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National Healthcare Disparities Report, 2003

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Chapter 3. Quality of Health Care (continued)

Mental Health

Key Findings:
  • Rates of suicide are lower among minority groups.
  • Suicide is higher among high school dropouts and high school graduates compared with persons with any college education.

Why mental health is important

Mental illness is a category of diseases and problems which include major and minor depression, schizophrenia, substance abuse, bipolar disorder, Alzheimer's disease, and other disorders of the brain/mind. The personal and social costs associated with inadequate mental health care are staggering:

  • The direct costs of mental disorders totaled $69 billion in 1996, while lost productivity and premature death accounted for an additional $75 billion. Mental disorders are the second leading cause of disability in established market economies such as the United States, accounting for over 15% of disability-adjusted life-years.
  • Almost 15 million persons aged 18 and over, or 7% of the population, have a serious mental illness that substantially interferes with or limits one or more major life activities.99
  • Depressive disorders account for about one-third of mental disorders. In any year, about 6.5% of women and 3.3% of men will have major depression. Major depression accounts for 6.8% of disability-adjusted life years and is associated with high rates of suicide.100

Although treatments of mental disorders are highly effective, only a quarter of persons with mental disorders and 40% of persons with serious mental illness seek help from the health care system. When patients do interact with health care providers, disorders such as depression often go undiagnosed.

Racial, ethnic, and socioeconomic disparities in mental health care have been documented in use of psychiatric medications101 and of psychiatric outpatient,102 emergency,103 and inpatient services.104

How the Nation is doing

NHQR Findings:

Pharmacological treatment of depression has improved over time although opportunities for improvement remain. The NHQR also notes that while the suicide rate for adults has been relatively stable over time, the suicide rate for young adults has nearly tripled over the past four decades. (Refer to the NHQR for details).

NHDR Findings:

Treatment of depression is examined in this section (Tables 12 and 13). (Additional measures related to access to and receipt of mental health care and substance abuse treatment can be found in the chapter on Access and Receipt of Care.)

There is not yet broad agreement within the mental health field on a core set of national mental health quality of care performance measures. But rather than omitting mental illness in its first report entirely, the NHQR turned to a reliable source of performance information on the quality of care for depression provided to managed care enrollees: the Health Plan Employer Data and Information Set (HEDIS®) measures. Unfortunately, racial, ethnic, and socioeconomic comparisons cannot be performed using HEDIS® data. Hence, the issue of disparities in pharmacological treatment of depression is not addressed in this section.

Effective treatment of depression may reduce rates of suicide. Suicide rates are lower among blacks (5.6 per 100,000 population) and APIs (5.8 per 100,000), than whites (11.5 per 100,000), and lower among Hispanics (6.1 per 100,000) than non-Hispanic whites (12.1 per 100,000). Rates of suicide death are higher among high school dropouts (18.4 per 100,000 population) and high school graduates (18.8 per 100,000) compared with persons with any college education (9.3 per 100,000). However, suicide may be influenced by factors other than mental health care. Further measures of mental health disparities by race, ethnicity, and socioeconomic position are clearly required (Source: NVSS-M).

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Respiratory Diseases

Key Findings:
  • Black children have much higher hospitalization rates for asthma than white children.
  • Many racial and ethnic minorities and individuals of lower socioeconomic status are less likely to receive recommended immunizations for influenza and pneumococcal disease.
  • When racial and ethnic minorities are hospitalized for pneumonia, differences in quality of care received are observed.

Why respiratory diseases are important

Respiratory diseases cause activity limitation in 2.6 million persons. Annual costs of respiratory diseases exceed $116 billion, including $65 billion in health care expenditures.58 Major respiratory diseases include:

  • Chronic lower respiratory disease, such as chronic obstructive pulmonary disease (COPD) and asthma. COPD is the fourth leading cause of death; and
  • Acute lower respiratory infection, such as influenza and pneumonia, which together are the seventh leading cause of death.105

Asthma affects about 15 million persons, and prevalence and mortality are increasing.106 Each year, about 11 million persons experience asthma attacks and 5,500 persons die of the disease. Pneumonia is a leading cause of hospitalization among children and the elderly, and treatment costs in the United States exceed $9.7 billion.107

While not generally considered a respiratory disease, tuberculosis often has pulmonary manifestations. While progress toward elimination of tuberculosis was delayed by the resurgence of the disease between 1985 and 1992 and by emergence of drug-resistant strains,108 rates of new tuberculosis cases continue to fall.109

Many respiratory diseases can be effectively prevented and managed. Vaccination of the elderly and high-risk adults is a highly effective strategy for reducing illness and death associated with pneumococcal disease and influenza. Consensus guidelines on the management of asthma are widely accepted and disseminated.110 Anti-tuberculous medications are highly effective when treatment is adhered to and completed.

