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National Healthcare Disparities Report, 2007

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Patient Safety

Type of statistic Number
Number of Americans who die each year from medical errors (1999 est.) 44,000-98,00067
Number of Americans who die in the hospital each year due to 18 types of medical injuries (2000 est.) at least 32,00068
Rate of adverse drug reactions during hospital admissions 2.0%-6.7%69, 70, 71, 72
Rate of adverse drug events among Medicare beneficiaries in ambulatory settings 50 per 1,000 person-years
Percentage of serious, life-threatening, or fatal events deemed preventable 40%
Cost (in lost income, disability, and health care costs) attributable to medical errors (1999 est.) $17 billion-$29 billion67
Groups with higher rates of some adverse safety events racial minorities73,74

Note: Statistics may vary from previous years due to revised and updated source statistics or addition of new data sources.

Although patient safety is one of the six Institute of Medicine aims for the health care system, the landmark report on patient safety, To Err Is Human, does not mention race or ethnicity when discussing the problem of patient safety.2 A recent review of the literature found only 9 of 323 articles on pediatric patient safety (3.1%) included race or ethnicity in the analysis. Five of the nine studies used data from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project.75 This section highlights six measures of patient safety in three areas:

  • Postoperative complications.
  • Other complications of hospital care.
  • Complications of medications.

For findings related to all core measures of patient safety, go to Table 2.2a.

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Postoperative Complications

Adverse health events can occur during episodes of care, especially during and right after surgery. Although some of the events may be related to a patient's underlying condition, many of them can be avoided if adequate care is provided.

Postoperative care composite. Patients are vulnerable to experiencing a variety of complications soon after they undergo surgery. Complications may include, but are not limited to, pneumonia, urinary tract infection, and blood clots.

Figure 2.31. Medicare surgical patients with postoperative care complications, by race, 2003-2005

Bar chart shows Medicare surgical patients with postoperative care complications, by race: 2003--Total, 6.7%; White, 6.4%; Black, 10.4%. 2004--Total, 6.3%; White, 5.9%; Black, 9.0%; 2005. Total, 6.6%. White, 4.5%. Black, 7.5%.

Source: Centers for Medicare & Medicaid Services, Medicare Patient Safety Monitoring System, 2003-2005.

Denominator: Hospitalized Medicare patients having surgery, all ages.

Note: Postoperative care complications included in this composite are postoperative pneumonia, urinary tract infection, and venous thromboembolic event (blood clot). Note that this composite measure changed from 2004 to 2005, with the alteration of the complications of urinary tract infections being changed to catheter-associated urinary tract infections. Sensitivity analysis carried out on the composite shows that this change does not significantly alter the composite estimate. Data were unavailable for Asians, Native Hawaiians or Other Pacific Islanders, and American Indians and Alaska Natives.

  • From 2003 to 2005, the gap between Blacks and Whites decreased (Figure 2.31). However, in 2005, Black surgical patients continued to have significantly higher rates than White patients for postoperative complications (7.51% compared with 4.48%).

Postoperative wound infections. Infections acquired during hospital stays (nosocomial infections) are among the most serious safety concerns. A common hospital-acquired infection is a wound infection following surgery. Hospitals can reduce the risk of wound infection after surgery by making sure patients get the right antibiotics at the right time on the day of their surgery. However, taking these antibiotics for more than 24 hours after routine surgery is usually not necessary and can increase the risk of side effects such as stomach aches, serious types of diarrhea, and antibiotic resistance. Among adult Medicare patients having surgery, the NHDR tracks a composite of two measures: receipt of antibiotics within 1 hour prior to surgical incision and discontinuation of antibiotics within 24 hours after end of surgery.

Figure 2.32. Appropriate timing of antibiotics received by adult surgical Medicare patients, by race/ethnicity, 2005

Bar chart shows appropriate timing of antibiotics received by adult surgical Medicare patients, by race/ethnicity. Total, 75.2; White, 75.2; Black, 75.2; Asian, 70.8; AI/AN, 77.5; Hispanic, 69.8.

Key: AI/AN=American Indian or Alaska Native.

