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National Healthcare Disparities Report, 2003

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Chapter 3. Quality of Health Care

Introduction

Many studies and commentators have pointed out the gap between ideal health care and the actual health care that Americans often receive.1 All too frequently, patients receive care that does not meet clinical standards for "best practice" or that responds insufficiently to the needs of individual patients. As medical knowledge and practice become more complex, quality-related problems are likely to persist or worsen. This is especially worrisome given the increased demands on the health care system posed by the aging of the American population. Fundamental changes may be needed to address a health care delivery system that is decentralized and that has not taken full advantage of advances in information technology to improve quality.

While disparities in access to health care and receipt of health care services have been studied for many decades, the study of disparities in the quality of health care is relatively new. Published just last year, the Institute of Medicine's report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, provided definitive evidence that racial and ethnic disparities in quality of health care exist across a range of illnesses and health care services.2 Much still remains to be learned, however, about the magnitude and extent of disparities in the quality of health care related to socioeconomic factors. Moreover, only recently have scientists and quality improvement experts begun to address the issue of how best to measure, track, and improve quality of health care in diverse populations.3

In 2001, the National Quality Forum (NQF), a private organization seeking to develop and implement a national strategy for health care quality measurement and reporting, convened experts to consider two overarching questions:

  • Can existing, commonly used health care quality measures appropriately address the needs of minority patients, or are new measures needed to more accurately evaluate minority health care quality?
  • What unique challenges are involved in reporting health care quality information to minority consumers?

The conclusions and recommendations of these experts guided the work for this first NHDR.4 The recommendation to use existing measure sets for studying the quality of health care of minority populations led to the adoption of the consensus measure set developed for the first NHDR.

Hence, whenever possible, the NHDR and the NHQR use the same measures of quality of health care. This is not always possible, however, due to sample size constraints and the lack of reliable information on race, ethnicity, or socioeconomic status in some databases. As a result, NHDR dropped 12 measures from the NHQR quality of care measure set. For 5 additional measures, alternative data sources with reliable information on race and ethnicity were identified and used. These are:

  • CMS's End-Stage Renal Disease (ESRD) Clinical Performance Measures Project (CPMP) for ESRD measures
  • CMS's Nursing Home Resident Profile Table (RPT) database for long-term care measures.

In addition, sample size was often a limiting factor for measures of quality of health care, which are frequently restricted to persons with particular medical conditions. Often, insufficient sample sizes of individuals affected by specific conditions were available to produce reliable estimates of the quality of health care for many racial, ethnic, and socioeconomic groups.

Both the NHQR and the NHDR organize the quality of care measures into four main categories:

  • Effectiveness (i.e., care based on scientific knowledge; it is provided to all patients who could benefit and not provided to patients unlikely to benefit);
  • Safety (i.e., care that avoids injuring patients with care intended to benefit them);
  • Timeliness (i.e., care that reduces waiting times and delays in receipt of care); and
  • Patient centeredness (i.e., care that is respectful and responsive to the individualized needs, preferences, and values of patients).

This chapter will examine racial, ethnic, and socioeconomic disparities in quality of health care for the entire population. In it, various racial and ethnic groups, as well as people of differing socioeconomic status, are compared for each of the quality of care measures. Summary tables present disparities across all measures and share a common key:

Key to Quality of Health Care Tables
Dark circle.: Selected population and comparison population receive about same quality of health care
Circle that is shaded black on the top half, and white on the bottom half.: Selected population receives better quality care than the comparison population
Circle that is shaded white on the top half, and black on the bottom half.: Selected population receives worse quality care than the comparison population
Clear circle: Data are collected but do not meet criteria for statistical reliability

Because of the large volume of measures and populations, this chapter presents only a small subset of the findings. It focuses upon areas in which disparities are prevalent either across multiple populations or across several related measures and illustrates specific types of disparities with data that represent existing measures. When Healthy People 2010 measures are available, these measures are highlighted.

For an analysis of disparities in quality of health care as they relate to priority populations, as defined in the Agency for Healthcare Research and Quality's (AHRQ) authorizing legislation, go to Chapter 5. Because many disparities cut across multiple populations, Chapter 5 focuses on disparities that are specific to each population group.

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Effectiveness

Key Finding:
  • Patient race, ethnicity, and socioeconomic status are important indicators of the effectiveness of health care.

The effectiveness of health care can be defined as the extent to which scientifically proven services and treatments are provided to all who could benefit and not provided to those unlikely to benefit. Prerequisites to the measurement of effectiveness include: evidence that a given treatment works and established guidelines that govern the types of patients to whom the treatment should be applied. Of the various elements of health care quality, effectiveness has been the most extensively studied.

The impact of disparities in health care is specific to particular conditions. This section examines disparities in the effectiveness of care for:

  • Cancer
  • Chronic kidney disease
  • Diabetes
  • Heart disease
  • HIV/AIDS
  • Maternal and child health
  • Mental health
  • Respiratory diseases
  • Long term care

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Cancer

Key Findings:
  • Minorities and persons of lower socioeconomic status are less likely to receive cancer screening services and more likely to have late-stage cancer when the disease is diagnosed. Exception: Black women have higher screening rates for cervical cancer.
  • Blacks and persons of lower socioeconomic status also have higher death rates from cancer.

