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2006 National Healthcare Quality Report

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Chapter 2. Effectiveness

As noted in Chapter 1, effectiveness of care is presented under nine clinical condition/care setting areas: cancer; diabetes; end stage renal disease (ESRD); heart disease; HIV and AIDS; maternal and child health; mental health and substance abuse; respiratory diseases; and nursing home, home health, and hospice care. The nine individual sections of this chapter highlight a small number of core measures; results for all core measures are found in the List of Core Report Measures at the end of this report.

In this chapter, measures are organized into several categories as related to the patient's need for preventive care, treatment of acute illness, and chronic disease management. There is sizable overlap among these categories, and some measures may be considered to belong in more than one category. Outcome measures are particularly difficult to categorize when prevention, treatment, and management all play important roles. Nevertheless, for the purposes of this report, measures are placed into categories that best fit the general descriptions below:

Prevention

Caring for healthy people is an important component of health care. Educating people about healthy behaviors can help postpone or avoid illness and disease. Additionally, detecting health problems at an early stage increases the chances of effectively treating them, often reducing suffering and expenditures.

Treatment

Even when preventive care is ideally implemented, it cannot entirely avert the need for acute care. Delivering optimal treatments for acute illness can help reduce the consequences of illness and promote the best recovery possible.

Management

Some diseases, such as diabetes and end stage renal disease, are chronic, which means they cannot simply be treated once; they must be managed across a lifetime. Management of chronic disease often involves lifestyle changes and regular contact with a provider to monitor the status of the disease. For patients, effective management of chronic disease can mean the difference between normal, healthy living and frequent medical problems.

The measures highlighted on the following pages are categorized as follows:

Section Measure
Prevention:
Cancer Colorectal cancer screening
Cancer Advanced stage colorectal cancer
Cancer Colorectal cancer mortality
Diabetes Lower extremity amputations
Heart disease Counseling smokers to quit smoking
Heart disease Counseling obese adults about overweight*
Heart disease Counseling obese adults about exercise
HIV and AIDS New AIDS cases
HIV and AIDS Eligible AIDS patients receiving PCP and MAC prophylaxis*
Maternal and child health Receipt of prenatal care in the first trimester
Maternal and child health Receipt of all recommended immunizations by young children
Maternal and child health Vision checks for children
Maternal and child health Counseling parents about healthy eating in children
Maternal and child health Children told by health provider they were overweight*
Mental health and substance abuse Suicide deaths
Respiratory diseases Pneumococcal vaccination
Treatment:
Heart disease Receipt of recommended care for acute heart failure
Heart disease Receipt of recommended care for heart attack
Heart disease Inpatient mortality following heart attack
Maternal and child health Hospital admissions for pediatric gastroenteritis
Mental health and substance abuse Receipt of needed treatment for illicit drug use
Mental health and substance abuse Receipt of treatment for depression
Respiratory diseases Receipt of recommended care for pneumonia
Respiratory diseases Receipt of antibiotics for the common cold
Respiratory diseases Completion of tuberculosis therapy
Management:
Diabetes Receipt of three recommended diabetes services
Diabetes Controlled hemoglobin, cholesterol, and blood pressure*
Diabetes State variation in retinal eye exams*
End stage renal disease (ESRD) Adequacy of hemodialysis
End stage renal disease (ESRD) Registration for transplantation
Respiratory diseases Hospital admissions for pediatric asthma
Respiratory diseases Asthma management for long-term controli*
Nursing home, home health, and hospice care Use of restraints among chronic care nursing home residents
Nursing home, home health, and hospice care Presence of pressure ulcers among nursing home residents
Nursing home, home health, and hospice care Improvement in ambulation in home health episodes
Nursing home, home health, and hospice care Acute care hospitalization of home health patients
Nursing home, home health, and hospice care Receipt of right amount of pain medicine by hospice patients*
Nursing home, home health, and hospice care Receipt of care consistent with patient's stated end-of-life wishes*

* Supplemental measure


i Includes four supplemental measures: counseling persons with asthma about recognizing early signs of an attack, counseling persons with asthma about changing their environment, use of a controller medication, and receipt of an asthma management plan.


Cancer

Importance and Measures

Type of statistic Number
Mortality
Number of deaths (2006 est.) 564,8301
Cause of death rank (2004) 2nd2
Prevalence
Number of Americans that have been diagnosed with cancer (2003 est.) 10,500,0003
Incidence
New cases of cancer (2006 est.) 1,399,7901
New cases of colorectal cancer (2006 est.) 148,6101
Cost
Total costii 2006) $206.3 billion4
Direct costsiii (2006) $78.2 billion4
Cost effectivenessiv of colorectal cancer screening $0-$14,000/QALY5
Cost effectiveness of breast cancer screening $35,000-$165,000/QALY5
Measures

Evidence-based consensus defining good quality care and how to measure it currently exists for only a few cancers and a few aspects of care. Breast and colorectal cancers have high incidence rates and are highlighted in alternate years of the report. The 2005 NHQR highlighted breast cancer; this year's focus is on colorectal cancer—specifically, prevention. The core report measures are:

  • Colorectal cancer screening.
  • Colorectal cancer first diagnosed at an advanced stage.
  • Colorectal cancer mortality.

ii Total cost equals cost of medical care (direct cost) and economic costs of morbidity and mortality (indirect cost).
iii Direct costs are defined as “personal health care expenditures for hospital and nursing home care, drugs, home care, and physician and other professional services.” 4
ivCost effectiveness is here measured by the average net cost of each quality adjusted life year (QALY) that is saved by the provision of a particular health intervention. QALYs are a measure of survival adjusted for its value: 1 year in perfect health is equal to 1.0 QALY, while a year in poor health would be something less than 1.0. A lower cost per QALY saved indicates a greater degree of cost effectiveness. For example, the net cost for colorectal cancer screening ranges from $0 to $14,000 for each QALY saved.


Findings

Prevention: Colorectal Cancer Screening

Prevention of colorectal cancer includes modifying risk factors, such as diet, weight, physical activity, smoking, and alcohol, and screening for early disease. Early detection of cancer increases treatment options and the chances for survival. Colorectal cancer screening is able to detect abnormal growths before they develop into cancer.6 The U.S. Preventive Services Task Force recommends colorectal cancer screening for men and women age 50 and older.7 Screening tests for colorectal cancer include fecal occult blood test (FOBT), flexible sigmoidoscopy, colonoscopy, proctoscopy, and barium enema.

Figure 2.1. Adults age 50 and older who report having ever received a sigmoidoscopy, colonoscopy, or proctoscopy or who report fecal occult blood test within the past 2 years, 2000 and 2003

Figure 2.1. Adults age 50 and older who report having ever received a sigmoidoscopy, colonoscopy, or proctoscopy or who report fecal occult blood test within the past 2 years, 2000 and 2003

Source: Centers for Disease Control and Prevention, National Health Interview Survey, 2000 and 2003.

Reference population: Civilian noninstitutionalized population age 50 and older.

Note: Total rate is adjusted to the 2000 U.S. standard population.

  • The proportion of adults who reported ever having received a sigmoidoscopy, colonoscopy, or proctoscopy or an FOBT within the past 2 years increased from 49.8% in 2000 to 51.7% in 2003 (Figure 2.1).
  • From 2000 to 2003, the proportion of adults age 65 and over who report ever receiving a sigmoidoscopy, colonoscopy, or proctoscopy or an FOBT within the previous 2 years increased from 56.8% to 59.2%. The proportion did not change significantly for adults ages 50-64.
  • In both data years, adults age 65 and over were more likely than adults ages 50-64 to report ever having received a sigmoidoscopy, colonoscopy or proctoscopy or an FOBT within the past 2 years.

Figure 2.2. Adults age 50 and older who report having ever received a sigmoidoscopy or colonoscopy, by State, 2002 and 2004

Figure 2.2. Adults age 50 and older who report having ever received a sigmoidoscopy or colonoscopy, by State, 2002 and 2004

Source: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System, 2002 and 2004.

Key: Above average = rate is significantly above the reporting States' average in both 2002 and 2004. Below average = rate is significantly below the reporting States' average in both 2002 and 2004.

Reference population: Civilian noninstitutionalized adults age 50 and over.

Note: Age adjusted to the 2000 U.S. standard population. “Reporting States' average” is the weighted average of all reporting States (50 in this case, including the District of Columbia), which is a separate figure from the national average. The weighted average is the average of all States weighted by the State's population.