Source: Centers for Medicare & Medicaid Services, Medicare Quality Improvement Organization Program, 2005.

Denominator: Medicare patients age 18 and over having surgery.

Note: Whites, Blacks, Asians, and AI/ANs are non-Hispanic groups. Data were insufficient for this analysis for Native Hawaiians or Other Pacific Islanders.

  • The proportion of appropriately timed antibiotics provided to Medicare surgery patients was significantly lower for Hispanics (69.8%) and Asians (70.8%) than for Whites (75.2%; Figure 2.32). The proportion was higher for AI/ANs than Whites (77.5% compared with 75.2%). Other differences were not statistically significant.

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Other Complications of Hospital Care

Types of care delivered in hospitals in addition to surgery can place patients at risk for injury or death.

Adverse events associated with central venous catheters. Patients who require a central venous catheter to be inserted into the great vessels of their heart tend to be severely ill. However, the procedure itself can result in a number of infectious and non-infectious complications.

Figure 2.33. Central venous catheter complications among Medicare patients, by race, 2004-2005

Bar chart shows central venous catheter complications among Medicare patients, by race. 2004--Total, 3; White, 2.8; Black, 3.8. 2005--Total, 4.1; White, 3.8; Black, 5.8.

Source: Centers for Medicare & Medicaid Services, Medicare Patient Safety Monitoring System, 2004-2005.

Denominator: Hospitalized Medicare patients with central venous catheter placement, all ages.

Note: Central venous catheter complications included in this composite are bloodstream infection and mechanical adverse events. Sensitivity analysis carried out on the composite shows that this change does not significantly alter the composite estimate. Data were not available for Asians, Native Hawaiians or Other Pacific Islanders, and American Indians and Alaska Natives.

  • No significant racial disparities in rates of central venous catheter complications among Medicare patients were observed (Figure 2.33).
  • From 2004 to 2005, the rate of central venous catheter complications increased significantly overall (from 3.0% to 4.1%). This increase in the composite measure was due to the significant increase in mechanical adverse events, since the rate of bloodstream infections associated with central venous catheters did not change significantly between 2004 and 2005 (data not shown).

Deaths following complications of care. Many complications that arise during hospital stays cannot be prevented. However, rapid identification and aggressive treatment of complications may prevent these complications from leading to death. This indicator, also called "failure to rescue," tracks deaths among patients whose hospitalizations are complicated by pneumonia, thromboembolic event, sepsis, acute renal failure, shock, cardiac arrest, and gastrointestinal bleeding or acute ulcer.

Figure 2.34. Deaths per 1,000 patients ages 18-74 following complications of care, by race/ethnicity, 2001-2004

Trend line graph shows deaths per 1,000 patients ages 18-74 following complications of care, by race/ethnicity. Total: 2001, 140.0; 2002, 134.6; 2004, 122.6. White: 2001, 137.3; 2002, 133.0; 2004, 122.3. Black: 2001, 142.3; 2002, 133.6; 2004, 116.8. API: 2001, 163.3; 2002, 146.5; 2004, 140.3. Hispanic: 2001, 145.4; 2002, 141.3; 2004, 130.4.

Key: API=Asian or Pacific Islander.

Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project (HCUP), State Inpatient Databases (SID) disparities analysis file, 2001-2004.

Denominator: Patients ages 18-74 from U.S. community hospitals whose hospitalization is complicated by pneumonia, thromboembolic event, sepsis, acute renal failure, shock, cardiac arrest, or gastrointestinal bleeding or acute ulcer. 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.

Note: Data were not available for American Indians and Alaska Natives. Data for 2003 were not available.

  • From 2001 to 2004, there was significant improvement overall in the rates of in-hospital deaths following complications of care (from 140 per 1,000 in 2001 to 122.6 per 1,000 in 2004; Figure 2.34).
  • During this period, the gap between Blacks and non-Hispanic Whites in the rates of in-hospital deaths following complications of care remained the same. In 2004, the rate was significantly lower for Blacks than for non-Hispanic Whites (116.8 per 1,000 compared with 122.3 per 1,000).
  • The gap between Hispanics and non-Hispanic Whites remained the same. In 2004, there was no significant difference for Hispanics compared with non-Hispanic Whites.

