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National Healthcare Disparities Report, 2007

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Asians

Previous NHDRs showed that Asians had similar or better quality of care than Whites but worse access to care than Whites for many measures tracked in the reports. Findings based on core report measures of quality and access to health care that support estimates for either Asians or Asians and Pacific Islanders in aggregate are shown below.

Figure 4.5. Asians compared with Whites on measures of quality and access

Stacked columns chart shows Asians compared with Whites on measures of quality and access.  Quality (30 CRM): Worse, 8; Same, 11; Better, 11. Access (7 CRM): Worse, 1; Same, 5; Better, 1.

Better = Asians receive better quality of care or have better access to care than Whites.

Same = Asians and Whites receive about the same quality of care or access to care.

Worse = Asians receive poorer quality of care or have worse access to care than Whites.

CRM = core report measures (Table 1.2).

Note: Data presented are the most recent available.

  • For 8 of the 30 core report measures of quality, Asians had significantly poorer quality of care than Whites, while for 11 measures, Asians had significantly better quality of care than Whites (Figure 4.5). The median difference over all 30 core report measures was −20%.
  • For 1 of the 7 core report measures of access, Asians had significantly worse access to care than Whites. The median difference over all 7 core report measures was 16%.

Figure 4.6. Change in Asian-White disparities over time

Stacked columns chart shows change in Asian-White disparities over time. Quality (27 CRM): Worsening greater than 5%, 4; Worsening 1-5%, 3; Same, 9; Improving 1-5%, 10; Improving greater than 5%, 1. Access (6 CRM): Worsening greater than 5%, 1; Worsening 1-5%, 0; Same, 2; Improving 1-5%, 1; Improving greater than 5%, 2.

Improving >5% = Asian-White difference becoming smaller at rate greater than 5% per year.

Improving 1-5% = Asian-White difference becoming smaller at rate between 1% and 5% per year.

Same = Asian-White difference not changing.

Worsening 1-5% = Asian-White difference becoming larger at rate between 1% and 5% per year.

Worsening >5% = Asian-White difference becoming larger at rate greater than 5% per year.

CRM = core report measures (Table 1.2).

Note: The time period for this figure is the most recent and oldest years of data used in the NHDR. Only 33 core report measures could be tracked over time for Asians and Whites.

  • Of core report measures of quality that could be tracked over time for Asians and Whites, Asian-White differences became smaller for 11 measures but larger for 7 measures (Figure 4.6). For 9 measures, Asian-White differences did not change over time.
  • Of core report measures of access that could be tracked over time for Asians and Whites, Asian-White differences became smaller for 3 measures but larger for 1 measure. For 2 measures, the Asian-White difference did not change over time.

Focus on Asian Subpopulations

The Asian population in the United States is highly heterogeneous. The term "Asian" refers to people who identify their country of origin to be located in East Asia, Southeast Asia, or the Indian subcontinent (for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam).9 Asians are approximately 4.2% of the U.S. population, or 11.9 million people. According to Census 2000 data, approximately 23% of Asians identified themselves as Chinese, 20% Filipino, 16% Asian Indian, 10% Korean, and 9.7% Japanese.9

Research has shown that within-category variation (that is, variation across Asian subpopulations) is sometimes as large as the differences between Asians and Whites.10, 11 In order to show differences within racial groups, this year's NHDR includes information from the California Health Interview Survey (CHIS) on Asian subpopulations in California. This is especially important for these relatively smaller groups, as most national data sources do not have sufficient data to report data for these groups. The geographic distribution of Asian subpopulations allows such comparisons in California using the CHIS data. About 4.2 million Asians, or 14.9% of the Asian population in the United States, live in California, which has the largest proportion of Asians of all States.9 The proportion of many Asian subpopulations residing in California is also greater than the proportion in the overall U.S. population. For example, the Vietnamese population is 1.3% of California's population compared with only 0.4% of the U.S. population, and the Filipino population is 2.7% of California's population compared with only 0.7% of the U.S. population.

Selected measures from the CHIS are presented here, including breast cancer screening, diabetes care, influenza vaccinations, uninsurance, and emergency room visits. These data show that disparities for Asians exist, not only in comparison with Whites but also within Asian subgroups (Chinese, Filipino, Japanese, Korean, Vietnamese, and South Asian) and across Asian subgroups by income and insurance status. Differences in English proficiency and place of birth are also significant. The following section shows only some of the significant disparities for these groups in California from CHIS data.