  • Variation was seen among States in the rates of receipt of colorectal cancer screening. In 2002, the reporting States' average was 49.8%, ranging from 38.0% to 65.7%. In 2004 the all-States average improved to 54.6%, ranging from 46.0% to 66.7% (Figure 2.2).
  • Six Statesv were significantly above the reporting States' average in both 2002 and 2004, with a combined average rate of 62.9% in 2004.
  • Seven Statesvi were significantly below the reporting States' average in both 2002 and 2004, with a combined average rate of 47.2% in 2004.
  • Twenty-nine States showed improvement on this measure from 2002 to 2004, while no State showed deterioration. Missouri, New Hampshire, Maine, and Virginia each improved by an average annual rate greater than 10%.

v The States are Minnesota, Wisconsin, Michigan, Delaware, Connecticut, and the District of Columbia.
vi The States are Wyoming, Nebraska, Oklahoma, Arkansas, Louisiana, Mississippi, and West Virginia.


Prevention: Advanced Stage Colorectal Cancer

Cancers can be diagnosed at different stages of development. Cancers diagnosed early before spread has occurred are generally more amenable to treatment and cure; cancers diagnosed late with extensive spread often have poor prognoses. The rate of cases of cancer that are diagnosed at late or advanced stages is a measure of the effectiveness of cancer screening efforts and of cancer diagnosis following a positive screening test.

Figure 2.3. Age-adjusted rate of late stage colorectal cancer per 100,000 population age 50 and older, 1992-2003

Figure 2.3. Age-adjusted rate of late stage colorectal cancer per 100,000 population age 50 and older, 1992-2003

Source: Surveillance, Epidemiology, and End Results Program, 1992-2003.

Reference population: U.S. population age 50 and older.

Note: Age adjusted to the 2000 U.S. standard population.

  • Between 1992 and 2003, the overall rate of late stage colorectal cancer decreased from 104.9 to 85.3 per 100,000 population (Figure 2.3).
Prevention: Colorectal Cancer Mortality

The death rate from a disease is a function of many determinants including the causes of the disease, social forces, and how well the health care system performs in providing good prevention, treatment, and management of the disease. Colorectal cancer mortality reflects the impact of colorectal cancer screening, diagnosis, and treatment and is measured as the number of deaths per 100,000 population. Declines in colorectal cancer mortality can be attributed, in part, to improvements in early detection and treatment.

Figure 2.4. Age adjusted cancer deaths per 100,000 population per year for colorectal cancer, all ages, 2000-2003

Figure 2.4. Age adjusted cancer deaths per 100,000 population per year for colorectal cancer, all ages, 2000-2003

Source: National Center for Health Statistics, National Vital Statistics System - Mortality, 2000-2003.

Reference population: U.S. population.

Note: Age adjusted to the 2000 standard population.

  • Between 2000 and 2003, the rate of colorectal cancer deaths decreased from 20.8 to 19.1 per 100,000 population (Figure 2.4).
  • At 19.1 deaths per 100,000 population, the overall colorectal cancer death rate in 2003 was higher than the Healthy People 2010 target of 13.9. At the present rate of change, this target will not be met by 2010.

Diabetes

Importance and Measures

Type of statistic Number
Mortality
Number of deaths (2004) 72,8152
Cause of death rank (2004) 6th2
Prevalence
Total number of Americans with diabetes (2005) 20,800,0008
Incidence
New cases (age 20 and over, 2005) 1,500,0008
Cost
Total cost (2002) $132 billion9
Direct medical costs (2002) $92 billion9
Measures

Effective management of diabetes includes appropriate receipt of recommended processes such as hemoglobin A1c tests, eye exams, and foot exams, as well outcome measures expected to correlate positively with these processes (such as control of cholesterol, blood pressure, and HbA1cvii levels). In addition, hospital admission rates among patients with diabetes for amputations of a leg or foot can be an indicator of appropriate care for this condition.

The three core report measures highlighted in this section are:

  • Lower extremity amputations.
  • Receipt of three recommended diabetic services.
  • Controlled hemoglobin, cholesterol, and blood pressure.

In addition, a supplemental measure is also presented:

  • State variation in retinal eye exams.

vii HbA1c is glycosylated hemoglobin—the higher the level of glucose in the blood, the higher the HbA1c level.


Findings

Prevention: Lower Extremity Amputations

Although diabetes is the leading cause of lower extremity amputations, amputations can be avoided through proper care on the part of patients and providers. Hospital admissions for lower extremity amputations for patients with diagnosed diabetes reflect poorly controlled diabetes. Better management of diabetes would prevent the need for lower extremity amputations.

Figure 2.5. Hospital admissions for lower extremity amputations per 1,000 adult patients with diagnosed diabetes, United States

Figure 2.5. Hospital admissions for lower extremity amputations per 1,000 adult patients with diagnosed diabetes, United States

Source: Centers for Disease Control and Prevention, National Hospital Discharge Survey.

Reference population: Civilian noninstitutionalized adults age 18 and older with diagnosed diabetes, from the National Health Interview Survey, 1999-2001 and 2002-2004.

Note: Total rate is age adjusted to the 2000 standard population.

  • From 1999-2001 to 2002-2004, the overall rate of lower extremity amputations in adults with diagnosed diabetes fell from 5.5 to 4.4 per 1,000 population (Figure 2.5).
  • From 1999-2001 to 2002-2004, lower extremity amputation rates fell from 6.1 to 4.6 per 1,000 population and 9.2 to 6.9 per 1,000 population for adults with diagnosed diabetes ages 45-64 and 65 and older, respectively.
  • The Healthy People 2010 target rate of 1.8 lower extremity amputations in adults with diagnosed diabetes per 1,000 population has not been met by any age group or by the total population age 18 and older.
Management: Receipt of Three Recommended Diabetes Services

The NHQR uses a composite measure to track the national rate of the receipt of all three recommended diabetes interventions.

Figure 2.6. Adults age 40 and older with diagnosed diabetes who received at least one HbA1c test, retinal exam, and foot exam in the past year, 2000-2003

Figure 2.6. Adults age 40 and older with diagnosed diabetes who received at least one HbA1c test, retinal exam, and foot exam in the past year, 2000-2003

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2000-2003.

Reference population: Civilian, noninstitutionalized population with diagnosed diabetes age 40 and older.

Note: Rates are age adjusted. Recommended services for diabetes are (1) HBA1c testing, (2) retinal eye examination, and (3) foot examination in past year. Data include persons with both type 1 and type 2 diabetes.

  • From 2000 to 2003, the number of adults with diagnosed diabetes age 40 and older who received an HbA1c test, a retinal exam, and a foot exam increased from 41.2% to 47.8% (Figure 2.6).
  • From 2000 to 2003, the rate of receipt for foot exams for adults age 40 and older with diagnosed diabetes increased from 65.4% to 72.7%, but the rates for HbA1c tests and retinal exams remained stable.
Management: Controlled Hemoglobin, Cholesterol, and Blood Pressure

Persons diagnosed with diabetes are often at higher risk for other cardiovascular risk factors such as high blood pressure and high cholesterol. Having these conditions in combination with diagnosed diabetes increases the likelihood of complications, such as heart and kidney diseases, blindness, nerve damage, and stroke. Patients who manage their diagnosed diabetes and maintain HbA1c level of <7%, total cholesterol of <200 mg/dL, and blood pressure of <140/80viii mm Hg can decrease these risks.

Figure 2.7. Adults age 40 and older with diagnosed diabetes with HbA1c, total cholesterol, and blood pressure under control, 1988-1994, 1999-2002

Figure 2.7. Adults age 40 and older with diagnosed diabetes with HbA1c, total cholesterol, and blood pressure under control, 1988-1994, 1999-2002

Source: National Center for Health Statistics, National Health and Nutrition Examination Survey, 1988-1994, and 1999-2002.

Reference population: Civilian noninstitutionalized population with diagnosed diabetes age 40 and over.

Note: Age adjusted to the 2000 U.S. standard population.

  • In 1999-2002, 48.1% of those diagnosed with diabetes had their total cholesterol under control (<200 mg/dL). This is an improvement over the 1988-1994 rate of 29.9% for this measure (Figure 2.7).
  • In 1999-2002, 45.5% of those diagnosed with diabetes had their HbA1c level under optimal control (i.e., <7.0%). This percentage is statistically unchanged from the 1988-1994 time period.
  • In 1999-2002, 53.4% of those diagnosed with diabetes had their blood pressure under control (<140/80 mm Hg), which is not significantly different from the 1988-1994 time period.

viii Blood pressure control guidelines were updated in 2005. Previously, having a blood pressure reading of <140/90 mm Hg was considered under control. For this measure, the new threshold of <140/80 mm Hg has been applied to historical data for the sake of consistency and comparability.