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Complications of Medications

Complications of medications are common safety problems. Some adverse drug events may be related to misuse of medication but others are not. However, prescribing medications that are inappropriate for a specific population may increase the risk of adverse drug events.

Adverse drug events in the hospital. Some medications used in hospitals can cause serious complications. The Medicare Patient Safety Monitoring System tracks a number of "high risk" drugs and the adverse events associated with them. Adverse drug events can include serious bleeding associated with intravenous heparin, low molecular weight heparin, or warfarin and hypoglycemia associated with insulin or oral hypoglycemics.

Figure 2.35. Medication-related adverse drug events among Medicare inpatients, by race, 2005

Bar chart shows medication-related adverse drug events among Medicare inpatients, by race.  Intravenous heparin--Total, 13.0%; White, 13.0%; Black, 10.7%. Low molecular weight heparin--Total, 7.0%; White, 6.8%; Black, 6.5%. Warfarin--Total, 6.9%; White, 6.9%; Black, 6.6%. Insulin/hypoglycemics--Total, 11.3%; White, 10.7%; Black, 15.5%.

Source: Centers for Medicare & Medicaid Services, Medicare Patient Safety Monitoring System, 2005.

Denominator: Random sample of Medicare medical records of patients receiving the drug, all ages.

  • In 2005, between 7% and 13% of Medicare patients experienced an adverse drug event in the hospital, depending on the type of drug (Figure 2.35).
  • The percent of patients taking low molecular weight heparin who experienced an adverse drug event improved significantly for all groups between 2004 and 2005. No other improvements, however, were achieved between 2004 and 2005. (Data not shown.)
  • In 2005, as in 2004, hospitalized Black Medicare beneficiaries were significantly more likely to have adverse drug events associated with insulin or oral hypoglycemics than White Medicare beneficiaries.

Inappropriate medication use among the elderly. Some drugs that are appropriate for some patients are considered potentially harmful for elderly patients but nevertheless are prescribed to them.xix, 76 Inappropriate medication use by the elderly includes drugs that should often be avoided for elderly patients.

Figure 2.36. Inappropriate medication use by the elderly, by race, 2000-2004

Trend line chart shows inappropriate medication use by the elderly, by race. Total: 2000, 19.1%; 2001, 18.9%; 2002, 18.4%; 2003, 18.7%; 2004, 16.6%. White: 2000, 18.9%; 2001, 15.7%; 2002, 18.1%; 2003, 17.4%; 2004, 16.8%. Black: 2000, 19.3%; 2001, 19.2%; 2002, 18.7%; 2003, 18.6%; 2004, 16.6%.

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2000-2004.

Reference population: Civilian noninstitutionalized population age 65 and over.

Note: Data were insufficient for this analysis for Asians, Native Hawaiians and Other Pacific Islanders, and American Indians and Alaska Natives.

  • From 2000 to 2004, there was significant improvement in the rate for Whites (from 19.3% to 16.8%) while the rate for Blacks did not change significantly. In 2004, there were no significant differences between Blacks and Whites for inappropriate medication use by the elderly (Figure 2.36).

xix Drugs that should always be avoided for elderly patients include barbiturates, flurazepam, meprobamate, chlorpropamide, meperidine, pentazocine, trimethobenzamide, belladonna alkaloids, dicyclomine, hyoscyamine, and propantheline. Drugs that should often be avoided for elderly patients include carisoprodol, chlorzoxazone, cyclobenzaprine, metaxalone, methocarbamol, amitriptyline, chlordiazepoxide, diazepam, doxepin, indomethacin, dipyridamole, ticlopidine, methyldopa, reserpine, disopyramide, oxybutynin, chlorpheniramine, cyproheptadine, diphenhydramine, hydroxyzine, promethazine, and propoxyphene.