Figure 4.7. Women age 40 and over who reported they had a mammogram in the past 2 years, by race, Asian subgroup, and insurance status, California only, 2005

Bar chart shows California women age 40 and over who reported they had a mammogram in the past 2 years, by race, Asian subgroup, and insurance status. Total, 78.4%; White, 80.7%; Asian, 74.6%; Chinese, 76.4%; Filipino, 77.4%; Japanese, 80.2%; Korean, 58.1%; Vietnamese, 72.4%; South Asian, 77.6%; Asian with Private insurance, 78.8%; Asian with Public Insurance, 75.8%; Uninsured Asian, 56.7%.

Source: University of California, Los Angeles, Center for Health Policy Research, California Health Interview Survey.

Note: Public insurance includes people with Medicare and/or Medicaid coverage for this measure.

Reference population: Civilian noninstitutionalized women age 40 and over in California.

  • Overall, the proportion of women in California age 40 and over who reported they had a mammogram in the past 2 years was 78.4% (Figure 4.7).
  • The proportion was significantly lower for Asians than Whites (74.6% compared with 80.7%). Among Asian subpopulations, the proportion was lowest for Koreans (58.1%).
  • The proportion was significantly lower for uninsured compared with privately insured Asian women (56.7% compared with 78.8%).

Figure 4.8. People age 40 and over with diabetes who had hemoglobin A1c measurement, retinal exam, and foot exam within the past year, by race and level of English proficiency, California only, 2005

Bar chart shows people in California age 40 and over with diabetes who had hemoglobin A1c measurement, retinal exam, and foot exam within the past year, by race and level of English proficiency.  Total in California, 44.8%; White, 49.6%; All Asians, 45.3%; Asian Native English Speaker, 59.1%; Asian Proficient English, 52.5%; Asian Low/No English, 26.2%.

Source: University of California, Los Angeles, Center for Health Policy Research, California Health Interview Survey.

Reference population: Civilian noninstitutionalized adults age 40 and over in California with diabetes.

  • There were no significant differences between Asians and Whites in the proportion of Californians with diabetes who had all three recommended diabetes services, but there were significant differences among Asians by level of English proficiency (Figure 4.8).
  • In 2005, the proportion of Asian adults in California with low English proficiency who received all three recommended services for diabetes was less than half that of Asian native English speakers (26.2% compared with 59.1%).
  • The percentage of adults in California who received all three recommended services for diabetes overall was 44.8%.

Figure 4.9. People under age 65 uninsured all year, by race and Asian subgroup, California only, 2001, 2003, and 2005

Trend line chart shows people in California under age 65 uninsured all year, by race and Asian subgroup. California total: 2001, 12.4%; 2003, 11.9%; 2005, 11.1%. White: 2001, 6.1%; 2003, 5.9%; 2005, 5.8%. All Asians: 2001, 11.0%; 2003, 9.8%; 2005, 11.6%. Chinese: 2001, 9.9%; 2003, 10.8%; 2005, 8.9%. Filipino: 2001, 6.9%; 2003, 4.9%; 2005, 10.1%. Korean: 2001, 31.0%; 2003, 25.0%; 2005, 29.7%. Vietnamese: 2001, 13.5%; 2003, 11.8%; 2005, 11.9%. South Asian: 2001, 5.2%; 2003, 3.0%; 2005, 9.0%.

Source: University of California, Los Angeles, Center for Health Policy Research, California Health Interview Survey.

Reference population: Civilian noninstitutionalized population under age 65 in California.

  • While the overall proportion of Californians uninsured all year decreased from 2001 to 2005 (from 12.4% to 11.1%), there were no significant changes for any Asian subgroup during this period (Figure 4.9).
  • In 2005, two times as many Asian as non-Hispanic White Californians were uninsured all year (11.6% of Asians compared with 5.8% of Whites).
  • The proportion uninsured was also significantly higher for all Asian subgroups than Whites, except for South Asians. The proportion was over five times higher for Koreans than for Whites (29.7% compared with 5.8%).