There are racial and socioeconomic differences in respiratory disease prevalence. For example, asthma is more prevalent among minorities and low income persons,111 and asthma attack rates and mortality are higher among blacks compared with whites. Hospitalization and emergency room visits for asthma continue to rise among minority populations.112 Tuberculosis is highly concentrated in two populations: foreign-born persons and U.S.-born non-Hispanic blacks. Non-Hispanic blacks account for almost half of all cases among U.S.-born persons. In addition, there are differences in influenza vaccination among Medicare beneficiaries113 and in management of asthma among managed care enrollees.114, 115

How the Nation is doing

NHQR Findings:

The NHQR found decreases in hospitalization rates for asthma between 1994 and 2000, but noted continued opportunities for improvement in asthma management. The NHQR found no change in the rate of inappropriate antibiotic prescriptions for the common cold between 1997-1998 and 1999-2000. (Go to the NHQR for details).

NHDR Findings:

This section examines six aspects of the quality of health care for respiratory diseases (Tables 14 and 15):

  • Influenza immunization
  • Pneumococcal immunization
  • Treatment of pneumonia
  • Treatment of upper respiratory infection
  • Management of asthma
  • Treatment of tuberculosis

Black, Hispanic, low income, and less educated elders are less likely to receive flu shots. Sixty-five percent of persons aged 65 and above report that they received an influenza vaccine (Figure 9) (NHIS, 2000); 35% still do not receive this vaccine. Blacks (52%) are more likely than whites (34%) to fail to receive the vaccination. Those of low socioeconomic status are also less likely to receive immunization. Specifically, the poor (44%) and near poor (39%) are more likely than their high income counterparts (31%) to forego flu shots. Similarly, those with less than a high school education (42%) and high school graduates (34%) are more likely than those with any college education (30%) to miss the vaccine.

Among the elderly, Hispanics (44%) are more likely to go without an influenza vaccine than non-Hispanic whites (33%). Similarly, among persons 65 and over, blacks, Hispanics, and persons of lower socioeconomic position are less likely to receive pneumococcal vaccination. Among high risk persons aged 18-64, Hispanics (10%) are less likely to report pneumococcal vaccination than non-Hispanic whites (16%).

Many respiratory hospitalizations are avoidable with immunization and effective primary care. APIs and Hispanics have lower rates of hospitalization for influenza compared with non-Hispanic whites. Again, information on patient income and education is not available. Using median income of patient's ZIP Code as a proxy of socioeconomic position, patients who live in lower income areas have higher rates of hospitalization for influenza compared with residents of higher income ZIP Codes (HCUP SID 16-State database, 2000). Hospitalization rates among black children (60 per 10,000 population) and adults (21 per 10,000) tend to be higher than rates among white children (17 per 10,000) and adults (8 per 10,000) (NHDS, 2000). Information on patient income or education is not available.

Figure 9. Percent of persons 65 and over who report receiving influenza vaccination in the past year

(U.S. total = 65%)

Figure 9. Percent of persons 65 and over who report receiving influenza vaccination in the past year

Notes:
ˆ Indicates reference group.
*p<0.05 and relative rate >10% for comparison of group with reference group. Note that relative rate >10% is achieved for the inverse of this measure, percent of persons 65 and over who do not report receiving influenza vaccination in the past year.
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.

Though many cases of pneumonia can be prevented, there are important measures of the quality of care provided to patients hospitalized with pneumonia. Among Medicare beneficiaries, non-Hispanic blacks and Hispanics tend to receive lower quality pneumonia treatment and AI/ANs tend to receive higher quality care compared with non-Hispanic whites. Because information on patient income and education is unavailable, the NHDR uses both Medicare and Medicaid coverage as a proxy for low-income seniors. Such "dual-eligibles" who are hospitalized for pneumonia are less likely to receive influenza and pneumococcal screening or vaccination than other Medicare beneficiaries. (Source: Medicare Quality Improvement Organization program)

In summary, many racial and ethnic minorities and persons of lower socioeconomic position persons are less likely to receive recommended immunizations for influenza and pneumococcus. In some instances, these lower rates of vaccination are associated with higher rates of potentially avoidable respiratory admissions. Once hospitalized, some ethnic and racial minorities, as well as lower income patients, suffer worse quality of care for pneumonia. These differential rates of vaccination and hospitalization present opportunities for provider-based and community-based interventions to reduce disparities.