Management: State Variation in Retinal Eye Exams

Because persons with diagnosed diabetes are at an increased risk of vision loss due to complications such as diabetic retinopathy, cataracts, and glaucoma, effective management of diabetes includes yearly retinal eye exams.

Figure 2.8. State variation in rates of receipt of annual retinal eye exam among persons with diagnosed diabetes ages 40 and older, 2004

Figure 2.8. State variation in rates of receipt of annual retinal eye exam among persons with diagnosed diabetes ages 40 and older, 2004

Source: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System, 2004.

Key: Above average = rate is significantly above the reporting States' average in 2004. Below average = rate is significantly below the reporting States' average in 2004.

Reference population: Civilian noninstitutionalized population age 40 and older.

Note: Age adjusted to the 2000 U.S. standard population. The “reporting States' average” is the weighted average of all reporting States (41 in this case, including the District of Columbia), which is a separate figure from the national average.

  • In 2004, State rates of receipt of retinal eye exams ranged from 56.3% to 78.2%, with a reporting States' average of 67.4%.
  • Fifteen Statesix were significantly above the reporting States' average in 2004, with a combined average rate of 75.0% in 2004 (Figure 2.8).
  • Two Statesx were significantly below the reporting States' average in 2004, with a combined average rate of 58.1%.

ix The States are Connecticut, Delaware, Florida, Iowa, Maryland, Minnesota, New Hampshire, New Jersey, New Mexico, North Carolina, South Dakota, Tennessee, Vermont, Washington, and Wisconsin.
x The States are Idaho and Mississippi.


End Stage Renal Disease (ESRD)

Importance and Measures

Type of statistic Number
Mortality
Total ESRD deaths (2003) 82,58810
Prevalence
Total cases (2003) 452,95710
Incidence
New cases (2003) 102,56710
Cost
Total ESRD program expenditures (2003) $27.3 billion10
Measures

The NHQR includes six measures of ESRD management to assess the quality of care provided to renal dialysis patients. The two core report measures highlighted here are:

  • Adequacy of hemodialysis.
  • Registration for transplantation.

Findings

Management: Patients With Adequate Hemodialysis

Dialysis removes harmful waste buildup that occurs when kidneys fail to function. Hemodialysis is the most common method used to treat advanced and permanent kidney failure. The adequacy of dialysis is measured by the percentage of hemodialysis patients with a urea reduction ratio (URR) equal to or greater than 65%; this measure indicates how well urea, a waste product in the blood, is eliminated by the dialysis machine.

Figure 2.9. Medicare hemodialysis patients age 18 and older with adequate dialysis (urea reduction ratio 65% or higher), 2001-2004

Figure 2.9. Medicare hemodialysis patients age 18 and older with adequate dialysis (urea reduction ratio 65% or higher), 2001-2004

Source: Centers for Medicare & Medicaid Services ESRD Clinical Performance Measures Project, 2001-2004.

Reference population: ESRD hemodialysis patients age 18 and older.

  • Between 2001 and 2004, the percentage of all hemodialysis patients with adequate dialysis improved, from 84% to 87% (Figure 2.9), as well as for all age groups (data not shown).

Figure 2.10. Medicare hemodialysis patients with adequate dialysis (urea reduction ratio 65% or higher), by State 2003 and 2004

Figure 2.10. Medicare hemodialysis patients with adequate dialysis (urea reduction ratio 65% or higher), by State 2003 and 2004

Source: Centers for Medicare & Medicaid Services ESRD Clinical Performance Measures Project, 2003 and 2004.

Key: Above average = rate is significantly above the all-States average in both 2003 and 2004. Below average = rate is significantly below the all-States average in both 2003 and 2004.

Reference population: ESRD hemodialysis patients and peritoneal dialysis patients.

Note: The “all-States average” is the average of all reporting States (52 in this case, including the District of Columbia and Puerto Rico), which is a separate figure from the national average.

  • In 2003, the all-States average was 91.4%, ranging from 87.5% (North Dakota) to 96.9% (New Mexico). In 2004, the all-States average rose to 92.4%, ranging from 86.5% (Utah) to 97.9% (Maine).
  • Eighteen Statesxi were significantly above the all-States average in both 2003 and 2004, with a combined average rate of 95.1% in 2004 (Figure 2.10).
  • Eight Statesxii were significantly below the all-States average in both 2003 and 2004, with a combined average rate of 90.3% in 2004.
  • Twenty States showed improvement on this measure from 2003 to 2004, while one State declined.

xi The States are Hawaii, Washington, Oregon, Arizona, Montana, Wyoming, Colorado, New Mexico, Texas, South Dakota, Minnesota, Indiana, South Carolina, North Carolina, New Jersey, Connecticut, Massachusetts, and Maine.
xii The States are California, Missouri, Wisconsin, Tennessee, Georgia, West Virginia, Maryland, and New York.


Management: Registration for Transplantation

Kidney transplantation is a procedure that replaces a failing kidney with a healthy kidney. If a patient is deemed a good candidate for transplant, he or she is placed on the transplant program's waiting list. Dialysis patients wait for transplant centers to match them with the most suitable donor.

Figure 2.11. Medicare dialysis patients registered on waiting list for transplantation, 1999-2003

Figure 2.11. Medicare dialysis patients registered on waiting list for transplantation, 1999-2003

Source: Centers for Medicare & Medicaid Services, ESRD Clinical Performance Measures Project, 1999-2003.

Reference population: ESRD hemodialysis patients and peritoneal dialysis patients under age 70.

  • In 2003, 16.8% of dialysis patients were registered on a waiting list for transplantation. This rate did not change significantly from 1999 for the total population or for any age group (Figure 2.11).
  • In all 5 data years, likelihood of being on a transplantation waiting list decreased significantly with age.

Heart Disease

Importance and Measures

Type of statistic Number
Mortality
Number of deaths (2004) 654,0922
Cause of death rank (2004) 1st2
Prevalence
Number of cases of coronary heart disease each year (1999-2002) 13,200,00011
Number of cases of heart failure each year (1999-2002) 5,000,00011
Number of cases of high blood pressure each year (1999-2002) 65,000,00011
Number of heart attacks each year (1999-2002) 7,200,00011
Incidence
Number of new cases of congestive heart failure each year (1999-2002) 550,00011
Cost
Total cost of cardiovascular disease (2006 est.) $403.0 billion4
Total cost of congestive heart failure (2006 est.) $29.6 billion11
Direct medical costs of cardiovascular disease (2005 est.) $257.6 billion4
Cost effectiveness of hypertension screening $14,000-$35,000/QALY5
Cost effectiveness of aspirin chemoprophylaxis cost savingxiii, 5
Measures

The NHQR tracks several quality measures for preventing and treating heart disease, including the following six core report measures:

  • Counseling smokers to quit smoking.
  • Counseling obese adults about overweight.
  • Counseling obese adults about exercise.
  • Receipt of recommended care for acute heart failure.
  • Receipt of recommended care for heart attack (acute myocardial infarction, or AMI).
  • Inpatient mortality following heart attack.

xiii This intervention results in net cost savings to society as opposed to those interventions which may increase health benefit costs.


Findings

Prevention: Counseling Smokers To Quit Smoking

Smoking may be the single most important modifiable risk factor for heart disease, and providers can encourage patients to quit smoking.

Figure 2.12. Current smokers age 18 and older with a routine office visit who reported receiving advice to quit smoking 2000-2003

Figure 2.12. Current smokers age 18 and older with a routine office visit who reported receiving advice to quit smoking 2000-2003

Source: Agency for Healthcare Research and Quality, Center for Financing, Access and Cost Trends, Medical Expenditure Panel Survey, 2000-2003.

Reference population: Civilian noninstitutionalized population age 18 and older.