Figure 4.10. Adults age 65 and over who received influenza vaccination in the past year, by race and income, California only, 2005

Bar chart shows adults age 65 and over who received influenza vaccination in the past year, by race and income, California only. Poor: Total, 64.3%; White, 57.9%; Asian, 75.7%. Near poor: Total, 62.0%; White, 60.5%; Asian, 74.7%. Middle income: Total, 65.8%; White, 67.1%; Asian, 59.9%. High income: Total, 67.7%; White, 68.5%; Asian, 70.6%.

Source: University of California, Los Angeles, Center for Health Policy Research, California Health Interview Survey.

Reference population: Civilian noninstitutionalized adults in California age 65 and over.

  • Among poor Californians, the proportion of adults age 65 and over who received a flu shot was significantly higher for Asians than Whites (75.7% compared with 57.9%).
  • Among near poor Californians, the proportion was also significantly higher for Asians than Whites (74.7% compared with 60.5%).
  • There were no significant differences among middle and high income groups (Figure 4.10).

Figure 4.11. People with emergency department visit in the past year, by race and Asian subgroup, California only, 2001 and 2005

Bar chart shows people with emergency department visit in the past year, by race and Asian subgroup, California only.  California total: 2001, 18.2%; 2005, 18.9%. White: 2001, 19.1%. 2005, 19.9%. Asian: 2001, 11.5%; 2005, 11.6%. Chinese: 2001, 10.2%; 2005, 8.9%. Filipino: 2001, 13.2%; 2005, 15.4%. Japanese: 2001, 16.7%; 2005, 16.1%. Korean: 2001, 7.8%; 2005, 6.9%. Vietnamese: 2001, 9.1%; 2005, 9.0%. South Asian: 2001, 11.9%; 2005, 12.5%.

Source: University of California, Los Angeles, Center for Health Policy Research, California Health Interview Survey.

Reference population: Civilian noninstitutionalized population in California.

  • The proportion of Californians with an emergency department visit in the past year increased overall, but there were no significant changes from 2001 to 2005 in the proportions for Asian subgroups (Figure 4.11).
  • In 2005, the proportion was lower for Asians than Whites overall (11.6% compared with 19.9%) and for all Asian subgroups. The proportion was less than half that of Whites for Koreans (6.9%) and Vietnamese (9.0%).

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American Indians and Alaska Natives

Previous NHDRs showed that American Indians and Alaska Natives had poorer quality of care and worse access to care than Whites for many measures tracked in the reports. Findings based on core report measures (Table 1.2) of quality and measures of access that support estimates for AI/ANs are shown below.

Figure 4.12. AI/ANs compared with Whites on measures of quality and access

Stacked column chart shows AI/ANs compared with Whites on measures of quality and access. Quality (20 CRM): Worse, 5; Same, 12; Better, 3. Access (5 CRM): Worse, 2; Same, 3; Better, 0.

Better = AI/ANs receive better quality of care or have better access to care than Whites.

Same = AI/ANs and Whites receive about the same quality of care or access to care.

Worse = AI/ANs receive poorer quality of care or have worse access to care than Whites.

AI/AN = American Indian or Alaska Native.

CRM = core report measures (Table 1.2).

Note: Data presented are the most recent available.

  • Only about half of the core report measures supported estimates of quality for AI/ANs.
  • For 5 of the 20 core report measures of quality, AI/ANs had significantly poorer quality of care than Whites (Figure 4.12). AI/AN-White differences ranged from AI/ANs being more than twice as likely as Whites to lack early prenatal care to AI/ANs being only about half as likely to die from breast cancer. The median difference over all 20 core report measures was 12%.
  • For 2 of the 5 core report measures of access, AI/ANs had significantly worse access to care than Whites. Differences ranged from AI/ANs under age 65 being over twice as likely as Whites to lack health insurance to AI/ANs being 25% less likely than Whites to delay receiving medical care due to financial problems. The median difference over all 5 core report measures was 30%.

Figure 4.13. Change in AI/AN-White disparities over time

Stacked column chart shows change in AI/AN-White disparities over time. Quality (17 CRM): Worsening greater than 5%, 0; Worsening 1-5%, 4; Same, 7; Improving 1-5%, 3; Improving greater than 5%, 3. Access (4 CRM): Worsening greater than 5%, 0; Worsening 1-5%, 1; Same, 1; Improving 1-5%, 0; Improving greater than 5%, 2.