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Long Term Care

Key Findings:
  • The percent of residents in physical restraints is higher among Hispanics and APIs compared with non-Hispanic whites.
  • The percent of residents with pressure sores is higher among non-Hispanic blacks and lower among APIs compared with non-Hispanic whites.

Why long term care is important

Long term care is the provision of personal, social, and medical services to persons who have functional or cognitive limitations in their ability to perform self-care and other activities necessary to live independently. As the number of elderly Americans increases from 35 million in 2000 to an estimated 71 million in 2030,116 the need for long-term care is expected to increase.

Long term care includes the provision of services at home, in the community, and in special facilities.

  • Home health care is available for those who can be managed at home. In 1996, about 12,000 home health care agencies provided care to 7.8 million persons, about two-thirds of whom were aged 65 and above.117
  • Nursing homes are often a better option for those with serious disabilities that require 24-hour care or whose needs can be better met in a special facility. More than half of all nursing home residents are aged 85 and above. Nursing home care costs on average, $56,000 per person per year, and expenditures total almost $80 billion, about half of which is paid by Medicaid and Medicare.118 Approximately 70% of nursing home residents are supported in part by Medicaid.118

Use of home health care and of nursing home care has declined in recent years.120 CMS data indicate that there are currently 1.4 million nursing home residents, down from 1.6 million in 1999.119 At the same time, because growth in the elderly population over 75 has outpaced growth in the supply of nursing home beds, nursing homes are caring for older patients with more functional limitations.120, 121

Studies indicate that racial, ethnic, and socioeconomic disparities in nursing home care exist,122 particularly with respect to differences in the management of pain123 and the receipt of rehabilitative services.124 Concerns about nursing home quality, as well as lawsuits against nursing homes, are on the rise.125

How the Nation is doing

NHQR Findings:

The NHQR found that while use of restraints in nursing homes may have declined, many opportunities to improve the quality of nursing home care exist. (Go to the NHQR for details).

NHDR Findings:

Nursing facility care is examined in this section (Table 16). Additional measures related to receipt of nursing home, home health, and hospice care can be found in Chapter 4. (Measures related to palliative (e.g., hospice) care for cancer patients can be found in the Cancer section of this chapter, and measures related to immunizations received by nursing home residents can be found in the Respiratory Diseases section of this chapter.)

Racial and ethnic minorities have more favorable quality of care on some measures and less favorable care on others. For example, the percent of nursing home residents who report pain is lower among non-Hispanic blacks (7%), Hispanics (7%), and APIs (5%) than among non-Hispanic whites (10%). However, the percent of residents in physical restraints is higher among Hispanics (12%) and APIs (12%) than among non-Hispanic whites (8%). The percent of residents with pressure sores is higher among non-Hispanic blacks (10%) and lower among APIs (7%) compared with non-Hispanic whites (8%). Overall, there are opportunities for improvement in nursing homes, though few examples of significant disparities. (Source: CMS's Nursing Home Resident Profile Table).

In summary, patient race, ethnicity, and socioeconomic status are important indicators of the effectiveness of health care.

Patient Safety

Key Findings:
  • Racial and ethnic minorities have higher rates of hospital-acquired infections.
  • Racial and ethnic minorities have higher rates of some complications of care, such as respiratory failure after surgery, and lower rates of other complications, such as hip fracture after surgery.
  • Many racial and ethnic minorities have lower rates of injury related to labor and delivery and lower rates of inpatient death when hospitalized for conditions that should not lead to death.
  • Many racial and ethnic minorities as well as the uninsured are more likely to be asked by their provider about medications and treatments from other doctors.
  • For all findings, patient race, ethnicity, and socioeconomic position are associated with an increased risk of poor care.

Why patient safety is important

The prime directive of medical care is to do no harm, but the Institute of Medicine report, To Err is Human, estimated that 44,000 to 98,000 Americans die each year as a result of medical errors, making it the eighth leading cause of death.126 This report also estimates costs attributable to medical errors total $29 billion annually.

