who a re expected to re t u rn home. National Healthcare Disparities Report Quality of Health Care ? In both 2002 and 2003, the proportion of long-stay residents who were phy s i c a l ly restrained was higher among APIs and Hispanics compared with non-Hispanic Whites (Figure 2.22). ? From 2002 to 2003, the proportion of long-stay residents who were phy s i c a l ly restrained fell from 9.3% to 7.8%. Improvements were observed among all racial/ethnic gr o u p s . Management: Prevalence of Pre s s u re Sores Among Nursing Home Residents Both long-stay and short - s t ay nursing home residents should be assessed by nursing home staff for presence or risk of developing pressure sores. Nursing homes can help to prevent or heal pressure sores by ke e p i n g residents clean and dry and by changing their position frequently or helping them move around, making sure residents get proper nutrition, and using soft padding to reduce pressure on the skin. Howeve r, some residents m ay get pressure sores even when the nursing home provides good preve n t ive care. Patients who are bedridden or who cannot control their bladder or bowels are considered to be at high risk because of moisture a gainst the skin. Figure 2.23. Pressure sores among high-risk (left) and low-risk (right) long-stay nursing home residents by race/ethnicity, 2002-2003 51 Key: API=Asian or Pacific Islander; AI/AN=American Indian or Alaska Native. S o u rce: CMS Minimum Data Set, 2002-2003. Data are from the third quarter of each calendar year. R e f e rence population: Long-stay nursing home re s i d e n t s . N o t e : White, Black, API, and AI/AN are non-Hispanic groups. Long-stay is defined by CMS as residents who were not recently admitted to a nursing home following a hospital stay. ? In 2002 and 2003, the proportion of high-risk long-stay residents who had pressure sores was higher among Blacks, AI/ANs, and Hispanics compared with non-Hispanic Whites (Figure 2.23). ? In both years, the proportion of low-risk long-stay residents who had pressure sores was lower among Blacks, APIs, and Hispanics compared with non-Hispanic Whites. National Healthcare Disparities Report Quality of Health Care Figure 2.24. Pressure sores among short-stay nursing home residents by race/ethnicity, 2002-2003 K e y : API=Asian or Pacific Islander; AI/AN=American Indian or Alaska Native. S o u rc e : CMS Minimum Data Set, 2002-2003. Data are full calendar year estimates. R e f e rence population: Short-stay nursing home re s i d e n t s . N o t e : White, Black, API, and AI/AN are non-Hispanic groups. S h o r t - s t a y re s i d e n t s a re persons needing skilled nursing care or rehabilitation services following a hospital stay but who are expected to re t u rn home. ? In 2002 and 2003, the proportion of short - s t ay residents who had pressure sores was higher among Blacks and Hispanics compared with non-Hispanic Whites (Figure 2.24). 52 Treatment: Improvement by Home Health Patients in Walking or Moving Around H ow well a patient improves in ability level while getting home health care is a reflection of the agency ?s quality of service, the patient?s level of cooperation, and the patient?s ava i l a ble support system. Improved ambu l a t i o n , i.e., getting better at walking or using a wheel chair, is a measure of improved outcomes.v i A higher percentage of patients who can improve their walking and their mobility is a good sign of progress and improved outcomes. The patients can achieve independence and self confidence in performing their activities. The home health a g e n cy staff should evaluate the patients for any special assistance or equipment they might require and assist and train the patients in the use of the device or equipment. Figure 2.25. Home health care episodes with patients who get better at walking or moving around, by race (left) and ethnicity (right), 2002-2003 Key: NHOPI=Native Hawaiian or Other Pacific Islander; AI/AN=American Indian or Alaska Native. S o u rc e : CMS Outcome and Assessment Information Set, 2 0 0 2 - 2 0 0 3 . R e f e rence population: Patients with home health c a re episodes. Note: An ?episode? is the time during which a patient is under the direct care of a home health agency. It starts with the beginning/re s u m p t i o n of care and finishes when the patient is discharged or t r a n s f e r red to an inpatient f a c i l i t y. Some patients have multiple episodes in a year. v i In cases of patients with some neurological conditions, such as progr e s s ive multiple sclerosis or Pa r k i n s o n ?s disease, a m bulation may not improve even when the nursing home or home health service provides good care. National Healthcare Disparities Report Quality of Health Care ? In both years, the proportion of home health care patients who got better at walking and moving around was higher among Asians and Native Hawaiians or Other Pa c i fic Islanders compared with Whites (Fi g u r e 2 . 2 5 ) . Treatment: Acute Care Hospitalization of Home Health Patients I m p r ovement in the acute care hospitalization outcome is demonstrated by a decrease in the percentage of patients who had to be admitted to the hospital. Thus lower percentages are the desirable outcome. Howeve r, patients may need to go into the hospital while they are getting care; and, in some instances, this may not be avo i d a ble even with good home health care. Acute care hospitalization may be avoided if the home health staff a d e q u a t e ly checks the patient?s health condition at each visit to detect problems early. Staff must also assess the patient?s ability to eat, drink, and take medication, as well as obstacles to a safe home environment. T h ey should also coordinate the patient?s care by reg u l a r ly communicating with patients, informal careg ive r s , doctors, and other care prov i d e r s . Figure 2.26. Home health care episodes with patients who were admitted to the hospital, by race (left) and ethnicity (right), 2002-2003 53 Key: NHOPI=Native Hawaiian or Other Pacific Islander; AI/AN=American Indian or Alaska Native. S o u rce: CMS Outcome and Assessment Information Set, 2003. R e f e rence population: Patients with home health care episodes. N o t e : An ?episode? is the time during which a patient is under the direct care of a home health agency. It starts with the b e g i n n i n g / resumption of care and finishes when the patient is discharged or transferred to an inpatient facility. Some patients have multiple episodes in a year. ? In both years, the proportion of home health care patients who were admitted to the hospital was higher among Blacks and AI/ANs and lower among Asians compared with Whites (Figure 2.26). ? In 2002, multiple race home health care patients were more like ly than Whites to be hospitalized. ? In both years, the proportion of home health care patients who were admitted to the hospital was higher among Hispanics compared with non-Hispanic W h i t e s . National Healthcare Disparities Report Quality of Health Care Patient Safety Number of Americans that die each year from medical errors (1999 est.) . . . . . . . . . . . . . .4 4 , 0 0 0 - 9 8 , 0 0 06 5 Number of Americans that die in the hospital each year due to 18 types of medical injuries (2000 est.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .at least 32,0006 6 Rate of adverse drug reactions in hospital admissions . . . . . . . . . . . . . . . . . . . . . . . . . . .2 . 0 % - 6 . 7 %67 68 69 70 Rate of adverse drug events among Medicare benefi c i a r i e s in ambu l a t o ry settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50 per 1,000 person-ye a r s Percentage of serious, life-threatening, or fatal events deemed preve n t a bl e . . . . . . . . . . . . . . . . . . . . . .4 0 % Cost (in lost income, disability, and health care costs) attribu t a ble to medical errors (1999 est.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$29 billion6 5 Groups with higher rates of some safety eve n t s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . racial minorities71 72 This section highlights six measures of patient safety in three areas: nosocomial infections, postoperative complications and other adverse events, and inappropriate medication use by the elderly. (For findings related to all core report measures of patient safety, see Ta ble 2.2a.) 54 Nosocomial Infections Infections acquired during hospital care, or nosocomial infections, are one of the most serious patient safety c o n c e rns. Figure 2.27. Hospital-acquired bloodstream infections in Medicare patients, by race, 2002-2003 S o u rc e : M e d i c a re Patient Safety Monitoring System, 2002-2003. R e f e rence population: Random sample of Medicare medical re c o rd s . ? No significant differences in the proportion of discharged Medicare patients who had a hospital-acquired bloodstream infection were o b s e rve d, although this could be due to small sample sizes (Figure 2.27). ? From 2002 to 2003, the overall rate of hospital-acquired bloodstream infections fell from 0.40% to 0.15%. Significant i m p r ovements were observed among W h i t e s . National Healthcare Disparities Report Quality of Health Care Adverse Events and Postoperative Complications of Care In addition to nosocomial infections, various adverse events and complications can occur after surg i c a l procedures. Although some of the events may be related to a patient?s underlying condition, many of them can be avoided if adequate care is provided. Postoperative Blood Clots After surg e ry, patients are at higher risk for developing blood clots in their legs. This risk can be reduced by getting patients to walk as soon as possible after surg e ry and by giving patients medications and treatments that prevent blood clots. Figure 2.28. Medicare surgical patients with postoperative venous thromboembolic event, by race, 2002-2003 55 S o u rc e : M e d i c a re Patient Safety Monitoring System, 2002-2003. R e f e rence population: Random sample of Medicare medical re c o rd s . ? No significant differences were observed in the proportion of Medicare surgical patients with p o s t o p e r a t ive thromboembolic events, although this could be due to small sample sizes (Figure 2.28). ? From 2002 to 2003, the proportion of Medicare patients with postoperative blood clots did not change s i g n i fi c a n t ly overall or within any racial/ethnic gr o u p . National Healthcare Disparities Report Quality of Health Care Postoperative Hip Fracture Patients may be especially vulnerable to some adverse events, such as falling and breaking bones, right after s u rg e ry. This risk of falling can be reduced by putting bed rails up, monitoring ambulation, and remov i n g items from the room that could cause patients to trip or slip while wa l k i n g . Figure 2.29. Postoperative hip fracture per 1,000 adult surgical patients, by race/ethnicity, 2001-2002 56 S o u rc e : HCUP State Inpatient Databases disparities analysis file, 2 0 0 1 - 2 0 0 2 . R e f e rence population: S u rgical patients age 18 and over in community hospitals. ? No significant racial/ethnic disparities in rates of postoperative hip fractures were observed in 2001 or 2002 (Figure 2.29). ? From 2001 to 2002, the rate of postoperative hip fracture among adult surgical patients did not change s i g n i fi c a n t ly overall or in any racial/ethnic gr o u p . National Healthcare Disparities Report Quality of Health Care Adverse Events Associated With Central Venous Catheters Pa rt of the risk for complications during insertion of a central venous catheter (CVC) may be related to the u n d e r lying severity of illness of patients who require this procedure. Thus, inserting a CVC into the gr e a t vessels can result in a number of non-infection adverse eve n t s . Figure 2.30. Central venous catheter placements with associated mechanical adverse events in Medicare patients, by race, 2002-2003 57 S o u rc e : M e d i c a re Patient Safety Monitoring System, 2002-2003. R e f e rence population: Random sample of Medicare medical re c o rd s . Note: Some apparent diff e rences between populations in the figure a re not significant due to small sample sizes. ? No significant racial disparities in rates of CVC mechanical adverse events among Medicare patients were observed (Figure 2.30). ? From 2002 to 2003, the overall proportion of CVC placements with associated mechanical adverse eve n t s among Medicare patients fell from 3.2% to 2.0%. National Healthcare Disparities Report Quality of Health Care I a t rogenic Pneumothorax A number of medical procedures can invo l ve the risk of accidentally puncturing a lung. These include vascular catheterization; thoracentasis; intubations; mechanical ventilation; placing and adjusting cardiac p a c e m a kers; and operations on the larynx and bronchus, in the abdominal cav i t y, on respiratory systems, or on skin or breast. Figure 2.31. Iatrogenic pneumothorax per 1,000 adult discharges, by race/ethnicity, 2001-2002 58 K e y : API=Asian or Pacific Islander. S o u rc e : HCUP State Inpatient Databases disparities analysis file, 2 0 0 1 - 2 0 0 2 . R e f e rence population: Patients discharged from community hospitals, age 18 and over. ? In both years, the rate of iatrogenic pneumothorax was lower among Hispanics compared with W h i t e s ( Figure 2.31). ? From 2001 to 2002, the rate of iatrogenic pneumothorax did not change signifi c a n t ly overall or in any racial/ethnic gr o u p . National Healthcare Disparities Report Quality of Health Care I n a p p ropriate Medication Use by the Elderly A d verse drug events can result from errors in prescribing or administering medication or lack of adherence by patients. Standard, national measures on adverse drug events and medication errors are still lacking. Howeve r, as comorbidities increase and metabolism and other health-related factors change in the elderly, some dru g s should often or always be avoided by this age group. Examining the extent to which medicines that are inappropriate and potentially harmful to patients are prescribed is an altern a t ive way to assess safe use of m e d i c a t i o n .7 3 Figure 2.32. Inappropriate use of medications by community dwelling adults age 65 and older, by race, 2002 59 S o u rc e : Medical Expenditure Panel Survey, 2002. R e f e rence population: Civilian noninstitutionalized population age 65 and over. ? There were no statistically significant differences in rates of inappropriate medication use among elderly Blacks and Whites due to small sample size (Figure 2.32). National Healthcare Disparities Report Quality of Health Care T i m e l i n e s s Timeliness is the health care system?s capacity to provide care quickly after a need is recognized. Ti m e l i n e s s7 4 is one of the six dimensions of quality established by the Institute of Medicine as a priority for improve m e n t in the health care system.2 For patients, lack of timeliness can result in emotional distress, physical harm, and financial consequences.7 5 For example, stroke patients? m o rtality and long-term disability are larg e ly influenced by the timeliness of therapy76 77 Ti m e ly delive ry of appropriate care can also help reduce mort a l i t y and morbidity for chronic conditions such as chronic kidney disease.78 E a r ly care for comorbid conditions has been shown to reduce hospitalization rates and costs for Medicare benefi c i a r i e s .7 9 Some research suggests that, over the course of 30 years, the costs of treating complications from diabetes can approach $50,000 per p a t i e n t ,8 0 and early care for complications in patients with diabetes can help to reduce these costs.8 1 Ti m e ly outpatient care can reduce admissions for pediatric asthma, which account for $835 million in total hospitalization charges annually.82 83 Measures of timeliness highlighed in this section include getting care for illness or injury as soon as wa n t e d and emerg e n cy department visits where the patient left without being seen. (For findings related to all core r e p o rt measures of timeliness, see Ta bles 2.3a and 2.3b. ) 60 National Healthcare Disparities Report Quality of Health Care Getting Care for Illness or Injury As Soon As Wanted Timeliness of Primary Care: Adults A patient?s primary care provider should be the point of first contact for most illnesses and injuries. T h e ability of patients to receive illness and injury care in a timely fashion is a key element in a patient-focused health care system. Figure 2.33. Adults age 18 and over who reported sometimes or never getting care for illness or injury as soon as wanted in the past year, by race, ethnicity, income, and education, 2002 61 S o u rce: Medical Expenditure Panel Survey, 2002. R e f e rence population: Civilian noninstitutionalized population age 18 and older. ? The proportion of adults who reported sometimes or never getting care for illness or injury as soon as wanted was higher among Blacks and Asians compared with Whites; among Hispanics compared with non-Hispanic Whites; among poor, near poor, and middle income individuals compared with high income individuals; and among persons with less than a high school education compared with persons with some college (Figure 2.33). Racial and ethnic minorities are disproport i o n a t e ly of lower socioeconomic status. To distinguish the eff e c t s of race, ethnicity, income, and education on timeliness of primary care, this measure is stratified by income and education level. National Healthcare Disparities Report Quality of Health Care Figure 2.34. Adults who reported sometimes or never getting care for illness or injury as soon as wanted in the past year, by race (left) and ethnicity (right) stratified by income, 2002 62 S o u rce: Medical Expenditure Panel Survey, 2002. R e f e rence population: Civilian noninstitutionalized population age 18 and older. Figure 2.35. Adults who reported sometimes or never getting care for illness or injury as soon as wanted in the past year, by race (left) and ethnicity (right) stratified by education, 2002 S o u rce: Medical Expenditure Panel Survey, 2002. R e f e rence population: Civilian noninstitutionalized population age 18 and older. National Healthcare Disparities Report Quality of Health Care ? Socioeconomic status explains some but not all of the ethnic differences in timeliness of primary care. ? Hispanics of eve ry income and education level, with the exception of the high income group, were more l i ke ly than respective non-Hispanic Whites to report problems getting care for illness or injury as soon as t h ey wanted (Figures 2.34 and 2.35). ? In contrast, most Black-White differences were not significant after stratification by income and education. Only among high school graduates were Blacks more like ly than Whites to report probl e m s with timeliness. Timeliness of Primary Care: Children Children often need care for illness or injury. Ti m e ly receipt of pediatric care can prevent disease complications, alleviate discomfort, and reduce parental anxiety. Figure 2.36. Children whose parents or guardians reported that their child sometimes or never got care for illness or injury as soon as wanted in the past year, by race, ethnicity, and income, 2002 63 S o u rce: Medical Expenditure Panel Survey, 2002. R e f e rence population: Civilian noninstitutionalized population ages 0 - 1 7 . ? The proportion of children who sometimes or never got care for illness or injury as soon as wanted wa s higher among Hispanics compared with non-Hispanic Whites and among poor, near poor, and middle income children compared with high income children (Figure 2.36). National Healthcare Disparities Report Quality of Health Care Emergency Department Vists Where Patient Left Without Being Seen In 2001, patients who had an emerg e n cy department (ED) visit in the United States spent an average of 3.2 hours waiting to be seen. This may reflect the 20% increase in ED visit volumes over the past 10 years, as the number of ED facilities has decreased by 15%.84 While there are many reasons that a patient seeking care in an emerg e n cy department may leave without being seen, long waits tend to exacerbate this probl e m . Figure 2.37. Emergency department visits in which patient left without being seen, by race, 1997-2002 64 S o u rce: National Hospital Ambulatory Medical Care Survey, 1997- 2002. R e f e rence population: Patients visiting EDs of non-Federal, short- s t a y, and general hospitals, exclusive of Federal, military, and Department of Veterans Affairs hospitals. ? From 1997-1998 to 2001-2002, the overall proportion of emerg e n cy department visits in which the patient left before being seen increased from 1.2% to 1.7%. Significant increases were seen among Whites (Figure 2.37). ? In all time periods, Blacks were more like ly to leave before being seen compared with W h i t e s . National Healthcare Disparities Report Quality of Health Care Patient Centere d n e s s Patient centered care requires good patient-provider communication so that patients? needs and wants are understood and addressed, and patients understand and participate in their own care.85 86 87 88 This style of care has been shown to improve patients? h e a l t h .86 87 88 89 U n f o rt u n a t e ly, there are barriers to good communication: about a third of Americans are suboptimaly ?health literate,? 90 91 which means they lack the ?capacity to obtain, process, and understand basic health information and services needed to make appropriate health d e c i s i o n s .? 9 2 T h ey receive less preve n t ive care, 9 3 h ave poorer understanding of their conditions and care, 90 94 95 higher use of emerg e n cy and inpatient services, higher rates of rehospitalization, 96 97 l ower adherence to m e d i c a t i o n s ,9 6 and lower participation in medical decisionmaking.9 8 L ow health literacy costs an estimated $29 billion to $69 billion per ye a r. 9 9 P r oviders also differ in communication profi c i e n cy, including va r i e d listening skills and views of symptoms and treatment eff e c t iveness, compared with their patients? v i ew s . 1 0 0 Additional factors influencing patient centeredness and patient-provider communication include language b a rriers and effects of disabilities on patients? health care experiences. Racial and ethnic differences in patient centered care have been observe d, though findings are somewh a t c o m p l ex. Some research reveals that minorities report worse health care experiences and poorer communication than W h i t e s . 101 102 103 Other studies find minorities are equally or more satisfied with their c a r e . 104 105 106 107 Additional research shows race and ethnicity as weak, inconsistent predictors of health care 65 ex p e r i e n c e s . 104 108 109 Patient Experience of Care: Adults This ye a r, using methods developed for the CAHPS? ( f o rm e r ly known as Consumer Assessment of Health P l a n s 1 1 0) survey, the NHDR presents a composite measure which combines four of the measures used in p r evious NHDRs into a single core report measure. (For findings related to all core report measures of patient centeredness, see Ta bles 2.3a and 2.3b. ) National Healthcare Disparities Report Quality of Health Care Figure 2.38. Adults whose health providers sometimes or never listened carefully, explained things clearly, respected what they had to say, and spent enough time with them, by race, ethnicity, income, and education, 2002 Key: AI/AN=American Indian or Alaska Native. S o u rce: Medical Expenditure Panel Survey, 2002. 