  • In 2003, 66.1% of smokers with routine office visits during the preceding year reported that their providers had advised them to quit, an increase from 61.9% in 2000. This rate remained statistically unchanged for every age group during this time period (Figure 2.12).
  • In all 4 data years, smokers age 18-44 were less likely than the other age groups to receive advice to quit smoking.
Prevention: Counseling Obese Adults About Overweight

Over 32 percent of adults age 20 and older in the United States are obese,12, xiv putting them at increased risk for many chronic, often deadly conditions such as hypertension, cancer, diabetes, and coronary heart disease.13 Although physician guidelines recommend that health care providers screen all adult patients for obesity,14 obesity remains underdiagnosed among U.S. adults.15

Figure 2.13. Obese adults age 20 and older who were told by a doctor or health professional that they were overweight, 1999-2002

Figure 2.13. Obese adults age 20 and older who were told by a doctor or health professional that they were overweight, 1999-2002

Source: Centers for Disease Control and Prevention, National Health and Nutrition Examination Survey (NHANES), 1999-2002.

Reference population: Civilian noninstitutionalized adults age 20 and older.

  • In 1999-2002, 67.8% of obese adults were told they were overweight by a doctor or health professional (Figure 2.13).
  • During the time period from 1999-2002, obese adults ages 45-64 (77.4%) and age 65 and older (71.6%) were more likely than those ages 20-44 (60.7%) to be told by a doctor or health professional that they were overweight.

xiv Obesity is defined as having a body mass index of 30 or higher.


Prevention: Exercise Counseling for Obese Adults

Physician-based exercise counseling is an important component of effective weight loss interventions,14 and it has been shown to produce increased levels of physical activity among sedentary patients.16 Regular exercise aids in weight loss and blood pressure control efforts, reducing the risk of heart disease, stroke, diabetes, and other comorbidities of obesity.

Figure 2.14. Obese adults age 18 and older who were given advice about exercise, 2002 and 2003

Figure 2.14. Obese adults age 18 and older who were given advice about exercise, 2002 and 2003

Source: Agency for Healthcare Research and Quality, Center for Financing, Access and Cost Trends, Medical Expenditure Panel Survey, 2002 and 2003.

Reference population: Civilian noninstitutionalized adults age 18 and older.

  • In 2003, 58.2% of obese adults were given advice about exercising. This figure did not change significantly from 2002, nor did it change for any population subgroup (Figure 2.14).
  • In both 2002 and 2003, obese adults ages 45-64 and 65 and older were more likely to receive advice about exercise than were obese adults ages 18-44.
Treatment: Receipt of Recommended Care for Acute Heart Failure

The NHQR tracks the national rates of the receipt of a recommended test for heart functioning (heart failure patients having evaluation of left ventricular ejection fraction, or LVEF), for recommended medication treatment (patients with left ventricular dysfunction prescribed ACE inhibitor at discharge), and an overall composite measure based on the opportunities model which describes the proportion of all “opportunities” in which heart failure patients receive recommended care.

Figure 2.15. Receipt of recommended care for acute heart failure among Medicare patients: overall composite and two components, 2000-2001, 2002, 2003, and 2004

Figure 2.15. Receipt of recommended care for acute heart failure among Medicare patients: overall composite and two components, 2000-2001, 2002, 2003, and 2004

Key: LVEF = left ventricular ejection fraction; ACE = angiotensin-II converting enzyme.

Source: Centers for Medicare & Medicaid Services, Medicare Quality Improvement Organization Program, 2000-2001, 2002, 2003, and 2004.

Denominator: Medicare patients hospitalized with a principal diagnosis of acute heart failure.

  • The overall heart failure composite showed improvement in the provision of recommended care for Medicare patients with heart failure from 68.5% of the opportunities to provide recommended care in 2000-2001 to 77.7% in 2004 (Figure 2.15).
  • The LVEF measure showed improvement from 69.1% in 2000-2001 to 81.6% in 2004, but the ACE inhibitor measure showed no change.

Figure 2.16. Receipt of recommended care for acute heart failure among Medicare patients, by State, 2004

Figure 2.16. Receipt of recommended care for acute heart failure among Medicare patients, by State, 2004

Source: Centers for Medicare & Medicaid Services, Medicare Quality Improvement Organization Program, 2004.

Key: Above average = rate is significantly above the all-States average in 2004. Below average = rate is significantly below the all-States average in 2004.

Denominator: Medicare patients hospitalized with a principal diagnosis of acute heart failure.

Note: The “all-States average” is the average of all reporting States (51 in this case, including the District of Columbia), which is a separate figure from the national average.

  • In 2004, the all-States average was 77.7%, with States ranging from a low of 64.1% to a high of 86.8%.
  • Sixteen Statesxv were significantly above the all-States average in 2004 (Figure 2.16), with a combined average rate of 83.2%.
  • Thirteen Statesxvi were significantly below the all-States average in 2004, with a combined average rate of 71.0%.

xv The States are Arizona, Wisconsin, Michigan, Ohio, North Carolina, Maryland, Delaware, Pennsylvania, New Jersey, New York, Connecticut, Rhode Island, Massachusetts, Vermont, New Hampshire, and Maine.
xvi The States are Idaho, Montana, Wyoming, North Dakota, New Mexico, Texas, Oklahoma, Kansas, Missouri, Arkansas, Kentucky, Alabama, and West Virginia.


Treatment: Receipt of Recommended Care for Heart Attack

There is consensus that recommended care for patients with a heart attack includes administration of aspirin within 24 hours of heart attack and at discharge, administration of beta-blocker within 24 hours of attack and at discharge, angiotensin-II converting enzyme (ACE) inhibitor treatment among patients with left ventricular systolic dysfunction, and counseling to quit smoking among smokers. The NHQR reports on these measures, as well as a composite of these measures which addresses the proportion of all opportunities in which heart attack patients receive recommended care.

Figure 2.17. Receipt of recommended care for heart attack among Medicare patients age 18 and older: overall composite and six components, 2000-2001, 2002, 2003, and 2004

Figure 2.17. Receipt of recommended care for heart attack among Medicare patients age 18 and older: overall composite and six components, 2000-2001, 2002, 2003, and 2004

Source: Centers for Medicare & Medicaid Services, Medicare Quality Improvement Organization Program, 2000-2001, 2002, 2003, and 2004.

Denominator: Medicare beneficiaries hospitalized with a principal diagnosis of acute myocardial infarction.

  • The overall heart attack composite shows improvement in the provision of recommended care for Medicare patients with heart attacks from 77.2% of the opportunities to provide recommended care in 2000-2001 to 85.6% in 2004 (Figure 2.17).
  • Five of the component measures showed improvement, including aspirin within 24 hours of admission (from 85.1% to 88.5%), aspirin at discharge (from 85.9% to 91.0%), counseling for smoking cessation (from 42.7% to 68.1%), beta-blocker within 24 hours of admission (from 69.3% to 82.5%), and betablocker at discharge (from 78.5% to 89.0%).
  • From 2000/2001 to 2004, ACE inhibitor use fell from 73.9% to 68.5%.
Treatment: Inpatient Mortality Following Heart Attack

Survival following admission for a heart attack reflects multiple patient factors, such as a patient's comorbidities, as well as health care system factors, such as the possible need to transfer hospitals in order to receive services. It may also partly reflect receipt of appropriate health services.

Figure 2.18. Deaths per 1,000 admissions with a heart attack as principal diagnosis, age 18 and older, 2001-2003

Figure 2.18. Deaths per 1,000 admissions with a heart attack as principal diagnosis, age 18 and older, 2001-2003

Source: HCUP Nationwide Inpatient Sample, 1994, 1997, 2001-2003.

Denominator: Any person, age 18 and older, U.S. citizen or foreign, using non-Federal, community hospitals in the United States, with a heart attack as principal diagnosis.

Note: Rates are adjusted by age, gender, age-gender interactions, and APR-DRG scoring of risk of mortality.

  • Between 1994 and 2003, the overall inpatient mortality rate for heart attacks declined from 119.9 to 86.9 deaths per 1,000 admissions with heart attack (Figure 2.18).

HIV and AIDS

Importance and Measures

Type of statistic Number
Mortality
Number of AIDS deaths (2004) 15,79817
Prevalence
Number of persons in U.S. living with HIV (2003 est.) 1,039,000-1,185,00018
Number of persons in U.S. living with AIDS (2004) 415,19317
Incidence
New cases of HIV annually (2003 est.) approximately 40,00018
New AIDS cases (2004 est.) 42,51417
Cost
Federal spending on HIV/AIDS care (fiscal year 2004) $11.6 billion19
Measures

This section highlights one core report measure focusing on quality of preventive care for HIV-infected individuals:

  • New AIDS cases.

