Skip Navigation U.S. Department of Health and Human Services www.hhs.gov
Agency for Healthcare Research Quality www.ahrq.gov
Archive print banner
National Healthcare Disparities Report, 2004

This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: https://info.ahrq.gov. Let us know the nature of the problem, the Web address of what you want, and your contact information.

Please go to www.ahrq.gov for current information.

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 may be more significant than barriers that do not affect utilization patterns. Many landmark reports on disparities have relied on measures of heath care utilization26,27,28, and these data demonstrate some of the largest differences in care among diverse groups. More recent efforts to understand and inform health care delivery continue to include measures of health care utilization29,30.

Interpreting 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 fact, high use of some inpatient services may reflect impaired access to outpatient services. Hence, the summary table on health care utilization uses a different key from other summary tables of access to care. Rather than indicating better or worse access, symbols on this table simply identify the amount of care received by racial, ethnic, and socioeconomic groups relative to their comparison groups.

Each year, the Nation's 12 million health services workers provide about 820 million office visits and 590 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 people in hospice settings31. Each year, about 70% of the civilian noninstitutionalized population visit a medical provider's office or outpatient department, about 60% receive a prescription medication, and about 40% visit a dental provider32.

National health expenditures totaled $1.3 trillion in fiscal year 2002, about 13% of the gross domestic product. Governments account for 43% of the U.S. total, about 33% from the Federal Government in the form of Medicare and Medicaid payments and grants to States and about 10% from State and local governments. After almost a decade of modest growth, health care spending per capita rose 10% in 2001; premiums for private health insurance increased 12.7% in 200233. Health expenditures among the civilian noninstitutionalized population in America are extremely concentrated, with 5% of the population accounting for 55% of outlays34. 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 overuse, misuse, and waste35.

The first NHDR reported that different racial, ethnic, and SES groups had different patterns of health care utilization. Asians and Hispanics tended to have lower use of most health care services including routine care, emergency department visits, avoidable 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 emergency departments and hospitals, including higher rates of avoidable 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 emergency departments, hospitals, and home heath care. This year, findings related to select health care utilization measures are highlighted.

General Medical Care

Many Americans require office or outpatient services, dental services, and prescription medications on a regular basis as well as emergency room and inpatient hospital services at some point in their lives. Lower receipt of office or outpatient visits may indicate better health, patient preferences, or problems with access to services.

Figure 3.9. People with an office or outpatient visit in past year by race (top), ethnicity (middle), and income (bottom), 1999-2001

Figure 3.9. People with an office or outpatient visit in past year by race, 1999-2001. Select Full Text Description [D] for details.

[D] Select for Full Text Description.

Figure 3.9. People with an office or outpatient visit in past year by ethnicity, 1999-2001. Select Full Text Description [D] for details.

[D] Select for Full Text Description.

Figure 3.9. People with an office or outpatient visit in past year by income, 1999-2001. Select Full Text Description [D] for details.

[D] Select for Full Text Description.

Source: Medical Expenditure Panel Survey, 1999-2001.

Reference population: Civilian, noninstitutionalized population.

Note: For findings related to all routine and acute care measures, go to Tables 3.4a and 3.4b.

  • In all 3 years, the proportion of people who had an office or outpatient visit in the past year was lower among blacks and APIs than among whites; among Hispanics than among non-Hispanic whites; and among poor, near poor, and middle income groups than among the high income group (Figure 3.9).
  • Between 1999 and 2001, rates of office or outpatient use increased among the high income group but did not change significantly among any racial or ethnic groups.

To distinguish the effects of race, ethnicity, and income on health care utilization and to identify populations at greatest risk for barriers to health care utilization, measures are presented by income level.

Figure 3.10. People with an office or outpatient visit in past year by race (top) and ethnicity (bottom) stratified by income, 2001

Figure 3.10. People with an office or outpatient visit in past year by race stratified by income, 2001. Select Full Text Description [D] for details.

[D] Select for Full Text Description.

Figure 3.10. People with an office or outpatient visit in past year by ethnicity stratified by income, 2001. Select Full Text Description [D] for details.

[D] Select for Full Text Description.

Source: Medical Expenditure Panel Survey, 2001.