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Timeliness

Timeliness is the health care system's capacity to provide care quickly after a need is recognized. For patients, lack of timeliness can result in emotional distress, physical harm, and financial consequences.77,78 For example, stroke patients' mortality and long-term disability are largely influenced by the timeliness of therapy79, 80 Timely delivery of appropriate care can also help reduce mortality and morbidity for chronic conditions such as chronic kidney disease,81 and timely antibiotic treatments are associated with improved clinical outcomes.82 Timely delivery of childhood immunizations helps maximize protection from vaccine-preventable diseases while minimizing risks to the child and reducing the chance of disease outbreaks.83

Early care for comorbid conditions has been shown to reduce hospitalization rates and costs for Medicare beneficiaries.84 Some research suggests that, over the course of 30 years, the costs of treating diabetic complications can approach $50,000 per patient.85 Early care for complications in patients with diabetes can reduce overall costs of the disease.86 Timely outpatient care can reduce admissions for pediatric asthma, which account for $1.25 billion in total hospitalization charges annually.87 The measure of timeliness highlighted in this section is getting care for illness or injury as soon as wanted. (For findings related to all core measures of timeliness, go to Tables 2.3a and 2.3b.)

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Getting Care for Illness or Injury As Soon As Wanted

The ability of patients to receive illness and injury care in a timely fashion is a key element in a patient centered health care system.

Figure 2.37. Adults age 18 and over who reported sometimes or never getting care for illness or injury as soon as wanted in the past year, by race, ethnicity, and income, 2002-2004

Trend line graphs show adults age 18 and over who reported sometimes or never getting care for illness or injury as soon as wanted 2in the past year. By Race: Total: 2002, 15.3%; 2003, 14.3%; 2004, 14.2%. White: 2002, 14.5%; 2003, 13.4%; 2004, 13.1%. Black: 2002, 19.0%; 2003, 18.4%; 2004, 17.2%. Asian: 2002, 22.7%; 2003, 26.3%; 2004, 26.7%. By Ethnicity: Non-Hispanic White: 2002, 12.9%; 2003, 12.4%; 2004, 12.1%. Hispanic: 2002, 25.8%; 2003, 20.6%; 2004, 19.6%.

Trend line graphs show adults age 18 and over who reported sometimes or never getting care for illness or injury as soon as wanted in the past year. By Income: Poor: 2002, 22.8%; 2003, 25.8%; 2004, 25.0%. Near Poor: 2002, 20.3%; 2003, 17.5%; 2004, 15.6%. Middle Income: 2002, 15.9%; 2003, 13.3%; 2004, 13.5%. High Income: 2002, 9.9%; 2003, 9.7%; 2004, 10.3%.

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2004.

Reference population: Civilian noninstitutionalized population age 18 and over.

Note: Data were insufficient for this analysis for American Indians and Alaska Natives

  • From 2002 to 2004, the gap between Asians and Whites in the proportion of adults who reported sometimes or never getting care for illness or injury as soon as wanted remained the same (Figure 2.37). In 2004, the proportion was about two times higher for Asians than for Whites (26.7% compared with 13.1%).
  • The gap between Hispanics and non-Hispanic Whites in the proportion of adults who reported delayed care decreased. However, Hispanics remained more likely than non-Hispanic Whites to report sometimes or never getting care for illness or injury as soon as wanted (19.6% compared with 12.1% in 2004).
  • The gap between poor and high income people remained the same on this measure. In 2004, poor adults were more than twice as likely as high income adults to report sometimes or never getting care for illness or injury as soon as wanted (25.0% compared with 10.3%).

Racial and ethnic minorities are disproportionately of lower socioeconomic status. To distinguish the effects of race, ethnicity, income, and education on timeliness of primary care, this measure is stratified by income and education level.

Figure 2.38. Adults who reported sometimes or never getting care for illness or injury as soon as wanted in the past year, by race (left) and ethnicity (right), stratified by income, 2004

Bar charts show adults who reported sometimes or never getting care for illness or injury as soon as wanted in the past year, by race and ethnicity, stratified by income. Poor: White, 23.9%; Black, 26.5%. Near Poor: White, 14.6%; Black, 16.1%. Middle Income: White, 12.2%; Black, 14.8%. High Income: White, 9.9%; Black, 11.3%. Poor: Non-Hispanic White, 23.2%; Hispanic, 27.1%. Near Poor: Non-Hispanic White, 12.9%; Hispanic, 20.0%. Middle Income: Non-Hispanic White, 11.8%; Hispanic, 15.2%. High Income: Non-Hispanic White, 9.4%; Hispanic, 17.9%.