In addition, a supplemental measure related to prevention of opportunistic infections among HIV patients with low CD4 cell counts is also presented:

  • Eligible AIDS patients receiving prophylaxis for Pneumocystis pneumonia (PCP) and Mycobacterium avium complex (MAC).

Findings

Prevention: New AIDS Cases

Changes in HIV infection rates reflect changes in behavior by at-risk individuals that may only partly be influenced by the health care system. However, individual and community programs have shown progress in influencing behavior change. Changes in the incidence of new AIDS cases are affected by changes in HIV infection rates and by the availability of appropriate treatments for HIV-infected individuals. Improved treatments that extend life for those with the disease are reflected in the fact that the number of deaths due to AIDS fell from about 18,000 to 16,000 between 2003 and 2004 after showing no change for the previous 3 years.17

Figure 2.19. New AIDS cases per 100,000 population ages 13 and older, 1998-2004

Figure 2.19. New AIDS cases per 100,000 population ages 13 and older, 1998-2004

Source: Centers for Disease Control and Prevention, National Center for HIV, STD, and TB Prevention, HIV/AIDS Reporting System, 1998-2004.

Reference population: U.S. population age 13 and older.

  • The overall rate of new AIDS cases per 100,000 has not changed significantly between 1998 and 2004. However, during that same time span, the rate of new AIDS cases decreased for adults ages 18-44 while increasing for children ages 13-17, adults ages 45-64, and adults age 65 and older (Figure 2.19).
  • The 2004 national rate of 17.1 new AIDS cases per 100,000 persons is well above the Healthy People 2010 target of 1.0 new case per 100,000 persons. If current trends continue, the target will not be met.
Prevention: PCP and MAC Prophylaxis

Management of chronic HIV disease includes outpatient and inpatient services. Because national data on HIV care are not routinely collected, HIV measures tracked in NHQR come from the HIV Research Network, which consists of 18 medical practices across the United States that treat large numbers of HIV patients. Although program data are collected from all Ryan White CARE Act grantees, the aggregate nature of the data makes it difficult to assess the quality of care provided by Ryan White CARE Act providers. Without adequate treatment, as HIV disease progresses, CD4 cell counts fall and patients become increasingly susceptible to opportunistic infections. When CD4 cell counts fall below 200, medicine to prevent development of Pneumocystis pneumonia (PCP) is routinely recommended; when CD4 cell counts fall below 50, medicine to prevent development of disseminated Mycobacterium avium complex (MAC) infection is routinely recommended.20

Figure 2.20. Percentage of eligible AIDS patients age 18 and older receiving PCP and MAC prophylaxis, 2003

Figure 2.20. Percentage of eligible AIDS patients age 18 and older receiving PCP and MAC prophylaxis, 2003

Source: HIV Research Network, 2003.

Reference population: Adult patients with AIDS with CD4 cell counts below 200 (PCP) or CD4 cell counts below 50 (MAC).

Note: Data from the HIV Research Network are not nationally representative of the level of care received by all Americans living with HIV. Participation in this network is voluntary, and network data only represent patients who are actually receiving care. Furthermore, data shown above are not representative of the HIV Research Network as a whole, because they represent only a subset of network sites that have the best quality data. (For more information on the HIV Research Network, see: http://www.ahrq.gov/data/hivnet.htm.)

  • Of those patients eligible (3,094 AIDS patients with at least two CD4 cell counts below 200), 84.0% received PCP prophylaxis (Figure 2.20), which is below the Healthy People 2010 target of 95%.
  • Of those patients eligible (957 AIDS patients with at least two CD4 cell counts below 50), 84.3% received MAC prophylaxis, which is below the Healthy People 2010 target of 95%.

Maternal and Child Health

Importance and Measures

Type of statistic Number
Mortality
Number of maternal deaths (2003) 49521
Number of infant deaths (2004) 27,8962
Demographics
Number of children under 18 (2005) 73,469,98422
Number of babies born in United States (2004) 4,115,59023
Cost
Total cost of health care for children (2002) $79 billion24
Cost effectiveness of vision screening for children $0-$14,0005
Cost effectiveness of childhood immunization seriesxvii cost saving5
Measures

The NHQR tracks several prevention and treatment measures related to maternal and child health care throughout the report. The core report measures highlighted in this section are:

  • Receipt of prenatal care in the first trimester.
  • Receipt of all recommended immunizations by young children.
  • Vision checks for children.
  • Counseling parents about healthy eating in children.
  • Hospital admissions for pediatric gastroenteritis.

In addition one supplemental measure is also presented:

  • Weight monitoring of overweightxviii children.

xvii The childhood immunization series includes vaccinations for diphtheria-tetanus-pertussis; measles-mumps-rubella; inactivated polio virus; Haemophilus influenzae type B; hepatitis B; and varicella.
xviii Overweight is defined as having a body mass index of 25 or higher.


Findings

Prevention: Prenatal Care in the First Trimester

Pregnant women are at risk for high blood pressure, gestational diabetes, and other disorders. Prenatal care is a preventive service intended to identify and manage risk factors in pregnant women and their unborn children in order to improve the chances of a healthy mother and child during pregnancy, birth, and early childhood. Prenatal care is recommended during the first trimester and throughout pregnancy.

Figure 2.21. Percent of women of all ages who delivered live births and who received prenatal care in the first trimester of pregnancy, 1998-2003

Figure 2.21. Percent of women of all ages who delivered live births and who received prenatal care in the first trimester of pregnancy, 1998-2003

Source: National Vital Statistics System - Natality, 1998-2003.

Reference population: Women with live births.

  • The percentage of women who received prenatal care in the first trimester of pregnancy increased gradually from 82.8% in 1998 to 84.1% in 2003 (Figure 2.21).
  • As of 2003, the percentage of women who received prenatal care in the first trimester of pregnancy had not yet achieved the Healthy People 2010 target of 90%. At the current average annual rate of change, this target is not projected to be met.
Prevention: Receipt of All Recommended Immunizations by Young Children

Immunizations are important for reducing mortality and morbidity. They protect recipients, as well as others in the community who cannot be vaccinated from illness and disability. Recommended vaccines for children ages 19-35 months include four doses of diphtheria-tetanus-pertussis (DTaP) vaccine, three doses of polio vaccine, one dose of measles-mumps-rubella (MMR) vaccine, three doses of H. influenzae type B vaccine, and three doses of hepatitis B vaccine.

Figure 2.22. Children ages 19-35 months who received all recommended vaccines, 1998-2004

Figure 2.22. Children ages 19-35 months who received all recommended vaccines, 1998-2004

Source: National Immunization Survey, 1998-2004.

Reference population: U.S. civilian noninstitutionalized population: children, ages 19-35 months.

  • From 1998 to 2004, the percentage of children ages 19-35 months who received all recommended vaccines increased from 72.7% to 80.9% (Figure 2.22).
Prevention: Vision Checks for Children

Vision checks for children may detect problems of which children and their parents were previously unaware. Early detection also improves the chances that corrective treatments will be successful.

Figure 2.23. Children ages 3-6 who ever received a vision check, 2001-2003

Figure 2.23. Children ages 3-6 who ever received a vision check, 2001-2003

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2001-2003.

Reference population: U.S. civilian noninstitutionalized population: children ages 3-6.

Note: Rates are age adjusted.

  • The percentage of children ages 3-6 who ever received a vision check did not change significantly from 2001 to 2003 (Figure 2.23).
Prevention: Counseling Parents About Children Healthy Eating in Children

Childhood represents a unique period when healthy, life-long habits of diet and exercise can be formed, and physicians play an important role in encouraging these good behaviors in children. Overweight and obesity during childhood often persist into adulthood, with consequences that are numerous and costly. Unfortunately, the prevalence of overweight and obesity among children has risen dramatically in recent decades.25

Children require healthy diets for proper growth and development. Those with unhealthy eating patterns are at a greater risk of obesity, type 2 diabetes, cardiovascular disease, impaired growth, and many other conditions. The American Academy of Pediatrics recommends that pediatricians discuss and promote healthy diets with their patients.25

Figure 2.24. Children ages 2-17 whose parents or guardians reported advice from a doctor or other health provider about healthy eating, 2001-2003

Figure 2.24. Children ages 2-17 whose parents or guardians reported advice from a doctor or other health provider about healthy eating, 2001-2003

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2001-2003.

Reference population: U.S. civilian noninstitutionalized population: children ages 2-17.

Note: Rates are age adjusted.