Adverse drug reactions occur in 6.7% of hospitalized patients127 and are rising.128 Adverse drug events that are preventable occurred in about 2% of admissions to Utah hospitals129 and Boston teaching hospitals;130 20% of these events were life-threatening. Among Medicare beneficiaries in an ambulatory setting, the overall rate of adverse drug events was 50 per 1,000 person years; over 40% of serious, life-threatening, or fatal events were deemed preventable.131

Relatively little is known about disparities in medical error. Blacks appear to be at greater risk for serious adverse events related to digitalis therapy132 and pharmacologic treatment of diabetes.133 Language barriers may increase the risk of drug complication among outpatients.134 However, among hospitalized children, those who live in low income ZIP Codes have lower rates of medical errors compared with children from high income ZIP Codes.135 Uninsured patients are more likely to suffer negligent medical injury in hospitals.136

How the Nation is doing

NHQR Findings:

The NHQR found that rates of many postoperative complications increased from 1994 to 2000. (Go to the NHQR for details.)

NHDR Findings:

Six aspects of patient safety are included in this section (Tables 17 and 18):

  • Complications of care
  • Nosocomial infections
  • Injuries or adverse events due to technical errors
  • Birth-related trauma
  • Potentially avoidable death
  • Medication safety

Because information on patient income and education are unavailable, the NHDR uses the median income of the patient's ZIP Code as a proxy of socioeconomic position. These inpatient measures are part of the Patient Safety Indicators developed by AHRQ (HCUP SID 16 State database).137

Racial and ethnic minorities and the poor have higher rates of severe breathing problems after surgery. Minorities and the poor also have higher rates of some complications of care: postoperative hemorrhage or hematoma with surgical drainage or evacuation postoperative respiratory failure, postoperative physiologic/metabolic derangement, and decubitus ulcers. For example, rates of postoperative respiratory failure are higher among persons who live in poor areasi (4.9 per 1,000 relevant discharges), near-poor areasii (4.2 per 1,000), and medium-income areasiii (4.2 per 1,000), compared with high-income areaiv residents persons who live in (3.7 per 1,000) (Figure 10) (HCUP SID 16 state database, 2000).

In contrast, rates of complications of anesthesia are lower among non-Hispanic blacks (0.57 per 1000 relevant discharges) and Hispanics (0.53 per 1,000) compared with non-Hispanic whites (0.74 per 1,000) and residents of poor areas (0.56 per 1,000 relevant discharges) compared with residents of high-income areas (0.71 per 1,000).

Racial and ethnic minorities and the low-income have higher rates of severe infection after surgery. Minorities and the poor have higher rates of nosocomial infections. For example, rates of postoperative septicemiav are higher among non-Hispanic blacks (17.3 per 1,000 relevant discharges), Hispanics (14.9 per 1,000), and APIs (14.5 per 1,000) compared with non-Hispanic whites (10.9 per 1,000). Postoperative septicemia rates are also higher among residents of poor areas (15.3 per 1,000 relevant discharges), near-poor areas (13.0 per 1,000), compared with high-income areas (11.3 per 1,000) (Figure 11) (HCUP SID 16-State database, 2000).


i "Poor areas" are defined as having ZIP Codes with median incomes of under $25,000.
ii "Near-poor areas" are defined as having ZIP Codes with median incomes of $25,000-$34,999.
iii "Medium income areas" are defined as having ZIP Codes with median incomes of $35,000-$44,999.
iv "High-income areas" are defined as having ZIP Codes with median incomes of $45,000 and higher.
v Bacterial infection with invasion of the bloodstream and systemic illness.


Figure 10. Postoperative respiratory failure per 1,000 elective surgical discharges

(Total 16 States = 4.0)

Figure 10. Postoperative respiratory failure per 1,000 elective surgical discharges

Notes:
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: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, State Inpatient Database (16 States), 2000.

Figure 11. Postoperative septicemia per 1,000 elective surgical discharges of 4+ days

(Total, 16 States = 12.1)

Figure 11. Postoperative septicemia per 1,000 elective surgical discharges of 4+ days

Notes:
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: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, State Inpatient Database (16-State), 2000.