66 R e f e rence population: Civilian noninstitutionalized population age 18 and older. ? The proportion of adults whose health providers sometimes or never listened carefully, explained things c l e a r ly, respected what they had to say, and spent enough time with them was higher among Asians and AI/ANs than Whites and among Hispanics than non-Hispanic Whites (Figure 2.38). ? The proportion of adults whose health providers sometimes or never listened carefully, explained things c l e a r ly, respected what they had to say, and spent enough time with them was higher among poor, near p o o r, and middle income compared with high income persons and among persons with a high school d egree or less compared with those with some colleg e . Racial and ethnic minorities are disproport i o n a t e ly of lower socioeconomic status. To distinguish the eff e c t s of race, ethnicity, income, and education on patient-provider communication, this measure is stratified by income and education level. National Healthcare Disparities Report Quality of Health Care Figure 2.39. Adults whose health providers sometimes or never listened carefully, explained things clearly, respected what they had to say, and spent enough time with them by race (left) and ethnicity (right) stratified by income, 2002 67 S o u rce: Medical Expenditure Panel Survey, 2002. R e f e rence population: Civilian noninstitutionalized population age 18 and older. Note: Sample sizes were too small to provide estimates for poor and near poor Asians. Figure 2.40. Adults whose health providers sometimes or never listened carefully, explained things clearly, respected what they had to say, and spent enough time with them by race (left) and ethnicity (right) stratified by education, 2002 S o u rce: Medical Expenditure Panel Survey, 2002. R e f e rence population: Civilian noninstitutionalized population age 18 and older. Note: Sample sizes were too small to provide estimates for Asians with less than a high school education. National Healthcare Disparities Report Quality of Health Care ? Socioeconomic status explains some but not all of the racial and ethnic differences in patient-prov i d e r c o m m u n i c a t i o n . ? Hispanics of eve ry income and education level, with the exception of the poor, are more like ly than r e s p e c t ive non-Hispanic Whites to report poor communication (Figures 2.39 and 2.40). ? Within income and education levels, Asians are often more like ly than Whites to report poor patient- p r ovider communication. Patient Experience of Care: Childre n Childhood presents a unique opportunity to promote health through preve n t ive and routine care, identify health problems early, and establish healthy lifestyle behaviors. Communication in children?s health care can pose a particular challenge as children are often less able to express their health care needs and preferences, and a third party (i.e., a parent or guardian) is invo l ved in communication and decisionmaking. Optimal communication in children?s health care can therefore have a significant impact on receipt of high quality care and subsequent health status. This is especially true for children with special health care needs (CSHCN). Figure 2.41. Children less than 18 years whose parents or guardians reported that their child?s health providers sometimes or never listened carefully, explained things clearly, respected what they had to say, 68 and spent enough time with them, by race, ethnicity, income, and special health care needs, 2002 Key: CSHCN = children with special health care needs. S o u rce: Medical Expenditure Panel Survey, 2002. R e f e rence population: Civilian noninstitutionalized population less than 18 years old. National Healthcare Disparities Report Quality of Health Care ? The proportion of children whose parents or guardians reported that their child?s health prov i d e r s sometimes or never listened carefully, explained things clearly, respected what they had to say, and spent enough time with them was higher among Hispanics compared with non-Hispanic Whites and among p o o r, near poor, and middle income persons compared with high income persons (Figure 2.41). ? The proportion of children whose parents or guardians reported that their child?s health prov i d e r s sometimes or never listened carefully, explained things clearly, respected what they had to say, and spent enough time with them was higher among children with special health care needs compared with children without special health care needs. ? Racial differences were not statistically signifi c a n t . Racial and ethnic minorities are disproport i o n a t e ly of lower socioeconomic status. To distinguish the eff e c t s of race, ethnicity, and income on patient-provider communication in children?s care, this measure is stratifi e d by income. Figure 2.42. Children less than 18 years whose parents or guardians reported that their child?s health providers sometimes or never listened carefully, explained things clearly, respected what they had to say, and spent enough time with them by race (left) and ethnicity (right) stratified by income, 2002 69 S o u rce: Medical Expenditure Panel Survey, 2002. R e f e rence population: Civilian noninstitutionalized population less than 18 years old. Note: Sample sizes were too small to provide estimates for Blacks with high incomes. National Healthcare Disparities Report Quality of Health Care ? Income explains some but not all of the differences in patient-provider communication among diff e r e n t e t h n i c i t i e s . ? Middle and high income Hispanic children?s parents and guardians are more like ly than respective non- Hispanic White children?s parents to report poor patient-provider communication (Figure 2.42). ? Although there was not a significant percentage difference by race among the total population, parents of near poor Black children are less like ly than respective White children?s parents to report poor patient- p r ovider communication. 70 National Healthcare Disparities Report Quality of Health Care Table 2.1a. Racial and Ethnic Differences in Effectiveness of Care C o re Report Measure Racial Differe n c ei Ethnic Differe n c ei i Black A s i a ni i i N H O P Ii i i AI/AN >1 Race Hispanic C a n c e r Women age 40 and over who had a m a m m ogram within the past 2 years iv = = Rate of breast cancers diagnosed at late s t a g ev = Cancer deaths per 100,000 female population per year for breast cancerv i D i ab e t e s Adults with diabetes who had hemog l o b i n A1c measurement, retinal eye exam, and = foot exam in the past ye a rv i i Hospital admissions for lower ex t r e m i t y amputations in patients with diabetes per 1,000 populationv i i i 71 End Stage Renal Disease H e m o d i a lysis patients with urea reduction ratio 65% or higheri x = = D i a lysis patients registered on the waiting list for transplantationx H e a rt Disease C u rrent smokers age 18 and over receiv i n g advice to quit smokingv i i = Hospital care for heart attack patientsx i = Deaths per 1,000 adult admissions with acute myocardial infarction (heart attack)x i i = = Hospital care for heart failure patientsx i = = = = i Compared with W h i t e s . i i Compared with non-Hispanic W h i t e s . i i i Findings are presented separately for Asians and NHOPIs wh e n ever possible. Howeve r, some data sources collected data for Asians and Pa c i fic Islanders (APIs) as a single population; in these cases, the Asian and NHOPI cells are merged into a single cell representing APIs. iv Source: National Health Interv i ew Survey, 2003. v Source: Surveillance, Epidemiolog y, and End Results program, 2002. This source does not provide rate estimates for Asians and NHOPIs separately bu t in aggr egate as Asian and Pa c i fic Islander. This source did not collect information for >1 race. v i Source: National Vital Statistics System-Mort a l i t y, 2002. This source did not collect information on Asians and NHOPIs separately but in aggr egate as Asian and Pa c i fic Islander. This source did not collect information for >1 race. v i i Source: Medical Expenditure Panel Survey, 2002. vi i i Source: National Hospital Discharge Survey, 2001-2003. This source did not collect information for >1 race. Missing rates preclude analysis by ethnicity. i x Source: CMS End Stage Renal Disease Clinical Pe r f o rmance Measures Project, 2003. x U.S. Renal Data System, 2002. This source did not collect information on Asians and NHOPIs separately but in aggr egate as Asian and Pa c i fic Islander. This source did not collect information for >1 race. x i Source: CMS Quality Improvement Organization program, 2003. This source categorizes race/ethnicity information as a single item: non-Hispanic White, non-Hispanic Black, Hispanic, Asian and Pa c i fic Islander, American Indian and Alaska Native. These contrasts compare each group with non- Hispanic Whites. x i i Source: HCUP State Inpatient Databases disparities analysis file, 2002. This source categorizes race/ethnicity information as a single item: non- Hispanic White, non-Hispanic Black, Hispanic, Asian and Pa c i fic Islander. These contrasts compare each group with non-Hispanic W h i t e s . Key: NHOPI=Native Hawaiian or Other Pa c i fic Islander; AI/AN=American Indian or Alaska Native . National Healthcare Disparities Report Quality of Health Care Table 2.1a. Racial and Ethnic Differences in Effectiveness of Care (continued) C o re Report Measure Racial Differe n c ei Ethnic Differe n c ei i Black A s i a ni i i N H O P Ii i i AI/AN >1 Race Hispanic HIV and A I D S HIV patients with CD4 <200 who receive PCP prophy l a x i s iv = = N ew AIDS cases per 100,000 population 13 and ove rv = M a t e rnal and Child Health P r egnant women receiving prenatal care in first trimesterv i I n fant mortality per 1,000 live births, b i rt h weight <1,500 gr a m sv i = = = Children 19-35 months who received all recommended va c c i n e sv i i = = = = 72 Adolescents (13-15) who receive d 3 or more doses of hepatitis B va c c i n ev i i i = = Hospital admissions for pediatric gastroenteritis per 100,000 populationi x = = Children 2-17 with advice about p hysical activ i t yx = = = = Children 2-17 with a dental visitx = i Compared with W h i t e s . ii Compared with non-Hispanic W h i t e s . iii Findings are presented separately for Asians and NHOPIs wh e n ever possible. Howeve r, some data sources collected data for Asians and Pa c i fic Islanders (APIs) as a single population; in these cases, the Asian and NHOPI cells are merged into a single cell representing APIs. iv Source: HIV Research Network, 2002. This source categorizes race/ethnicity information as a single item: non-Hispanic White, non-Hispanic Black, Hispanic, Asian and Pa c i fic Islander, American Indian and Alaska Native. These contrasts compare each group with non-Hispanic Whites. v Source: Centers for Disease Control and Prevention, 2003. This source categorizes race/ethnicity information as a single item: non-Hispanic White, non- Hispanic Black, Hispanic, Asian and Pa c i fic Islander. These contrasts compare each group with non-Hispanic W h i t e s . vi Source: National Vital Statistics System-Natality, 2002. This source did not collect information for >1 race. vii Source: National Immunization Survey, 2003. viii Source: National Health Interv i ew Survey, 2003. ix Source: HCUP State Inpatient Databases disparities analysis file, 2002. This source categorizes race/ethnicity information as a single item: non- Hispanic White, non-Hispanic Black, Hispanic, Asian and Pa c i fic Islander. These contrasts compare each group with non-Hispanic W h i t e s . x Source: Medical Expenditure Panel Survey, 2002. Key: NHOPI=Native Hawaiian or Other Pa c i fic Islander; AI/AN=American Indian or Alaska Native . Key to Symbols Used in Quality of Health Care Tabl e s : = Group and comparison group receive about same quality of health care or have similar outcomes. Group receives better quality of health care than the comparison group or has better outcomes. Group receives poorer quality of health care than the comparison group or has worse outcomes. Blank cell: Reliable estimate for group could not be made. National Healthcare Disparities Report Quality of Health Care Table 2.1a. Racial and Ethnic Differences in Effectiveness of Care (continued) C o re Report Measure Racial Differe n c ei Ethnic D i f f e re n c ei i Black A s i a ni i i N H O P Ii i i AI/AN >1 Race Hispanic Mental Health and Substance A bu s e Adults with serious psychological distress who receive mental health treatment or c o u n s e l i n giv Suicide deaths per 100,000 populationv Persons age 12 and over who needed treatment for substance abuse who = r e c e ived such treatmentiv Patients receiving substance abuse treatment who completed treatmentv i = R e s p i ratory Diseases Persons 65 and over who ever received pneumococcal va c c i n a t i o nv i i 73 Hospital care for pneumonia patientsv i i i = = = Rate antibiotics prescribed at visits with a diagnosis of common cold per 10,000 populationi x Tuberculosis patients who complete course of treatment within 12 months of = = = treatment initiationx Hospital admissions for asthma per 100,000 population under 18x i = i Compared with W h i t e s . ii Compared with non-Hispanic W h i t e s . iii Findings are presented separately for Asians and NHOPIs wh e n ever possible. Howeve r, some data sources collected data for Asians and Pa c i fic Islanders (APIs) as a single population; in these cases, the Asian and NHOPI cells are merged into a single cell representing APIs. iv Source: Substance A buse and Mental Health Services Administration, National Survey on Drug Use and Health, 2003. v Source: National Vital Statistics System-Mort a l i t y, 2002. This source did not collect information on Asians and NHOPIs separately but in aggr egate as Asian and Pa c i fic Islander. This source did not collect information for >1 race. vi Substance A buse and Mental Health Services Administration, Treatment Episode Data Set, 2002. This source categorizes race/ethnicity information as a single item: non-Hispanic White, non-Hispanic Black, Hispanic. These contrasts compare each group with non-Hispanic W h i t e s . vii Source: National Health Interv i ew Survey, 2003. viii Source: CMS Quality Improvement Organization program, 2003. This source categorizes race/ethnicity information as a single item: non-Hispanic White, non-Hispanic Black, Hispanic, Asian and Pa c i fic Islander, American Indian and Alaska Native. These contrasts compare each group with non- Hispanic Whites. ix Source: National A m bu l a t o ry Medical Care Survey/National Hospital A m bu l a t o ry Medical Care Survey, 2001-2002. This source did not collect infor- mation for >1 race. Missing rates preclude analysis by ethnicity. x Source: CDC National TB Surveillance System, 2001. This source did not collect information on Asians and NHOPIs separately but in aggr egate as Asian and Pa c i fic Islander. This source did not collect information for >1 race. xi Source: HCUP State Inpatient Databases disparities analysis file, 2002. This source categorizes race/ethnicity information as a single item: non-Hispanic White, non-Hispanic Black, Hispanic, Asian and Pa c i fic Islander. These contrasts compare each group with non-Hispanic W h i t e s . Key: NHOPI=Native Hawaiian or Other Pa c i fic Islander; AI/AN=American Indian or Alaska Native . National Healthcare Disparities Report Quality of Health Care Table 2.1a. Racial and Ethnic Differences in Effectiveness of Care (continued) C o re Report Measure Racial Differe n c ei Ethnic D i f f e re n c ei i Black A s i a ni i i N H O P Ii i i AI/AN >1 Race H i s p a n i c N u rsing Home and Home Health Care L o n g - s t ay nursing home residents who were phy s i c a l ly restrainediv = High risk long-stay nursing home residents with pressure soresiv = S h o rt - s t ay nursing home residents who h ave pressure soresiv = = Home health care patients who get better at walking or moving aroundv = = = = Home health care patients who had to be admitted to the hospitalv = = i Compared with W h i t e s . 74 ii Compared with non-Hispanic W h i t e s . iii Findings are presented separately for Asians and NHOPIs wh e n ever possible. Howeve r, some data sources collected data for Asians and Pa c i fic Islanders (APIs) as a single population; in these cases, the Asian and NHOPI cells are merged into a single cell representing APIs. iv Source: CMS Minimum Data Set, 2003. This source categorizes race/ethnicity information as a single item: non-Hispanic White, non-Hispanic Black, Hispanic, Asian and Pa c i fic Islander. Contrasts compare each group with non-Hispanic Whites. v Source: CMS Outcome and Assessment Information Set, 2003. Key: NHOPI=Native Hawaiian or Other Pa c i fic Islander; AI/AN=American Indian or Alaska Native . Key to Symbols Used in Quality of Health Care Tabl e s : = Group and comparison group receive about same quality of health care or have similar outcomes. Group receives better quality of health care than the comparison group or has better outcomes. Group receives poorer quality of health care than the comparison group or has worse outcomes. Blank cell: Reliable estimate for group could not be made. National Healthcare Disparities Report Quality of Health Care Table 2.1b. Socioeconomic Differences in Effectiveness of Care C o re Report Measure I n c o m e Educational I n s u ra n c e D i f f e re n c ei D i f f e re n c ei i D i f f e re n c ei i i < 1 0 0 % 1 0 0 - 1 9 9 % 2 0 0 - 3 9 9 % 1 race. vi Source: Medical Expenditure Panel Survey, 2002. vii Source: National Vital Statistics System-Natality, 2002. This source did not collect information for >1 race. viii Source: National Immunization Survey, 2003. Key: HS=high school. National Healthcare Disparities Report Quality of Health Care Table 2.1b. Socioeconomic Differences in Effectiveness of Care (continued) C o re Report Measure I n c o m e Educational I n s u ra n c e D i f f e re n c ei D i f f e re n c ei i D i f f e re n c ei i i < 1 0 0 % 1 0 0 - 1 9 9 % 2 0 0 - 3 9 9 % 1 race. vi Substance A buse and Mental Health Services Administration, Treatment Episode Data Set, 2003. vii Source: National Health Interv i ew Survey, 2003. Key: HS=high school. Key to Symbols Used in Quality of Health Care Tabl e s : =: Group and comparison group receive about same quality of health care or have similar outcomes. Group receives better quality of health care than the comparison group or has better outcomes. Group receives poorer quality of health care than the comparison group or has worse outcomes. Blank cell: Reliable estimate for group could not be made. National Healthcare Disparities Report Quality of Health Care Table 2.2a. Racial and Ethnic Differences in Patient Safety C o re Report Measure R a c i a l Ethnic D i f f e re n c ei D i f f e re n c ei i B l a c k A s i a ni i i N H O P Ii i i AI/AN >1 Race H i s p a n i c Nosocomial Infections Medicare beneficiaries with hospital- acquired bloodstream infectioniv = Medicare beneficiaries with ve n t i l a t o r- associated pneumoniaiv = Complications of Care Po s t o p e r a t ive hip fractures per 1,000 s u rgical discharges age 18 and ove rv = = Medicare beneficiaries with p o s t o p e r a t ive pulmonary embolus or deep vein thrombosisiv = I a t r ogenic pneumothorax per 1,000 r e l evant discharg e sv = = Medicare beneficiaries with central 77 venous catheter-associated mechanical c o m p l i c a t i o niv = Obstetric Tra u m a Obstetric trauma per 1,000 vaginal d e l iveries without instrument assistancev = Medication Safety E l d e r ly with inappropriate medicationsv i = i Compared with W h i t e s . ii Compared with non-Hispanic W h i t e s . iii Findings are presented separately for Asians and NHOPIs wh e n ever possible. Howeve r, some data sources collected data for Asians and Pa c i fic Islanders (APIs) as a single population; in these cases, the Asian and NHOPI cells are merged into a single cell representing APIs. iv Source: Medicare Patient Safety Monitoring System, 2002. v Source: HCUP State Inpatient Databases disparities analysis file, 2002. This source categorizes race/ethnicity information as a single item: non-Hispanic White, non-Hispanic Black, Hispanic, Asian and Pa c i fic Islander. These contrasts compare each group with non-Hispanic W h i t e s . vi Source: Medical Expenditure Panel Survey, 2001. This source did not collect information on Asians and NHOPIs separately but in aggr egate as A s i a n and Pa c i fic Islander. This source did not collect information for >1 race. Key: NHOPI=Native Hawaiian or Other Pa c i fic Islander; AI/AN=American Indian or Alaska Native . Key to Symbols Used in Quality of Health Care Tabl e s : = Group and comparison group receive about same quality of health care or have similar outcomes. Group receives better quality of health care than the comparison group or has better outcomes. Group receives poorer quality of health care than the comparison group or has worse outcomes. Blank cell: Reliable estimate for group could not be made National Healthcare Disparities Report Quality of Health Care Table 2.3a. Racial and Ethnic Differences in Timeliness and Patient Centeredness C o re Report Measure R a c i a l Ethnic D i f f e re n c ei D i f f e re n c ei i B l a c k A s i a ni i i N H O P Ii i i AI/AN >1 Race H i s p a n i c Ti m e l i n e s s Adults who sometimes or never can get care for illness or injury as soon as wa n t e div = E m e rg e n cy department visits in which the patient left without being seenv Patient Centeredness Adults whose health providers sometimes or never listened carefully, explained things, showed respect, and = = spent enough time with themiv Children whose health providers 78 sometimes or never listened carefully, explained things, showed respect, and spent enough time with themiv = = = i Compared with W h i t e s . ii Compared with non-Hispanic W h i t e s . iii Findings are presented separately for Asians and NHOPIs wh e n ever possible. Howeve r, some data sources collected data for Asians and Pa c i fi c Islanders (APIs) as a single population; in these cases, the Asian and NHOPI cells are merged into a single cell representing APIs. iv Source: Medical Expenditure Panel Survey, 2002. This source did not collect information for >1 race. v Source: National Hospital A m bu l a t o ry Medical Care Survey ? Emerg e n cy Department, 2001-2002. Missing rates preclude analysis by ethnicity. Key: NHOPI=Native Hawaiian or Other Pa c i fic Islander; AI/AN=American Indian or Alaska Native . Key to Symbols Used in Quality of Health Care Tabl e s : = Group and comparison group receive about same quality of health care or have similar outcomes. Group receives better quality of health care than the comparison group or has better outcomes. Group receives poorer quality of health care than the comparison group or has worse outcomes. Blank cell: Reliable estimate for group could not be made. National Healthcare Disparities Report Quality of Health Care Table 2.3b. Socioeconomic Differences in Timeliness and Patient Centeredness C o re Report Measure I n c o m e Educational I n s u ra n c e D i f f e re n c ei D i f f e re n c ei i D i f f e re n c ei i i < 1 0 0 % 1 0 0 - 1 9 9 % 2 0 0 - 3 9 9 % 1 race. v Source: National Hospital A m bu l a t o ry Medical Care Survey ? Emerg e n cy Department, 2001-2002. Missing rates preclude analysis by ethnicity. Key: HS=high school. Key to Symbols Used in Quality of Health Care Tabl e s : =: Group and comparison group receive about same quality of health care or have similar outcomes. Group receives better quality of health care than the comparison group or has better outcomes. Group receives poorer quality of health care than the comparison group or has worse outcomes. Blank cell: Reliable estimate for group could not be made. National Healthcare Disparities Report Quality of Health Care References 1 . 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Cited in: U.S. Department of Health and Human Services, Healthy People 2010 (2nd ed.). Washington, DC: U.S. Govt. Print. Off.; November 2000, p. 11 - 9. 9 0 . Gazmararian J, Williams MV, Peel J, Baker DW. Health literacy and knowledge of chronic disease. Patient Educ Couns. 2003 N ov ; 5 1 ( 3 ) : 2 6 7 - 7 5 . 9 1 . Pa r ker RM, Ratzan SC, Lurie N. Health literacy: a policy challenge for advancing high-quality health care. Health A ff ( M i l lwood). 2003 Jul-Aug;22(4):147-53. 9 2 . Selden C, Zorn M, Ratzan S, Pa r ker RM, compilers. Health Literacy: January 1990 through October 1999 [bibl i ogr a p hy ] . Fe b ru a ry 2000; p. vi. (Current Bibl i ographies in Medicine; CBM 2000-1). Cited in: U.S. Department of Health and Human S e rvices, Healthy People 2010 (2nd ed.). Washington, DC: U.S. Govt. Print. Off.; November 2000, p. 11 - 20. 9 3 . Scott TL, Gazmararian JA, Williams MV, Baker DW. Health literacy and preve n t ive health care use among Medicare enrollees in a managed care organization. Med Care. 2002 May;40(5):395-404. Cited in: Gazmararian JA, Curran JW, Pa r ke r RM, et al. Public health literacy in America: an ethical imperative . Am J Prev Med. 2005 A p r ; 2 8 ( 3 ) : 3 1 7 - 2 2 . 9 4 . Williams M, Baker DW, Pa r ker RM, Nurss JR. Relationship of functional health literacy to patients? k n owledge of their chronic disease. A study of patients with hy p e rtension and diabetes. Arch Intern Med 1998 Jan 26;158(2):166-72. Cited in: U.S. Department of Health and Human Services, Healthy People 2010 (2nd ed.). Washington, DC: U.S. Govt. Print. Off . ; N ovember 2000, p. 11 - 9. National Healthcare Disparities Report Quality of Health Care 9 5 . Williams M, Baker DW, Honig EG, et al. Inadequate literacy is a barrier to asthma knowledge and self-care. Chest. 1998 Oct;114(4):1008-15. Cited in: U.S. Department of Health and Human Services, Healthy People 2010 (2nd ed.). Wa s h i n g t o n , DC: U.S. Govt. Print. Off.; November 2000, p. 11 - 9. 9 6 . B a ker DW, Pa r ker RM, Williams MV, Clark WS. Health literacy and the risk of hospital admission. J Gen Intern Med. 1998 Dec;13(12):791-8. Cited in: Gazmararian JA, Curran JW, Pa r ker RM, et al. Public health literacy in America: an ethical i m p e r a t ive. Am J Prev Med. 2005 A p r ; 2 8 ( 3 ) : 3 1 7 - 2 2 . 9 7 . B a ker DW, Gazmararian JA, Williams MV, et al. Functional health literacy and the risk of hospital admission among Medicare managed care enrollees. Am J Public Health 2002;92:1278-83. Cited in: Gazmararian JA, Curran JW, Pa r ker RM, et al. Public health literacy in America: an ethical imperative. Am J Prev Med. 2005 Apr;28(3):317-22. 9 8 . Berkman N, DeWalt D, Pignone MP, et al. Literacy and Health Outcomes. Summary, Evidence Report / Te c h n o l og y Assessment No. 87. Rockville, MD: A g e n cy for Healthcare Research and Quality; 2004. AHRQ Pub. No. 04-E007-1. 9 9 . Institute of Medicine, Committee on Health Literacy. Health Literacy: A Prescription to End Confusion. (Nielsen-Bohlman L, Panzer AM, Kindig DA, Eds.) Washington, DC: National Academies Press; 2004. 1 0 0 . Rhoades DR, McFarland KF, Finch WH, Johnson AO. Speaking and interruptions during primary care office visits. Fa m Med. 2001 Jul-Aug;33(7):528-32. 1 0 1 . Weech-Maldonado R, Morales LS, Spritzer K, et al. Racial and ethnic differences in parents? assessments of pediatric care in Medicaid managed care. Health Serv Res. 2001 Jul;36(3):575-94. 1 0 2 . Johnson R, Saha S, Arbelaez JJ, et al. Racial and ethnic differences in patient perceptions of bias and cultural competence in health care. J Gen Intern Med 2004 Fe b ; 1 9 ( 2 ) : 1 0 1 - 1 0 . 85 1 0 3 . Weech-Maldonado R, Morales LS, Elliot M, et al. Race/ethnicity, language, and patients? assessments of care in Medicaid managed care. Health Serv Res. 2003 Jun;38(3):789-808. 1 0 4 . Hall JA, Dornan MC. Patient sociodemographic characteristics as predictors of satisfaction with medical care: a meta- a n a lysis. Soc. Sci. Med. 1990;30(7):811-18. 1 0 5 . Morales LS, Elliott MN, Weech-Maldonado R, et al. Differences in CAHPS adult survey reports and ratings by race and ethnicity: an analysis of the National CAHPS benchmarking data 1.0. Health Serv Res. 2001 Jul;36(3):595-617. 1 0 6 . M u rr ay-Garcia JL, Selby JV, Schmittdiel J, et al. Racial and ethnic differences in a patient survey: patients? values, ratings, and reports regarding physician primary care performance in a large health maintenance organization. Med Care. 2000 M a r ; 3 8 ( 3 ) : 3 0 0 - 1 0 . 1 0 7 . Lurie N, Zhan C, Sangl J, et al. Variation in racial and ethnic differences in consumer assessments of health care. Am J Manag Care. 2003 Jul;9(7):502-9. 1 0 8 . Fox JG, Storms DM. A different approach to sociodemographic predictors of satisfaction with health care. Soc Sci Med [A]. 1981 Sep;15(5):557-64. 1 0 9 . Pascoe GC. Patient satisfaction in primary health care: a literature rev i ew and analysis. Eval Program Plann. 1983;6(3-4):185-210. 