Why cancer is important

Cancer is the second leading cause of death in the United States after heart disease, and cancer causes one in four deaths.5,6,7

  • In 2003, an estimated 1.3 million persons in the United States will be diagnosed with cancer and over 550,000 persons will die from it.8 More than half of new cancer cases and cancer deaths can be attributed to four cancers: lung, colorectal, breast and prostate.9 Lung cancer alone causes over 150,000 deaths per year.10, 11
  • While cancer incidence rates have increased gradually in recent years, cancer death rates have declined.
  • Economic costs of cancer are high; in 2002, total costs exceeded $171 billion, and direct costs for physicians, hospitals, and drugs exceeded $60 billion.12

Cancer incidence and death rates vary by race and ethnicity.

  • Blacks have a 10% higher cancer incidence rate and a 30% higher cancer death rate compared with whites.13 While cancer death rates are declining more quickly for blacks compared with whites, cancer survival is lower among blacks for almost all cancers regardless of site or stage.14 Other minorities are disproportionately affected by select cancers.
  • Compared with whites, Hispanics have higher rates of cervical, esophageal, gallbladder, and stomach cancer; Asians have higher rates of stomach and liver cancer; and Alaska Natives have higher rates of colorectal cancer.

Cancer care also varies by race, ethnicity, and socioeconomic status.15

  • Studies indicate differences in screening for breast cancer16 and colorectal cancer.17 Some populations also are diagnosed with prostate cancer at earlier stages of the disease, while others are more likely to have it diagnosed at a later stage.18
  • Differences in primary treatment of breast cancer,19, 20, 21, 22 cervical cancer,23 colorectal cancer,24 early stage lung cancer25 and prostate cancer,26, 27 as well as adjuvant therapy for breast cancer,28, 29 colorectal cancer30, 31 and prostate cancer,32 exist.
  • Research also indicates that there are both differences in follow-up care after diagnosis of breast cancer33 and colorectal cancer34, 35 and differences in health care expenditures by cancer patients.36

How the Nation is doing

NHQR Findings:

The NHQR found that the rates of cervical cancer and colorectal cancer diagnosed at late stage have declined over time. However, delays in screening for breast, cervical and colorectal cancer remain. In addition, patterns of hospice use suggest that patients with cancer are not placed in palliative care settings until very close to death; median length of stay by cancer patients in hospice is just 15 days. Refer to NHQR for details.

NHDR Findings:

The NHDR examines three aspects of cancer care (Tables 1 and 2):

  • Screening for breast, cervical, and colorectal cancer
  • Cancer treatment
  • Palliative care (e.g., hospice care)

Screening for breast, cervical, and colorectal cancer is a highly effective means of reducing mortality caused by these cancers. Mammography can detect breast cancer at an early stage when chances for cure are highest. Pap testing can detect precancerous cervical changes and prevent the progression to invasive cervical cancer. Fecal occult blood testing and lower endoscopy can detect precancerous colorectal polyps and prevent the development of colorectal cancer.

Yet minorities and persons of lower socioeconomic status are less likely to receive cancer screening services. For example, black, Asian, and American Indian or Alaska Native (AI/AN) women aged 40 and over are less likely than white women to receive mammography. Similarly, Hispanic women are less likely to receive mammography compared with non-Hispanic white women. Lower income, less educated, and uninsured women are less likely to receive mammography compared with higher income, better educated, and privately insured women, respectively. (Source: NHIS, 2000)

Overall, 81% of women 18 and older report a Pap smear in the past 3 years (Figure 1) (NHIS, 2000). Although certain minorities and persons of lower socioeconomic status are less likely to receive cancer screening, there appears to be no significant difference in Pap smear rates between black and white women.

Figure 1. Percent of women (18 and over) who report they had a Pap smear within the past 3 years, age-adjusted.

(U.S. total = 81%)

Figure 1. Percent of women (18 and over) who report they had a Pap smear within the past 3 years, age-adjusted. There are four different bar graphs for race, ethnicity, income, and education.

Notes:
ˆIndicates reference group.
*<0.05 and relative rate >10% for comparison of group with reference group. Note that a relative rate>10% is achieved for the inverse of this measure, percent of women who report that they did not have a Pap smear within the past 3 years.
Key: NHOPI=Native Hawaiian or Other Pacific Islander; AI/AN=American Indian/Alaska Native; HS=High School
DSU=Data do not meet the criteria for statistical reliability, data quality, or confidentiality.

Source: National Center for Health Statistics, National Health Interview Survey, 2000.

Racial, ethnic, and socioeconomic differences in cervical cancer screenings:

  • Asian, Hispanic, low income, and less educated women are less likely than the general population to report having Pap smears.
  • However, black women are more likely than the general population to report having Pap smears.

Asian women report that they have not had a Pap smear in the past 3 years (34%) more frequently than whites (18%) or blacks (16%). Hispanics (23%) are also more likely to have not had Pap smears than their non-Hispanic white counterparts (17%). Similarly, poori (27%), near poorii (25%), and middle incomeiii (19%) women are more likely than high incomeiv women (12%), and women with less than a high school education (26%) and high school graduates (19%) are more likely than women with any college education (14%) to report not having a Pap smear in the past 3 years.

Without screening, cancers may not be detected until they grow large or metastasize to distant sites and cause symptoms. Such late stage cancers are usually associated with more limited treatment options and poorer survival. Overall, minorities are more likely to be diagnosed with late-stage breast cancer and colorectal cancer compared with whites. Data on cancer diagnoses at late stage come from the Surveillance, Epidemiology and End Results (SEER) database.