Reference population: Civilian noninstitutionalized population.

  • Income explains some but not all of the differences in health care utilization by race and ethnicity.
  • Racial and ethnic differences are observed across all income groups (Figure 3.10).

Nursing Home and Home Health Care

Nursing home and home health care includes the provision of personal, social, and medical services to people who have functional or cognitive limitations in their ability to perform self-care and other activities necessary to live independently. This NHDR reports on data from the CMS Medicare Current Beneficiary Survey to provide estimates of nursing home and Medicare-covered home health care by race, ethnicity, and SES.

Figure 3.11. Medicare beneficiaries 65 and older with Medicare-covered home health care in past year by race (top), ethnicity (middle), and income (bottom), 1998-2000

Figure 3.11. Medicare beneficiaries 65 and older with Medicare-covered home health care in past year by race, 1998-2000. Select Full Text Description [D] for details.

[D] Select for Full Text Description.

Figure 3.11. Medicare beneficiaries 65 and older with Medicare-covered home health care in past year by ethnicity, 1998-2000. Select Full Text Description [D] for details.

[D] Select for Full Text Description.

Figure 3.11. Medicare beneficiaries 65 and older with Medicare-covered home health care in past year by income, 1998-2000. Select Full Text Description [D] for details.

[D] Select for Full Text Description.

Source: Medicare Current Beneficiary Survey, 1998-2000.

Reference population: Medicare beneficiaries age 65 and over.

Note: For findings related to all chronic care measures, go to Tables 3.4a and 3.4b.

  • In all 3 years, the proportion of elderly Medicare beneficiaries who had Medicare-covered home health care in the past year was higher among black compared with white elderly and among poor and near poor compared with high income elderly; ethnic differences were not noted (Figure 3.11).
  • Between 1998 and 2000, rates of Medicare-covered home health care use declined among white, non-Hispanic white, poor, and near poor elderly.

Avoidable Admissions

Avoidable admissions are hospitalizations that potentially could have been averted by high quality outpatient care. They 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. While not all admissions for these conditions can be avoided, rates in populations tend to vary with access to outpatient services. For example, better access to care should facilitate the diagnosis of appendicitis before rupture occurs.

Racial, ethnic, and socioeconomic differences in avoidable admissions are well documented; rates are higher among blacks compared with whites and among low income compared with high income individuals36,37,38. As the numbers of avoidable hospitalizations for some conditions increased between 1980 and 1998, the gaps between these demographic groups widened39.

Avoidable hospitalizations tracked in the NHDR include hospitalizations for hypertension, angina, chronic obstructive pulmonary disease, bacterial pneumonia, and perforated appendix and come from AHRQ's Healthcare Cost and Utilization Project State Inpatient Databases disparities analysis file. This file is designed to provide national estimates using weighted records from a sample of hospitals from 22 States that have 63% of U.S. hospital discharges. These 22 States participate in HCUP and have relatively complete race and ethnicity data.

Figure 3.12. Perforated appendix per 1,000 admissions with appendicitis by race/ethnicity (top) and area income (median income of ZIP Code of residence) (bottom), 2001

Figure 3.12. Perforated appendix per 1,000 admissions with appendicitis by race/ethnicity, 2001. Select Full Text Description [D] for details.

[D] Select for Full Text Description.

Figure 3.12. Area income (median income of ZIP Code of residence), 2001. Select Full Text Description [D] for details.

[D] Select for Full Text Description.

Source: HCUP State Inpatient Databases disparities analysis file, 2001.

Reference population: Patients hospitalized with appendicitis.

Note: White, Black, and API are non-Hispanic groups. For findings related to all avoidable admissions, go to Tables 3.4a and 3.4b.

  • In 2001, rates of perforated appendix per 1,000 admissions for appendicitis were higher among blacks and Hispanics compared with non-Hispanic whites and higher among residents of ZIP Codes with median income < $25,000, $25,000 to $34,999, and $35,000 to $44,999 compared with residents of ZIP Codes with income $45,000 and over (Figure 3.12).