1 1 0 . H a rgr aves JL, Hays RD, Cleary PD. Psychometric properties of the Consumer Assessment of Health Plans Study (CAHPS) 2.0 adults core survey. Health Serv Res 2003 Dec;38(6 Pt 1):1509-27. National Healthcare Disparities Report 86 National Healthcare Disparities Report Access to Health Care Chapter 3. Access to Health Care M a ny Americans have good access to health care that enables them to benefit fully from the Nation?s health care system. Howeve r, others face barriers that make the acquisition of basic health services difficult. A s demonstrated by ex t e n s ive research and confi rmed in the 2003 and 2004 National Healthcare Disparities R e p o rts, racial and ethnic minorities and persons of low SES are disproport i o n a t e ly represented among those with access problems. Poor access to health care comes at both a personal and societal cost: for example, if persons do not receive vaccinations they may become ill and spread disease to others, increasing the burden of disease for society overall, in addition to the burden borne indiv i d u a l ly. Components of Health Care Access Access to health care means having ?the timely use of personal health services to achieve the best health o u t c o m e s .?1 Attaining good access to care requires three discrete steps: ? Gaining entry into the health care system. ? Getting access to sites of care where patients can receive needed serv i c e s . ? Finding providers who meet the needs of individual patients and with whom patients can develop a relationship based on mutual communication and tru s t .2 87 Health care access is measured in several ways including: ? S t ructural measures of the presence or absence of specific resources that facilitate health care, such as h aving health insurance or a usual source of care. ? Assessments by patients of how easily they are able to gain access to health care. ? Utilization measures of the ultimate outcome of good access to care?i.e., the successful receipt of needed serv i c e s . How This Chapter Is Organized This chapter presents new information about disparities in access to health care in America. It is divided into t wo sections: ? Fa c i l i t a t o rs and barriers to health care?including measures of health insurance coverage, having a usual source of care and primary care prov i d e r, and patient perceptions of need. ? Health care utilization?including measures of receipt of dental care, emerg e n cy care, potentially avo i d a ble admissions, mental health care, and substance abuse treatment. I n f o rmation about patient-provider communication is found in the section on patient centeredness in Chapter 2, Quality of Health Care. As in previous NHDRs, this chapter focuses on disparities in access to care related to race, ethnicity, and SES in the general U.S. population. Disparities in access to care within specific priority populations are discussed in Chapter 4, Priority Populations. A n a lyses of changes over time and stratifi e d a n a lyses are also presented within this chapter. National Healthcare Disparities Report Access to Health Care A d d i t i o n a l ly, this year the NHDR focuses on a narr ower set of measures than the full set of measures tracke d in previous reports. With guidance from the Interagency Work Groups advising the NHDR and NHQR, this n a rr ower set of core report measures was established. The core report measures aim to be representative of the overall NHDR measure set; but, because they are fewer in number, they are more manageable for p o l i cy m a kers and others to understand and apply when utilizing the NHDR. For details on the process used to e s t a blish core report measures, see Chapter 1, Introduction and Methods. It is primarily core report measures that are presented in the 2005 NHDR and that will be tracked in future iterations of the NHDR. Howeve r, the entire NHDR measure set will continue to appear in the appendixe s ; a n d, from year to ye a r, supplemental measures (those from the overall NHDR measure set that are not core r e p o rt measures) will be presented in the text of the NHDR as well. This ye a r ?s report includes a small number of supplemental measures, though none appear in this chapter. 88 National Healthcare Disparities Report Access to Health Care Facilitators and Barriers to Health Care Facilitators and barriers to health care discussed in this section include health insurance, having a usual source of care (including having a usual source of ongoing care and a usual primary care provider), and patient perceptions of need. (See Ta bles 3.1a and 3.1b for a summary of findings related to all core report measures on facilitators and barriers to health care.) Health Insurance Health insurance facilitates entry into the health care system. The uninsured are more like ly to die early3 - 5 a n d h ave poor health status6 7; the costs of early death and poor health among the uninsured total $65 billion to $130 billion.3 8 The financial burden of uninsurance is also great for uninsured individuals; almost 50% of personal bankru p t cy filings are due to medical ex p e n s e s .9 The uninsured report more problems getting care,9 10 are diagnosed at later disease stages, and get less therapeutic care.9 11 T h ey are sicker when hospitalized and more like ly to die during their stay.1 1 Figure 3.1. Persons under age 65 with health insurance, by race (this page, left), ethnicity (this page, right), income (next page, left), and education (next page, right), 1999-2003 89 National Healthcare Disparities Report Access to Health Care Key: AI/AN=American Indian or Alaska Native; NHOPI=Native Hawaiian or Other Pacific Islander. 90 S o u rc e : National Health Interview Survey, 1999-2003. R e f e rence population: Civilian noninstitutionalized persons under age 65. N o t e : M e a s u re is age adjusted. NHIS respondents are asked about health insurance coverage at the time of interview; respondents are c o n s i d e red uninsured if they lack private health insurance, public assistance, Medicare, Medicaid, a State-sponsored health plan, other g o v e rnment sponsored programs, a military health plan, or if their only coverage is through the Indian Health Service. ? In all 5 years, the proportion of persons with insurance was lower among Blacks and AI/ANs compared with Whites; among Hispanics compared with non-Hispanic Whites; among poor, near poor, and middle income persons compared with high income persons; and among persons with a high school education or less compared with persons with some college (Figure 3.1). ? From 2000 to 2002 the proportion of persons with insurance was also lower among persons of multiple races compared with Whites; in 2000 the proportion was lower among NHOPIs compared with W h i t e s . In 2003, both disparities had been eliminated. ? From 1999 to 2003, rates of insurance decreased for Whites, middle and high income persons, and persons of eve ry education level, while rates increased for the poor. Racial and ethnic minorities are disproport i o n a t e ly of lower socioeconomic status. To distinguish the eff e c t s of race, ethnicity, income, and education on health insurance coverage, this measure is stratified by income and education level. National Healthcare Disparities Report Access to Health Care Figure 3.2. Persons under age 65 with health insurance by race (left) and ethnicity (right) stratified by income, 2003 Key: AI/AN=American Indian or Alaska Native. 91 S o u rce: National Health Interview Survey, 2003. R e f e rence population: Civilian noninstitutionalized persons under age 65. Note: M e a s u re is age adjusted. NHIS respondents are asked about health insurance coverage at the time of interview; respondents are c o n s i d e red uninsured if they lack private health insurance, public assistance, Medicare, Medicaid, a State-sponsored health plan, other g o v e rnment sponsored programs, a military health plan, or if their only coverage is through the Indian Health Service. Figure 3.3. Persons under age 65 with health insurance by race (left) and ethnicity (right) stratified by education, 2003 Key: AI/AN=American Indian or Alaska Native. S o u rce: National Health Interview Survey, 2003. R e f e rence population: Civilian noninstitutionalized persons under age 65. N o t e : M e a s u re is age adjusted. NHIS respondents are asked about health insurance coverage at the time of interview; respondents are c o n s i d e red uninsured if they lack private health insurance, public assistance, Medicare, Medicaid, a State-sponsored health plan, other g o v e rnment sponsored programs, a military health plan, or if their only coverage is through the Indian Health Service. National Healthcare Disparities Report Access to Health Care ? Socioeconomic status explains some but not all of the differences in rates of insurance among persons under age 65 by race and ethnicity (Figures 3.2 and 3.3). ? Hispanics of eve ry income and education level were less like ly than respective non-Hispanic Whites to h ave health insurance. ? AI/AN-White differences were significant among all income groups other than the poor and among all education groups other than persons with less than a high school education. High income Blacks and Blacks with a high school education or any college education were less like ly than respective Whites to h ave health insurance; near poor Blacks and Blacks with less than a high school education were more l i ke ly than respective Whites to have insurance. ? No group achieved the Healthy People 2010 goal of 100% of Americans with health insurance. Because uninsured persons often postpone seeking care, have difficulty obtaining care when they ultimately seek it, and must bear the full brunt of health care costs, prolonged periods of uninsurance can have a p a rt i c u l a r ly serious impact on a person?s health and stability. Over time, the cumulative consequences of being uninsured compound, resulting in a population at particular risk for suboptimal health care and health status. Figure 3.4. Persons under age 65 uninsured all year by race (this page left), ethnicity (this page, right), 92 income (next page, left), and education (next page, right), 1999-2002 National Healthcare Disparities Report Access to Health Care S o u rc e : Medical Expenditure Panel Survey, 1999-2002. R e f e rence population: Civilian noninstitutionalized persons under age 65. N o t e : In 2002, survey respondents could report more than one race. Racial categories shown here for 2002 exclude multiple race 93 individuals and hence are not directly comparable to earlier years. Estimates for racial groups other than Whites and Blacks are significantly a ffected by this change and are not shown here. ? In all 4 years, the proportion of persons uninsured all year was higher among Hispanics compared with non-Hispanic Whites; among poor, near poor, and middle income persons compared with high income persons; and among persons with a high school education or less compared with persons with some c o l l ege (Figure 3.4). ? The proportion of persons uninsured all year was higher among Blacks compared with Whites in 1999 and 2000. In 2001 and 2002, this disparity was eliminated. ? From 1999 to 2002, rates of uninsurance rose among Whites, non-Hispanic Whites, middle income persons, and high school graduates. National Healthcare Disparities Report Access to Health Care Usual Source of Care H aving a usual source of care (a facility where one reg u l a r ly receives care) helps persons get into the health care system, yet over 40 million Americans do not have a specific source of ongoing care.1 2 Persons without a usual source of care report more difficulties obtaining needed serv i c e s1 3 and fewer preve n t ive serv i c e s , including blood pressure monitoring, flu shots, prostate exams, Pap tests, and mammogr a m s .1 4 Specific Source of Ongoing Care Higher costs, poorer outcomes, and greater disparities are observed among individuals without a usual source of care.1 5 Figure 3.5. Persons with a specific source of ongoing care by race (top left), ethnicity (top right), income (bottom left), and education (bottom right), 1999-2003 94 Key: AI/AN=American Indian or Alaska Native. S o u rc e : National Health Interview Survey, 1999-2003. R e f e rence population: Civilian noninstitutionalized population. N o t e : M e a s u re is age adjusted. National Healthcare Disparities Report Access to Health Care ? In all 5 years, the proportion of persons with a specific source of ongoing care was lower among Hispanics compared with non-Hispanic Whites; among poor, near poor, and middle income persons compared with high income persons; and among persons with a high school education or less compared with persons with at least some college (Figure 3.5). ? In all years except 2001, the proportion of persons with a specific source of ongoing care was lowe r among Asians and Blacks compared with Whites; and in 2001 and 2002, the proportion was lowe r among persons of multiple races compared with W h i t e s . ? From 1999 to 2003, the proportion of persons with a source of ongoing care improved for the ove r a l l U.S. population. Improvements were observed among Whites; non-Hispanic Whites; poor, near poor, and high income persons; and persons with at least some college. ? No group achieved the Healthy People 2010 goal of 96% of Americans with a specific source of ongoing c a r e . Usual Primary Care Pro v i d e r H aving a usual primary care provider (a doctor or nurse from whom one reg u l a r ly receives care) is associated with patients? greater trust in their prov i d e r1 6 and with good patient-provider communication which, in turn , increases the likelihood that patients receive appropriate care.1 7 By learning about patients? d iverse health care 95 needs over time, a usual primary care provider can coordinate care (e.g., visits to specialists) that best meets patient needs.1 8 I n d e e d, having a usual primary care provider correlates with receipt of higher quality care.1 9 - 2 1 Figure 3.6. Persons who have a usual primary care provider by race, ethnicity, income, and education, 2002 Key: AI/AN=American Indian or Alaska Native. S o u rce: Medical Expenditure Panel Survey, 2002. R e f e rence population: Civilian noninstitutionalized population. Note: A usual primary care provider is defined as the source of care that a person usually goes to for new health problems, pre v e n t i v e health care, and referrals to other health pro f e s s i o n a l s . National Healthcare Disparities Report Access to Health Care ? The proportion of persons with a usual primary care provider was lower among Asians compared with Whites; among Hispanics compared with non-Hispanic Whites; and among poor, near poor, and middle income persons compared with high income persons (Figure 3.6). ? No group achieved the Healthy People 2010 goal of 85% of Americans with a usual primary care p r ov i d e r. To distinguish the effects of race, ethnicity, income, and education on having a usual primary care prov i d e r, this measure is stratified by income and education level. Figure 3.7. Persons who have a usual primary care provider by race (left) and ethnicity (right) stratified by income, 2002 96 K e y : AI/AN=American Indian or Alaska Native. S o u rc e : Medical Expenditure Panel Survey, 2002. R e f e rence population: Civilian noninstitutionalized population. Note: Sample sizes were too small to provide estimates for AI/ANs with high incomes. National Healthcare Disparities Report Access to Health Care Figure 3.8. Persons who have a usual primary care provider by race (left) and ethnicity (right) stratified by education, 2002 Key: AI/AN=American Indian or Alaska Native. 97 S o u rce: Medical Expenditure Panel Survey, 2002. R e f e rence population: Civilian noninstitutionalized population. Note: Sample sizes were too small to provide estimates for AI/ANs with less than a high school education or some college education, and multiple race persons with a high school education or less. ? Socioeconomic status explains some but not all of the racial and ethnic differences in having a usual p r i m a ry care provider (Figures 3.7 and 3.8). ? Hispanics of eve ry income and education level are less like ly than respective non-Hispanic Whites to h ave a usual primary care prov i d e r. ? Within income and education levels, racial minorities are often less like ly than Whites to have a usual p r i m a ry care prov i d e r. National Healthcare Disparities Report Access to Health Care Patient Perceptions of Need Patient perceptions of need include perceived difficulties or delays in obtaining care and problems getting care as soon as it is wanted. Although patients may not always be able to assess their need for care, probl e m s getting care when patients perceive that they are ill or injured like ly reflect significant barriers to care. Figure 3.9. Families in which a member was unable or delayed in receiving needed medical care, dental care, or prescription medicines, by race, ethnicity, and income, 2002 98 Key: AI/AN=American Indian or Alaska Native. S o u rce: Medical Expenditure Panel Survey, 2002. R e f e rence population: Civilian noninstitutionalized population. ? The proportion of families in which a member was unable or delayed in receiving needed medical care, dental care, or prescription medicines was higher among families headed by multiple race indiv i d u a l s compared with White individuals; among poor, near poor, and middle income families compared with high income families; and among families headed by individuals with less than a high school education compared with individuals with some college education (Figure 3.9). ? Families headed by Asians were less like ly to report this problem than families headed by W h i t e s . ? O ver 60% of families who reported this problem reported a financial or insurance reason for it. Fa m i l i e s headed by minorities and families of lower SES were more like ly to report a financial or insurance reason than families headed by Whites or of higher SES, respective ly. National Healthcare Disparities Report Access to Health Care Health Care Utilization Measures of health care utilization complement patient reports of barriers to care and permit a fuller understanding of access to care. Barriers to care that are associated with differences in health care utilization m ay be more significant than barriers that do not affect utilization. Many landmark reports on disparities have relied on measures of heath care utilization,2 2 - 2 4 and these data demonstrate some of the largest differences in care among diverse groups. More recent eff o rts to inform health care delive ry continue to include measures of health care utilization.25 26 I n t e rpreting health care utilization data is more complex than analyzing data on patient perceptions of access to care. Besides access to care, health care utilization is strongly affected by health care need and patient preferences and values. In addition, greater use of services does not necessarily indicate better care. In fa c t , high use of some inpatient services may reflect impaired access to outpatient services. Therefore, the key to symbols used in Ta bles 3.2a and 3.2b, which summarize findings on all core report measures related to health care utilization, is different from that used for Ta bles 3.1a and 3.1b. Rather than indicating better or wo r s e access compared with the comparison group, symbols on the utilization tables simply identify the amount of care received by racial, ethnic, and socioeconomic groups relative to their comparison groups. Each ye a r, the Nation?s 12 million health services wo r kers provide about 820 million office visits and 590 99 million hospital outpatient visits and treat 35 million hospitalized patients, 2.5 million nursing home residents, 1.4 million home health care patients, and 100,000 persons in hospice settings.2 7 Each ye a r, about 70% of the c ivilian noninstitutionalized population visit a medical prov i d e r ?s office or outpatient department, about 60% r e c e ive a prescription medicine, and about 40% visit a dental prov i d e r.2 8 National health expenditures totaled over $1.5 trillion in fiscal year 2002, about 14.9% of the gross domestic p r o d u c t .2 9 G ove rnments account for 46% of the U.S. total?over 32% from the Federal Gove rnment in the f o rm of Medicare and Medicaid payments and grants to States and over 13% from State and local g ove rnments. Health care spending per capita rose 9.3% from 2001 to 20023 0; premiums for private health insurance increased 12.7% in 2002.3 1 Health expenditures among the civilian noninstitutionalized population in America are ex t r e m e ly concentrated, with 5% of the population accounting for 55% of outlay s .3 2 In addition, it has been estimated that as much as $390 billion a year?almost a third of all health care expenditures?are the result of poor quality care, including ove ruse, misuse, and wa s t e .3 3 The 2003 NHDR and the 2004 NHDR reported that different racial, ethnic, and SES groups had diff e r e n t p a t t e rns of health care utilization. Asians and Hispanics tended to have lower use of most health care serv i c e s including routine care, emerg e n cy department visits, avo i d a ble admissions, and mental health care. Blacks tended to have lower use of routine care, outpatient mental health care, and outpatient HIV care but higher use of emerg e n cy departments and hospitals, including higher rates of avo i d a ble admissions, inpatient mental health care, and inpatient HIV care. Lower SES individuals tended to have lower use of routine care and outpatient mental health care and higher use of emerg e n cy departments, hospitals, and home heath care. T h i s ye a r, findings related to dental care, emerg e n cy department visits, potenially avo i d a ble admissions, and mental health care and substance abuse treatment are highlighted. National Healthcare Disparities Report Access to Health Care Dental Visits R egular dental visits promote prevention, early diagnosis, and optimal treatment of oral diseases and conditions. Failure to visit the dentist can result in delayed diagnosis, overall compromised health, and, o c c a s i o n a l ly, even death.1 3 Racial and socioeconomic differences in oral health are well documented, with minorities and poorer populations bearing a disproportionate burden of oral diseases.3 4 Figure 3.10. Persons with a dental visit in the past year by race, ethnicity, income, and education, 2002 100 K e y : NHOPI=Native Hawaiian or Other Pacific Islander; AI/AN=American Indian or Alaska Native S o u rc e : Medical Expenditure Panel Survey, 2002. R e f e rence population: Civilian noninstitutionalized population. ? The proportion of persons with a dental visit in the past year was lower among Blacks, Asians, A I / A N s , and persons of multiple races compared with Whites; among Hispanics compared with non-Hispanic Whites; among poor, near poor, and middle income persons compared with high income persons; and among persons with a high school education or less compared with persons with at least some colleg e ( Figure 3.10). ? At 43.5%, the proportion of the total U.S. population with a dental visit in the past year fell short of the H e a l t hy People 2010 goal of 56%. National Healthcare Disparities Report Access to Health Care To distinguish the effects of race, ethnicity, and socioeconomic status on health care utilization and to identify populations at greatest risk for barriers to health care utilization, this measure is stratified by income and education leve l . Figure 3.11. Persons with a dental visit in the past year by race (left) and ethnicity (right) stratified by income, 2002 101 K e y : AI/AN=American Indian or Alaska Native; NHW=non-Hispanic White. S o u rc e : Medical Expenditure Panel Survey, 2002. R e f e rence population: Civilian noninstitutionalized population. N o t e : Sample sizes were too small to provide estimates for high income AI/ANs. National Healthcare Disparities Report Access to Health Care Figure 3.12. Persons with a dental visit in the past year by race (left) and ethnicity (right) stratified by education, 2002 102 K e y : AI/AN=American Indian or Alaska Native. S o u rc e : Medical Expenditure Panel Survey, 2002. R e f e rence population: Civilian noninstitutionalized population. Note: Sample sizes were too small to provide estimates for AI/ANs with less than high school education or some college education. ? Socioeconomic status explains some but not all of the racial and ethnic differences in rates of dental visits (Figures 3.11 and 3.12). ? Hispanics of eve ry income and education level are less like ly than respective non-Hispanic Whites to h ave had a dental visit. ? Within each income and education group, racial minorities are typically less like ly to have had a dental v i s i t . National Healthcare Disparities Report Access to Health Care Emergency Department Vi s i t s Without good access to health care, persons sometimes resort to using the emerg e n cy department when care is needed. A high rate of emerg e n cy department visits may suggest that a population lacks access to preve n t ive and routine care and other avenues of treatment. Delaying care until care is urgent often results in poorer health outcomes and increased health care costs. Figure 3.13. Emergency department visits per 100 population by race, 1997-2002 103 S o u rce: National Hospital Ambulatory Medical Care Survey, 1997- 2 0 0 2 . ? In 2001-2002, rates of emerg e n cy department visits were signifi c a n t ly higher among Blacks compared with Whites (Figure 3.13). ? O ver the 1997-1998 to 2001-2002 time periods, the rate of emerg e n cy department visits did not change s i g n i fi c a n t ly overall or for Blacks or Whites; in all years, Blacks had a signifi c a n t ly higher rate of e m e rg e n cy department visits than W h i t e s . National Healthcare Disparities Report Access to Health Care Potentially Avoidable Admissions Po t e n t i a l ly avo i d a ble admissions are hospitalizations that might have been ave rted by good quality outpatient care. T h ey relate to conditions for which good outpatient care can prevent the need for hospitalization or for which early intervention can prevent complications or more severe disease. Though not all admissions for these conditions can be avo i d e d, rates in populations tend to va ry with access to outpatient serv i c e s .3 5 Fo r example, better access to care should facilitate the diagnosis of appendicitis before rupture occurs. Racial, ethnic, and socioeconomic differences in avo i d a ble admissions are well documented; rates are higher among Blacks compared with Whites and among low income compared with high income indiv i d u a l s .3 6 - 3 8 A s the numbers of avo i d a ble hospitalizations for some conditions increased between 1980 and 1998, the ga p s b e t ween these demographic groups widened.3 9 Data for perforated appendix presented here come from A