Rates of cancer death may reflect a variety of factors not associated with health care such as genetic disposition, diet, and lifestyle. However, screening and early treatment can lead to significant reductions in mortality, particularly for breast and cervical cancer.

Cancer death rates tend to be higher among blacks and people of lower socioeconomic status. However, death rates from all cancers are lower among APIs (125 per 100,000 population) and AI/ANs (127 per 100,000) compared with whites (198 per 100,000). Cancer death rates are also lower among Hispanics (121 per 100,000) compared with non-Hispanic whites (203 per 100,000), but highest among blacks (250 per 100,000) (National Vital Statistics System – Mortality, 2000). Mortality statistics include educational attainment of decedents age 25 to 64. Among persons age 25 to 64, rates of cancer death from all cancers are also higher among persons with less than a high school education (141 per 100,000) and high school graduates (141 per 100,000) compared with persons with any college education (75 per 100,000)

At the end of life, many cancer patients benefit from palliative care in hospices. Data on palliative care only permit comparisons of blacks and whites. No evidence of a significant black-white disparity is present (Source: National Home and Hospice Care Survey, 2000).

Overall, there are significant disparities in cancer screening, diagnosis and outcomes. Many racial and ethnic minorities and persons of lower socioeconomic position persons are less likely to have indicated cancer screening, are more likely to have late-stage cancer when cancer is diagnosed, and are more likely to die from cancer. A notable exception: black women have higher screening rates for cervical cancer and no evidence of later stage cervical cancer presentation. While not clearly causally related to the lack of disparity, effective community-based cancer screening and outreach programs may be responsible.


i "Poor" is defined as persons with family incomes less than 100% of Federal poverty thresholds.
ii "Near poor" is defined as persons with family incomes between 100% and 199% of Federal poverty thresholds.
iii "Middle income" is defined as persons with family incomes between 200% and 39% of Federal poverty thresholds.
iv "High income" is defined as persons with family incomes of 400% or more of Federal poverty thresholds.


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Chronic Kidney Disease

Key Finding:
  • While there are racial differences in the adequacy of hemodialysis and likelihood of transplantation, it is unclear to what degree this may be related to underlying differences in severity of illness, comorbidities, or patient preferences.

Why chronic kidney disease is important

Chronic kidney disease has been defined as structural or functional damage to the kidney with or without impairment of the kidney's ability to filter water and waste from the body.37

  • Using this definition, 11% of the U.S. adult population has chronic kidney disease.38 Of these 19.2 million persons, 8.3 million have moderate impairment of the kidney function and almost 400,000 have ESRD requiring renal replacement therapy to sustain life.39
  • Each year, almost 100,000 new ESRD patients begin treatment with either dialysis or renal transplantation, and about 70,000 ESRD patients, 19% of the total ESRD population, die.
  • Expenditures of the ESRD program totaled over $19 billion in 2000, of which the Medicare program paid $14 billion.40

Racial and ethnic minorities develop ESRD at a younger age and have rates of ESRD that are several-fold higher than whites. In spite of these differences, racial and ethnic minorities tend to have better survival after development of ESRD compared with whites.40

However, research has demonstrated that racial and ethnic disparities in care for chronic kidney disease exist.41 There are significant differences in the rate of referral to renal transplant centers, placement on a waiting list, timing of placement on a transplant waiting list, and receipt of a kidney transplant.42, 43

How the Nation is doing

NHQR Findings:

The NHQR found that management of ESRD has improved over time. While the numbers of renal transplants have increased in recent years, too few transplants take place. Specifically, only 20% of ESRD patients are placed on a transplantation waiting list and only 20% of these persons actually succeed in getting a new kidney. (Go to the NHQR for details.)

NHDR Findings:

The NHDR examines two aspects of care for chronic kidney disease (Table 3):

  • Management of ESRD
  • Renal transplantation

Management of ESRD often involves dialysis to remove bodily waste and fluid. Data on the management of hemodialysis patients come from CMS's End Stage Renal Disease Clinical Performance Measurement Program. This quality improvement program has led to dramatic improvements in hemodialysis, as well as reductions in differences in adequacy of dialysis between black and white hemodialysis patients.44 Compared to white adults (86%), black adults achieve adequate hemodialysisi less often (82%), while Asian adults achieve it more often (92%). In contrast, evidence of significant racial or ethnic disparity in management of anemia, commonly caused by ESRD, is not present.

Renal transplantation offers many advantages over dialysis including improved long term survival. Data on renal transplantation come from the United States Renal Data System (USRDS). Compared with whites (26%), blacks (14%) and AI/AN (13%) are less likely to report registration for kidney transplantation. Compared with non-Hispanic whites (28%), Hispanics (16%) are also less likely to report kidney transplant registration. Actual receipt of a kidney transplant within 3 years of renal failure is lower among blacks (10%), APIs (20%), and AI/ANs (11%) compared with whites (26%); it is also lower among Hispanics (17%) compared with non-Hispanic whites (28%).