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2004.

Reference population: Civilian noninstitutionalized population age 18 and over.

Note: Data were insufficient for this analysis for Asians, Native Hawaiians or Other Pacific Islanders, and American Indians and Alaska Natives.

Figure 2.39. Adults who reported sometimes or never getting care for illness or injury as soon as wanted in the past year, by race (left) and ethnicity (right), stratified by education, 2004

Bar charts show adults who reported sometimes or never getting care for illness or injury as soon as wanted in the past year, by race and ethnicity, stratified by education. Less than High School: White, 19.0%; Black, 17.9%. High School Grad: White, 12.6%; Black, 21.2%. Some College: White, 10.9%; Black, 13.6%. Less than High School: Non-Hispanic White, 18.2%; Hispanic, 20.5%. High School Grad: Non-Hispanic White, 12.1%; Hispanic, 17.6%. Some College: Non-Hispanic White, 10.1%; Hispanic, 20.6%.

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2004.

Reference population: Civilian noninstitutionalized population age 18 and over.

Note: Data were insufficient for this analysis for Asians, Native Hawaiians or Other Pacific Islanders, and American Indians and Alaska Natives.

  • Socioeconomic status explains some but not all of the ethnic differences in timeliness of primary care (Figures 2.38 and 2.39).
  • After stratification by income, high income Hispanics were still significantly more likely than high income non-Hispanic Whites to report problems getting care for illness or injury as soon as they wanted (17.9% compared with 9.4%).
  • After stratification by education, Blacks with a high school education were still significantly more likely than Whites of the same education level to report problems getting care for illness or injury as soon as they wanted (21.2% compared with 12.6%).
  • After stratification by education, among people with some college, Hispanics were twice as likely as non-Hispanic Whites to report problems getting care for illness or injury as soon as they wanted (20.6% compared with 10.1%).

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Patient Centeredness

The Institute of Medicine identifies patient centeredness as a core component of quality health care.2 Patient centeredness is defined as: "[H]ealth 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."88 Patient centeredness "encompasses qualities of compassion, empathy, and responsiveness to the needs, values, and expressed preferences of the individual patient."89

Patient centered care is supported by good patient-provider communication so that patients' needs and wants are understood and addressed, and patients understand and participate in their own care.88, 90, 91, 92 This style of care has been shown to improve patients' health and health care.90, 91, 93, 94, 95 Unfortunately, there are barriers to good communication: about a third of Americans are suboptimally "health literate,"96, 97 which means they lack the "capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions."98 They receive less preventive care99 and have poorer understanding of their conditions and care,96, 100, 101 higher use of emergency and inpatient services, higher rates of rehospitalization,102, 103 lower adherence to medications,102 and lower participation in medical decision-making.104 Low health literacy costs an estimated $29 billion to $69 billion per year.105 Providers also differ in communication proficiency, including varied listening skills and views of symptoms and treatment effectiveness compared with their patients' views.106

Patient centeredness has been shown to reduce both underuse and overuse of medical services107 and can reduce strains on system resources or save money by reducing the number of diagnostic tests and referrals.93 Additional factors influencing patient centeredness and patient-provider communication include language barriers, racial/ethnic concordance between the patient and provider, effects of disabilities on patients' health care experiences, and providers' cultural competency. Efforts to improve these possible impediments to patient centeredness are underway. For example, the Office of Minority Health, part of the Department of Health and Human Services, has developed a set of Cultural Competency Curriculum Modules that aim to equip providers with cultural and linguistic competencies to help eliminate disparities.xx, 108 These are based on the National Standards on Culturally and Linguistically Appropriate Services (CLAS), which are directed at health care organizations with the aim to improve the patient centeredness of care for people with limited English proficiency.