H R Q ?s Healthcare Cost and Utilization Project State Inpatient Databases disparities analysis file. This file is designed to provide national estimates using we i g h t e d records from a sample of hospitals from 22 States that have 63% of U.S. hospital discharges. These 22 States p a rticipate in HCUP and have relative ly complete race and ethnicity data. Figure 3.14. Perforated appendix per 1,000 admissions with appendicitis by race/ethnicity and area income 104 (median income of ZIP Code of residence), 2001 and 2002 K e y : API=Asian or Pacific Islander. S o u rc e : HCUP State Inpatient Databases disparities analysis file, 2 0 0 1 - 2 0 0 2 . R e f e rence population: Patients hospitalized with appendicitis. Note: White, Black, and API are non-Hispanic gro u p s . ? In both years, the rate of perforated appendix was higher among non-Hispanic Blacks and Hispanics compared with non-Hispanic Whites; the rate was also higher among residents of ZIP Codes with median income <$25,000, $25,000-$34,999, and $35,000-$44,999 compared with residents of ZIP Codes with income $45,000 and over (Figure 3.14). ? From 2001 to 2002, a significant change in the rate of perforated appendix was not evident for any group. National Healthcare Disparities Report Access to Health Care To distinguish the effects of race/ethnicity and income on health care utilization, this measure is stratified by income leve l . Figure 3.15. Perforated appendix per 1,000 admissions with appendicitis by race/ethnicity stratified by area income (median income of ZIP Code of residence), 2002 Key: API=Asian or Pacific Islander. S o u rc e : HCUP State Inpatient Databases disparities analysis file, 105 2 0 0 2 . R e f e rence population: Patients hospitalized with appendicitis. N o t e : White, Black, and API are non-Hispanic gro u p s . ? Area income explains some but not all of the racial/ethnic differences in rates of perforated appendix ( Figure 3.15). ? In general, Blacks have a higher rate of perforated appendix than Whites across area income levels. ? Racial/ethnic differences in perforated appendix are generally small for Hispanics and APIs compared with Whites within each area income group. National Healthcare Disparities Report Access to Health Care Mental Health Care and Substance Abuse Tre a t m e n t Mental Health Care O ver 40 million persons ages 18 to 64 had a mental disorder in 2004.4 0 Although the prevalence of mental disorders for racial and ethnic minorities in the United States is similar to that for W h i t e s ,4 1 d i fferences in care can be observed. Mental health care is defined as having counseling, inpatient care, outpatient care, or prescription medications for problems with emotions, nerves, or mental health and does not include alcohol or d rug treatment. Compared with Whites, minorities have less access to mental health care and are less like ly to r e c e ive needed serv i c e s .4 2 Racial, ethnic, and socioeconomic differences in the use of psychiatric m e d i c a t i o n s4 3 and of psychiatric outpatient,4 4 e m e rg e n cy,4 5 and inpatient serv i c e s4 6 h ave also been documented. These differences may reflect, in part, variation in preferences and cultural attitudes towa r d mental health. Figure 3.16. Adults who received mental health treatment/counseling in the past year by race, ethnicity, income, and education, 2003 106 Key: AI/AN=American Indian or Alaska Native. S o u rce: SAMHSA National Survey on Drug Use and Health, 2003. R e f e rence population: U.S. population age 18 and older. ? The proportion of persons who received mental health treatment/counseling was lower among Blacks, Asians, and AI/ANs compared with Whites; among Hispanics compared with non-Hispanic W h i t e s ; among middle income persons compared with high income persons; and among persons with a high school education or less compared with persons with at least some college (Figure 3.16). ? The proportion of persons who received mental health treatment was higher among poor persons compared with high income persons. National Healthcare Disparities Report Access to Health Care To distinguish the effects of race, ethnicity, and socioeconomic status on mental health treatment/counseling, this measure is stratified by income and education leve l . Figure 3.17. Persons who received mental health treatment/counseling in the past year by race (left) and ethnicity (right) stratified by income, 2003 107 Key: AI/AN=American Indian or Alaska Native. S o u rc e : SAMHSA National Survey on Drug Use and Health, 2003. R e f e rence population: U.S. population age 18 and older. N o t e : Sample sizes were too small to provide estimates for near poor and high income AI/ANs. Figure 3.18. Persons who received mental health treatment/counseling in the past year by race (left) and ethnicity (right) stratified by education, 2003 Key: AI/AN=American Indian or Alaska Native. S o u rce: SAMHSA National Survey on Drug Use and Health, 2003. R e f e rence population: U.S. population age 18 and older. National Healthcare Disparities Report Access to Health Care ? Socioeconomic status explains some but not all of the racial and ethnic differences in mental health treatment. At eve ry income and education level, Hispanics are less like ly than non-Hispanic Whites to h ave received mental health treatment (Figures 3.17 and 3.18). ? At higher income and education levels, Blacks are less like ly than Whites to have received mental health treatment/counseling; among the poor and among individuals with less than a high school education, Black-White differences are not signifi c a n t . ? Among the poor and among high school graduates, AI/ANs are less like ly than Whites to have receive d mental health treatment/counseling, but AI/AN-White differences are not significant in other income and education gr o u p s . Substance Abuse Tre a t m e n t In 2003, about 16 million Americans age 12 and older were heavy alcohol drinkers and about 54 million had a recent binge drinking episode.4 7 About 20 million persons age 12 and older were illicit drug users and about 71 million reported recent use of a tobacco product.4 7 The direct costs of mental disorders and substance abu s e amounted to $99 billion in 1996; lost productivity and premature death accounted for an additional $75 b i l l i o n .4 1 Racial, ethnic, and socioeconomic differences in substance abuse treatment4 7 are observed wh i c h m ay, in part, reflect variation in preferences and cultural attitudes toward mental health and substance abu s e . 108 Nonetheless there is a significant treatment gap: 15% of Blacks who needed treatment received it, 10% of Whites who needed treatment received it, 7% of Hispanics who needed treatment received it, and only 2% of Asians who needed treatment received treatment.4 7 Figure 3.19. Persons age 12 or older who received any illicit drug or alcohol treatment in the past year, by race, ethnicity, income, and education, 2003 K e y : AI/AN=American Indian or Alaska Native. S o u rc e : SAMHSA National Survey on Drug Use and Health, 2003. R e f e rence population: U.S. population age 12 and older. N o t e : The figure reflects both prevalence and treatment; pre v a l e n c e likely has an effect on racial/ethnic diff e rences in treatment. ? The proportion of persons age 12 or older who r e c e ived any illicit drug or alcohol treatment was greater among AI/ANs compared with Whites; among poor, near poor, and middle income persons compared with high income persons; and among persons with a high school education or less compared with persons with any college education. ? A significant difference between the proportion of Hispanics and non-Hispanic Whites who received a ny illicit drug or alcohol treatment was not o b s e rved. National Healthcare Disparities Report Access to Health Care Table 3.1a. Racial and Ethnic Differences in Facilitators and Barriers to Health Care C o re Report Measure R a c i a l Ethnic D i f f e re n c ei D i f f e re n c ei i B l a c k A s i a ni i i N H O P Ii i i AI/AN >1 Race H i s p a n i c Health Insurance Cove ra ge Persons under 65 with health insuranceiv = = = Persons uninsured all ye a rv = = = Usual Source of Care Persons who have a specific source of ongoing careiv = = Persons who have a usual primary care p r ov i d e rv = = = Patient Pe rceptions of Need Families that experience difficulties or d e l ays in obtaining health care or do not = = = r e c e ive needed carev Families that experience difficulties or 109 d e l ays in obtaining health care due to financial or insurance reasonsv Pa t i e n t - P rovider Communication Adults whose health providers sometimes or never listened carefully, explained things, showed respect, and spent enough time with themv = = Children whose health providers sometimes or never listened carefully, explained things, showed respect, and spent enough time with themv = = = i Compared with W h i t e s . ii Compared with non-Hispanic W h i t e s . i i i Findings are presented separately for Asians and NHOPI wh e n ever possible. Howeve r, some data sources collected data for Asians and Pa c i fic Islanders (APIs) as a single population; in these cases, the Asian and NHOPI cells are merged into a single cell representing APIs. iv Source: National Health Interv i ew Survey, 2003. v Source: Medical Expenditure Panel Survey, 2002. Key: NHOPI=Native Hawaiian or Other Pa c i fic Islander; AI/AN=American Indian or Alaska Native. Key to Symbols Used in Access to Health Care Tabl e s : = Group and comparison group have about same access to health care. Group has better access to health care than the comparison gr o u p . Group has worse access to health care than the comparison gr o u p . Blank cell: Reliable estimate for group could not be made. National Healthcare Disparities Report Access to Health Care Table 3.1b. Socioeconomic Differences in Facilitators and Barriers to Health Care C o re Report Measure I n c o m e Educational I n s u ra n c e D i f f e re n c ei D i f f e re n c ei i D i f f e re n c ei i i < 1 0 0 % 1 0 0 - 1 9 9 % 2 0 0 - 3 9 9 % 1 Race H i s p a n i c Dental Care Persons with a dental visit in the past ye a riv = E m e rgency Care E m e rg e n cy department visits per 100 p o p u l a t i o nv Avo i d able Admissions Admissions for perforated appendix per 1,000 admissions with appendicitisv i = Mental Health Care and Substance A buse Treatment Adults who received mental health treatment or counseling in the past ye a rv i i = Persons age 12 and older who received 111 illicit drug or alcohol abuse treatment in = = the past ye a rv i i i Compared with W h i t e s . i i Compared with non-Hispanic W h i t e s . i i i Findings are presented separately for Asians and NHOPIs wh e n ever possible. Howeve r, some data sources collected data for Asians and Pa c i fic Islanders (APIs) as a single population; in these cases, the Asian and NHOPI cells are merged into a single cell representing APIs. ivSource: Medical Expenditure Panel Survey, 2002. v Source: National Hospital A m bu l a t o ry Medical Care Survey ? Emerg e n cy Department, 2001-2002. Missing rates preclude analysis by ethnicity. v i Source: HCUP SID disparities analysis file, 2002. This source categorizes race/ethnicity ve ry diff e r e n t ly from other sources. Race/ethnicity inform a t i o n is categorized as a single item: Non-Hispanic White, Non-Hispanic Black, Hispanic, Asian or Pa c i fic Islander. These contrasts compare each group with non-Hispanic Whites. v i i Source: Substance A buse and Mental Health Services Administration, National Survey on Drug Use and Health, 2003. Key: NHOPI=Native Hawaiian or Other Pa c i fic Islander; AI/AN=American Indian or Alaska Native . Key to Symbols Used in Health Care Utilization Tabl e s : = Group and comparison group receive about same amount of health care. Group receives more health care than the comparison gr o u p . Group receives less health care than the comparison gr o u p . Blank cell: Reliable estimate for group could not be made. National Healthcare Disparities Report Access to Health Care Table 3.2b. Socioeconomic Differences in Health Care Utilization C o re Report Measure I n c o m e E d u c a t i o n a l I n s u ra n c e D i f f e re n c ei D i f f e re n c ei i D i f f e re n c ei i i < 1 0 0 % 1 0 0 - 1 9 9 % 2 0 0 - 3 9 9 % 1 4 . The Importance of Primary Care Physicians as the Usual Source of Healthcare in the A c h i evement of Prevention Goals. One- Pager No. 4. The Robert Graham Center: Po l i cy Studies in Fa m i ly Practice and Primary Care; Fe b ru a ry 2000. < w w w. gr a h a m - c e n t e r. o rg / x 1 5 9 . x m l > 1 5 . The Importance of Having Health Insurance and a Usual Source of Care.One-Pager No. 29. The Robert Graham Center: Po l i cy Studies in Fa m i ly Practice and Primary Care; September 2004. 1 6 . Mainous AG 3rd, Baker R, Love MM, et al. Continuity of care and trust in one's physician: evidence from primary care in the United States and the United Kingdom. Fam Med. 2001 Jan;33(1):22-7. 1 7 . S t a r field B. Primary Care: Balancing Health Needs, Services and Te c h n o l og y. New York: Oxford University Press; 1998. 1 8 . Fo rrest C, Starfield B. The effect of first-contact care with primary care clinicians on ambu l a t o ry health care expenditures. J Fam Pract. 1996 Jul;43(1):40-8. Cited in: Healthy People 2010 (Conference Edition, in Two Volumes). Washington, DC: U.S. Department of Health and Human Services; January 2000. 1 9 . Parchman ML, Burge SK, Residency Research Network of South Texas Inve s t i gators. Continuity and quality of care in type 2 diabetes: a Residency Research Network of South Texas study. J Fam Pract. 2002 Jul;51(7):619-24. National Healthcare Disparities Report Access to Health Care 2 0 . Christakis DA, Wright JA, Zimmerman FJ, et al. Continuity of care is associated with high-quality care by parental report . Pediatrics. 2002 (Apr);109(4):e54. 2 1 . I n kelas M, Schuster MA, Olson LM, et al. Continuity of primary care clinician in early childhood. Pediatrics. 2004 June;113(6 Suppl):1917-25. 2 2 . Tr evino F, Moss A J. Health Indicators for Hispanic, Black and White Americans. 88pp. (PHS) 84-1576. PB87-156956. PC A05 MF A02. September 1984. 2 3 . U.S. Department of Health and Human Services. Report of the Secretary's Task Force on Black and Minority Health. Washington, DC: DHHS; 1985. 2 4 . Institute of Medicine. Access to Health Care in America. Washington, DC: National A c a d e my Press; 1993. 2 5 . National Quality Fo rum. Improving Healthcare Quality for Minority Patients. Washington, DC: National Quality Fo ru m ; 2 0 0 2 . 2 6 . Institute of Medicine, Committee on Guidance for Designing a National Healthcare Disparities Report. Guidance for the National Healthcare Disparities Report. Swift EK (Ed.). Washington, DC: National Academies Press; 2002, p. 20. 2 7 . National Center for Health Statistics. Health, United States, 2002: With Chartbook on Trends in the Health of A m e r i c a n s . Hyattsville, MD: NCHS; 2002. 2 8 . Krauss N, Machlin S, Kass BL. Use of health care services, 1996. Rockville, MD: A g e n cy for Health Care Po l i cy and Research; 1999. MEPS Findings No. 7, AHCPR Pub. No. 99-0018. 114 2 9 . Centers for Medicare & Medicaid Services. Ta ble 1. National health expenditures and selected economic indicators, leve l s and average annual percent change: selected calendar years 1990-2013; 2004. Accessed August 1, 2005. 3 0 . Centers for Medicare & Medicaid Services. Ta ble 3. National health expenditures; aggr egate and per capita amounts, percent d i s t r i bution and average annual percent change by source of funds: selected calendar years 1990-2013; 2004. < w w w. c m s . h h s . g ov/statistics/nhe/projections-2003/t3.asp> Accessed August 1, 2005. 3 1 . S t runk B, Ginsbu rg PB, Gabel JR. Tracking health care costs: gr owth accelerates again in 2001. Health A ff (Millwood). 2002 Jul-Dec;Suppl Web Exclusives:W299-W310. 3 2 . Berk ML, Monheit AC. The concentration of health care expenditures, revisited. Health A ff (Millwood). 2001 Mar- A p r ; 2 0 ( 2 ) : 9 - 1 8 . 3 3 . M i d west Business Group on Health. Reducing the Costs of Po o r-Quality Health Care Through Responsible Purchasing Leadership; 2003. [www. m b g h . o rg / c o s t q u a l i t y.html] Accessed August 2, 2005. 3 4 . U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: National Institute of Dental and Craniofacial Research, National Institutes of Health; May 2000. 3 5 . Bindman A, Grumbach K, Osmond D, et al. Preve n t a ble hospitalizations and access to health care. JAMA. 1995 Jul 2 6 ; 2 7 4 ( 4 ) : 3 0 5 - 1 1 . 3 6 . Gaskin D, Hoffman C. Racial and ethnic differences in preve n t a ble hospitalizations across 10 states. Med Care Res Rev. 2000;57 (Suppl 1):85-107. 3 7 . Blustein J, Hanson K, Shea S. Preve n t a ble hospitalizations and socioeconomic status. Health A ff (Millwood). 1998 M a r- A p r ; 1 7 ( 2 ) : 1 7 7 - 8 9 . 3 8 . Culler S, Parchman ML, Przybylski M. Factors related to potentially preve n t a ble hospitalizations among the elderly. Med Care. 1998 Jun;36(6):804-17. 3 9 . Kozak L, Hall MJ, Owings MF. Trends in avo i d a ble hospitalizations, 1980-1998. Health A ff (Millwood). 2001 Mar- A p r ; 2 0 ( 2 ) : 2 2 5 - 3 2 . National Healthcare Disparities Report Access to Health Care 4 0 . Kessler R, McGonagle KA, Zhao S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey. Arch Gen Psychiatry. 1994 Jan;51(1):8-19. 4 1 . U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General. Rockville, MD: Substance A buse and Mental Health Services Administration, Center for Mental Health Services and National Institutes of Health, National Institute of Mental Health; 1999. 4 2 . U.S. Department of Health and Human Services. Mental Health: Culture, Race, Ethnicity?A Supplement to Mental Health: R e p o rt of the Surgeon General. Exe c u t ive Summary. Rockville MD: Substance A buse and Mental Health Serv i c e s Administration/Center for Mental Health Services; 2001. 4 3 . M e l fi C, Croghan T W, Hanna MP, Robinson RL. Racial variation in antidepressant treatment in a Medicaid population. J Clin P s y c h i a t ry. 2000 Jan;61(1):16-21. 4 4 . Kales H, Blow FC, Bingham CR, et al. Race, psychiatric diagnosis, and mental health care utilization in older patients. Am J Geriatr Psychiatry. 2000 Fa l l ; 8 ( 4 ) : 3 0 1 - 9 . 4 5 . S egal S, Bola JR, Watson MA. Race, quality of care, and antipsychotic prescribing practices in psychiatric emerg e n cy serv i c- es. Psychiatr Serv. 1996 Mar;47(3):282-6. 4 6 . Chung H, Mahler JC, Kakuma T. Racial differences in treatment of psychiatric inpatients. Psychiatr Serv. 1995 J u n ; 4 6 ( 6 ) : 5 8 6 - 9 1 . 4 7 . Substance A buse and Mental Health Services Administration. Results from the 2003 National Survey on Drug Use and Health: National Findings. Rockville, MD; Substance A buse and Mental Health Services Administration, Office of A p p l i e d Studies; 2004. NHDUH Series H-25, DHHS Pub. No. SMA 04-3964. 115 National Healthcare Disparities Report 116 National Healthcare Disparities Report Priority Populations Chapter 4. Priority Populations M a ny Americans enjoy easy access to one of wo r l d ?s finest health care delive ry systems. Howeve r, as demonstrated in previous NHDRs, some Americans do not have full access to the best quality health care. To examine the issue of disparities in health care, Congress directed AHRQ to produce an annual report to track ?prevailing disparities in health care delive ry as it relates to racial factors and socioeconomic factors in priority populations.? While the emphasis is on disparities related to race, ethnicity, and SES, this directive includes a charge to examine disparities in ?priority populations??groups with unique health care needs or issues that require special attention. This chapter addresses the congressional directive on priority populations. Chapters 2 and 3 of this report examine racial, ethnic, and socioeconomic differences in quality of health care and access to health care in the general U.S. population; this chapter focuses on differences within and across priority populations. Fo r example, comparisons are made between Black and White women and between children from low and high income families. This approach may help policy m a kers to understand the impact of racial, ethnic, and socioeconomic differences on specific populations and target quality improvement programs toward groups in greatest need. Appendix D includes detailed tables that allow examination of racial, ethnic, and socioeconomic disparities both in the general population and across priority populations for most measures. 117 Priority Populations A H R Q ?s priority populations, specified by Congress in the Healthcare Research and Quality Act of 1999 ( P u blic Law 106-129), are: ? Minority gr o u p s ? L ow income gr o u p s ? Wo m e n ? C h i l d r e n ? E l d e r ly ? I n d ividuals with special health care needs, including individuals with disabilities and individuals wh o need chronic care or end-of-life health care. In addition, this legislation directs AHRQ to examine health care delive ry in rural areas. Hence, this chapter addresses each of these priority populations as well as residents of rural areas. National Healthcare Disparities Report Priority Populations How This Chapter Is Organized This chapter presents new information about disparities in quality of and access to health care in priority populations. It is presented in the following order: ? Racial and ethnic minorities ? L ow income gr o u p s ? Wo m e n ? C h i l d r e n ? E l d e r ly ? Residents of rural areas ? I n d ividuals with special health care needs To avoid repetition of findings from previous chapters on race, ethnicity, and SES, the first two sections summarize quality of and access to health care for racial and ethnic minorities and low income groups. Subsequent sections focus on the remaining priority populations and examine disparities in care within each population group and changes in disparities over time. To present this greater detail, these sections highlight a small number of measures. Results for all measures are found in the detailed appendix tabl e s . 118 It should be noted that this chapter does not provide a comprehensive assessment of health care differences in each priority population. Most of the measures tracked in the NHDR were selected to be applicable across m a ny population groups; only a few, such as immunizations among children and screening for breast cancer among women, were specific to particular groups. For some groups, these general measures ove r l o o k i m p o rtant health care problems specific to particular populations. In addition, national data may not address key health issues for specific population groups and are often unable to generate reliable estimates for many smaller groups. Instead, this chapter should be seen as a starting point, identifying some problem areas and indicating gaps in current data and understanding. National Healthcare Disparities Report Priority Populations Racial and Ethnic Minorities Racial and Ethnic Minorities In 2000, about 30% of the U.S. population identified themselves as members of racial or ethnic minority groups. By 2050, it is projected that these groups will account for almost half of the U.S. population. Census 2000 counted over 36 million Blacks or African Americans (12.9% of the U.S. population); over 35 million Hispanics or Latinos who live in the United States (12.5%) and another 3.8 million who live in the C o m m o n wealth of Puerto Rico1; almost 12 million Asians (4.2%)2; 874,000 Native Hawaiians and Other Pa c i fic Islanders (0.3%)3 ; and over 2 million American Indians and Alaska Natives (0.7%), of whom 38% reside on Federal trust lands.4 Racial and ethnic minorities are more like ly than non-Hispanic Whites to be poor or near poor.5 In addition, Hispanics, Blacks, and some Asian subgroups are less like ly than non- Hispanic Whites to have a high school education.6 In general, racial and ethnic minorities often ex p e r i e n c e poorer access to care and lower quality of preve n t ive, primary, and specialty care.5 6 In previous chapters of this report, health care differences by raciali and ethnici i c a t egories as defined by the O ffice of Management and Budget7 and used by the U.S. Census Bureau are described.8 In this section, quality of and access to health care for each minority group is summarized. Criteria for importance are that the difference is statistically significant at the alpha=0.05 level, two-tailed test and that the relative diff e r e n c e is at least 10% different from the reference group when framed positive ly as a favo r a ble outcome or nega t ive ly as an adverse outcome. Access measures focus on facilitators and barriers to health care and exclude health 119 care utilization measures. In addition, changes in differences related to race and ethnicity over time are examined in this section. Both absolute and relative differences are compared in current data and historical data. Core report measures for which both the absolute differences and the relative differences are becoming smaller over time are identifi e d as improving disparities. Core report measures for which both the absolute differences and the relative d i fferences are becoming larger over time are identified as worsening disparities. Uncommonly, absolute and r e l a t ive differences do not agree on direction of change. In these cases, direction of change is unclear and results for these measures are not presented. As in previous NHDRs, this section includes information on programs and issues that may affect racial and ethnic disparities. The assessment of disparities faced by American Indians and Alaska Natives includes i n f o rmation on the approx i m a t e ly 60% of American Indians and Alaska Natives who obtain care from Indian Health Service (IHS) facilities. N ew in this ye a r ?s report is a special focus on the effects of language barriers and country of birth on quality of and access to care. Data from the Medical Expenditure Panel Survey are used to present findings on speaking a language other than English and being born in a foreign country. i Races include: Black or African American, Asian, Native Hawaiian or Other Pa c i fic Islander, American Indian and A l a s k a N a t ive, White, and persons of multiple races. ii Ethnicity differentiates Hispanics and non-Hispanics. This report also distinguishes non-Hispanic Whites and non- Hispanic