Mental Health Care and Substance Abuse Treatment

Over 40 million people ages 18 to 64 had a mental disorder in the past year40, and about 20 million had a serious mental disorder that substantially limited activities41. In 2003, about 16 million Americans age 12 and older were heavy alcohol drinkers and about 54 million had a recent binge drinking episode41. About 20 million people age 12 and older were illicit drug users and about 71 million reported recent use of a tobacco product41. The direct costs of mental disorders and substance abuse amounted to $99 billion in 1996; lost productivity and premature death accounted for an additional $75 billion42. Although the prevalence of mental disorders for racial and ethnic minorities in the United States is similar to that for whites42, differences in care can be observed. Compared with whites, minorities have less access to mental health care and are less likely to receive needed services43. Racial, ethnic, and socioeconomic differences in the use of psychiatric medications44 and of psychiatric outpatient45, emergency46, and inpatient services47 and substance abuse treatment41 have also been documented. These differences may reflect, in part, variation in preferences and cultural attitudes towards mental health and substance abuse.

Figure 3.13. Adults who reported they received mental health treatment or counseling in the past year by race, ethnicity, and education, 2001-2002

Figure 3.13. Adults who reported they received mental health treatment or counseling in the past year by race, ethnicity, and education, 2001-2002. Select Full Text Description [D] for details.

[D] Select for Full Text Description.

Source: SAMHSA, National Household Survey on Drug Abuse, 2001, and National Survey on Drug Use and Health, 2002.

Reference population: Civilian, noninstitutionalized population age 18 and older.

Note: For findings related to all mental health care measures, go to Tables 3.4a and 3.4b.

  • In both 2001 and 2002, the proportion of adults with mental health treatment or counseling in the past year was lower among blacks and Asians compared with whites and lower among Hispanics compared with non-Hispanic whites (Figure 3.13).
  • Between 2001 and 2002, receipt of mental health care treatment or counseling increased among white, Asian, non-Hispanic white, and Hispanic adults and adults with college education.

HIV Care

Between 850,000 and 950,000 individuals are infected with HIV in the United States, an estimated quarter of whom are unaware that they are infected48. Each year, about 40,000 people acquire HIV infection49,50. Since the use of highly active antiretroviral therapy (HAART) to treat HIV infection became widespread in 1996, new AIDS cases declined from the mid-1990's to 2001 but then leveled off in 200251. Since its emergence, more than 500,000 Americans have died from AIDS, including over 16,000 people in 200251.

AIDS incidence and death rates vary by race and ethnicity. Blacks make up about 12% of the U.S. population, but they accounted for 50% of the new AIDS cases reported in the United States in 200252. Hispanics also have higher AIDS incidence rates compared with whites and accounted for 6,998 of the 40,793 new AIDS cases reported in 200253. AIDS is the leading cause of death among black women 25 to 34 and black men 35 to 4454. Racial, ethnic, and socioeconomic differences in care for HIV and AIDS have been documented in, for example, receipt of antiretroviral therapy and therapy to prevent Pneumocystis pneumonia (PCP), a common infection among AIDS patients55,56,57.

HIV care can include outpatient and inpatient services. Because national data on HIV care are not routinely collected, HIV measures tracked in NHDR come from the HIV Research Network, which consists of 18 medical practices across the United States that treat large numbers of HIV patients. HIV patients typically require four or more ambulatory visits per year to ensure adequate monitoring of their disease with CD4 counts and viral loads58.

Figure 3.14. Adult HIV patients with four or more ambulatory visits in the past year by race/ethnicity, 2001

Figure 3.14. Adult HIV patients with four or more ambulatory visits in the past year by race/ethnicity, 2001. Select Full Text Description [D] for details.

[D] Select for Full Text Description.

Source: HIV Research Network, 2001.

Reference population: HIV patients age 18 and older receiving care from HIV Research Network providers.

Note: White, Black, API, and AI/AN are non-Hispanic groups. For findings related to all HIV care measures, go to Tables 3.4a and 3.4b.

  • In 2001, the proportion of adults with HIV with four or more ambulatory visits in the past year was lower among black and higher among Hispanic compared with non-Hispanic white HIV patients (Figure 3.14).
Table 3.1 Patient Perceptions of Care

Return to Contents

 

 

The information on this page is archived and provided for reference purposes only.

 

AHRQ Advancing Excellence in Health Care