The NHDR includes one core measure of patient centeredness—a composite measure on the patient experience of care—and two new supplemental measures. Because having a diverse workforce of health care providers may be an important component of patient centered health care for many patients, this year's report includes a new supplemental measure of workforce diversity—race/ethnicity of the Nation's registered nurse (RN) workforce. A supplemental measure focusing on health literacy of U.S. adults is also presented. (For findings related to all core measures of patient centeredness, go to Tables 2.3a and 2.3b.)


xx This online program (available at www.thinkculturalhealth.org) is accredited for 9 Continuing Medical Education credits for physicians and 10.8 and 0.9 Continuing Education Units for nurses and pharmacists, respectively.


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Patient Experience of Care

Using methods developed for the CAHPS® (Consumer Assessment of Healthcare Providers and Systems) survey,109 the NHDR uses a composite measure that combines four measures of patient-provider communication into a single core measure—providers who sometimes or never listen carefully, explain things clearly, respect what patients say, and spend enough time with patients.

Figure 2.40. Composite: Adult ambulatory patients who reported poor communication with health providers,* by race (top left), ethnicity (top right), and income (bottom left), 2002-2004

Trend line graphs show a composite of adult ambulatory patients who reported poor communication with health providers. By Race: Total: 2002, 10.8%; 2003, 9.8%; 2004, 9.6%. White: 2002, 10.4%; 2003, 9.4%; 2004, 9.0%. Black: 2002, 11.4%; 2003, 11.3%; 2004, 11.3%. Asian: 2002, 14.5%; 2003, 13.5%; 2004, 14.3%. More than 1 Race: 2002, 13.8%; 2003, 15.2%; 2004, 14.4%. By Ethnicity: Non-Hispanic White: 2002, 9.9%; 2003, 8.9%; 2004, 8.7%. Hispanic: 2002, 15.6%; 2003, 13.6%; 2004, 12.2%. By Income: Poor: 2002, 15.8%; 2003, 15.2%; 2004, 15.8%. Near Poor: 2002, 12.5%; 2003, 11.9%; 2004, 11.0%. Middle Income: 2002, 11.2%; 2003, 10.1%; 2004, 9.8%. High Income: 2002, 8.9%; 2003, 7.8%; 2004, 7.6%.

* Average percent of adults age 18 and over who had a doctor's office or clinic visit in the last 12 months and reported poor communication with health providers (i.e., that their health providers sometimes or never listened carefully, explained things clearly, showed respect for what they had to say, and spent enough time with them).

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2004.

Denominator: Civilian noninstitutionalized population age 18 and over.

Note: Data were insufficient for this analysis for Native Hawaiians or Other Pacific Islanders and American Indians and Alaska Natives.

  • From 2002 to 2004, the gap between Blacks and Whites and between Asians and Whites on this measure did not change. In 2004, Blacks and Asians were more likely than Whites to report they had poor communication with their health providers (11.3% for Blacks and 14.3% for Asians compared with 9% for Whites; Figure 2.40).
  • The gap between Hispanics and non-Hispanic Whites in the proportion of adults who reported poor communication with their health providers decreased from 2002 to 2004. However in 2004, the proportion was higher for Hispanics than for non-Hispanic Whites (12.2% compared with 8.7%).
  • The gap between poor and high income people increased. In 2004, the proportion of adults who reported poor communication was higher for poor people than for high income people (15.8% compared with 7.6%).

Racial and ethnic minorities are disproportionately of lower socioeconomic status. To distinguish the effects of race, ethnicity, income, and education on patient-provider communication, this measure is stratified by income and education level.

Figure 2.41. Composite: Adult ambulatory patients who reported poor communication with health providers,* by race (left) and ethnicity (right), stratified by income, 2004

Trend line graphs show composite for adult ambulatory patients who reported poor communication with health providers, stratified by income. By Race: Poor: White, 14.9; Black, 16.5; Asian, no data. Near Poor: White, 10.4; Black, 12; Asian, no data. Middle Income: White, 9.6; Black, 9.8; Asian, 13.9. High Income: White, 7.2; Black, 8.5; Asian, 13.5. By Ethnicity: Poor: Non-Hispanic White, 14.8; Hispanic, 15.4. Near Poor: Non-Hispanic White, 10.1; Hispanic, 12.1. Middle Income: Non-Hispanic White, 9.3; Hispanic, 11.9. High Income: Non-Hispanic White, 7.1; Hispanic, 10.5.