Blacks. National Healthcare Disparities Report Priority Populations Racial and Ethnic Minorities Blacks or African Americans P r evious NHDRs showed that Blacks had poorer quality of care and worse access to care than Whites for m a ny measures tracked in the reports. Findings based on 46 core report measures of quality and 8 core report measures of facilitators and barriers to health care are shown below. Figure 4.1. Blacks compared with Whites on measures of quality and access B e t t e r = Blacks receive better quality of care or have better access to care than W h i t e s . S a m e = Blacks and Whites receive about the same quality of care or access to care . Worse = Blacks receive poorer quality of care or have worse access to care than W h i t e s . CRM = core report measure s . Note: Data presented are the most recent available. ? For 20 of the 46 core report measures of quality, Blacks had poorer quality of care than Whites (Figure 4.1). Black-White d i fferences ranged from Blacks being over 10 times more like ly 120 than Whites to be diagnosed with AIDS to Blacks being 59% less like ly than Whites to be given antibiotics for the common cold. The median difference over all of the core report measures was 9% (Blacks 9% more like ly than Whites to r e c e ive poorer quality care). ? For 4 of the 8 core report measures of access, Blacks had signifi c a n t ly worse access to care than W h i t e s . Black-White differences ranged from Blacks under age 65 being 17% more like ly than Whites to lack health insurance to Blacks being 7% less like ly than Whites to report difficulties or delays getting care. The median difference over all of the core report measures was 10% (Blacks 10% more like ly than Whites to have worse access to care). Figure 4.2. Change in Black-White disparities over time I m p roving = Black-White diff e rence becoming smaller. Worsening = Black-White diff e rence becoming larg e r. CRM = core report measure s . Note: The most recent and oldest years of data available are compare d . ? Of core report measures of quality that could be tracked over time for Blacks and Whites, Black-White differences became smaller for 23 measures but larger for 17 measures (Figure 4.2). For 2 measures?late stage breast cancer and p o s t o p e r a t ive venous thromboembolic event?Black-White d i fferences were no longer statistically signifi c a n t . ? Of core report measures of access that could be tracked over time for Blacks and Whites, Black-White differences became smaller for all measures. For 1 measure?being uninsured all year?the Black-White difference was no longer statistically s i g n i fi c a n t . National Healthcare Disparities Report Priority Populations Racial and Ethnic Minorities Hispanics or Latinos P r evious NHDRs showed that Hispanics had poorer quality of care and worse access to care than non-Hispanic Whites for many measures tracked in the reports. Findings based on 38 core report measures of quality and 8 core report measures of access to health care that support estimates for Hispanics are shown below. Figure 4.3. Hispanics compared with non-Hispanic Whites on measures of quality and access B e t t e r = Hispanics receive better quality of care or have better access to care than non-Hispanic Whites. Same = Hispanics and non-Hispanic Whites receive about the same quality of care or access to care . Wo r s e = Hispanics receive poorer quality of care or have worse access to care than non-Hispanic Whites. CRM = core report measure s . Note: Data presented are the most recent available. ? For 20 of the 38 core report measures of quality, Hispanics had poorer quality of care than non-Hispanic Whites. Differences 121 ranged from Hispanics being over 3.7 times more like ly to be diagnosed with AIDS to Hispanics being 40% less like ly to die of breast cancer. The median difference over all of the core r e p o rt measures was 16% (Hispanics 16% more like ly than non-Hispanic Whites to receive poorer quality care). ? For 7 of the 8 core report measures of access, Hispanics had worse access to care than non-Hispanic Whites (Figure 4.3). Differences ranged from Hispanics under age 65 being 2.9 times more like ly to lack health insurance to Hispanics being 18% less like ly to report difficulties or delays getting care. T h e median difference over all of the core report measures was 87% (Hispanics 87% more like ly than non- Hispanic Whites to have worse access). Figure 4.4. Change in Hispanic?non-Hispanic White disparities over time I m p ro v i n g = Hispanic?non-Hispanic White diff e rence becoming smaller. Wo r s e n i n g = Hispanic?non-Hispanic White diff e rence becoming larg e r. CRM = core report measure s . Note: The most recent and oldest years of data available are compare d . ? Of core report measures of quality that could be tracked over time for Hispanics and non-Hispanic Whites, Hispanic?non- Hispanic White differences became smaller for 14 measures but larger for 20 measures (Figure 4.4). For 2 measures? persons with diabetes with three recommended services and persons in need of substance abuse treatment who received it? n ew significant differences were seen. ? Of core report measures of access that could be tracked over time for Hispanics and non-Hispanic Whites, Hispanic?non- Hispanic White differences became smaller for 1 measure but l a rger for 5 measures. The 2 patient communication measures s h owed the biggest increases in Hispanic?non-Hispanic White d i ff e r e n c e s . National Healthcare Disparities Report Priority Populations Racial and Ethnic Minorities A s i a n s P r evious NHDRs showed that Asians had similar or better quality of care than Whites but worse access to care than Whites for many measures tracked in the reports. Findings based on 32 core report measures of quality and 7 core report measures of facilitators and barriers to health care that support estimates for either Asians or Asians and Pa c i fic Islanders in aggr egate are shown below. Figure 4.5. Asians compared with Whites on measures of quality and access B e t t e r = Asians receive better quality of care or have better access to care than W h i t e s . S a m e = Asians and Whites receive about the same quality of care or access to care . Wo r s e = Asians receive poorer quality of care or have worse access to care than W h i t e s . CRM = core report measure s . Note: Data presented are the most recent available. ? For 7 of the 32 core report measures of quality, Asians had s i g n i fi c a n t ly poorer quality of care than Whites, while for 12 measures, Asians had signifi c a n t ly better quality of care than Whites (Figure 4.5). The median difference over all of the core 122 r e p o rt measures was -4% (Asians 4% less like ly than Whites to receive poorer quality care). ? For 3 of the 7 core report measures of access, Asians had s i g n i fi c a n t ly worse access to care than Whites. Asian-White d i fferences ranged from Asian parents being 57% more like ly to report communication problems with their child?s providers to Asians being 40% less like ly to report difficulties or delay s getting care. The median difference over all of the core report measures was 20% (Asians 20% more l i ke ly than Whites to have worse access to care). Figure 4.6. Change in Asian-White disparities over time I m p ro v i n g = Asian-White diff e rence becoming smaller. Wo r s e n i n g = Asian-White diff e rence becoming larg e r. CRM = core report measure s . Note: The most recent and oldest years of data available are compare d . ? Of core report measures of quality that could be tracked over time for Asians and Whites, Asian-White differences became smaller for 13 measures but larger for 12 measures (Figure 4.6). For 2 measures?elderly with pneumococcal vaccine and adults with provider communication probl e m s ? n ew significant d i fferences were seen. ? O n ly 2 core report measures of access could be tracked over time for Asians and Whites. Asian-White differences became smaller for both measures. National Healthcare Disparities Report Priority Populations Racial and Ethnic Minorities American Indians and Alaska Natives P r evious NHDRs showed that American Indians and Alaska Natives (AI/ANs) had poorer quality of care and worse access to care than Whites for many measures tracked in the reports. Findings based on 21 core report measures of quality and 6 core report measures of access are shown below. Figure 4.7. AI/ANs compared with Whites on measures of quality and access Better = AI/ANs receive better quality of care or have better access to care than W h i t e s . Same = AI/ANs and Whites receive about the same quality of care or access to care . Worse = AI/ANs receive poorer quality of care or have worse access to care than W h i t e s . CRM = core report measure s . Note: Data presented are the most recent available. ? Less than half of the core report measures supported estimates for quality for A I / A N s . ? For 8 of the 21 core report measures of quality, AI/ANs had s i g n i fi c a n t ly poorer quality of care than Whites (Figure 4.7). AI/AN-White differences ranged from AI/ANs being twice as 123 l i ke ly as Whites to lack early prenatal care to AI/ANs being 67% less like ly to develop late stage breast cancer. The median d i fference over all of the core report measures was 8% ( A I / A N s 8% more like ly than Whites to receive poorer quality care). ? For 3 of the 6 core report measures of access, AI/ANs had signifi c a n t ly worse access to care than W h i t e s . AI/AN-White differences ranged from AI/ANs under age 65 being over twice as like ly as Whites to lack health insurance to AI/ANs being 23% more like ly than Whites to lack a primary care prov i d e r. T h e median difference over all of the core report measures was 41% (AI/ANs 41% more like ly than Whites to h ave worse access). Figure 4.8. Change in AI/AN-White disparities over time I m p roving = AI/AN-White diff e rence becoming smaller. Wo r s e n i n g = AI/AN-White diff e rence becoming larg e r. CRM = core report measure s . Note: The most recent and oldest years of data available are compare d . ? Less than half of the core report measures supported estimates for changing disparities for A I / A N s . ? Of core report measures of quality that could be tracked over time for AI/ANs and Whites, AI/AN-White differences became smaller for 8 measures but larger for 8 measures (Figure 4.8). For 1 measure?recommended care for heart attack?AI/ANs r e c e ived signifi c a n t ly poorer care in 2003, though a significant d i fference was not observed in 2002. ? O n ly 2 core report measures of access could be tracked over time for AI/ANs and Whites. AI/AN-White differences became smaller for both measures. National Healthcare Disparities Report Priority Populations Racial and Ethnic Minorities Focus on Indian Health Service Facilities About 60% of AI/ANs nationwide rely on the Indian Health Service to provide access to health care.9 In the 2005 NHDR, among persons with diabetes served by IHS facilities, rate of flu vaccine was relative ly c o m p a r a ble to rates in the overall U.S. population of persons with diabetes, while rates of annual retinal eye exam and foot examination were lowe r.1 0 Due to low numbers and lack of data, information about A I / A N hospitalizations is difficult to obtain in most Federal and State hospital utilization data sources. The 2005 NHDR addresses this gap by examining hospitalizations in IHS and tribal hospitals for diabetes and for perforated appendix. Diabetes is one of the leading causes of morbidity and mortality among A I / A N populations, and its prevention and control are a major focus of the IHS Director?s Chronic Disease Initiative as well as the IHS Health Promotion/Disease Prevention Initiative. The hospitalization rate for long-term complications due to diabetes has decreased almost 10% since 1997. Addressing barriers of access to health care is a large part of the overall IHS goal which strives to assure that comprehensive, culturally acceptabl e personal and public health services are ava i l a ble and accessible to American Indian and Alaska Native p e r s o n s .9 For the more than 538,000 Native Americans living on reservations or other trust lands where the climate is inhospitable, the roads are often impassable, and transportation is scarce, health care facilities are far from accessibl e .1 1 Figure 4.9. Hospitalizations for long-term complications among persons with diabetes per 100,000 124 population 18 years and older in IHS and tribal hospitals (left) and nationally (right) by race/ethnicity S o u rce: IHS, National Patient Information Reporting System, 2003 and HCUP State Inpatient Databases disparities analysis file, 2002. ? Hospitalizations for long-term complications of diabetes among AI/ANs 18 years and older in IHS hospitals were 247 per 100,000 population in IHS service areas in 2003 (Figure 4.9, left). In comparison, national rates were higher among Blacks (328) and Hispanics (239) than non-Hispanic Whites (91) in 2002 (Figure 4.9, right). National Healthcare Disparities Report Priority Populations Racial and Ethnic Minorities Figure 4.10. Hospitalizations for perforated appendix per 1,000 admissions with appendicitis in IHS and tribal hospitals (left) and nationally (right) by race/ethnicity 125 S o u rc e : IHS, National Patient Information Reporting System, 2003 and HCUP State Inpatient Databases disparities analysis file, 2002. ? Hospitalizations for perforated appendix among AI/ANs in IHS hospitals were 375 per 1,000 admissions with appendicitis in IHS service areas in 2003 (Figure 4.10, left). In comparison, national rates we r e higher among Blacks (350) and Hispanics (315) than non-Hispanic Whites (299) in 2002 (Figure 4.10, r i g h t ) . National Healthcare Disparities Report Priority Populations Racial and Ethnic Minorities Native Hawaiians and Other Pacific Islanders The ability to assess disparities among Native Hawaiians and Other Pa c i fic Islanders (NHOPIs) for the NHDR has been hampered by two main issues. First, the NHOPI racial categ o ry is relative ly new to Federal data collection. Prior to 1997, NHOPIs were classified as part of the Asian and Pa c i fic Islander racial categ o ry and could not be identified separately in most Federal data. In 1997, the Office of Management and Budget p r o m u l gated new standards for Federal data on race and ethnicity and mandated that information about NHOPIs be collected separately from information about A s i a n s .8 Federal agencies had until 2003 to be fully compliant with these standards. Because both the 2003 and 2004 NHDRs report predominantly on data collected between 1999 and 2001, many of the databases used had not fully transitioned to the new standards. Hence, few databases could provide any estimates for the NHOPI population. Second, when inform a t i o n about this population was collected, databases often included insufficient numbers of NHOPIs to allow r e l i a ble estimates. C o n s e q u e n t ly, in previous NHDRs, estimates for the NHOPI population could be generated for only a handful of NHDR measures. Similarly, in this NHDR, of the 45 core report measures of quality, estimates for NHOPIs could be made for only 5?2 measures from the National Vital Statistics System-Natality, 1 measure from the National Immunization Survey, and 2 measures from the CMS Home Health Care Outcome and Assessment Information Set. Of the 8 core report measures of access, estimates for NHOPIs could be made 126 for only 1?persons under age 65 with health insurance from the National Health Interv i ew Survey. A lack of quality data on this population prohibits the NHDR from detailing disparities for this group. Howeve r, as data become ava i l a ble, this information will be included in future report s . National Healthcare Disparities Report Priority Populations Racial and Ethnic Minorities Focus on Language Barriers and Immigrants Language Spoken at Home Quality health care requires that patients and providers communicate eff e c t ive ly. Language is a barrier to quality health care for many racial and ethnic minorities. About 47 million Americans, or 18% of the population, spoke a language other than English at home in 2000, up from 32 million in 1990. Of these i n d ividuals, 28 million (about 11% of the population) spoke Spanish, 10 million (about 4% of the population) s p o ke another Indo-European language, and 7 million (about 3% of the population) spoke an Asian or Pa c i fi c Islander language at home. Almost half of persons who spoke a foreign language at home reported not speaking English ve ry we l l .1 2 Findings are presented below on differences in one quality measure focusing on patient centeredness?the patient experience of care?and one access measure?usual source of care? b e t ween persons who speak English at home and those who speak some other language at home. Patient centere d n e s s : patient experience of care. Communication problems between the patient and p r ovider can lead to lower patient adherence to medications and decreased participation in medical decisionmaking. This ye a r, using methods developed for the CAHPS? Health Plan Survey,( form e r ly know n as Consumer Assessment of Health Plans),13 the NHDR presents a composite measure which combines four of the measures used in previous NHDRs into a single core report measure for patient experience of care and c o m m u n i c a t i o n . 127 F i g u re 4.11. Adults whose health providers sometimes or never listened care f u l l y, explained things, showed respect, and spent enough time with them, by race and ethnicity, and language spoken at home, 2002 S o u rce: Medical Expenditure Panel Survey, 2002. R e f e rence population: Civilian noninstitutionalized population. ? The overall proportion of adults whose health providers sometimes or never listened carefully, ex p l a i n e d things, showed respect, and spent enough time with them was higher among individuals who speak a foreign language at home compared with individuals who speak English at home (Figure 4.11). National Healthcare Disparities Report Priority Populations Racial and Ethnic Minorities ? Compared with Whites who speak English at home, the proportion of adults with communication p r o blems was higher among Whites and Asians who speak some other language at home. ? Compared with non-Hispanic Whites who speak English at home, the proportion of adults with communication problems was higher among non-Hispanic Whites and Hispanics who speak some other language at home as well as Hispanics who speak English at home. Access to care : usual source of care. The patient-primary care provider relationship is built upon mutual respect, trust, and understanding. Language barriers may impair the development of such relationships. Figure 4.12. Persons who have a usual primary care provider, by race and ethnicity, and language spoken at home, 2002 128 S o u rc e : Medical Expenditure Panel Survey, 2002. R e f e rence population: Civilian noninstitutionalized population. ? The overall proportion of persons who have a usual primary care provider was lower among indiv i d u a l s who speak a foreign language at home compared with individuals who speak English at home (Fi g u r e 4 . 1 2 ) . ? Compared with Whites who speak English at home, the proportion of persons who have a usual primary care provider was lower among Whites, Blacks, and Asians who speak some other language at home as well as Blacks and Asians who speak English at home. ? Compared with non-Hispanic Whites who speak English at home, the proportion of persons with a usual p r i m a ry care provider was lower among non-Hispanic Whites and Hispanics who speak some other language at home as well as Hispanics who speak English at home. National Healthcare Disparities Report Priority Populations Racial and Ethnic Minorities Country of Birth I m m i grants often encounter barriers to high quality health care. About 30 million persons living in the United States in 2000 were born outside the United States, up from 20 million in 1990. Asians and Hispanics are much more like ly to be foreign born. About 70% of Asians and 40% of Hispanics in the United States are foreign born compared with 6% of Whites and Blacks.1 4 This section identifies differences in one quality measure focusing on treatment?completion of tuberculosis therapy?and one measure of access to care? uninsurance?for Americans born outside of the United States. Tre a t m e n t : completion of tuberculosis thera py. C e rtain diseases are concentrated among Americans born in other countries. For example, more than half of tuberculosis cases in the Nation are among foreign-born i n d ividuals, and the case rate among foreign-born individuals is more than eight times higher than among i n d ividuals born in the United States. The percentage of cases of tuberculosis among U. S . - b o rn individuals is decreasing while the percentage of cases among foreign-born individuals is increasing.1 5 Adherence to recommended treatments is important for reducing drug resistant tuberculosis and leads to completion of t h e r a py within 12 months of diagnosis. Figure 4.13. Completion of therapy for tuberculosis within 12 months of being diagnosed among persons born outside the United States, by race and ethnicity, 2001 129 Key: API=Asian or Pacific Islander. S o u rce: Centers for Disease Control and Prevention, National Tu b e rculosis Surveillance System, 2001. R e f e rence population: Civilian noninstitutionalized population. ? Among persons born outside the United States, Blacks are more like ly than Whites to complete therapy for tuberculosis within 12 months (Figure 4.13). National Healthcare Disparities Report Priority Populations Racial and Ethnic Minorities Access to care : u n i n s u ra n c e. Persons born outside the United States may have less access to resources, such as health insurance, that facilitate getting needed health care. Figure 4.14. Persons under age 65 uninsured all year, by race and ethnicity, stratified by place of birth, 2002 ; 130 S o u rce: Medical Expenditure Panel Survey, 2002. R e f e rence population: Civilian noninstitutionalized population. ? The overall proportion of persons younger than 65 uninsured all year was higher among foreign-born persons compared with individuals born in the United States (Figure 4.14). ? Compared with U. S . - b o rn Whites, the proportion of persons under age 65 uninsured all year was higher among Whites and Blacks born outside the United States as well as Blacks born in the United States. ? Compared with U. S . - b o rn non-Hispanic Whites, the proportion of persons uninsured all year was higher among non-Hispanic Whites and Hispanics born outside the United States as well as Hispanics born in the United States. National Healthcare Disparities Report Priority Populations Low Income Gro u p s Low Income Gro u p s The poor are defined as persons living in families whose household income falls below specific pove rt y thresholds. These thresholds va ry by fa m i ly size and composition and are updated annually by the U. S . Bureau of the Census. After falling for nearly a decade, the numbers of poor persons in America rose from 31.6 million in 2000 to 34.6 million in 2002, and the pove rty rate increased from 11.3% to 12.1% over the same period. Pove rty varies by race and ethnicity. In 2002, 24% of Blacks, 22% of Hispanics, 10% of Asians, and 10% of Whites were poor.1 6 Persons with low incomes often experience worse health and are more like ly to die p r e m a t u r e ly.17 18 19 20 In general, the poor have reduced access to high quality care. Income-related diff e r e n c e s in quality of care that are independent of health insurance coverage have also been demonstrated.2 1 In previous chapters of this report, health care differences by income were described. In this section, disparities in quality of and access to health care for poori i i compared with high incomeiv i n d ividuals are summarized. For each core report measure, poorer persons can have health care that is worse than, about the same as, or better than health care received by high income persons. Only relative differences of at least 10% that are statistically significant with p<0.05 are discussed in this report. Access measures focus on fa c i l i t a t o r s and barriers to health care and exclude health care utilization measures. 