In summary, there are significant racial disparities in the adequacy of hemodialysis and likelihood of transplantation. However, it is not clear to what degree these disparities may be related to underlying differences in severity of illness, comorbidities, or patient preferences. Regardless, quality improvement strategies that have resulted in demonstrable reductions in black-white differences in hemodialysis may offer important insights into efforts to reduce health care disparities.


i "Adequate hemodialysis" is defined as a urea reduction ratio of 65% or higher.


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Diabetes

Key Findings:
  • While blacks and Hispanics have higher complication rates from diabetes, there are very small differences in receipt of recommended diabetic services.

Why diabetes is important

The prevalence of diabetes has risen in recent years, and this trend is projected to continue. A chronic condition, diabetes usually can be effectively controlled through a combination of primary care, specialty care referral, and patient self-management.45, 46 The benefits of controlling glycemia, lipids, and blood pressure and of screening for diabetic retinopathy, nephropathy and foot disease are well demonstrated and form the basis for regularly published standards of care.47 Unfortunately, recommended diabetes care is often not achieved.48

National statistics on the disease highlight the challenge it poses:

  • Diabetes afflicts over 17 million people in the United States, including 20% of persons over age 65, and about one million new cases are diagnosed annually.
  • Diabetes was the sixth leading cause of death in 1999, when about 200,000 death certificates listed diabetes as an underlying or contributing cause of death.
  • Diabetes is also the leading cause of blindness, nontraumatic lower extremity amputation, and ESRD, and increases the risk of heart disease, stroke, neuropathy, and complication of pregnancy.49, 50
  • The costs of diabetes total about $132 billion, including over $90 billion in direct medical expenditures and about $40 billion due to lost productivity and premature death.51

Significant racial, ethnic, and socioeconomic differences in diabetes have been observed.

  • The prevalence of diabetes is higher among blacks and Hispanics and among less educated persons.52
  • Blacks, American Indians and Hispanics have higher diabetes death rates. Blacks also have higher rates of serious complications from diabetes, including higher rates of ESRD due to diabetes53 and higher rates of lower extremity amputation.54, 55 Black diabetics are more likely than white diabetics to receive patient education56 and to be treated with insulin.57

How the Nation is doing

NHQR Findings:

The NHQR found that only a fifth of diabetics receive all five services that are commonly recommended (i.e., annual retinal eye exams, annual influenza vaccinations, annual HbA1c checks, annual foot exams and biannual lipid profiles). While hospitalizations for uncontrolled diabetes fell significantly between 1994 and 2000, rates of lower extremity amputation have remained stable. (Refer to the NHQR for details.)

NHDR Findings:

The NHDR examines two aspects of the management of diabetes (Tables 4 and 5):

  • Receipt of diabetes services
  • Hospitalizations for diabetes and its complications

Lower income and less educated adults with diabetes are less likely to report eye exams, but racial or ethnic differences are not significant. Patients with diabetes require multiple health care services to stay healthy, including: periodic hemoglobin A1c measurement to maintain optimal glycemic control; screening for diabetic eye and foot complications; screening for elevated lipids, which is often associated with diabetes; and immunization against influenza, which can be particularly severe among diabetic patients.

Diabetic patients of lower socioeconomic position are less likely to receive some recommended diabetic services. For example, poor (63%), near poor (64%), and middle income patients (61%) are less likely than those with high incomes (74%) to receive an annual retinal eye examination. Similarly, those with less than a high school education (64%) and high school graduates (61%), compared with persons with any college education (74%), are less likely to undergo annual retinal eye exams (Figure 2) (MEPS, 2000). In contrast, racial and ethnic differences in receipt of diabetic services are relatively small.

Figure 2. Percent of adults with diabetes who had a retinal eye examination in past year

(U.S. total = 67%)

Figure 2. Percent of adults with diabetes who had a retinal eye examination in past year

Notes:
ˆIndicates reference group.
*p<0.05 and relative rate >10% for comparison of group with reference group.
Key: NHOPI=Native Hawaiian or Other Pacific Islander; AI/AN=American Indian/Alaska Native; HS=High School
DSU=Data do not meet the criteria for statistical reliability, data quality, or confidentiality.

Source: Agency for Healthcare Research and Quality. Medical Expenditure Panel Survey, 2000.

Blacks, Hispanics, and persons who live in poor neighborhoods are hospitalized more often for complications of diabetes, but Asians or Pacific Islanders are hospitalized less often. When diabetic management is chronically inadequate, diabetics may experience long-term complications and avoidable hospitalizations. Using State administrative data from the Healthcare Cost and Utilization Project, State Inpatient Databases (HCUP SID) in 16 States, significant disparities are noted by race, ethnicity, and socioeconomic status.

Overall, blacks and Hispanics have higher rates of hospitalization for diabetes and its complications. In contrast, Asians and Pacific Islanders have lower hospitalization rates. Using median income of ZIP Code of residence as a proxy of patients' socioeconomic position, lower income patients tend to have higher rates of hospitalization for diabetes and its complications (Figure 3) (Source: HCUP SID, 2000).

Figure 3. Hospital admissions for long term complications of diabetes per 100,000 population, (age-adjusted)

(Total 16 States = 117 per 100,000)

Figure 3. Hospital admissions for long term complications of diabetes per 100,000 population, (age-adjusted)

Notes:
ˆIndicates reference group.
*p<0.05 and relative rate >10% for comparison of group with reference group..
Key: NHOPI=Native Hawaiian or Other Pacific Islander; AI/AN=American Indian/Alaska Native; HS=High School
DSU=Data do not meet the criteria for statistical reliability, data quality, or confidentiality.
Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, State Inpatient Database, 2000.