Differences in rates of injuries and adverse events due to technical errors tend to be less pronounced than disparities in other aspects of patient safety. However, Hispanics and residents of poor areas have lower rates of some of these measures. For example, rates of iatrogenic pneumothorax are lower among Hispanics (0.61 per 1,000) compared with non-Hispanic whites (0.75 per 1,000) and residents of poor areas (0.67 per 1,000 discharges) compared with residents of high-income areas (0.75 per 1,000) (HCUP SID 16-State database, 2000).

Blacks, Hispanics, and women who live in poor neighborhoods have lower rates of trauma associated with deliveries. Minorities and residents of lower income ZIP Codes also have lower rates of birth-related trauma. For example, rates of obstetric trauma during instrument-assisted deliveries, primarily serious lacerations, are lower among non-Hispanic blacks (193 per 1,000 instrument-assisted deliveries) and Hispanics (200 per 1,000) compared with non-Hispanic whites (235 per 1,000) and lower among residents of poor areas (183 per 1,000 instrument-assisted deliveries) and near-poor areas (207 per 1,000), compared with residents of high-income areas (238 per 1,000) (Figure 12) (HCUP SID 16 State database, 2000). It should be noted that since episiotomies increase the risk for "obstetric trauma," these procedures may account for the differential rates.138

Figure 12. Obstetric trauma per 1,000 instrument-assisted deliveries

(Total 16 States = 225)

Figure 12. Obstetric trauma per 1,000 instrument-assisted deliveries

Notes:
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: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, State Inpatient Database (16 States), 2000.

Hispanics and Asians or Pacific Islanders have lower death rates when hospitalized for less severe conditions. Differences in potentially avoidable death are noted. Death rates in low-mortality DRGsi were significantly lower among Hispanics (0.41 per 1000 relevant admissions) and APIs (0.41 per 1000) compared with non-Hispanic whites (0.48 per 1000) (Figure 13) (HCUP SID 16 State database, 2000).

Figure 13. Deaths per 1,000 admissions in low-mortality DRGs

(Total 16 States = 0.46)

Figure 13. Deaths per 1,000 admissions in low-mortality DRGs

Notes:
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: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, State Inpatient Database (16 States), 2000.

A measure of medication safety, the percentage of persons who report that their provider does not usually ask about medications and treatments other doctors may give, overlaps with the concept of patient-provider communication, which is discussed in the Access chapter. Black (86%) and Hispanic (86%) patients are more likely to report that their provider does not ask about medications and treatments other doctors may give than white (80%) compared with non-Hispanic white (79%) patients, respectively (MEPS, 1999).

In summary, racial and ethnic minorities often have higher rates of some complications, though they have lower rates on other patient safety measures.


i DRGs are Diagnosis Related Groups. Low mortality DRGs are DRGs that generally have mortality rates under 0.5%, excluding trauma, immunocompromised, and cancer patients.


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Timeliness

Key Findings:
  • Persons with lower income and less education face many barriers to receiving timely care.
  • Households headed by Hispanics were more likely than those headed by non-Hispanics to report difficulties obtaining care.
  • Many minorities are more likely to experience long wait times to see their health care provider.
  • Compared with whites, blacks also experience longer waits in emergency departments and are more likely to leave without being seen.

Health care cannot prevent death and disability if it is delivered too late. For this reason, timeliness is a critical aspect of high-quality health care. Delays in health care delivery can lead to complications that not only make recovery more difficult, but also increase health care costs. Unfortunately, patients frequently face delays when scheduling appointments, visiting their health care providers, and entering hospital emergency departments.

Two aspects of timeliness are included in this section (Tables 19 and 20):

  • Patient perceptions of inadequate access and need
  • Waiting times

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Patient Perceptions of Inadequate Access and Need

Patients' perceptions are inherently subjective and, therefore, difficult to standardize and quantify. But the unmet needs that result from insufficient access and receipt of treatment are tangible. If critical needs continue to go unmet, health care problems may worsen and the patient may ultimately enter the health care system with a much more advanced stage of illness. The NHDR focuses on measures of delayed care, the confidence a person has that he or she could obtain needed care, and ability to see clinicians when the person deems it necessary.