131 In addition, changes in differences related to income over time are examined in this section. Both absolute and relative differences are compared in current data and historical data. Core report measures for which both the absolute differences and the relative differences are becoming smaller over time are identified as i m p r oving disparities. Core report measures for which both the absolute differences and the relative d i fferences are becoming larger over time are identified as worsening disparities. Uncommonly, absolute and r e l a t ive differences do not agree on direction of change. In these cases, direction of change is unclear and results for these measures are not presented. As in previous NHDRs, this section includes information on programs that may affect low income gr o u p s . Community health centers (CHCs) are vital sources of health care for many low income individuals. The care d e l ivered in CHCs is also eff e c t ive in reducing disparities: Black-White disparities in overall mortality and prenatal care and Hispanic-White disparities in tuberculosis case rates and prenatal care are smaller in States with better coverage of low income individuals by CHCs.2 2 I n f o rmation on quality of and access to care p r ovided by CHCs as well as on racial, ethnic, and socioeconomic differences in CHC care is also presented in this section. iii Household income less than Federal pove rty thresholds. ivHousehold income 400% of Federal pove rty thresholds and higher. National Healthcare Disparities Report Priority Populations Low Income Gro u p s Figure 4.15. Poor compared with high income individuals on measures of quality and access B e t t e r = Poor receive better quality of care or have better access to care than high income individuals. S a m e = Poor and high income individuals receive about the same quality of care or access to care . Wo r s e = Poor receive poorer quality of care or have worse access to care than high income individuals. CRM = core report measure s . Note: Data presented are the most recent available. ? Less than half of the core report measures supported estimates of quality for the poor. ? For 11 of the 13 core report measures of quality with income data, the poor had signifi c a n t ly poorer quality of care than high income individuals (Figure 4.15). Po o r-high income diff e r e n c e s ranged from poor parents being over three times more like ly than high income parents to report communication problems with their child?s providers to poor individuals being 10% less l i ke ly to lack needed substance abuse treatment. The median 132 d i fference was 40% (the poor 40% more like ly than high income individuals to receive poorer quality care). ? For all 8 core report measures of access, the poor had signifi c a n t ly worse access to care than high income i n d ividuals. Po o r-high income differences ranged from the poor under age 65 being over six times as l i ke ly as high income individuals to lack health insurance to the poor being 67% more like ly to lack a p r i m a ry care prov i d e r. The median relative rate was 2.5 (the poor are 2.5 times more like ly than high income individuals to have worse access). Figure 4.16. Change in poor-high income disparities over time I m p ro v i n g = Poor-high income diff e rence becoming smaller. Wo r s e n i n g = Poor-high income diff e rence becoming larg e r. CRM = core report measure s . Note: The most recent and oldest years of data available are compare d . ? Less than half of the core report measures supported estimates of changing disparities in quality for the poor. ? Of core report measures of quality that could be tracked over time for poor and high income individuals, poor-high income d i fferences became smaller for 5 measures but larger for 5 measures (Figure 4.16). For 1 measure?smokers with advice to quit?a new significant difference was seen. ? Of core report measures of facilitators and barriers to health care that could be tracked over time for poor and high income i n d ividuals, poor-high income differences became smaller for 1 measure but larger for 4 measures. While more access measures showed decline than showed improvement in income-related disparities, the largest magnitude change observed was a narr owing of the poor-high income gap in health insurance. National Healthcare Disparities Report Priority Populations Low Income Gro u p s Focus on Chronic Care in Federally Supported Health Centers Health centers were first developed to provide accessible, aff o r d a ble, personal health care services to low income families, and they continue to do so under Section 330 of the Health Centers Consolidation Act of 1996, which is administered by the Health Resources and Services Administration (HRSA). In 2003, 890 health centers provided health care to 12.3 million patients living in rural and urban medically underserve d areas. For the past 40 years, health centers operating at the community level have provided regular access to high q u a l i t y, fa m i ly - o r i e n t e d, comprehensive primary and preve n t ive health care, regardless of ability to pay. Health centers serve clients that are primarily low income and minorities including migrant/seasonal fa rm wo r kers; homeless individuals and families; individuals living with HIV/AIDS infection; and a large number of unemployed and impoverished people with chronic diseases. Among the 12.3 million patients who sought care in health centers in 2003, 39% were uninsured, 64% were ethnic minorities, 69% had incomes less than 100% of the pove rty level, and 30% were best served in a language other than English, indicating that health centers are the safety net provider for vulnerable populations.2 3 The network of health centers across the Nation continues to gr ow as new health centers are added each ye a r from grants distributed through the President?s Health Centers Initiative. The 5-year President?s Health Centers Initiative plans to add 1,200 new and expanded health centers to cover an additional 6 million people 133 s e rved by 2006. Increasing access to care will be important especially for those who require we l l - c o o r d i n a t e d, continuous care, such as those with chronic conditions. Among all health problems, chronic disease is the most perva s ive, costly, and preve n t a ble, as 7 out of 10 Americans die each year of chronic diseases and 1 out of 10 faces major limitations in activ i t y.2 4 Of all health center patients that were seen in 2003, 6% were seen for diabetes, and 2% were seen for asthma.2 3 Data on the quality of care received by patients receiving care from community health centers were obtained from the 2002 HRSA Community Health Center User Survey. This survey was funded by HRSA and consists of 2,129 interv i ews from 70 selected grantees that nationally represent 6 million CHC users. Quality measures highlighted in this section were selected because they are clinically meaningful. One treatment measure and two management measures are highlighted in this section: Component of health care need: M e a s u re : Tr e a t m e n t Advice to obese patients on diet/eating habits M a n a g e m e n t Annual visit to eye doctor by patients with diabetes M a n a g e m e n t Counseling on asthma self-managment E ff o rts to further improve the quality of care provided to patients with chronic conditions are being addressed through HRSA?s Health Disparities Collaborative, a national eff o rt to achieve strategic system change in the d e l ive ry of primary health care. This health initiative seeks to generate and document improved health outcomes for underserved populations and transform clinical practice through evidence-based models of care. The Health Disparities Collaborative has focused on diabetes, cardiovascular disease, depression, asthma, c a n c e r, diabetes prevention, overall prevention, access and patient flow redesign, and perinatal and patient s a f e t y. National Healthcare Disparities Report Priority Populations Low Income Gro u p s Quality of Health Care Tre a t m e n t : a dvice to obese patients on diet/eating hab i t s. Obesity can contribute to other medical probl e m s such as cardiovascular disease and stroke. Counseling on diet is an important preve n t ive care measure. Figure 4.17. Obese persons in community health centers who were asked about their diet and eating habits in the past 12 months, by race/ethnicity, education level, and insurance status, 2002 S o u rce: HRSA Community Health Center User Survey, 2002. R e f e rence population: Obese persons who received care in community health centers. N o t e : Whites and Blacks are non-Hispanic populations. Obese persons are those who had a body mass index greater than 30. 134 ? In 2002, 53% of obese persons were asked about their diet and eating habits in the past 12 months. ? S i g n i ficant differences between racial/ethnic, education, and insurance groups were not observed ( Figure 4.17). M a n a ge m e n t : a n nual visit to eye doctor by patients with diab e t e s . Receipt of an annual eye exam by patients with diabetes is a we l l - e s t a blished process of care measure. Figure 4.18. Persons with diabetes in community health centers who saw an eye doctor in the last 12 months by race/ethnicity, education level, and insurance status, 2002 S o u rce: HRSA Community Health Center User Survey, 2002. R e f e rence population: Persons with diabetes who sought care in community health centers. Note: Whites and Blacks are non-Hispanic populations. ? In 2002, 63% of persons with diabetes who sought care in community health centers saw an eye doctor in the last 12 months. ? The percentage of persons with diabetes who saw an eye doctor in the last 12 months was s i g n i fi c a n t ly higher among people with public insurance compared with people with private or no insurance (Figure 4.18). No other significant d i fferences were observed. ? For all groups, health centers exceeded the Healthy People 2010 baseline of 47% but did not reach the H e a l t hy People 2010 target (75%). National Healthcare Disparities Report Priority Populations Low Income Gro u p s M a n a ge m e n t : counseling on asthma self-manage m e n t . Appropriate asthma self-management may reduce the likelihood of asthma attacks and, in turn, the potential need for hospitalization. Figure 4.19. Persons with asthma in community health centers who were ever counseled about ways to manage their asthma by race/ethnicity, education level, and insurance status, 2002 S o u rce: HRSA Community Health Center User Survey, 2002. R e f e rence population: Persons with asthma who received care in community health centers. Note: Whites and Blacks are non-Hispanic populations. ? In 2002, 45.5% of persons with asthma who sought care in a community health center were counseled on ways to manage their asthma. ? The percentage of persons counseled on ways to manage their asthma was signifi c a n t ly higher among people with public insurance compared with people with private or no insurance (Figure 4.19). No other significant differences were o b s e rved. 135 ? For all groups, health centers exceeded the H e a l t hy People 2010 baseline (8.4%) and target (30%) for persons counseled on ways to manage their asthma. National Healthcare Disparities Report Priority Populations Wo m e n Wo m e n Census 2000 counted 140 million females, 51% of the U.S. population, of whom 40 million are members of racial or ethnic minority gr o u p s .2 5 By 2050, it is projected that just under half of females in the United States will be members of racial or ethnic minority gr o u p s .2 6 The ratio of males to females is highest at birth, wh e n male infants outnumber female infants, and gr a d u a l ly declines with age due to higher male mortality rates. Among Americans 85 and older, women outnumber men by more than 2 to 1.2 7 Pove rty disproport i o n a t e ly a ffects women; almost 13 million women lived in households with incomes below the Federal pove rty level in 2 0 0 1 .2 8 Women in the United States have a life ex p e c t a n cy 5 years longer than men2 9 and lower age-adjusted death rates than men for 13 of the 15 leading causes of death.3 0 H oweve r, women are more like ly than men to report h aving arthritis, asthma, autoimmune diseases, and depression.3 1 O verall, many wo m e n ?s health needs are i n a d e q u a t e ly addressed.3 2 Among women, racial and ethnic differences in mortality and health status are o b s e rved. Black women have higher death rates than White women due to heart disease, cancer, and stroke while Hispanic, API, and AI/AN women have lower death rates due to these conditions.3 1 Black and Hispanic women are also more like ly to report fair or poor overall health and having diabetes. Poor or near poor wo m e n are more like ly to report fair or poor overall health; limitations of activity; and having anxiety or depression, 136 a rthritis, asthma, diabetes, hy p e rtension, obesity, and osteoporosis.3 3 In general, gender differences in quality of care are small. Howeve r, significant gender differences in c a r d i ovascular care have been demonstrated. Among women, racial, ethnic, and socioeconomic differences in quality of care exist. Racial and ethnic differences are noted in receipt of cardiovascular procedures, cancer screening, and management of fi b r o i d s .3 4 Socioeconomic differences are noted in receipt of Pap tests and m a m m ogr a m s .3 5 Women are more like ly to obtain preve n t ive services than men.3 1 Among women, racial, ethnic, and socioeconomic differences in access to care are observed. Black wo m e n are more like ly than White women to report forgoing needed physician care; and Hispanic women are more l i ke ly than non-Hispanic White women to report lack of health insurance and coverage for dental and vision care, not having a regular health care prov i d e r, not seeing a specialist when needed, and probl e m s communicating with phy s i c i a n s .3 6 Poor and near poor women are more like ly than high income women to r e p o rt lack of health insurance, dissatisfaction with their health plan when insured, and not having a usual source of care.3 5 M a ny measures of relevance to women are tracked in the NHDR. Findings presented here highlight six quality measures and one access measure of particular importance to women: Component of health care need: M e a s u re : P r eve n t i o n Osteoporosis screening, dental care Tr e a t m e n t Hospital care for heart attack M a n a g e m e n t Recommended services for diabetes M a t e rnal health Prenatal care Patient safety Obstetric trauma Access to care U n i n s u r a n c e A d d i t i o n a l ly this ye a r, the section on cancer in Chapter 2 focuses on breast cancer prevention. National Healthcare Disparities Report Priority Populations Wo m e n Quality of Health Care P revention: Osteoporosis Scre e n i n g Osteoporosis is a disease characterized by loss of bone tissue that increases the risk of fractures of the hip, spine, and wrist. About 10 million persons in the United States have osteoporosis and another 34 million with l ow bone mass are at risk for developing the disease. Women represent more than two-thirds of Americans at risk for or diagnosed with osteoporosis. White and Asian women are at greater risk for osteoporosis than Black and Hispanic wo m e n .3 7 Because older women are at highest risk for osteoporosis, the U.S. Preve n t ive S e rvices Task Force recommends routine osteoporosis screening of women 65 and older. Figure 4.20. Elderly female Medicare beneficiaries who reported ever being screened for osteoporosis with a bone mass or bone density measurement by race, ethnicity, and income, 2000 and 2002 137 K e y : API=Asian or Pacific Islander. S o u rce: M e d i c a re Current Beneficiary Survey, 2000 and 2002. R e f e rence population: Female Medicare beneficiaries age 65 and older living in the community. ? In both years, the proportion of elderly female Medicare beneficiaries who reported ever being screened for osteoporosis with a bone mass or bone density measurement was lower among Blacks and A P I s compared with Whites; among Hispanics compared with non-Hispanic Whites; and among poor, near p o o r, and middle income women compared with high income women (Figure 4.20). ? From 2000 to 2002, the proportion of elderly female Medicare beneficiaries who reported ever being screened for osteoporosis increased among eve ry racial and ethnic population and among near poor women, but the proportion did not change signifi c a n t ly for poor, middle income, and high income women. National Healthcare Disparities Report Priority Populations Wo m e n P revention: Dental Care R egular dental visits promote prevention, early diagnosis, and optimal treatment of craniofacial diseases and conditions. Failure to visit the dentist can result in delayed diagnosis, overall compromised health, and, o c c a s i o n a l ly, even death.3 8 Racial, socioeconomic, and gender differences in oral health are well documented, with minorities, poorer populations, and menv bearing a disproportionate burden of oral diseases.3 9 Figure 4.21. Persons with a dental visit in the past year by race, ethnicity, income, and education, 2002 138 K e y : AI/AN=American Indian or Alaska Native. S o u rce: Medical Expenditure Panel Survey, 2002. R e f e rence population: Civilian noninstitutionalized population. ? For both males and females, the proportion of persons with a dental visit was lower among Blacks, Asians, AI/ANs, and persons of multiple races compared with Whites; among Hispanics compared with non-Hispanic Whites; among poor, near poor, and middle income compared with high income persons; and among persons with a high school education or less compared with persons with at least some c o l l ege (Figure 4.21). ? The proportion of females with a dental visit was signifi c a n t ly higher than the proportion of males for all groups except Asians, AI/ANs, and persons of multiple races. vFor example, men have a higher rate of severe periodontal disease and oral and pharyngeal cancers compared with wo m e n . H oweve r, women are more like ly than men to experience pain from oral sores, jaw joints, and bu rning mouth syndrome. National Healthcare Disparities Report Priority Populations Wo m e n Treatment: Hospital Care for Heart Attack Each ye a r, about half a million women die of cardiovascular disease. Among these, 250,000 die of heart a t t a c k s .4 0 Although heart disease is the leading cause of death among both women and men, sex differences in c a r d i ovascular care have been demonstrated and may relate to sex differences in disease presentation. M o r e ove r, although major risk factors for cardiovascular disease can often be prevented or controlled through lifestyle changes, physicians are less like ly to counsel women than men about diet, exercise, weight reduction, and substance abu s e .41, 42 After a first heart attack, women are less like ly than men to receive diagnostic and therapeutic procedures4 3 and cardiac rehabilitation,44, 45 and they are more like ly to die or have a second heart a t t a c k .4 6 This ye a r, the NHDR introduces a new composite measure for acute care for heart attack, which incorp o r a t e s the following six measures from previous NHDRs: receipt of aspirin within 24 hours of hospitalization, receipt of aspirin upon discharge, receipt of beta-bl o c ker within 24 hours of hospitalization, receipt of beta- bl o c ker upon discharge, receipt of ACE inhibitor for left ventricular systolic dysfunction, and counseling about smoking cessation among smokers. Figure 4.22. Recommended hospital care received by Medicare patients with heart attack by gender, 2002- 2003 139 S o u rce: Centers for Medicare & Medicaid Services, Medicare Quality Improvement Organization Program, 2002-2003. R e f e rence population: M e d i c a re beneficiaries hospitalized for heart a t t a c k . Note: Composite is calculated by averaging the percent of the population that received each of the six incorporated components of care. See Chapter 1, Introduction and Methods for composite d e t a i l s . ? In both years, the percentage of Medicare patients with heart attack receiving recommended hospital care was lower among females compared with males (Figure 4.22). ? From 2002 to 2003, the percentage of Medicare patients with heart attack receiving recommended hospital care increased signifi c a n t ly for both females and males. National Healthcare Disparities Report Priority Populations Wo m e n Management: Recommended Services for Diabetes In 2002, over 9.3 million women in the United States had diabetes.47 Women are at greater risk than men for some complications related to diabetes, including diabetic ketoacidosis and cardiovascular disease due to d i a b e t e s .4 8 In addition, poorly controlled diabetes during early preg n a n cy increases the risk for spontaneous a b o rtion and major birth defects.4 7 E ff e c t ive management of diabetes includes hemoglobin A1c testing, eye examination, and foot examination in the past ye a r, as well as appropriate influenza immunization and lipid m a n a g e m e n t .49, 50 Figure 4.23. Women with diabetes who had three recommended services (hemoglobin A1c testing and eye and foot examination) by race, ethnicity, income, and education level, 2002 140 S o u rce: Medical Expenditure Panel Survey, 2002. R e f e rence population: Civilian noninstitutionalized women with diabetes age 18 and older. ? The proportion of women with diabetes who had three recommended services was lower among Hispanics compared with non-Hispanic Whites; and among poor, near poor, and middle income wo m e n compared with high income women (Figure 4.23). Other significant differences were not observed. National Healthcare Disparities Report Priority Populations Wo m e n M a t e rnal Health: Prenatal Care C h i l d b i rth and reproductive care are the most common reasons for women of childbearing age to use health care; and with more than 11,000 births each day in the United States, childbirth is the most common reason for hospital admission.5 1 G iven that birth outcomes may have lifetime effects, good maternity care has the potential to affect the future health and health care needs of the Nation.52 53 Figure 4.24. Mothers with prenatal care in the first trimester by race (top left), ethnicity (top right), and education (bottom left), 2000-2002 141 K e y : NHOPI=Native Hawaiian or Other Pacific Islander; AI/AN= American Indian or Alaska Native. S o u rce: National Vital Statistics System - Natality, 2000-2002. R e f e rence population: Women with live births. ? In all 3 years, the proportion of women who initiated prenatal care in the first trimester was l ower among Black, NHOPI, and AI/AN wo m e n compared with White women; among Hispanic compared with non-Hispanic White women; and among women with less than a high school education or high school graduates compared with women with any college education (Figure 4.24). ? B e t ween 2000 and 2002, rates of mothers initiating prenatal care in the first trimester improved s i g n i fi c a n t ly among all groups except NHOPIs, AI/ANs, and those with any college education. National Healthcare Disparities Report Priority Populations Wo m e n I n f o rmation about income is not typically collected on birth cert i ficates, so education is commonly used as a p r oxy for SES. Racial and ethnic minorities have disproport i o n a t e ly less education than Whites. To distinguish the effects of race, ethnicity, and education on quality of health care, this measure is stratified by l evel of education. Figure 4.25. Mothers with prenatal care in the first trimester by race (left) and ethnicity (right) stratified by education, 2001 142 K e y : NHOPI=Native Hawaiian or Other Pacific Islander; AI/AN=American Indian or Alaska Native. S o u rce: National Vital Statistics System - Natality, 2001. R e f e rence population: Women with live births. ? Education explains some but not all of the differences in health care among women by race and ethnicity. Racial and ethnic differences in mothers who initiate prenatal care in the first trimester tended to persist among women with similar education (Figure 4.25). ? O n ly college educated Whites, Asians, and non-Hispanic Whites achieved the Healthy People 2010 goal of 90% of mothers receiving prenatal care in the first trimester. National Healthcare Disparities Report Priority Populations Wo m e n Patient Safety: Obstetric Trauma Trauma during delive ry is a possible complication of adverse events related to maternity care. Figure 4.26. Obstetric trauma with 4th degree lacerations or other obstetric lacerations per 1,000 vaginal deliveries without instrument assistance by race/ethnicity and area income (median income of ZIP Code of residence), 2001 and 2002 143 K e y : API=Asian or Pacific Islander. S o u rc e : HCUP State Inpatient Databases disparities analysis file, 2001 and 2002. R e f e rence population: All hospital admissions with vaginal deliveries without instrument assistance. Note: White, Black, and API are non-Hispanic gro u p s . ? In both years, the rate of obstetric trauma was lower among non-Hispanic Blacks and Hispanics compared with non-Hispanic Whites and among persons with incomes of less than $25,000 compared with persons who earn $45,000 or more (Figure 4.26). ? In 2001 the rate of obstetric trauma was lower among non-Hispanic APIs compared with non-Hispanic W h i t e s . ? From 2001 to 2002, the rate of obstetric trauma decreased signifi c a n t ly for non-Hispanic Whites but did not change signifi c a n t ly for any other group. National Healthcare Disparities Report Priority Populations Wo m e n Access to Health Care Health Insurance Health insurance facilitates access to health care, which can have serious repercussions on health: the uninsured are more like ly to have poor health status54 55 and to die early.5 6 - 5 8 T h ey report more probl e m s getting care,59 60 are diagnosed at later disease stages, and get less therapeutic care.59 61 Data for prolonged periods of uninsurance are presented. Figure 4.27. Persons under age 65 uninsured all year by race, ethnicity, income, and education, 2002 144 K e y : AI/AN=American Indian or Alaska Native. S o u rce: Medical Expenditure Panel Survey, 2002. R e f e rence population: Civilian noninstitutionalized population. ? For both genders, the proportion of persons uninsured all year was higher among Hispanics compared with non-Hispanic Whites; among poor, near poor, and middle income compared with high income persons; and among persons with a high school education or less compared with persons with at least some college (Figure 4.27). ? There were no racial differences in uninsurance among women, but the proportion of uninsured A I / A N men was higher compared with White men. ? The proportion of uninsured females was signifi c a n t ly higher than the proportion of uninsured males for all groups except Asians, AI/ANs, persons of multiple races, and persons with at least some colleg e . National Healthcare Disparities Report Priority Populations C h i l d re n C h i l d re n Children comprise 26% of the U.S. population, or 72.3 million people.6 2 Racial and ethnic minorities account for almost 40% of all children.6 3 In 2003, 19% of the child population was Hispanic6 4 and 17% of children l ived in families with incomes below the Federal pove rty leve l .1 In 2003, Black children and American Indian or Alaska Native children had death rates about 1.5 to 2 times higher than White children. Black infants were more than twice as like ly as White infants to die during their first ye a r. Life ex p e c t a n cy at birth was 78 years for White children and 72.8 years for Black children, a d i fference of 6%.6 5 Quality of health care among children varies by race, ethnicity, and SES.6 6 D i fferences have been observed in childhood immunization,6 7 management of asthma,6 8 and evaluation and treatment for attention- d e fi c i t / hy p e r a c t ivity disorder.6 9 Access to health care among children also varies by race, ethnicity, and SES. D i fferences among children by race, ethnicity, and SES have been observed in rates of uninsurance and publ i c c ove r a g e7 0; getting a routine appointment as soon as wa n t e d, receiving needed care, and patient ex p e r i e n c e s during care7 1; rating of health care7 2; and health care utilization and ex p e n d i t u r e s .7 3 M a ny measures of relevance to children are tracked in the NHDR. Findings presented here highlight four quality measures and two access measures of particular importance to children: 145 Component of health care need: M e a s u re : P reve n t i o n Dental care,v i counseling about physical activ i t y Tr e a t m e n t Hospital admissions for pediatric ga s t r o e n t e r i t i s M a n a g e m e n t Hospital admissions for pediatric asthma Access to care Health insurance, usual source of care In addition, the final section of this chapter, which discusses individuals with special health care needs, includes findings related to children with special health care needs. v iIncludes 1 core measure?dental visits?and 1 supplemental measure?untreated dental caries. National Healthcare Disparities Report Priority Populations C h i l d re n Quality of Health Care P revention: Dental Care R egular dental visits promote prevention, early diagnosis, and optimal treatment of craniofacial diseases and c o n d i t i o n s ,3 8 including prevention of dental caries. Healthy People 2010?s goals for reductions in childhood dental caries include a decrease from 18% to 11% for children age 2-4 and from 61% to 51% for 15-ye a r- olds. Figure 4.28. Children ages 2-5 and 13-17 with untreated dental caries, by race/ethnicity (left) and income (right), 1999-2002 146 S o u rce: National Health and Nutrition Examination Survey, 1999-2002. R e f e rence population: Civilian noninstitutionalized population age 2-5 and 13-17. N o t e : C h i l d ren age 2-5 are examined for untreated dental caries in their primary teeth; children age 13-17 are examined for dental caries in their permanent teeth. These data were collected for Mexican Americans rather than all Hispanics. ? ? In 1999-2002, the proportion of children age 2-5 with untreated dental caries in primary teeth was higher among non-Hispanic Black and Mexican American children compared with non-Hispanic White children and among poor, near poor, and middle income children compared with high income children (Fi g u r e 4.28). ? The same disparities were observed in the proportion of children age 13-17 with untreated dental caries in permanent teeth. National Healthcare Disparities Report Priority Populations C h i l d re n To improve overall oral health, Healthy People 2010 also sets a goal of increasing the percentage of persons age 2 and older using the oral health system annually from 44% to 56%. Figure 4.29. Children age 2-17 with a dental visit in the past year by race, ethnicity, and income, 2002 K e y : AI/AN=American Indian or Alaska Native. S o u rce: Medical Expenditure Panel Survey, 2002. R e f e rence population: Civilian noninstitutionalized population age 2- 17. 