Diabetics are at high risk for developing foot ulcers and infections. When medical management of these conditions fails, amputation may be required. Overall, blacks have significantly higher rates of amputation for blacks (7.0 per 1000 diabetics) compared with whites (3.5 per 1000) (Source: NHDS, 1998-2000).

In summary, there are significant diabetes disparities in health care services and patient outcomes. Patients of lower socioeconomic position are less likely to receive recommended diabetic services and more likely to be hospitalized for diabetes and its complications. While blacks and Hispanics have higher diabetic complication rates, only small differences in the receipt of recommended diabetic services can be found. Further attempts to improve glycemic control for all patients may help to reduce the long-term adverse outcomes of diabetes.

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Heart Disease

Key Findings:
  • Many racial and ethnic minorities and persons of lower socioeconomic position are less likely to receive screening and treatment for cardiac risk factors.
  • Exception: Blacks are more likely to report blood pressure monitoring.
  • When hospitalized for acute myocardial infarction, Hispanics are less likely to receive optimal care.
  • "Dual-eligible" individualsi who are hospitalized for cardiac conditions are less likely to receive quality care than other Medicare beneficiaries.

Why heart disease is important

  • The leading cause of death for men and for women in the United States, heart disease was responsible for over 700,000 deaths in 2000. It is also the third leading cause of activity limitation. About 4.8 million Americans have heart failure, and 550,000 develop it each year.
  • The economic cost of heart disease is estimated to be $214 billion, including $115 billion in health care expenditures.
  • Two of the most common heart diseases are coronary heart disease and heart failure. About 12.6 million persons have coronary heart disease and over 1 million heart attacks occur each year.
  • Over the last three decades, deaths due to coronary heart disease have fallen dramatically, in part due to declining rates of smoking and high cholesterol, two key cardiovascular risk factors. Heart disease risk can be modified through early detection and lifestyle changes.

Differences in heart disease among racial and ethnic groups have been observed. In particular:

  • Heart disease deaths are higher among blacks and lower among Hispanics, Asians, and American Indians compared with non-Hispanic whites, although all groups have experienced declines in the past 15 years.
  • Coronary heart disease is more prevalent among blacks compared with whites and the prevalence among blacks is rising while the prevalence among whites is falling. In addition, coronary heart disease mortality is higher among blacks compared with whites.58

Racial, ethnic, and socioeconomic disparities in cardiovascular care have been extensively reviewed and documented.59 Differences in recommendations for,60 appropriateness of,61, 62 and receipt of coronary revascularization procedures have been repeatedly demonstrated.63, 64 In addition, differences in the management of acute myocardial infarction65, 66 and unstable angina67 and the diagnostic work-up of chest pain in the emergency room68 have been demonstrated.


i"Dual eligible" individuals are patients who use both Medicare and Medicaid coverage, a measure used as a proxy for low-income seniors


How the Nation is doing

NHQR Findings:

Blood pressure screening rates are high but cholesterol screening and smoking cessation rates are suboptimal. Rates of administration of aspirin to patients with acute myocardial infarction on hospital arrival are high, but rates of other recommended treatments for acute myocardial infarction are suboptimal.

NHDR Findings:

Given the evidence base and the quality measurement for heart disease, the NHDR examines numerous aspects of cardiovascular disease. Seven aspects of cardiovascular care considered in the NHDR are as follows (Tables 6 and 7):

  • Screening for high blood pressure
  • Screening for high cholesterol
  • Counseling on risk factors
  • Treatment of acute myocardial infarction
  • Treatment of acute heart failure
  • Management of hypertension
  • Management of congestive heart failure

High blood pressure, high cholesterol, and smoking are three of the most important risk factors for heart disease that can potentially be modified by screening and treatment.

Asian, Hispanic, low income, and less educated adults are less likely than the general population to have their blood pressure monitored. Overall, 90% of adults have had their blood pressure measured within the preceding 2 years and can state whether their blood pressure was normal or high. The proportion of persons who have not had their blood pressure measured is lower among blacks (8%) and higher among APIs (14%) compared with whites (10%), and higher among Hispanics (16%) compared with non-Hispanic whites (9%). This measure is also higher among poor (14%), near poor (13%), and middle income (10%) persons compared with high income persons (6%), and among persons with less than a high school education (16%) and high school graduates (10%) compared with persons with any college education (7%) (Figure 4). (Source: NHIS, 1998). The percent of adults with hypertension whose blood pressure is under control is lower among persons with less than a high school education (20%) compared with persons with any college education (34%) (Source: NHANES, 1999-2000).

American Indian or Alaska Natives, Hispanics, low income, and less educated adults are less likely to have their cholesterol checked than the general population. Screening for high cholesterol also demonstrates racial, ethnic, and socioeconomic disparity. The percent of adults who have had their blood cholesterol checked within the preceding 5 years is lower among AI/ANs (58%) compared with whites (67%) and among Hispanics (59%) compared with non-Hispanic whites (68%). This measure is also lower among poor (56%), near poor (60%), and middle income (67%) persons compared with high income persons (75%) and among persons with less than a high school education (58%) and high school graduates (69%) compared with persons with any college education (78%). (Figure 5) (Source: NHIS, 1998).