Improving >5% = AI/AN-White difference becoming smaller at rate greater than 5% per year.

Improving 1-5% = AI/AN-White difference becoming smaller at rate between 1% and 5% per year.

Same = AI/AN-White difference not changing.

Worsening 1-5% = AI/AN-White difference becoming larger at rate between 1% and 5% per year.

Worsening >5% = AI/AN-White difference becoming larger at rate greater than 5% per year.

AI/AN = American Indian or Alaska Native,

CRM = core report measures (Table 1.2)

Note: The time period for this figure is the most recent and oldest years of data used in the NHDR. Only 21 core report measures could be tracked over time for AI/ANs and Whites.

  • Fewer than half of the core report measures supported estimates for changing disparities for AI/ANs.
  • Of core report measures of quality that could be tracked over time for AI/ANs and Whites, AI/AN-White differences became smaller for six measures but larger for four measures (Figure 4.13). For seven measures, AI/AN-White differences did not change over time.
  • Of core report measures of access that could be tracked over time for AI/ANs and Whites, AI/AN-White differences became smaller for two measures but larger for one measure. For one measure, the AI/AN White difference did not change over time.

Focus on Indian Health Service Facilities

Many AI/ANs who are members of a federally recognized tribe nationwide rely on the Indian Health Service (IHS) to provide access to health care in the counties on or near reservations where they may obtain services.ix, 12, 13 Due to low numbers and lack of data, information about AI/AN hospitalizations is difficult to obtain in most Federal and State hospital utilization data sources. The NHDR addresses this gap by examining utilization data from IHS and tribal direct and contract hospitals. Diabetes is one of the leading causes of morbidity and mortality among AI/AN populations, and its prevention and control are a major focus of the IHS Director's Chronic Disease Initiative as well as the IHS Health Promotion/Disease Prevention Initiative. Addressing barriers of access to health care is a large part of the overall IHS goal, which strives to ensure that comprehensive, culturally acceptable personal and public health services are available and accessible to AI/ANs.

Figure 4.14. Hospitalizations for uncontrolled diabetes per 100,000 population 18 years and over in IHS and tribal direct and contract hospitals (left) and community hospitals (right), by race/ethnicity, 2003 and 2004

Two bar charts show hospitalizations for uncontrolled diabetes per 100,000 population 18 years and over in IHS and tribal direct and contract hospitals and community hospitals, by race/ethnicity. IHS and tribal hospitals (NPIRS): 2003, 37.8; 2004, 31.4. Community hospitals (HCUP SID): 2003--Total, 22.0; White, 13.5; Black, 67.5; API, 9.4; Hispanic, 48.2; 2004--Total, 22.1; White, 12.9; Black, 70.7; API, 10.8; Hispanic, 51.0.

Source: IHS and tribal direct and contract hospitals: IHS National Patient Information Reporting System (NPIRS); 2003-2004 community hospitals: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project State Inpatient Databases (HCUP SID) disparities analysis file, 2003 and 2004.

Key: API = Asian or Pacific Islander. White, Black, and API are non-Hispanic populations.

Note: The HCUP SID disparities analysis file is designed to provide national estimates using weighted records from a sample of hospitals from 23 States that have 64% of the U.S. resident population. Years of IHS data prior to 2003 use a denominator based on the 1990 Census. This source is not comparable with estimates following those years, which are based on 2000 Bridged Census Data. Therefore, for comparing IHS with national estimates, only 2003 and 2004 data from both data sources are presented.

  • From 2003 to 2004, the proportion of hospitalizations for uncontrolled diabetes decreased for AI/ANs in IHS and tribal hospitals (from 37.8 per 100,000 to 31.4 per 100,000).
  • There were no significant changes for other racial and ethnic groups in community hospitals during this period (Figure 4.14).

ix Of potentially eligible AI/ANs, 87% sought health care in 2001 at an IHS or tribally contracted facility, according to the most recent published IHS estimates developed by the Office of Public Health Support, Division of Program Statistics.