147 Note: AI/ANs sampled in MEPS tend to be largely non-re s e r v a t i o n , urban AI/ANs, which may not be re p resentative of dental care for all AI/ANs in the United States. ? The proportion of children with a dental visit in the past year was lower among Blacks and A s i a n s compared with Whites; among Hispanics compared with non-Hispanic Whites; and among poor, near p o o r, and middle income children compared with high income children (Figure 4.29). National Healthcare Disparities Report Priority Populations C h i l d re n P revention: Counseling About Physical Activity Lack of physical activity is a major contributor to childhood obesity. The President?s Council on Phy s i c a l Fitness and Sports recommends that children age 5-12 are phy s i c a l ly active for 60 minutes on most or all d ays. The recommendation for adolescents is 30 minutes a day. Routine promotion of physical activ i t y among young persons is widely recommended.7 4 Figure 4.30. Children age 2-17 whose parents/guardians reported advice from a doctor or other health provider about amount and kind of physical activity by race, ethnicity, and income, 2001 and 2002 148 S o u rc e : Medical Expenditure Panel Survey, 2001 and 2002. R e f e rence population: Civilian noninstitutionalized population age 2-17. ? In both 2001 and 2002, the proportion of children whose parents/guardians reported advice from a health p r ovider about physical activity was lower among children from poor, near poor, and middle income families compared with children from high income families (Figure 4.30). ? From 2001 to 2002, the proportion of children getting advice about physical activity increased from 28.0% to 31.9%. Improvements were observed among White, Black, non-Hispanic White, Hispanic, p o o r, and near poor children. National Healthcare Disparities Report Priority Populations C h i l d re n Treatment: Hospital Admissions for Pediatric Gastro e n t e r i t i s Pediatric gastroenteritis can develop into a life-threatening condition due to dehydration, especially among i n fants. Proper outpatient treatment of gastroenteritis may prevent hospitalization, and lower hospitalization rates may reflect access to better quality care. Figure 4.31. Hospital admissions for gastroenteritis per 100,000 population age 0-17 by race/ethnicity and area income (median income of ZIP Code of residence), 2001 and 2002 149 K e y : API=Asian or Pacific Islander. S o u rce: HCUP State Inpatient Databases disparities analysis file, 2001and 2002. R e f e rence population: C h i l d ren age 0-17. N o t e : White, Black, and API are non-Hispanic groups. ? In both 2001 and 2002, admissions for pediatric gastroenteritis were lower among API compared with White children and higher among children from ZIP Codes with median incomes of <$25,000, $25,000- $34,999, and $35,000-$44,999 compared with children from ZIP Codes with median incomes of $45,000 or more (Figure 4.31). ? From 2001 to 2002, admissions for pediatric gastroenteritis declined among Whites and did not change s i g n i fi c a n t ly for any other gr o u p . National Healthcare Disparities Report Priority Populations C h i l d re n Management: Hospital Admissions for Pediatric Asthma A disproportionate number of children have asthma. The prevalence rate for children age 0-17 is 83 per 1,000 while the prevalence rate for adults age 18 and older is 68 per 1,000.75 76 E m e rg e n cy room visit rates for asthma are highest among children age 0-4 (62 per 10,000 population), and the emerg e n cy room visit rate for Blacks is 380% higher than that for W h i t e s .7 7 Racial differences in asthma outcomes have also been o b s e rve d .7 8 Figure 4.32. Pediatric asthma admission rate per 100,000 population, by race/ethnicity stratified by area income (median income of ZIP Code of residence), 2002 150 Key: API=Asian or Pacific Islander. S o u rc e : HCUP State Inpatient Databases disparities analysis file, 2 0 0 2 . R e f e rence population: C h i l d ren age 0-17. Note: White, Black, and API are non-Hispanic groups. Income level is based on median income of patient?s ZIP Code. Sample sizes were too small to provide estimates for APIs with incomes less than $25,000. ? O verall, the rate of asthma admissions is higher among Black and lower among API children compared with White children (Figure 4.32). ? The rate is higher among children from ZIP Codes with median incomes of <$25,000, $25,000-$34,999, and $35,000-$44,999 compared with children from ZIP Codes with median incomes of $45,000 or more. ? Income explains some but not all of the differences in children?s hospitalization rates for asthma by r a c e / e t h n i c i t y. ? The rate of asthma admissions is higher among Blacks compared with Whites from eve ry income leve l and among Hispanics compared with non-Hispanic Whites from ZIP Codes with median incomes of $45,000 or more. The rate is lower among APIs from ZIP Codes with median income of $25,000- $34,999 compared with respective Whites. National Healthcare Disparities Report Priority Populations C h i l d re n Access to Health Care Health Insurance Insurance coverage is among the most important factors in access to health care. Special eff o rts have been made to provide insurance coverage to children.7 9 Figure 4.33. Children age 0-17 with health insurance, by race (top left), ethnicity (top right), and income (bottom left), 1999-2003 151 Key: AI/AN=American Indian or Alaska Native. S o u rce: National Health Interview Survey, 1999-2003. R e f e rence population: Civilian noninstitutionalized population. Note: Insurance status is determined at the time of interview. C h i l d ren are considered uninsured if they lack private health insurance, public assistance, Medicare, Medicaid, a State- s p o n s o red health plan, other government sponsored programs, a military health plan, or if their only coverage is through the Indian Health Service. ? In all 5 years, the proportion of children with health insurance was lower among AI/AN children compared with White children; among Hispanic children compared with non-Hispanic White children; and among poor, near poor, and middle income children compared with high income children (Figure 4.33). ? From 1999 to 2003, the overall rate of health insurance among children improved from 88.1% to 90.2%. Improvements were observed among White, Black, non-Hispanic White, Hispanic, poor, and near poor children. This coincided with the implementation of the State Children?s Health Insurance P r ogram (SCHIP) in 1998. National Healthcare Disparities Report Priority Populations C h i l d re n Usual Source of Care H aving a usual source of care is associated with a greater likelihood of obtaining needed preve n t ive s e rv i c e s .80 81 Figure 4.34. Children age 0-17 with a source of ongoing care, by race (top left), ethnicity (top right), and income (bottom left), 1999-2003 152 Key: AI/AN=American Indian or Alaska Native. S o u rce: National Health Interview Survey, 1999-2003. R e f e rence population: Civilian noninstitutionalized population. ? From 1999 to 2003, the proportion of children with a source of ongoing care was lower among Hispanic compared with non-Hispanic White children and among poor, near poor, and middle income compared with high income children ( Figure 4.34). ? In 3 of the 5 years, Black and Asian children were less like ly than White children to have a source of ongoing care. ? From 1999 to 2003, the overall proportion of children with a source of ongoing care improved from 93.3% to 94.6%. Improvements were o b s e rved among White, non-Hispanic White, Hispanic, and near poor children. In 2003, non-Hispanic White, middle income, and high income children had achieved the Healthy People 2010 target of 96% of persons with a source of ongoing care. National Healthcare Disparities Report Priority Populations E l d e r l y E l d e r l y Persons age 65 and over numbered more than 35 million in 2002, an increase of more than 10% over the p r evious decade. About 1 in eve ry 8 Americans is in this age group; and by the year 2030, the elderly population is projected to more than double to 71.5 million. Older women outnumber older men by nearly a third. Members of minority groups are projected to represent over one-quarter of the elderly in 2030, up from about 16% in 2000. About 3.6 million elderly lived below the p ove rty level in 2002, corresponding to a pove rty rate of over 10%. Another 2.2 million, or more than 6% of the elderly, were classified as near poor, with incomes between the pove rty level and 125% of this leve l .8 2 On average, 65-ye a r-olds can expect to live an additional 18.1 years. In 2003, 38.6% of noninstitutionalized older persons assessed their health as excellent or ve ry good compared with two-thirds of persons ages18-64. Older Blacks and Hispanics were less like ly to rate their health as excellent or good than older Whites. Most older persons have at least one chronic condition. In 1997, more than half of the elderly reported a disability and over a third reported a severe disability.8 2 The Medicare program provides core health insurance to nearly all elderly Americans and reduces many financial barriers to acute and postacute care services. The Medicare Prescription Drug Improvement and M o d e rnization Act of 2003 adds new prescription drug and preve n t ive benefits to Medicare and provides ex t r a 153 financial help to persons with low incomes. Consequently, differences in access to and quality of health care tend to be smaller among Medicare beneficiaries than among younger populations. Howeve r, racial, ethnic, and socioeconomic differences are still observed. S u rveys of the general population often do not include enough elderly to examine racial, ethnic, or socioeconomic differences in health care. Consequently, the NHDR relies upon data from the Medicare C u rrent Benefi c i a ry Survey to examine disparities in access to and quality of care. Findings presented here highlight three quality measures and two access measures of particular importance to the elderly : Component of health care need: M e a s u re : P r eve n t i o n Fecal occult blood test, dental care Ti m e l i n e s s Waiting 30 minutes or more to see a doctor Access to care Usual source of care, problems getting to the doctor National Healthcare Disparities Report Priority Populations E l d e r l y Quality of Health Care P revention: Fecal Occult Blood Te s t Fecal occult blood tests are an eff e c t ive way to detect colorectal cancer, improving the likelihood of early diagnosis, optimal treatment, and recove ry. In the 2003 NHDR, racial disparities in diagnosis of late-stage colorectal cancer were observed. Figure 4.35. Elderly Medicare beneficiaries with a home fecal occult blood test within the last 2 years by race, ethnicity, and income, 2000 and 2002 154 Key: API=Asian or Pacific Islander. S o u rc e : M e d i c a re Current Beneficiary Survey, 2000, 2002. R e f e rence population: M e d i c a re beneficiaries age 65 or older living in the community. N o t e : See Figure 4.25 of the 2004 NHDR and accompanying text for information on elderly Medicare beneficiaries with sigmoidoscopy or colonoscopy in 2000. ? In both 2000 and 2002, the percentage of elderly Medicare beneficiaries with a home fecal occult bl o o d test within the last 2 years was lower among Blacks compared with Whites and among poor and near poor beneficiaries compared with high income beneficiaries (Figure 4.35). ? In 2002 the percentage was also lower among middle income beneficiaries compared with high income b e n e ficiaries. Significant differences were not observed for any other population group. ? From 2000 to 2002 the percentage did not change signifi c a n t ly for any population group. ? In 2002, the Healthy People 2010 goal of 50% of Americans with a fecal occult blood test within the last 2 years was not achieved by any population group. National Healthcare Disparities Report Priority Populations E l d e r l y P revention: Dental Care R egular dental visits improve prevention, early diagnosis, and optimal treatment of craniofacial diseases and conditions. Missed dental care can result in delayed diagnosis, overall compromised health, and, occasionally, even death.3 8 Because dental conditions often develop across a lifetime, it is especially important for the e l d e r ly to receive regular dental care to ensure early diagnosis and optimal treatment. Figure 4.36. Elderly Medicare beneficiaries receiving dental care by race (top left), ethnicity (top right), and income (bottom left), 1998, 2000, 2002 155 Key: AI/AN=American Indian or Alaska Native; API=Asian or Pacific I s l a n d e r. S o u rc e : M e d i c a re Current Beneficiary Survey, 1998, 2000, 2002. R e f e rence population: M e d i c a re beneficiaries age 65 or older living in the community. Note: Though these data were collected via the Medicare Curre n t Beneficiary Survey, much of the dental care reported here is likely not connected to the Medicare program as Medicare generally does not cover dental services. ? In all 3 data years, the percentage of elderly Medicare beneficiaries receiving dental care was l ower among Blacks compared with Whites; among Hispanics compared with non-Hispanic W h i t e s ; and among poor, near poor, and middle income b e n e ficiaries compared with high income b e n e ficiaries (Figure 4.36). ? In 1998, the percentage receiving dental care wa s also lower among elderly AI/AN and API Medicare beneficiaries compared with Whites, but the difference was not significant in other years. ? From 1998 to 2002, the percentage did not change signifi c a n t ly for any population group. ? In 2002, the Healthy People 2010 goal of 83% of Americans receiving dental care was not achieved by a ny population group. National Healthcare Disparities Report Priority Populations E l d e r l y Timeliness: Waiting 30 Minutes or More To See a Doctor Ti m e ly delive ry of appropriate care has been shown to improve health care outcomes and reduce health care costs. Ti m e ly receipt of care is an especially important component of high quality care for the elderly due to the often increased medical needs of this population. Figure 4.37. Elderly Medicare beneficiaries who waited at least 30 minutes to see a doctor at their last visit by race (top left), ethnicity (top right), and income (bottom left), 1998, 2000, and 2002 156 K e y : API=Asian or Pacific Islander. S o u rc e : M e d i c a re Current Beneficiary Survey, 1998, 2000, 2002. R e f e rence population: M e d i c a re beneficiaries age 65 or older living in the community. ? In all 3 years, the percentage of elderly Medicare b e n e ficiaries who waited at least 30 minutes to see a doctor at their last visit was higher among Blacks compared with Whites; among Hispanics compared with non-Hispanic Whites; and among poor and near poor beneficiaries compared with high income beneficiaries (Figure 4.37). ? In 1998 and 2000, the percentage was also higher among middle income beneficiaries compared with high income beneficiaries; in 2000 and 2002, the percentage was higher among APIs compared with Whites. ? From 1998 to 2002, the percentage of elderly Medicare beneficiaries who waited at least 30 minutes to see a doctor at their last visit rose signifi c a n t ly for APIs but did not change signifi c a n t ly for any other population. National Healthcare Disparities Report Priority Populations E l d e r l y Access to Health Care Usual Source of Care H aving a usual source of care promotes receipt of needed services. Previous NHDRs reported that the elderly are more like ly than younger age groups to have a specific source of ongoing care, but racial, ethnic, and socioeconomic differences ex i s t . Figure 4.38. Elderly Medicare beneficiaries with no usual source of care by race (top left), ethnicity (top right), and income (bottom left), 1998, 2000, and 2002 157 S o u rc e : M e d i c a re Current Beneficiary Survey, 1998, 2000, 2002. R e f e rence population: M e d i c a re beneficiaries age 65 or older living in the community. ? In all 3 years, the percentage of elderly Medicare b e n e ficiaries who did not have a usual source of care was higher among poor and near poor b e n e ficiaries compared with high income b e n e ficiaries (Figure 4.38). ? B e t ween 1998 and 2002, report of a usual source of care improved among all racial, ethnic, and income groups except Hispanic benefi c i a r i e s . ? In 2002, the Healthy People 2010 goal of 96% of Americans with a source of care was achieved by White, non-Hispanic White, middle income, and high income elderly. National Healthcare Disparities Report Priority Populations E l d e r l y P roblems Getting to the Doctor The elderly more frequently than younger adults face difficulty using automobiles and public transport a t i o n and finding new locations. Therefore, getting to the doctor or other provider can pose a significant barrier to health care for the elderly. Figure 4.39. Elderly Medicare beneficiaries with problems getting to the doctor from home by race (top left), ethnicity (top right), and income (bottom left), 1998, 2000, and 2002 158 S o u rc e : M e d i c a re Current Beneficiary Survey, 1998, 2000, 2002. R e f e rence population: M e d i c a re beneficiaries age 65 or older living in the community. ? In 1998 and 2002, Hispanics were more like ly to h ave problems getting to the doctor compared with non-Hispanic Whites (Figure 4.39). ? In all 3 years, the proportion of elderly Medicare b e n e ficiaries who reported problems getting to their doctor from home was higher among poor and near poor compared with high income b e n e ficiaries. ? B e t ween 1998 and 2002, problems getting to the doctor from home did not change signifi c a n t ly for a ny racial, ethnic, or income gr o u p . National Healthcare Disparities Report Priority Populations Residents of Rural Are a s Residents of Rural Are a s One in 5 Americans lives in a nonmetropolitan area. Compared with their urban counterp a rts, rural residents are more like ly to be elderly, poor,8 3 in fair or poor health, to have chronic conditions, and to die from heart d i s e a s e .83 84 Rural residents are less like ly to receive recommended preve n t ive services and report, on ave r a g e , f ewer visits to health care prov i d e r s .8 5 Rural minorities appear to be part i c u l a r ly disadva n t a g e d, and diff e r e n c e s are observed in cancer screening and management of cardiovascular disease and diabetes.86 87 Although 20% of Americans live in rural areas,v i i o n ly 9% of physicians in America practice in those s e t t i n g s .8 8 Multiple programs help to deliver needed services in rural areas, such as the National Health S e rvice Corps Scholarship Program, Indian Health Service, and community health centers. Non-phy s i c i a n p r oviders also help to deliver care. Howeve r, many facilities upon which rural residents rely, such as small rural hospitals, have closed or are in financial distress.8 9 Tr a n s p o rtation needs are also pronounced among rural residents, who face longer distances to reach health care delive ry sites. Of the 940 ?frontier counties,?v i i i most have limited health care services and 78 do not have a ny.90 91 M a ny measures of relevance to residents of rural areas are tracked in the NHDR. Findings presented here highlight five quality measures and one access measure of particular importance to residents of rural areas: 159 Component of health care need: M e a s u re : P r eve n t i o n Counseling about physical activ i t y Tr e a t m e n t Inpatient deaths from heart attack M a n a g e m e n t Hospital admissions for pediatric asthma M a t e rnity care Obstetric trauma Ti m e l i n e s s Care for illness or injury as soon as wa n t e d Access to care Health insurance vii M a ny terms are used to refer to the continuum of geographic areas. For Census 2000, the Census Bureau?s classifi c a t i o n of ?rural? consists of all terr i t o ry, population, and housing units located outside of urban areas and urban clusters. T h e Census Bureau classified as ?urban? all terr i t o ry, population, and housing units located within a) core census block gr o u p s or blocks that have a population density of at least 1,000 people per square mile, and b) surrounding census blocks that have an overall density of at least 500 people per square mile. v i i i? Frontier counties? have a population density of less than 7 persons per square mile; residents travel long distances for care. National Healthcare Disparities Report Priority Populations Residents of Rural Are a s As in the 2004 NHDR, detailed geographic typologies have been applied to two AHRQ databases to understand variations in health care quality and access for a range of rural and urban locations (see Ta ble 4.1). HCUP State Inpatient Datab a s e s . Data from the HCUP State Inpatient Databases use Federal definitions of micropolitan and noncore based statistical areas (not metropolitan or micropolitan areas) published in June 2 0 0 3 .9 2 In addition, Urban Influence Codes are used to subdivide metropolian areas into large and small metropolitan areas. Urban-rural contrasts compare residents of small metropolitan, micropolitan, and noncore based statistical areas with residents of large metropolitan statistical areas. Medical Expenditure Panel Survey. Data from MEPS also use Federal definitions. In addition, Urban Influence Codes are used to subdivide noncore based statistical areas. Urban-rural contrasts compare residents of small metropolitan, micropolitan, and noncore based statistical areas with residents of large metropolitan statistical areas. Table 4.1. Urban-rural categories used in HCUP State Inpatient Databases and MEPS analyses HCUP SID disparities L a rge Small M i c r o p o l i t a n Noncore based statistical a n a lysis file, 2002: m e t r o p o l i t a n : m e t r o p o l i t a n : statistical area area (noncore): Not N ew Federal categ o r i e s Metropolitan M e t r o p o l i t a n (micro): Urban metropolitan or (metro) area (metro) area area of at least m i c r o p o l i t a n of 1 million of less than 10,000 but less 160 or more 1 million than 50,000 i n h a b i t a n t s i n h a b i t a n t s i n h a b i t a n t s MEPS, 2002: Divides metro L a rg e Small M i c r o p o l i t a n N o n c o r e N o n c o r e and noncore using Urban m e t r o p o l i t a n m e t r o p o l i t a n adjacent: not adjacent: Influence Codes Noncore Noncore adjacent to not adjacent metro or to metro m i c r o or micro National Healthcare Disparities Report Priority Populations Residents of Rural Are a s Quality of Health Care P revention: Counseling About Physical Activity Counseling children about the amount and type of physical activity that is healthy is an eff e c t ive way to reduce childhood obesity. Figure 4.40. Children age 2-17 with advice about physical activity by race (top left), ethnicity (top right), and income (bottom left), 2002 161 S o u rc e : Medical Expenditure Panel Survey, 2002. R e f e rence population: Civilian noninstitutionalized population age 2 - 1 7 . N o t e : Sample sizes were too small to provide estimates for re s i d e n t s of noncore areas. Large metro p o l i t a n = m e t ropolitan areas >1 million inhabitants; small metro p o l i t a n = m e t ropolitan areas <1 million inhabitants; micropolitan=urban area >10,000 and < 50,000 i n h a b i t a n t s . ? Across all geographic areas the proportion of children who received advice about physical a c t ivity was lower among persons from micropolitan (22.4%) and small metropolitan (29.4%) areas compared with persons from large metropolitan (35.6%) areas. ? The proportion of children who received advice about physical activity was lower among Blacks from small metropolitan areas compared with r e s p e c t ive