  • From 2001 to 2003, the proportion of children whose parents or guardians reported advice from a health provider about healthy eating improved from 47.7% to 51.6% (Figure 2.24).
  • While the proportion of children ages 6-17 who received counseling about healthy eating rose from 45.4% in 2001 to 49.2% in 2003, the rate remained stable for children ages 2-5 (i.e., the change for this age group from 2001 to 2003 was not statistically significant).
  • In all 3 data years, parents of children ages 6-17 were less likely than parents of children ages 2-5 to report receiving advice from a doctor or health provider about healthy eating.
Prevention: Weight Monitoring of Overweight Children

Pediatricians are advised to monitor body mass index (BMI) and excessive weight gain in children in order to recognize and address cases of overweight and obesity.25 When health care providers alert young patients and their parents about their overweight status, a new opportunity is created to develop healthy dietary and exercise habits that may be carried into adulthood.26

Figure 2.25. Overweight children and adolescents ages 2-19 who were told by a doctor or health professional that they were overweight, 1999-2002

Figure 2.25. Overweight children and adolescents ages 2-19 who were told by a doctor or health professional that they were overweight, 1999-2002

Source: Centers for Disease Control and Prevention, National Health and Nutrition Examination Survey (NHANES), 1999-2002.

Reference population: Civilian noninstitutionalized population ages 2-19.

Note: Overweight children are identified using age- and sex-specific reference data from the 2000 CDC BMI-for-age growth charts. Children and youth can be categorized as acceptable, underweight, at risk of overweight, or overweight. Children with BMI values at or above the 95th percentile of the sex-specific BMI growth charts are categorized as overweight.

  • During 1999-2002, 37.0% of overweight children and teens ages 2-19 were told by a doctor or health professional that they were overweight (Figure 2.25).
  • During 1999-2002, overweight children ages 2-5 (17.6%) and 6-11 (32.8%) were less likely than overweight children ages 12-19 (45.7%) to be told by a provider that they were overweight.
Treatment: Hospital Admissions for Pediatric Gastroenteritis

Pediatric gastroenteritis can develop into a life-threatening condition due to dehydration, especially among infants. Proper outpatient treatment of gastroenteritis may prevent hospitalization, and lower hospitalization rates may reflect access to better quality care.

Figure 2.26. Hospital admissions for pediatric gastroenteritis per 100,000 population, 1994, 1997, and 2000-2003

Figure 2.26. Hospital admissions for pediatric gastroenteritis per 100,000 population, 1994, 1997, and 2000-2003

Source: Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 1994, 1997, and 2000-2003.

Denominator: U.S. population under age 18.

Note: Adjusted by age and gender to the total U.S. population for 2000 as the standard population.

  • From 1994 to 2003, admissions for pediatric gastroenteritis have fallen from 129.6 to 90.8 per 100,000 children (Figure 2.26).

Mental Health and Substance Abuse

Importance and Measures

Type of statistic Number
Mortality
Cause of death rank - suicide (2004) 11th2
Alcohol-related motor vehicle deaths (2004) 16,69427
Students grades 9-12 who have seriously considered suicide (2005) 16.9%28
Prevalence
People 12 or older with alcohol and/or illicit drug dependence or abuse (2004) 22,506,00029
People with a major depressive episode (MDE) during past year 17,100,000 (8.0%)30
Lifetime prevalence of major depressive disorder 9.5%31
Lifetime prevalence of dysthymic disorder 6.1%31
People with any mental disorder in past year, U.S. (2001-2003) 28.1%32
People with anxiety disorders, U.S. (2001-2003) 18.7%32
People with mood disorders, U.S. (2001-2003) 9.7%32
People with impulse-control disorders, U.S. (2001-2003) 10.4%32
People with substance abuse disorders, U.S. (2001-2003) 7.2%32
Cost
Direct medical expenditures for substance abuse and mental disorders (2001 est.) $104 billion33
Cost effectiveness of problem drinking screening and brief counseling $14,000-$35,000/QALY5
Measures

The NHQR tracks measures for the treatment of diagnosable mental disorders in general, of substance abuse, and specifically the treatment for major depression. The measures for major depression include any treatment, practitioner contact for medication management, and the receipt of antidepressant medication both during the first 3 months following initial diagnosis (i.e., the acute phase) and through the continuation treatment phase. Mental health treatment is defined as counseling, inpatient care, outpatient care, or prescription medications for problems with emotions or anxiety and does not include alcohol or drug treatment. Because improved outcomes are correlated with treatment completion and length of stay in substance abuse treatment, the measure of the quality of substance abuse treatment presented in this report is the rate of persons who complete all parts of their treatment plan. This section highlights three core measures of mental health and substance abuse treatment:

  • Suicide death rate.
  • Receipt of treatment for illicit drug use.
  • Receipt of treatment for depression.

Findings

Prevention: Suicide Deaths

Suicide is often the result of untreated depression, and may be prevented when its warning signs are detected and treated.34

Figure 2.27. Suicide deaths per 100,000 population, 2000-2003

Figure 2.27. Suicide deaths per 100,000 population, 2000-2003

Source: National Center for Health Statistics, National Vital Statistics System - Mortality, 2000-2003.

Reference population: U.S. population, all ages.

Notes: Total rate is age adjusted to the 2000 standard population.

  • From 2000 to 2003, the suicide death rate increased for the population as a whole (from 10.4 to 10.8 deaths per 100,000 population), moving further away from the Healthy People 2010 target of 5.0 suicide deaths per 100,000 population (Figure 2.27).
  • From 2000 to 2003, the rate of suicide deaths per 100,000 population decreased for children ages 0-17 (from 1.5 to 1.3) and for adults age 65 and over (from 15.2 to 14.6). During the same period, the rate increased for adults ages 45-64 (from 13.5 to 15.0).
  • In all 4 data years, the rate of suicide deaths was higher for adults age 65 and older than for adults ages 18-44, and lower for children ages 0-17 than for adults ages 18-44.

Figure 2.28. Suicide deaths per 100,000 population, by State, 2003

Figure 2.28. Suicide deaths per 100,000 population, by State, 2003

Source: National Center for Health Statistics, National Vital Statistics System - Mortality, 2003.

Key: Above average = rate is significantly above the national average in 2003. Below average = rate is significantly below the national average in 2003.

Reference population: U.S. population.

Note: Rates are age adjusted to the 2000 standard population.

  • In 2003, 10 Statesxix had rates of suicide deaths that were lower than the national average of 10.8 per 100,000 population, with a combined average rate of 7.6 per 100,000 population. No State reached the Healthy People 2010 goal of 5.0 per 100,000 population (Figure 2.28).
  • In 2003, 20 Statesxx had rates of suicide deaths that were higher than the national average, with a combined average rate of 15.6 per 100,000 population.
  • Five States—Oregon, Colorado, Indiana, Kentucky, and Texas—showed increases in their rate of suicide deaths from 1999 to 2003. Louisiana and Maine demonstrated decreases in their rates of suicide deaths during the same time period.
  • The State rates of suicide deaths per 100,000 population ranged from a low of 5.9 to a high of 21.8.

xix The States are Minnesota, Illinois, Ohio, Maryland, New York, New Jersey, Connecticut, Rhode Island, Massachusetts, and the District of Columbia.
xx The States are Alaska, Washington, Oregon, Nevada, Idaho, Montana, Utah, Arizona, Wyoming, Colorado, New Mexico, South Dakota, Kansas, Oklahoma, Arkansas, Indiana, Kentucky, Tennessee, Florida, and West Virginia.


Treatment: Receipt of Needed Treatment for Illicit Drug Use

Substance abuse is a medical problem that requires timely treatment not only because of its health effects but also because drug use is associated with other adverse effects such as physical and domestic violence. In addition, because overall health care costs may be reduced by effective substance abuse and mental health treatment,35, 36 appropriate receipt and completion of treatment have both clinical and economic implications.

Figure 2.29. People ages 12 and over who received needed treatment for illicit drug use, 2002-2004

Figure 2.29. People ages 12 and over who received needed treatment for illicit drug use, 2002-2004

Source: SAMHSA, National Survey on Drug Use and Health, 2002-2004.

Reference population: U.S. civilian noninstitutionalized population age 12 and older who needed treatment for any illicit drug use.

Note: Treatment refers to treatment at a specialty facility, such as a drug and alcohol inpatient and/or outpatient rehabilitation facility, inpatient hospital care, or a mental health center.