* Average percent of adults age 18 and over who had a doctor's office or clinic visit in the last 12 months and reported poor communication with health providers (i.e., that their health providers sometimes or never listened carefully, explained things clearly, showed respect for what they had to say, and spent enough time with them).

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2004.

Denominator: Civilian noninstitutionalized population age 18 and over.

Note: Sample sizes were too small to provide estimates for poor and near poor Asians. The seemingly large difference between middle income Asians and Whites is not statistically significant due to small sample sizes.

Figure 2.42. Composite: Adult ambulatory patients who reported poor communication with health providers,* by race (left) and ethnicity (right), stratified by education, 2004

Bar charts show composite for adult ambulatory patients who reported poor communication with health providers, stratified by education. Less than High School: White, 12.1; Black, 14.3; Asian, no data. High School Grad: White, 9.2; Black, 12.7; Asian, 15.7. Some College: White, 8; Black, 8.6; Asian, 13.6.  Less than High School: Non-Hispanic White; 11.8, Hispanic, 13.4.  High School Grad: Non-Hispanic White, 9.2; Hispanic, 9.4. Some College: Non-Hispanic White; 7.7, Hispanic, 13.

* Average percent of adults age 18 and over who had a doctor's office or clinic visit in the last 12 months and reported poor communication with health providers (i.e., that their health providers sometimes or never listened carefully, explained things clearly, showed respect for what they had to say, and spent enough time with them).

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2004.

Denominator: Civilian noninstitutionalized population age 18 and over.

Note: Sample sizes were too small to provide estimates for Asians with less than a high school education and Asian high school graduates.

  • Socioeconomic status explains some but not all of the racial and ethnic differences in patient-provider communication (Figures 2.41 and 2.42).
  • In 2004, high income Hispanics were more likely to report they sometimes or never received patient centered care than high income non-Hispanic Whites (10.5% compared with 7.1%).
  • In 2004, among high school graduates, Blacks were more likely than Whites to report having had poor communication with their health providers (12.7% compared with 9.2%).
  • Among people with some college, Asians were more likely than Whites to report having had poor communication with their health providers (13.6% compared with 8.0%).
  • In 2004, college-educated Hispanics were significantly more likely than college-educated non-Hispanic Whites to report having had poor communication with their health providers (13.0% compared with 7.7%).

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Diversity of the Registered Nurse Workforce

In 2000, over 30% of Americans identified themselves as racial or ethnic minorities, and it is estimated that half of Americans will be minorities by 2050.110 Minority providers are more likely than their White colleagues to practice in underserved minority communities.111, 112 Health care workforce diversity is considered to be important for health care research, education, administration, and policy both to provide role models and to shape a health care system that meets the needs of all individuals. Diversity not only increases the opportunities for race- and language-concordant health care visits but also has the potential to improve cultural competency at the system, organizational, and provider levels through appropriate program design and policies, organizational commitment to culturally competent care, and cross-cultural education of colleagues.113 As such, it is an important element of a patient centered health care encounter.

Last year the NHDR presented data on physician diversity. This year the NHDR presents data on the diversity of the RN population from the National Sample Survey of Registered Nurses by comparing the percent of registered nurses with the general population in the United States. Next year the NHDR will focus on diversity in the practical nurse workforce.

The United States experienced the slowest growth in the nurse population between 1996 and 2000.114 The adequacy of nurse supply varies geographically throughout the Nation, with a general consensus that at the national level currently a moderate shortage of RNs exists.115 According to the National Center for Health Workforce Analysis (NCHWA) in the Bureau of Health Professions (BHPr), Health Resources and Services Administration (HRSA), the growth and aging of the population, along with the Nation's continued demand for the highest quality of care, will create a surging demand for the services of RNs over the coming two decades. At the same time, because many RNs are approaching retirement age and the nursing profession faces difficulties attracting new entrants and retaining the existing workforce, the RN supply remains flat.115 There is also growing concern about the lack of diversity in the nursing workforce.116