Whites; among Hispanics from large metropolitan areas compared with respective non-Hispanic Whites; and among poor, near poor, and middle income persons from large metropolitan areas and near poor and middle income persons from small metropolitan areas compared with respective high income persons (Figure 4.40). National Healthcare Disparities Report Priority Populations Residents of Rural Are a s Treatment: Inpatient Deaths From Heart Attack H e a rt disease is the leading cause of death for both men and women in the United States, responsible for almost 700,000 deaths in 2002. About 1.2 million heart attacks occur each ye a r. Data on inpatient hospital deaths for patients whose reason for admission is heart attack (acute myocardial infarction, or AMI) are presented. To distinguish the effects of race/ethnicity on the AMI inhospital mortality rate within urban and rural areas, racial/ethnic data are stratified by urban and rural location of patient residence. Figure 4.41. Deaths per 1,000 adult admissions with heart attack as principal diagnosis by race/ethnicity, 2002 162 K e y : API=Asian or Pacific Islander. S o u rc e : HCUP State Inpatient Databases disparities analysis file, 2 0 0 2 . R e f e rence population: Adults age 18 and older hospitalized for heart attack in community hospitals. N o t e : White, Black, and API are non-Hispanic groups. Sample sizes w e re too small to provide estimates for API residents of noncore a reas. Large metro p o l i t a n = m e t ropolitan areas >1 million inhabitants; small metro p o l i t a n = m e t ropolitan areas <1 million inhabitants; micropolitan=urban area >10,000 and < 50,000 inhabitants; noncore=not metropolitan or micro p o l i t a n . ? The overall AMI mortality rate was higher among persons from noncore and micropolitan areas compared with persons from large metropolitan areas (Figure 4.41). ? Within type of urban and rural areas, the rate of AMI mortality is lower among Blacks from larg e metropolitan areas and higher among APIs from from small metropolitan areas compared with respective Whites. National Healthcare Disparities Report Priority Populations Residents of Rural Are a s Management: Hospital Admissions for Pediatric Asthma Asthma affects about 15 million persons nationally; in 2002, asthma and chronic obstru c t ive pulmonary disease, or COPD (another lower respiratory disease), were the fourth leading cause of death9 3 in the Nation. A disproportionate number of children have asthma.75 76 To distinguish the effects of race/ethnicity on pediatric asthma admissions within urban and rural areas, racial/ethnic data are stratified by urban and ru r a l location. Figure 4.42. Pediatric asthma admissions per 100,000 population by race/ethnicity, 2002 163 S o u rce: HCUP State Inpatient Databases disparities analysis file, 2 0 0 2 . R e f e rence population: C h i l d ren age 0 to 17. Note: L a rge metro p o l i t a n = m e t ropolitan areas >1 million inhabitants; small metro p o l i t a n = m e t ropolitan areas <1 million inhabitants; m i c ropolitan=urban area >10,000 and < 50,000 inhabitants; n o n c o re=not metropolitan or micro p o l i t a n . ? The overall rate of pediatric asthma admissions was lower among persons from small metropolitan areas compared with persons from large metropolitan areas (Figure 4.42). ? The rate of pediatric asthma admissions was higher among Blacks in all areas compared with respective Whites and among Hispanics from large metropolitan areas compared with respective Whites. National Healthcare Disparities Report Priority Populations Residents of Rural Are a s M a t e rnity Care: Obstetric Tr a u m a C h i l d b i rth and reproductive care are the most common reasons for women of childbearing age to use health care; and with more than 11,000 births each day in the United States, childbirth is the most common reason for hospital admission.5 1 G iven that birth outcomes may have lifetime effects, good maternity care and avoidance of complications such as obstetric trauma has the potential to affect the future health and health care needs of the Nation.52 53 To distinguish the effects of race/ethnicity on the rate of obstetric trauma within urban and rural areas, racial/ethnic data are stratified by urban and rural location. Figure 4.43. Obstetric trauma with 4th degree lacerations or other obstetric lacerations per 1,000 vaginal deliveries without instrument assistance by race/ethnicity, 2002 164 K e y : API=Asian or Pacific Islander. S o u rc e : HCUP State Inpatient Databases disparities analysis file, 2 0 0 2 . R e f e rence population: Community hospital admissions with vaginal deliveries without instrument assistance. N o t e : White, Black, and API are non-Hispanic groups. Larg e m e t ro p o l i t a n = m e t ropolitan areas >1 million inhabitants; small m e t ro p o l i t a n = m e t ropolitan areas <1 million inhabitants; m i c ropolitan=urban area >10,000 and < 50,000 inhabitants; n o n c o re=not metropolitan or micro p o l i t a n . ? The overall rate of obstetric trauma did not differ signifi c a n t ly among patients from small metropolitan, micropolitan, or noncore statistical areas compared with patients from large metropolitan areas (Fi g u r e 4.43). ? Within urban and rural areas, the rate of obstetric trauma was lower among Blacks and Hispanics from l a rge metropolitan areas, Hispanics and APIs from micropolitan areas, and Hispanics from small metropolitan areas compared with respective Whites. National Healthcare Disparities Report Priority Populations Residents of Rural Are a s Timeliness: Care for Illness or Injury as Soon as Wa n t e d Ti m e ly delive ry of appropriate care has been shown to improve health care outcomes and reduce health care costs. Furt h e rmore, when patients need or want care, having access to that care improves their health care experience, which may further promote health. Figure 4.44. Adults who sometimes or never get care for illness or injury as soon as wanted by race (top) and ethnicity (bottom), 2002 165 S o u rce: Medical Expenditure Panel Survey, 2002. R e f e rence population: Civilian noninstitutionalized population. N o t e : Sample sizes were too small to provide estimates for residents of noncore areas. Large metro p o l i t a n = m e t ropolitan areas >1 million inhabitants; small metro p o l i t a n = m e t ropolitan areas <1 million inhabitants; micropolitan=urban area >10,000 and < 50,000 inhabitants. ? Across all geographic areas the proportion of persons who sometimes or never get care for illness or i n j u ry as soon as wanted did not differ signifi c a n t ly among patients from small metropolitan (14.6%) or micropolitan (14.2%) areas compared with patients from large metropolitan (16.2%) areas. ? Across the total U.S. population, Blacks more often than Whites and Hispanics more often than non- Hispanic Whites reported that they sometimes or never got care for illness or injury as soon as they wanted. Howeve r, within urban and rural areas, the disparity between Blacks and Whites was not s i g n i ficant, while the disparity between Hispanics and non-Hispanic Whites persisted for all urban and rural areas (Figure 4.44). National Healthcare Disparities Report Priority Populations Residents of Rural Are a s Figure 4.45. Adults who sometimes or never get care for illness or injury as soon as wanted by income (left) and education (right), 2002 166 S o u rc e : Medical Expenditure Panel Survey, 2002. R e f e rence population: Civilian noninstitutionalized population. N o t e : Sample sizes were too small to provide estimates for residents of noncore areas. Large metro p o l i t a n = m e t ropolitan areas >1 million inhabitants; small metro p o l i t a n = m e t ropolitan areas <1 million inhabitants; micropolitan=urban area >10,000 and < 50,000 inhabitants. ? Across all geographic areas the proportion of persons who sometimes or never get care for illness or i n j u ry as soon as wanted did not differ signifi c a n t ly among patients from small metropolitan (14.6%) or micropolitan (14.2%) areas compared with patients from large metropolitan (16.2%) areas. ? Across the total U.S. population, poor, near poor, and middle income persons more often than high income persons and persons with less than a high school education more often than persons with at least some college reported that they sometimes or never got care for illness or injury as soon as they wa n t e d ( Figure 4.45). ? Within urban and rural areas, disparities persisted for poor and near poor persons and persons with less than a high school education from eve ry urban and rural area. ? Middle income persons from large and small metropolitan areas also reported that they sometimes or n ever got care as soon as wanted more often than respective high income persons, but a signifi c a n t d i fference was not observed for middle income persons from micropolitan areas. National Healthcare Disparities Report Priority Populations Residents of Rural Are a s Access to Health Care Health Insurance Access to health care is a prerequisite to receipt of care, yet many Americans still face barriers to care. Health insurance facilitates access to health care, lack of which can have serious repercussions on health: the uninsured are more like ly to have poor health status54 55 and to die early.5 6 - 5 8 T h ey report more problems getting c a r e ,5 9 - 5 8 are diagnosed at later disease stages, and get less therapeutic care.59 61 Data for prolonged periods of uninsurance are presented. To distinguish the effects of socioeconomic status on uninsurance within urban and rural areas, income and education level data are stratified by urban and rural loacation. F i g u re 4.46. Persons under age 65 uninsured all year by income (left) and education level (right), 2002 167 S o u rc e : Medical Expenditure Panel Survey, 2002. R e f e rence population: Civilian noninstitutionalized population. N o t e : Sample sizes were too small to provide estimates for residents of noncore not adjacent areas with high incomes or less than a high school education. Large metro p o l i t a n = m e t ropolitan areas >1 million inhabitants; small metro p o l i t a n = m e t ropolitan areas <1 million inhabitants; micropolitan=urban area >10,000 and < 50,000 inhabitants; noncore adjacent=not metropolitan or micropolitan, and adjacent to m e t ropolitan or micropolitan; noncore not adjacent=not metropolitan or micropolitan, and not adjacent to metropolitan or micropolitan. ? Across all geographic areas the proportion of persons under age 65 uninsured all year did not diff e r s i g n i fi c a n t ly among patients from small metropolitan (13.3%), micropolitan (13.5%), noncore adjacent (15.4%), or noncore not adjacent (13.6%) areas compared with patients from large metropolitan (13.3%) areas. ? Across the total U.S. population the percentage of uninsured was higher among poor, near poor, and middle income persons compared with high income persons and among persons with a high school education or less compared with persons with at least some colleg e . ? Within urban and rural areas, poor, near poor, and middle income persons were more like ly than high income persons to be uninsured. Similarly, the percentage of uninsured was higher for persons with less than a high school education from eve ry urban and rural area, and for persons with a high school education from large and small metropolitan areas compared with respective groups with at least some c o l l ege (Figure 4.46). National Healthcare Disparities Report Priority Populations Individuals With Special Health Care Needs Individuals With Special Health Care Needs I n d ividuals with special health care needs include individuals with disabilities, individuals who utilize nursing home and home health care or end-of-life health care, and children with special heath care needs (CSHCN). M a ny measures of relevance to individuals with special health care needs are tracked in the NHDR. In the 2003 NHDR, a small amount of information about each population with special health care needs wa s presented. In the 2004 NHDR, disparities in health care for CSHCN were highlighted. This ye a r, data on quality and access are presented for younger and elderly Medicare beneficiaries with disabilities and for C S H C N, as follows: Elderly Medicare Beneficiaries With Disabilities Component of health care need: M e a s u re : P r evention Receipt of influenza va c c i n a t i o n Access to care P r o blems getting to the doctor Younger Medicare Beneficiaries With Disabilities Component of health care need: M e a s u re : 168 P r eve n t i o n Receipt of pneumonia va c c i n a t i o n Access to care D e l ays in care due to cost C h i l d ren With Special Health Care Needs Component of health care need: M ea s ure : Ti m e l i n e s s Care for illness or injury as soon as wa n t e d Patient centeredness Patient experience of care A d d i t i o n a l ly, findings for persons who utilize nursing home care are presented in the section on nursing home and home health care in Chapter 2, Quality of Health Care. Previous NHDR data sources for home health and end-of-life care were not ava i l a ble this ye a r, but it is anticipated that data from the redesigned National Nursing Home Survey will be ava i l a ble for the 2006 NHDR. National Healthcare Disparities Report Priority Populations Individuals With Special Health Care Needs Elderly Medicare Beneficiaries With Disabilities S everal ways of defining and measuring disability exist. Two of the more common approaches are to identify functional activity limitations or to identify those meeting the eligibility criteria for a program that addresses d i s a b i l i t y, such as Social Security Disability Insurance (SSDI). A particular challenge in reporting on racial, ethnic, and socioeconomic differences related to disability is that many data collections do not capture disability and, when collected, do not have adequate sample sizes to examine racial, ethnic, and socioeconomic d i fferences. This section uses data from the Medicare Current Benefi c i a ry Survey to examine disparities in quality and access faced by Medicare beneficiaries age 65 and over who report problems with activities of d a i ly living (ADLs) or instrumental activities of daily living (IADLs). About 42% of elderly Medicare b e n e ficiaries, or 14 million people, have one or more limitations. A n a lyses of trends in disability and functioning among older adults indicate improvements in the last decade, with the prevalence of disability declining during the 1990s. Howeve r, there are considerable gaps in availability of measures and understanding of trends in differences across major racial and ethnic groups with respect to functional limitations in the elderly population.9 4 P revention: Receipt of Influenza Va c c i n a t i o n The 2003 NHDR reported that among elderly with disabilities, the percentage reporting problems with quality 169 of care was higher among APIs compared with Whites and among persons living in poor households compared with those living in high income households. This year the NHDR reports on the annual receipt of a flu shot (influenza vaccination). This is an important component of high quality care for elderly people with disabilities, as this boosts the immune system and reduces the likelihood of flu-related health complications. Figure 4.47. Elderly Medicare beneficiaries with influenza vaccination in the last year by functional status, 2002 K e y : API=Asian or Pacific Islander; ADL=activity of daily living; IADL= instrumental activity of daily living. S o u rc e : M e d i c a re Current Beneficiary Survey, 2002. R e f e rence population: M e d i c a re beneficiaries age 65 or older living in the community. National Healthcare Disparities Report Priority Populations Individuals With Special Health Care Needs ? The percentage of elderly Medicare beneficiaries with a flu shot in the last year was higher among A P I s with functional limitations compared with those without limitations and among near poor benefi c i a r i e s with functional limitations compared with those without limitations (Figurer 4.47). ? Among beneficiaries with functional limitations, the percentage with a flu shot was lower among Blacks compared with Whites; among Hispanics compared with non-Hispanic Whites; and among poor b e n e ficiaries compared with high income beneficiaries. ? Among beneficiaries without limitations, the percentage with a flu shot was lower among APIs compared with Whites. No other significant differences were observed. ? In 2002, the Healthy People 2010 goal of 90% of Americans age 65 and over with a flu shot in the last year was not achieved by any population. Access to Care: Problems Getting to the Doctor The 2003 NHDR reported that the elderly were less like ly than younger age groups to report difficulties or d e l ays in obtaining health care, and to report not receiving routine care or care for illness or injury as soon as t h ey wanted. Racial, ethnic, and socioeconomic differences in barriers to care were also observed. Diffi c u l t y with transportation is one such barrier to health care. 170 Figure 4.48. Elderly Medicare beneficiaries with problems getting to the doctor from home by ethnicity and income, stratified by functional status, 2002 K e y : ADL=activity of daily living; IADL=instrumental activity of daily l i v i n g . S o u rc e : M e d i c a re Current Beneficiary Survey, 2002. R e f e rence population: M e d i c a re beneficiaries age 65 or older living in the community. ? O verall, elderly Medicare beneficiaries with one or more limitations were more like ly to report probl e m s getting to the doctor from home compared with those who had no limitations (Figure 4.48). ? Among beneficiaries with one or more limitations, problems were more like ly to be reported by Hispanics compared with non-Hispanic Whites and by the poor compared with middle income b e n e ficiaries. ? The same ethnic and income-related differences were observed among beneficiaries with no limitations. National Healthcare Disparities Report Priority Populations Individuals With Special Health Care Needs Younger Medicare Beneficiaries With Disabilities About 5.6 million beneficiaries under age 65 qualified for Medicare in 2001, and that number is expected to gr ow to more than 9 million by 2020.9 5 This section uses data from the Medicare Current Benefi c i a ry Survey to examine disparities faced by Medicare beneficiaries under age 65, most of whom qualify for Medicare on the basis of SSDI disability. P revention: Receipt of Pneumonia Va c c i n a t i o n For younger individuals with disabilities, receipt of a pneumonia vaccination can bring lifelong benefits by p r eventing pneumonia-related health complications. Figure 4.49. Medicare beneficiaries with disabilities under age 65 vaccinated for pneumonia by race (top left), ethnicity (top right), and income (bottom left), 1998, 2000, and 2002 171 K e y : AI/AN=American Indian or Alaska Native. S o u rc e : M e d i c a re Current Beneficiary Survey, 1998, 2000, 2002. R e f e rence population: M e d i c a re beneficiaries age 65 or older living in the community. N o t e : Sample size was too small to provide an estimate for AI/ANs in 2000. National Healthcare Disparities Report Priority Populations Individuals With Special Health Care Needs ? Disparities among younger Medicare beneficiaries with disabilities vaccinated for pneumonia are s o m ewhat complex. In 2002, the percentage of younger Medicare beneficiaries with disabilities vaccinated for pneumonia was lower among Hispanics compared with non-Hispanic Whites (Fi g u r e 4.49). ? In 1998 and 2000, the percentage was lower among poor beneficiaries compared with high income b e n e ficiaries, and in 2000 the percentage was also lower among near poor beneficiaries compared with high income beneficiaries. ? S i g n i ficant differences were not observed for any other population. ? From 1998 to 2002, the percentage of younger Medicare beneficiaries with disabilities vaccinated for pneumonia increased for Blacks, non-Hispanic Whites, and poor and near poor beneficiaries. T h e percentage did not change signifi c a n t ly for any other group. Access to Care: Delays in Care Due to Cost D e l aying health care can lead to diagnosis at more advanced disease stage and reduce opportunities for optimal treatment. Figure 4.50. Medicare beneficiaries under age 65 who delayed care due to cost, by race, ethnicity and 172 income, 2002 K e y :AI/AN= American Indian or Alaska Native. S o u rc e : M e d i c a re Current Beneficiary Survey, 2002. R e f e rence population: M e d i c a re beneficiaries under age 65 living in the community. ? In 2002, almost a quarter of Medicare beneficiaries under age 65 reported delaying care due to cost ( Figure 4.50). ? The proportion of Medicare beneficiaries under age 65 who delayed care due to cost was lower among Blacks compared with Whites and among Hispanics compared with non-Hispanic Whites. Income- related differences were not signifi c a n t . National Healthcare Disparities Report Priority Populations Individuals With Special Health Care Needs C h i l d ren With Special Health Care Needs Studying access to and quality of care for children with chronic conditions is difficult due to the low p r evalence of most conditions in children.9 6 - 9 8 From 12% to 23% of children have been identified as having a special health care need9 9 - 1 0 2?a chronic condition with a functional limitation or other consequence.9 7 A m o n g the most highly prevalent chronic conditions of childhood in 2002 were asthma (12% of children age 0-17), r e s p i r a t o ry allergies (12%), learning disabilities (8% of children age 3-17), and attention-deficit hy p e r a c t iv i t y disorder (7% of children age 3-17).1 0 3 By definition, children with special health care needs are children who require more medical care because t h ey are less healthy. As a result of requiring more medical care, CSHCN have higher medical expenses, on average, than other children.97 99 104 105 For more than 1 in 5 CSHCN, costs of care caused financial probl e m s for their fa m i l i e s .102 106 In addition to financial burdens, families of CSHCN spend considerable time caring for them. An estimated 13.5% of CSHCN had families who spent 11 or more hours per week providing or coordinating care.102 106 H aving higher health care needs makes CSHCN susceptible to access, cost, quality, and coverage we a k n e s s e s in the health care system. Studies have documented that poor and racial and ethnic minority children with chronic conditions may experience lower quality care.1 0 7 - 1 0 9 Children with chronic conditions are reported by their parents to be less like ly than other children to receive the full range of needed health serv i c e s .110 A m o n g 173 C S H C N, minorities are more like ly than White children to be without health insurance coverage or a usual source of care.1 1 1 Timeliness: Care for Illness or Injury as Soon as Wa n t e d Ti m e ly delive ry of appropriate care has been shown to improve health care outcomes and reduce health care costs, which may be part i c u l a r ly important for CSHCN. National Healthcare Disparities Report Priority Populations Individuals With Special Health Care Needs Figure 4.51. Among children with special health care needs who need care right away, those who can always get care for illness or injury as soon as wanted, by race (top left), ethnicity (top right), and family income (bottom left), 2001-2002 174 S o u rc e : Medical Expenditure Panel Survey, 2001-2002. R e f e rence population: Civilian noninstitutionalized population, age 0 - 1 7 . ? In both years, the proportion of children who could a lways get care for illness or injury as soon as wanted was lower among children with special health care needs (72.9% in 2001 and 72.7% in 2002) compared with children without special needs (78.7% in 2001 and 79.5% in 2002). ? In 2002, the proportion of children with special health care needs who could always get care for illness or i n j u ry as soon as wanted was lower among poor and near poor children compared with high income children (Figure 4.51). Racial and ethnic differences were not significant. ? From 2001 to 2002, the proportion of children with special health care needs who could always get care for illness or injury as soon as wanted did not change signifi c a n t ly for any racial, ethnic, or income gr o u p . National Healthcare Disparities Report Priority Populations Individuals With Special Health Care Needs Patient Centeredness: Patient Experience of Care Patient centered health care requires good communication to ensure that a patient?s needs and preferences are best met. For CSHCN, good communication with the child?s parent/guardian is especially important to ensure their more complex and greater health care needs are optimally addressed. Figure 4.52. Children with special health care needs whose parents/guardians reported that their child?s health providers sometimes or never listened carefully, explained things clearly, respected what they had to say, and spent enough time with them, by race (top left), ethnicity (top right), and family income (bottom left), 2001-2002 175 S o u rce: Medical Expenditure Panel Survey, 2001-2002. R e f e rence population: Civilian noninstitutionalized population, age 0 - 1 7 . Note: In 2002, survey respondents could report more than one race. Racial categories shown here for 2002 exclude multiple race individuals and hence are not directly comparable to earlier years. Estimates for racial groups other than Whites and Blacks are significantly affected by this change and are not shown here. National Healthcare Disparities Report Priority Populations Individuals With Special Health Care Needs ? In both years, parents/guardians of children with special health care needs were more like ly to report that their child?s health providers sometimes or never listened carefully, explained things clearly, respected what they had to say, and spent enough time with them (8.5% in 2001 and 8.2% in 2002) compared with parents of children without special health care needs (6.4% in 2001 and 6.3% in 2002). ? Among children with special health care needs those in poor and near poor families were more like ly to r e p o rt communication problems compared with those in high income families in both years (Fi g u r e 4.52). ? 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