Among persons who had a check-up in the past year, the percentage of smokers receiving advice to quit smoking is lower among Hispanics (51%) compared with non-Hispanic whites (63%) (Source: MEPS, 2000). Moreover, while extensive disparity related to income or education is not noted, this measure is lower among the uninsured (49%) compared with persons with private health insurance (62%).

Figure 4. Percent of adults who have had their blood pressure measured within the preceding 2 years and can state whether their blood pressure was normal or high, (age-adjusted)

(U.S. total = 90%)

Figure 4. Percent of adults who have had their blood pressure measured within the preceding 2 years and can state whether their blood pressure was normal or high, (age-adjusted)

ˆ Indicates reference group.
*p<0.05 and relative rate >10% for comparison of group with reference group. Note that a relative rate .10% is achieved for the inverse of this measure, percent of adults who have not had their blood pressure measured within the preceding 2 years.
Key: NHOPI=Native Hawaiian or Other Pacific Islander; AI/AN=American Indian/Alaska Native; HS=High School
DSU=Data do not meet the criteria for statistical reliability, data quality, or confidentiality.
Source: National Center for Health Statistics, National Health Interview Survey, 1998.

Acute myocardial infarction and congestive heart failure are two serious cardiac conditions that demonstrate significant disparities in cardiac care. Overall, Hispanics tend to receive lower quality care for acute myocardial infarction compared with non-Hispanic whites. Since patient income and education information is not available, "dual eligible" status—using both Medicare and Medicaid coverage—is used as a proxy for socioeconomic position. "Dual-eligible" individuals who are hospitalized for acute myocardial infarction are less likely to receive aspirin and beta blockers within 24 hours compared with other Medicare beneficiaries. When hospitalized for acute heart failure, dual-eligibles are less likely to receive ACE inhibitors at discharge. (Source: Medicare Quality Improvement Organization program). Rates of hospital admissions for congestive heart failure are higher among blacks (5.5 per 1,000 population) compared with whites (2.5 per 1,000) (Source: NHDS, 2000).

Figure 5. Percent of adults who have had their blood cholesterol checked within the preceding 5 years, (age-adjusted)

(U.S. total = 67%)

Figure 5. Percent of adults who have had their blood cholesterol checked within the preceding 5 years, (age-adjusted)

ˆ Indicates reference group.
*p<0.05 and relative rate >10% for comparison of group with reference group.
Key: NHOPI=Native Hawaiian or Other Pacific Islander; AI/AN=American Indian/Alaska Native; HS=High School
DSU=Data do not meet the criteria for statistical reliability, data quality, or confidentiality.
Source: National Center for Health Statistics, National Health Interview Survey. 1998.

In summary, many racial and ethnic minorities and persons of lower socioeconomic position are less likely to receive screening and treatment for cardiac risk factors. When hospitalized for acute myocardial infarction, Hispanics are less likely to receive optimal care. The combination of lower screening and effective treatment of risk factors, such as smoking among the uninsured, lend themselves to quality improvement initiatives that can potentially reduce heart disease disparities among populations at risk.

For the available NHDR measures, blacks suffer fewer cardiac disparities, especially when compared to other minority and socioeconomic groups. Blacks are more likely to receive blood pressure monitoring without any disparity in blood pressure management. The recognition of greater risk for significant cardiovascular disease among blacks may result in appropriately elevated rates of screening and treatment for risk factors. In addition, directed public education campaigns about cardiac risk factors and the importance of an involved patient may play an important role in the lower observed rate of cardiac disparities among blacks.

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HIV/AIDS

Key Findings:
  • Many racial and ethnic minorities and persons of lower socioeconomic position are more likely to die from HIV.
  • Minorities also account for a disproportionate share of new AIDS cases.

Why HIV/AIDS is important

Human immunodeficiency virus (HIV) infection and its late-stage manifestation, acquired immune deficiency syndrome (AIDS), form one of the most devastating global infection disease pandemics in history.

  • Worldwide, over 42 million persons are infected with the virus, and 40 million persons have died since the disease was first identified in 1981.69 In 2002, over 5 million persons around the globe were infected with the virus and more than 3 million persons died, including 610,000 children.70
  • Estimates indicate that, in the United States alone, between 850,000 and 950,000 individuals are infected, a quarter of whom do not yet know that they carry the disease.71 More than 450,000 Americans have died from the disease since its discovery, and over 14,000 persons died in 2000.72 Each year, about 40,000 persons acquire the infection, half of whom are under age 25.73, 74

Fortunately, great strides have been made in recent years in the management of this disease. Educational campaigns to prevent spread of the virus have been launched, treatments to control the virus and its associated opportunistic infections and cancers have been produced, and vaccines are under development.75, 76, 77, 78

HIV incidence and death rates vary by race and ethnicity.

  • While blacks make up about 12 percent of the U.S. population, they accounted for 50% of the new HIV cases reported in the United States in 2001.79
  • AIDS is the leading cause of death among black women 25 to 34 and black men 35 to 44.80 Hispanics also have higher AIDS incidence rates compared with whites.81

Racial, ethnic, and socioeconomic disparities in quality care for HIV/AIDS have been documented in, for example, receipt of antiretroviral therapy and prophylactic therapy to prevent Pneumocystis carinii pneumonia (PCP),82 receipt of highly active antiretroviral therapy,83 and management of PCP.84

How the Nation is doing

NHQR Findings:

The NHQR found decreases in both new AIDS cases and in AIDS mortality. (Go to the NHQR for details.)