Figure 2.43. Race/ethnicity of U.S. registered nurses versus the U.S. population, 2004xxi

Bar chart shows race/ethnicity of U.S. registered nurses versus the U.S. population. White: Registered Nurses, 81.8; U.S. population, 67.4. Hispanic or Latino: Registered Nurses, 1.7; U.S. population, 14.1. Black: Registered Nurses, 4.2; U.S. population, 12.2. Asian or NHOPI: Registered Nurses, 3.1. U.S. population, 4.2. AI/AN: Registered Nurses, 0.3; U.S. population, 0.8. More than 1 Race: Registered Nurses, 1.4; U.S. population, 1.3.

Key: NHOPI = Native Hawaiian or Other Pacific Islander; AI/AN=American Indian or Alaska Native.

Source: National Sample Survey of Registered Nurses, 2004.

Note: All racial groups are non-Hispanic. Asian and NHOPI are combined because this is how the National Sample Survey of Registered Nurses presents the data.

  • In 2004, 81.8% of registered nurses in the United States were White (Figure 2.43).
  • Relative to the U.S. population, Hispanic, Black, Asian, and AI/AN individuals were underrepresented in the RN workforce while Whites were overrepresented.

xxi The National Sample Survey of Registered Nurses reports racial/ethnic data for respondents with both racial and ethnic data (in accordance with Office of Management and Budget recommendations). For 7.5% of respondents, race and ethnicity are not both known. Therefore, these individuals are not included in the data presented.


Figure 2.44. Registered nurses per 100,000 population, by race/ethnicity, 2004

Bar chart shows race/ethnicity of registered nurses per 100,000 population. White, 1238; Hispanic, 119,; Black, 359; Asian, 706; NHOPI, 1534; AI/AN, 510; More than 1 Race, 1095.

Key: AI/AN = American Indian or Alaska Native; NHOPI = Native Hawaiian or Other Pacific Islander.

Source: National Sample Survey of Registered Nurses, 2004, for the registered nurse population by race/ethnicity; American Community Survey from the U.S. Census Bureau for the U.S. population by race/ethnicity.

Note: Hispanics include all races. Racial groups are non-Hispanic. These data are for all registered nurses, not all of whom are employed in nursing.

  • In 2004, there were 1,534 NHOPI registered nurses per 100,000 NHOPIs and 1,238 White RNs per 100,000 Whites (Figure 2.44). Hispanics had the fewest RNs per 100,000 population (119 RNs per 100,000 Hispanic population), followed by Blacks (359 RNs per 100,000 Black population).

Figure 2.45. Registered nurses, by race/ethnicity, 1980-2004

Line graph shows race/ethnicity of registered nurses from 1980 to 2004. Non-Hispanic Whites: 1980, 1,521,752; 1984, 1,705,393; 1988, 1,864,157; 1992, 2,018,456; 1996, 2,294,092; 2000, 2,333,896; 2004, 2,380,529. Racial/ethnic minorities: 1980, 119,512; 1984, 155,390; 1988, 154,859; 1992, 206,834; 1996, 246,365; 2000, 333,368; 2004, 311,177.

Source: National Sample Survey of Registered Nurses, 2004.

Note: Prior to 2000, race and ethnicity were asked in a single question. Racial/ethnic minorities include all races other than White and all Hispanics, regardless of race.

  • From 1980 to 2004, the number of racial/ethnic minority RNs increased threefold, from 119,512 to 311,177. The number of non-Hispanic White RNs increased by 56% during the same period, from 1,521,752 to 2,380,529 (Figure 2.45).
  • The rate of increase of racial/ethnic minority RNs was uneven, with some 4-year periods exceeding 30% (1980-1984; 1988-1992; 1996-2000) and other periods registering a slight decrease (1984-1988, 2000-2004).
  • Despite high rates of increase in the number of racial/ethnic minority RNs, the percentage of racial/ethnic minority RNs in the total RN workforce rose only from 7.3% in 1980, to 11.6% in 2004.
Chapter 2 (continued): Focus on Health Literacy Chapter 2 (continued): Effectiveness: Mental Health and Substance Abuse

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