  • Overall, 17.7% of those who met criteria for needing treatment for illicit drug use actually received it in 2004. This rate has not changed significantly since 2002 (Figure 2.29).
  • Of people that needed treatment for illicit drug use in 2004, only 18.0% of adults ages 18-44 and 9.6% of children ages 12-17 received it. These rates remain statistically unchanged from 2002.
  • In all 3 data years, children ages 12-17 who needed illicit drug treatment were less likely than adults ages 18-44 to receive such treatment.
Treatment: Receipt of Treatment for Depression

Almost 10% of the U.S. population will have a major depressive episode in their lifetime. Treatment can be very effective in reducing symptoms and associated illnesses and returning individuals to a productive lifestyle.

Figure 2.30. Adults age 18-64 with a history of major depressive episode who received treatment for depression in the past year, 2004

Figure 2.30. Adults age 18-64 with a history of major depressive episode who received treatment for depression in the past year, 2004

Source: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2004.

Reference population: U.S. civilian noninstitutionalized population age 18 and older.

  • In 2004, 65.1% of adults ages 18-64 with a major depressive episode received treatment for depression (Figure 2.30).
  • Among adults who experienced a major depressive episode, those ages 45-64 (73.5%) were more likely than those ages 18-44 (59.5%) to receive treatment for depression.

Respiratory Diseases

Importance and Measures

Type of statistic Number
Mortality
Number of deaths due to lung diseases (2001) 231,54537
Number of deaths, influenza and pneumonia combined (2004) 61,4722
Cause of death rank, influenza and pneumonia combined (2004) 9th2
Prevalence
People 18 and over who have asthma, U.S. (2003) 14,358,00038
People under 18 with an asthma attack in past 12 months, U.S. (2003) 3,975,00039
Incidence
Annual number of cases of the common cold in the U.S. (est) >1 billion40
Annual number of pneumonia cases due to Streptococcus pneumoniae 500,00041
Cost
Total cost of lung diseases (2006 est.) $144.2 billion4
Direct medical costs of lung diseases (2006 est.) $87.0 billion4
Total approximate cost of upper respiratory infections (annual) $40 billion42
Total cost of asthma (2004) $27.6 billion37
Direct medical costs of asthma (2004) $11.5 billion37
Cost effectiveness of tobacco use screening and brief intervention cost saving5
Cost effectiveness of influenza immunization $0-$14,000/QALY5
Cost effectiveness of pneumococcal immunization cost saving5
Measures

The NHQR tracks several quality measures for prevention and treatment of this broad category of illnesses that includes influenza, pneumonia, asthma, upper respiratory infection, and tuberculosis. The five core report measures highlighted in this section are:

  • Pneumococcal vaccination.
  • Receipt of recommended care for pneumonia.
  • Receipt of antibiotics for the common cold.
  • Completion of tuberculosis therapy.
  • Hospital admissions for pediatric asthma.

In addition, this year's report includes four supplemental measuresxxi on asthma management from the National Asthma Survey:

  • Asthma management for long-term control.

xxi The supplemental measures are: counseling persons with asthma about recognizing early signs of an attack, counseling persons with asthma about changing their environment, use of a controller medication, and receipt of an asthma management plan.


Findings

Prevention: Pneumococcal Vaccination

Vaccination is a cost effective strategy for reducing illness and death associated with pneumococcal disease and influenza.

Figure 2.31. Noninstitutionalized adults age 65 and over who ever received pneumococcal vaccination, 1999-2004

Figure 2.31. Noninstitutionalized adults age 65 and over who ever received pneumococcal vaccination, 1999-2004

Source: National Center for Health Statistics, National Health Interview Survey, 1999-2004.

Reference population: Civilian noninstutionalized population age 65 and older.

Note: Age adjusted to the 2000 standard population.

  • The percentage of adults age 65 and over who ever received pneumococcal vaccination increased from 49.9% in 1999 to 57.0% in 2004. The Healthy People 2010 target is 90% and is unlikely to be met at this rate of change (Figure 2.31).

Figure 2.32. Adults age 65 and older who ever received pneumococcal vaccination, by State, 2003 and 2004

Figure 2.32. Adults age 65 and older who ever received pneumococcal vaccination, by State, 2003 and 2004

Source: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System, 2003 and 2004.

Reference population: Civilian noninstitutionalized population age 65 and older.

Key: Above average = Rate is significantly above the reporting States' average in both 2003 and 2004. Below average = State is significantly below reporting States' average in both 2003 and 2004.

Note: Age adjusted to the 2000 standard population. “Reporting States' average” is the weighted average of all reporting States (50 in this case, including the District of Columbia), which is a separate figure from the national average.

  • In 2003, the all-States average was 64.1%, with a range from 49.9% to 72.2%. In 2004, the reporting States' average was 63.7%, with a range from 51.3% to 71.5%.
  • Nine Statesxxii were significantly above the reporting States' average in both 2003 and 2004, with a combined average rate of 69.5% in 2004 (Figure 2.32).
  • Three Statesxxiii were significantly below the reporting States' average in both 2003 and 2004, with a combined average rate of 56.0% in 2004.
  • Three States—Washington, Minnesota, and Idaho—showed decreases between 2003 and 2004 in the number of adults age 65 and older who had ever received a pneumococcal vaccination. Only one State, Missouri, showed improvement on this measure over this time period.

xxii The States are Oregon, Montana, Wyoming, Colorado, North Dakota, Oklahoma, Minnesota, Iowa, and Rhode Island.
xxiii The States are Illinois, Kentucky, and the District of Columbia.


Treatment: Receipt of Recommended Care for Pneumonia

Recommended care for patients with pneumonia includes receipt of: (1) initial antibiotics within 4 hours of hospital arrival; (2) antibiotics consistent with current recommendations; (3) blood culture before antibiotics are administered; (4) influenza vaccination status assessment/vaccine provision; and (5) pneumonia vaccination status assessment/vaccine provision. The NHQR tracks receipt of this care for each measure and as an overall composite.

Figure 2.33. Medicare patients with pneumonia who received recommended care for pneumonia: overall composite and five components, 2002-2004

Figure 2.33. Medicare patients with pneumonia who received recommended care for pneumonia: overall composite and five components, 2002-2004

Source: Centers for Medicare & Medicaid Services, Medicare Quality Improvement Organization Program, 2002-2004.

Denominator: Medicare patients hospitalized with a principal diagnosis of pneumonia or a principal diagnosis of either septicemia or respiratory failure and secondary diagnosis of pneumonia.

  • The overall pneumonia composite measure shows improvement in the provision of recommended care for Medicare patients with pneumonia from 54.3% of the time in 2002 to 64.4% in 2004 (Figure 2.33).
  • All component measures showed improvement: antibiotics within 4 hours rose from 63.1% to 70.1%; proper antibiotics selection rose from 67.9% to 75.6%; blood culture before first antibiotics dose rose from 81.0% to 83.4%; influenza vaccination status assessment/vaccine provision rose from 27.7% to 43.1%; and pneumococcal vaccination status assessment/vaccine provision rose from 26.1% to 43.5%.
Treatment: Receipt of Antibiotics for the Common Cold

Prescription of antibiotics does not treat or relieve symptoms of the common cold, and may lead to the development of antibiotic-resistant bacteria. Although physicians are slowly improving their antibiotic prescribing patterns, overuse of antibiotics is still a concern.43 Children have the highest rates of antibiotic use and the highest rates of infection with antibiotic-resistant bacterial pathogens.44

Figure 2.34. Rate of antibiotic drug utilization at ambulatory care visits with a diagnosis of common cold per 10,000 population, 1997-2004

Figure 2.34. Rate of antibiotic drug utilization at ambulatory care visits with a diagnosis of common cold per 10,000 population, 1997-2004

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, 1997-1998, 1999-2000, 2001-2002, and 2003-2004.

Denominator: U.S. noninstitutionalized population.

  • In 2003-2004, the overall rate of antibiotics prescribed at visits with a diagnosis of the common cold stood at 142.4 per 10,000, above the Healthy People 2010 target of 126.8 per 10,000. However, if current trends continue, this target will be achieved before the year 2010 (Figure 2.34).
  • From 1997-1998 to 2003-2004, the rate of antibiotics prescribed at visits with a diagnosis of common cold decreased overall for persons of all ages and for children ages 0-17. The rate did not change significantly for adults ages 18-44 (data not shown) or for adults ages 45-64 (data not shown).
Treatment: Completion of Tuberculosis Therapy

In order to be effective for individuals as well as the public, tuberculosis therapy must be taken to its completion. Failure to complete tuberculosis therapy puts patients at increased risk for treatment failure and for spreading the disease to others. Even worse, it may result in the development of drug-resistant strains of the disease.45

Figure 2.35. Completion of tuberculosis therapy within 1 year, 1998-2002

Figure 2.35. Completion of tuberculosis therapy within 1 year, 1998-2002

Source: National TB Surveillance System.