NHDR Findings:

This section examines two aspects of the quality of HIV/AIDS health care (Tables 8 and 9):

  • AIDS prevention
  • Management of HIV/AIDS

(Additional measures related to receipt of HIV care can be found in the chapter on Access to Health Care.)

While the overall rate of new AIDS cases is decreasing, new AIDS cases are reported at a higher rate among non-Hispanic blacks (75 per 100,000 population), Hispanics (26 per 100,000), and AI/ANs (12 per 100,000) compared with non-Hispanic whites (7 per 100,000). The new AIDS infection rate is even lower among APIs (4 per 100,000) (Source: CDC HIV/AIDS Surveillance System).

Effective treatments cannot cure HIV disease, but they can reduce or delay mortality from HIV-infection. Death rates due to HIV infection are higher among blacks (24 per 100,000 population) compared with whites (3 per 100,000); death rates are also higher among Hispanics (7 per 100,000) compared with non-Hispanic whites (2 per 100,000). There are a relationship between HIV morality and education; persons with less than a high school education (20 per 100,000) and high school graduates (13 per 100,000) had higher HIV death rates compared to persons with any college education (4 per 100,000) (Source: NVSS-M, 2000).

In summary, minorities account for a disproportionate share of new AIDS cases. In addition, many racial and ethnic minorities and persons of lower socioeconomic position are more likely to die from AIDS. However, given the complex relationship between HIV infection and mortality, factors such as lifestyle and patient preferences may play a role. Additional measures of HIV-related quality are needed to better understand health care disparities related to HIV treatment and outcomes.

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Maternal and Child Health

Key Findings:
  • Many racial and ethnic minorities and persons of lower socioeconomic position are less likely to receive timely prenatal care, are more likely to have low birthweight babies, and have higher rates of infant and maternal mortality.
  • Many racial and ethnic minorities and persons of lower socioeconomic position are less likely to receive childhood immunizations.

Why maternal and child health is important

The health and care of mothers and children is of critical importance to maximize the health of the next generation. Childbirth and reproductive care are the most common reasons for women of childbearing age to use health care. With more than 11,000 births each day in the United States, childbirth is the most common reason for hospital admission.85

  • In 2001, 11.9% of infants were born preterm, 7.7% were born with low birthweight, including 1.4% with very low birthweight, and 1.4 percent had low 5-minute Apgar scores.i Over time, rates of preterm birth and low and very low birthweight have increased, although rates of low Apgar scores and infant mortality have decreased.86
  • Comprehensive prenatal care can prevent complications of pregnancy and reduce neonatal mortality. Given that birth outcomes have effects that accrue over a lifetime, prenatal care is highly cost-effective.87

There are significant racial and ethnic differences in birth rates. For example:

  • Non-Hispanic blacks, Hispanics, and APIs have higher birth rates than non-Hispanic whites. Similarly, non-Hispanic blacks, Hispanics, and American Indians have higher birth rates among teenagers than non-Hispanic whites.
  • Black, American Indian, and Hawaiian mothers are more likely to have preterm, low birthweight, or low Apgar infants compared to white mothers. Similarly, Hispanic mothers are more likely to have preterm infants but less likely to have low birthweight or low Apgar infants compared with non-Hispanic white mothers.88
  • During their first year of life, black infants are more likely to die than non-Hispanic white infants.89

Racial, ethnic, and socioeconomic disparities in maternal and child health care, particularly with respect to maternal care processes (e.g., prenatal care counseling),90 use of prenatal care technologies,91 modes of delivery92, 93 and maternal care outcomes (e.g., birthweight and fetal and neonatal mortality)94 have been extensively documented. Similarly, minority children and children of lower socioeconomic position often receive different care than white children and more affluent children.95, 96, 97


i Apgar scores are routinely performed to evaluate the general physical condition of newborns. Scores range from 0 to 10. Scores of 7 or higher indicate good neonate physical condition; scores under 7 are considered low.


How the Nation is doing

NHQR Findings:

The NHQR found improvements in all maternal and child health measures over time, including maternity care, immunizations and treatment of pediatric gastroenteritis. Go to NHQR for details.

NHDR Findings:

Five aspects of the quality of maternal and child health care are included in this section (Tables 10 and 11):

  • Maternity care
  • Childhood immunization
  • Adolescent immunization
  • Childhood dental care
  • Treatment of pediatric gastroenteritis

(General measures of access to care, receipt of care and quality of care as they are applied to children can be found in Chapter 5.)

Many racial and ethnic minorities and less educated women are less likely than the general population to receive timely prenatal care. Optimal prenatal care should reduce rates of low birthweight and of infant and maternal death. About 83% of women start prenatal care in the first trimester while 17% do not. There are significantly lower rates of prenatal care among blacks (26%), Native Hawaiians or Other Pacific Islanders (NHOPI) (23%), and AI/ANs (31%), compared to whites (15%). Hispanics (25%) are also more likely than non-Hispanic whites (11%) to lack prenatal care during the first trimester. Similarly, pregnant women with less than a high school education (30%) and those who completed high school (17%) are more likely to lack prenatal care than women with any college education (8%). (Figure 6) (NVSS-Natality, 2000)

Babies born to black, NHOPI, AIAN, and less educated mothers are more likely to die at birth. However, babies born to Asian mothers are less likely than those born to white mothers to die at birth. Racial and ethnic minorities are also more likely to have low birthweight babies and infants who die in the first year of life. Less educated women experience similar patterns. Although Hispanic women are more likely to die from obstetrical complications, Hispanic infants do not have higher mortality rates. Overall, infant mortality rates are higher for blacks (13.5 deaths per 1000 live births), NHOPIs (8.2 per 1000), and AI/ANs (8.3 per 1000) and lower for Asians (4.5 per 1000) compared with whites (5.7 per 1000) (Figure 7) (NVSS-Mortality, 2000). These patterns typically persist after stratification for infant birth weight.