For the more than 538,000 AI/ANs living on reservations or other trust lands where the climate is inhospitable, the roads are often impassable, and transportation is scarce, health care facilities are far from accessible.14 These conditions contribute to high rates of perforated appendix and urinary tract infection hospitalizations, two problems that are receiving particular attention by IHS. Perforated appendix and urinary tract infection hospitalization rates, which decreased from 2003 to 2004, are illustrative of the efforts underway, as well as the work that needs to continue to achieve high quality, comprehensive care that is accessible to AI/ANs.15

Figure 4.15. Hospitalizations for perforated appendix per 1,000 population 18 years and over with appendicitis in IHS and tribal direct and contract hospitals (left), and community hospitals (right), by race/ethnicity, 2003 and 2004

Two bar charts show hospitalizations for perforated appendix per 1,000 population 18 years and over with appendicitis in IHS and tribal direct and contract hospitals and community hospitals, by race/ethnicity.  IHS and tribal hospitals (NPIRS): adults--2003 384.4; 2004, 363.3. Community hospitals (HCUP SID): Total--2003, 299.6; 2004, 291.5. White--2003, 294.6; 2004, 287.8. Black--2003, 334.2; 2004, 308.7. API--2003, 269.8; 2004, 266.8. Hispanic--2003, 293.8; 2004, 291.8.

Source: IHS and tribal direct and contract hospitals: IHS National Patient Information Reporting System (NPIRS); 2003-2004 community hospitals: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project State Inpatient Databases (HCUP SID) disparities analysis file, 2003 and 2004.

Key: API = Asian or Pacific Islander. White, Black, and API are non-Hispanic populations.

Note: The HCUP SID disparities analysis file is designed to provide national estimates using weighted records from a sample of hospitals from 23 States that have 64% of the U.S. resident population. Years of IHS data prior to 2003 use a denominator based on the 1990 Census. This source is not comparable with estimates following those years, which are based on 2000 Bridged Census Data. Therefore, for comparing IHS with national estimates, only 2003 and 2004 data from both data sources are presented.

  • From 2003 to 2004, the proportion of appendicitis hospitalizations with perforated appendix decreased for AI/ANs in IHS and tribal hospitals (from 384.4 per 1,000 to 363.3 per 1,000; Figure 4.15).
  • The proportion in community hospitals during this period also decreased overall (from 299.6 per 1,000 to 291.5 per 1,000), for Whites (from 294.6 per 1,000 to 287.8 per 1,000), and for Blacks (from 334.2 per 1,000 to 308.7 per 1,000).

Figure 4.16. Hospitalizations for urinary tract infection per 100,000 population 18 years and over in IHS and tribal direct and contract hospitals (left) and community hospitals (right), by race/ethnicity, 2003 and 2004

Two bar charts show hospitalizations for urinary tract infection per 100,000 population 18 years and over in IHS and tribal direct and contract hospitals  and community hospitals, by race/ethnicity. IHS and tribal hospitals (NPIRS): adults--2003, 212.1; 2004, 205.2. Community hospitals (HCUP SID): Total--2003, 165.3; 2004, 175.7. White--2003, 150.4; 2004, 159.5. Black--2003, 235.9; 2004, 255.6. API--2003, 115.7; 2004, 127.3. Hispanic--2003, 255.0; 2004, 262.6.

Source: IHS and tribal direct and contract hospitals: IHS National Patient Information Reporting System (NPIRS), 2003-2004; community hospitals: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project State Inpatient Databases (HCUP SID) disparities analysis file, 2003 and 2004.

Key: API = Asian or Pacific Islander. White, Black, and API are non-Hispanic populations.

Note: The HCUP SID disparities analysis file is designed to provide national estimates using weighted records from a sample of hospitals from 23 States that have 64% of the U.S. resident population. Years of IHS data prior to 2003 use a denominator based on the 1990 Census. This source is not comparable with estimates following that year, which are based on 2000 Bridged Census Data. Therefore, for comparing IHS with national estimates, only 2003 and 2004 data from both data sources are presented.

  • From 2003 to 2004, the proportion of hospitalizations for urinary tract infection for AI/AN adults in IHS hospitals decreased from 212.1 per 100,000 to 205.2 per 100,000 (Figure 4.16).
  • In comparison, from 2003 to 2004, hospitalizations for urinary tract infection in community hospitals increased overall (from 165.3 per 100,000 to 175.7 per 100,000) and for Whites (from 150.4 per 100,000 to 159.5 per 100,000).
Chapter 4 (continued): Hispanics or Latinos Chapter 4. Priority Populations

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