How the Nation is doing

Hispanic families and both families that are poor and have low education levels are more likely to report problems getting health care. In general, Hispanics and people of lower socioeconomic status are more likely to perceive unmet health care needs. For example, in the general population, about 10% of families report that they experience difficulties or delays in obtaining health care or that they do not receive needed health care for one or more family members (MEPS, 1999). Households headed by Hispanics were more likely (13%) than those headed by non-Hispanic whites (10%) to report difficulties obtaining care (Figure 14). Similarly, poor (15%), near poor (15%), and middle income (10%) persons are more likely to report difficulties obtaining care than higher income persons (6%). Families in which the head of the household has less than a high school education (13%), fare worse than those headed by college attendees (9%). Hispanics and those with low socioeconomic status are also more likely to experience difficulties or delays due to financial or insurance reasons, forego health care because the family needed the money, and have low confidence that they can get health care when they need it (MEPS, 1999).

Racial differences in perceptions of need are more complex. Households headed by blacks (8%) are less likely than those headed by whites (11%) to report that they experience difficulties or delays in obtaining health care (MEPS, 1999). In addition, Asians are more likely than whites to report difficulty scheduling appointments for routine care (MEPS, 2000).

In summary, Hispanics and people of lower socioeconomic status are more likely to report unmet health care needs, while racial differences tend to be smaller. While it is true that patient perceptions of unmet need may not correlate with actual access to needed services, these population differences provide important quality information to health care systems, especially those who care for priority populations with perceived unmet needs.

Figure 14. Percent of families that experience difficulties or delays in obtaining health care or do not receive needed health care for one or more family members

(U.S. total = 10%)

Figure 14. Percent of families that experience difficulties or delays in obtaining health care or do not receive needed health care for one or more family members

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

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Waiting Times

Why waiting times are important

Another dimension of timeliness is the amount of time a patient must wait, after entering the health care facility, before being seen by a health care provider. Long waits in a provider's office are inconvenient and lead to missed appointments and lower patient satisfaction.

In contrast, long waits in emergency departments can be fatal. Triage systems are effective at prioritizing patients by need, but long waits often prolong pain and fear. While patients seek care from emergency departments for different reasons and with varying levels of urgency, they wait an average of 45 minutes to see a physician. Those with emergent conditions (i.e., conditions that are ideally cared for in less than 15 minutes) wait an average of 24 minutes.139

How the Nation is doing

Disparities in emergency department waiting times are observed. Specifically, while differences in waits for emergent/urgent care are not noted, blacks and the uninsured are more likely than whites and the insured to report waiting over 1 hour for semi-urgent/non-urgent care and to report leaving the emergency department without being seen (NHAMCS-ED, 1999-2000).

In summary, many racial and ethnic minorities and people of lower socioeconomic position report longer waits to see health care providers. Overall, our health care system is not always respectful of patients' and providers' time. While waiting times may be related to patient health care needs and care-seeking behaviors, these population differences present important opportunities for system improvement.

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Patient Centeredness

Key Finding:
  • Blacks are more satisfied than whites that their providers listen carefully, explain things in a way they understand, show respect for what they had to say, and spend enough time with them.
  • Hispanics are less likely than non-Hispanic whites to report that their care is sufficiently patient centered.

Why patient centeredness is important

The Institute of Medicine defines patient centeredness as "health care that establishes a partnership among practitioners, patients, and their families (when appropriate) to ensure that decisions respect patients' wants, needs, and preferences and that patients have the education and support they need to make decisions and participate in their own care."140 Patient-centered care is guided by the patient's values and is personalized to ensure that provider instructions are properly understood and followed.

How the Nation is doing

NHQR Findings:

The NHQR found many areas for which patient centeredness of care could be improved. For example, the report identifies that less than half of those surveyed indicated that their provider always spent enough time with them, while 16% reported that they only sometimes or never did. The NHQR examined measures of the time spent with provider, as well as the patient's perceptions of the clinician's skill, degree to which they were treated with respect and dignity, and ability to understand the clinician's explanations. (Go to the NHQR for details.)

NHDR Findings:

Measures of patient centeredness overlap with several concepts discussed in Chapter 4 (Tables 21 and 22):

  • Patient-provider communication
  • Patient-provider relationship

Evidence of racial and ethnic differences in patient centeredness is present. For example, Hispanics are more likely than non-Hispanic whites (yet blacks are less likely than whites) to report that their providers "did not listen carefully" or "explain themselves clearly" (MEPS, 2000). Socioeconomic differences in other aspects of patient-provider communication were not observed. Further, information on patient-provider communication is provided in the Access to Care chapter.

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Equity

Equity encompasses that core need of the health care system to provide care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location and socioeconomic status. Equity is the focus of the NHDR and relates to all findings presented in this report.

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