Figure 6. Percent of pregnant women receiving prenatal care in first trimester

(U.S. total = 83%)

Figure 6. Percent of pregnant women receiving prenatal care in first trimester

Notes:
ˆ Indicates reference group.
*Relative rate >10% for comparison of group with reference group. Note that a relative rate >10% is achieved for the inverse of this measure, percent of pregnant women not receiving prenatal care in the first trimester.
Key: NHOPI=Native Hawaiian or Other Pacific Islander; AI/AN=American Indian/Alaska Native; HS=High School
DSU=Data do not meet the criteria for statistical reliability, data quality, or confidentiality.
Source: National Center for Health Statistics, National Vital Statistics System-Natality, 2000.

Black and low income children are less likely to receive all recommended vaccines.

Childhood and adolescent vaccination both protect its recipients from illness and disability and others in the community who cannot be vaccinated, such as small children and persons who are immunosuppressed. Vaccines routinely recommended for children tend to have net cost savings ranging from $24 saved for ever dollar spent on the diphtheria, tetanus, pertussis vaccine to $2 for the Haemophilus influenzae type b vaccine.98

Immunization of children and adolescents is an important means of reducing mortality and morbidity in these populations. Blacks are less likely to receive childhood immunizations compared with whites, and lower income children are less likely to receive immunizations compared with more affluent children.

For example, receipt of all recommended vaccinations is achieved by 74% of children ages 19 to 35 months, while 26% do not attain this goal. Black children are more likely to miss all recommended vaccinations (32%), compared with white children (25%). Similarly, children who are poor (32%), near poor (29%), and middle income (25%), compared with children from high income families (21%), do not receive all recommended vaccinations. (Figure 8) (National Immunization Survey, 2001).

Dental care for children is important to develop healthy dental habits. Among children, blacks (32%) are less likely than whites (50%), and Hispanics (27%) are less likely than non-Hispanic whites (55%) to visit a dentist. Similarly, fewer poor (32%), near poor (29%), and middle income (51%) children, compared with high income children (65%), and fewer uninsured children (22%), compared with privately insured children (54%), visit a dentist (MEPS, 1999).

Figure 7. Infant mortality per 1,000 live births, all births

(U.S. total = 6.9)

Figure 7. Infant mortality per 1,000 live births, all births

Notes:
ˆ Indicates reference group.
*Relative rate >10% for comparison of group with reference group.
Key: NHOPI=Native Hawaiian or Other Pacific Islander; AI/AN=American Indian/Alaska Native; HS=High School
DSU=Data do not meet the criteria for statistical reliability, data quality, or confidentiality.
Source: National Center for Health Statistics, National Vital Statistics System-Mortality, 2000.

Another measure of the quality of care for children is the rate of avoidable hospitalizations. For example, many hospitalizations for pediatric gastroenteritis should be avoidable with effective primary care. Rates of hospitalization for pediatric gastroenteritis are higher among Hispanic children (133 per 100,000 population) and lower among API children (47 per 100,000) compared with white children (107 per 100,000). Because information on patient income and education is not available, the median income of by patient ZIP Code is used as a proxy of socioeconomic position. Overall, hospitalization for gastroenteritis are higher among children who live in ZIP Codes with lower median incomes; incomes <$25,000(172 per 100,000 population), incomes of $25,000-$34,999 (157 per 100,000), and incomes of $35,000-$44,999 (124 per 100,000), compared with children who live in ZIP Codes with median incomes of $45,000 and over (86 per 100,000) (HCUP SID 16-State database, 2000).

In summary, there are significant disparities in maternal and child health. Overall, minorities and women of lower socioeconomic position are less likely to have timely prenatal care. This lower rate of prenatal care is coupled with a higher rate of low birthweight babies and infant mortality. However, birth outcomes may be affected by factors other than prenatal care, including maternal health, lifestyle, and patient preferences. Finally, many racial and ethnic minorities and persons of lower socioeconomic position are less likely to receive childhood immunizations.

Figure 8. Percent of children 19-35 months who receive all recommended vaccines

(U.S. total = 74%)

Figure 8. Percent of children 19-35 months who receive all recommended vaccines

Notes:
ˆ Indicates reference group.
*p<0.05 and relative rate >10% for comparison of group with reference group. Note that a relative rate >10% is achieved for the inverse of this measure, percent of children 19-35 months who have not received all recommended vaccines.
Key: NHOPI=Native Hawaiian or Other Pacific Islander; AI/AN=American Indian/Alaska Native; HS=High School
DSU=Data do not meet the criteria for statistical reliability, data quality, or confidentiality.
Source: National Center for Health Statistics, National Immunization Survey, 2001.

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