Reference population: U.S. civilian noninstitutionalized population.

  • From 1998 to 2002, the rate of completion of tuberculosis therapy within 1 year rose from 79.1% to 80.9% (Figure 2.35).
  • Only adults ages 18-44 showed a significant increase in completion of tuberculosis therapy. The percentage for this group rose from 76.6% in 1998 to 79.7% in 2002.
  • In all 5 data years, children under age 18 were more likely than adults ages 18-44 to complete tuberculosis therapy within 1 year.
  • From 1998 to 2001, adults 65 and older were more likely than adults ages 18-44 to complete tuberculosis therapy within 1 year.
Management: Hospital Admissions for Pediatric Asthma

Asthma can be effectively controlled over the long term with recommended medications, depending on severity of the disease, routine checkups, education of patients, and use of asthma management plans. Preventing hospital admissions for asthma is one measure of successful management of asthma at the population level.

Figure 2.36. Pediatric hospital admissions for asthma per 100,000 population ages 0-17, 1994, 1997, and 2000-2003

Figure 2.36. Pediatric hospital admissions for asthma per 100,000 population ages 0-17, 1994, 1997, and 2000-2003

Source: Agency for Healthcare Research and Quality, HCUP Nationwide Inpatient Sample, 1994, 1997, and 2000-2003.

Denominator: Persons under 18.

Note: Rates are adjusted by age and gender, using the total U.S. population for 2000 as the standard population.

  • In 2003, there were 216.9 admissions for asthma per 100,000 children. This rate was not significantly different from the rate of 229.3 per 100,000 in 1994. (Figure 2.36).
Management: Asthma Management for Long-term Control

The National Asthma Education and Prevention Program, coordinated by the National Heart, Lung, and Blood Institute, produces clinical guidelines built around four essential components of asthma management critical for effective long-term control of the disease—assessment and monitoring, controlling factors contributing to symptom exacerbation, pharmacotherapy, and education for partnership in care.46 The National Asthma Survey, sponsored by CDC's National Center for Environmental Health, is the most comprehensive national data set on asthma prevalence and asthma care and collects information on the components of asthma management.

Figure 2.37. People with current asthma who reported they were taught to recognize early signs of an attack, who were instructed to change their environment to help control their asthma, who reported using a controller medication in the past 3 months, and who reported they received an asthma management plan, 2003

Figure 2.37. People with current asthma who reported they were taught to recognize early signs of an attack, who were instructed to change their environment to help control their asthma, who reported using a controller medication in the past 3 months, and who reported they received an asthma management plan, 2003

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, and National Center for Environmental Health, National Asthma Survey, 2003.

Reference population: People with current asthma, all ages.

Note: Controller medications include inhalers, pills, syrups, and nebulizers.

  • In 2003, the percentage of those with current asthma who reported they were taught to recognize the early signs of an attack was 69.7% (Figure 2.37).
  • In 2003, 48.8% of people with current asthma reported they were told how to change their environment to help control their asthma.
  • In 2003, 40.4% of those with current asthma reported using a controller medication in the past 3 months.
  • In 2003, 27.7% of people with current asthma reported receiving an asthma management plan.

Nursing Home, Home Health, and Hospice Care

Importance and Measures

Type of statistic Number
Demographics
Number of nursing home residents (1999) 1,600,00047
Number of home health patients (2000) 1,460,80048
Number of current hospice care patients 105,50049
Discharges from nursing homes (1998-1999) 2,500,00047
Discharges from home health agencies (2000) 7,800,10048
Discharges from hospice care (2000) 621,10049
Cost
Total cost of nursing home services (2004) $115.2 billion50
Total cost of home health services (2004) $43.2 billion50
Annual national expenditures for hospice care for decedents (1992-1996) $1.232 billion51
Percent of health care expenditures for hospice care in last 6 months of life 74%51
Measures

The NHQR tracks 14 measures of nursing home care. Care is tracked among both postacute and chronic care residents. Postacute care involves a short stay in a nursing home after a hospital stay and is, in turn, followed by the patient's return to their home. It is contrasted against chronic care, in which the patient is expected to stay in the nursing home for a longer period of time. The NHQR also tracks 12 measures for home health care that reflect improvement or deterioration during the course of care. Two core report measures in nursing home care and two core report measures in home health care are highlighted in this section:

  • Use of restraints among chronic care nursing home residents.
  • Presence of pressure ulcers among nursing home residents.
  • Improvement in ambulation in home health episodes.
  • Acute care hospitalization of home health patients.

This year for the first time, the NHQR also includes supplemental measures of quality of care for hospice patients. Hospice care is delivered at the end of life to patients with a terminal illness or condition requiring comprehensive medical care as well as psychosocial and spiritual support for the patient and family. The goal of end-of-life care is to achieve a “good death” defined by the Institute of Medicine as one that is “free from avoidable distress and suffering for patients, families, and caregivers; in general accord with the patient's and families' wishes; and reasonably consistent with clinical, cultural, and ethical standards.”52

The National Hospice and Palliative Care Organization's Family Evaluation of Hospice Care survey examines the quality of hospice care for dying patients and their family members. Family respondents report how well hospices respect patient wishes, communicate about illness, control symptoms, support dying on one's own terms, and provide family emotional support.xxiv, 53

The two supplemental measures presented here from the National Hospice and Palliative Care Organization's Family Evaluation of Hospice Care survey are:

  • Receipt of right amount of pain medicine
  • Receipt of care consistent with patient's stated end-of-life wishes

xxiv This survey provides unique insight into end-of-life care and captures information about a large proportion of hospice patients but is limited by non-random data collection and a response rate of about 40%. Survey questions were answered by family members of patients who might not be fully aware of the patients' wishes and concerns. These limitations should be considered when interpreting these findings.


Findings

Management: Use of Restraints Among Chronic Care Nursing Home Residents

A physical restraint is any device, material, or equipment that keeps a resident from moving freely. A resident who is restrained daily can become weak and develop other medical complications. The use of physical and pharmacological restraints can result in a variety of emotional, mental, and physical problems. According to regulations for the nursing home industry, restraints should be used only to ensure the physical safety of a nursing home resident. The Centers for Medicare & Medicaid Services encourage gradual restraint reduction because of the many negative outcomes associated with restraint use.

Figure 2.38. Chronic care nursing home residents with physical restraints, 1999-2004

Figure 2.38. Chronic care nursing home residents with physical restraints, 1999-2004

Source: Centers for Medicare & Medicaid Services, Minimum Data Set, 1999-2004. Data are from the third quarter of each calendar year.

Denominator: All chronic care residents in Medicare or Medicaid certified nursing and long-term care facilities.

  • The overall proportion of chronic care nursing home residents who are physically restrained decreased from 10.7% in 1999 to 7.3% in 2004 (Figure 2.38).
  • Decreases in the use of physical restraints were also observed for all age groups (data not shown).

Figure 2.39. Chronic care nursing home residents with physical restraints, by State, 2004 and 2005

Figure 2.39. Chronic care nursing home residents with physical restraints, by State, 2004 and 2005

Source: Centers for Medicare & Medicaid Services, Minimum Data Set, Nursing Home Compare, 2004 and 2005.

Denominator: All chronic care residents in Medicare or Medicaid certified nursing and long-term care facilities.

Key: Higher rate = State has rate in use of restraints higher than the all-States average in both 2004 and 2005. Lower rate = State has rate in use of restraints lower than the all-States average in both 2004 and 2005.

Note: The “All-States average” is the average of all reporting States (51 in this case, including the District of Columbia), which is a separate figure from the national average.

  • The all-States average on this measure improved between 2004 and 2005, dropping from 7.4% to 6.8% during this time period. There was considerable variation in this measure among States during both years. States ranged from a low of 1.9% to a high of 15.9% in 2004 and from 1.7% to 14.6% in 2005 (Figure 2.39).
  • Twenty-five Statesxxv outperformed the all-States average (i.e., less use of physical restraints in chronic care nursing home residents in both 2004 and 2005), with a combined average rate of 3.7% in 2005.
  • Twelve Statesxxvi had rates higher than the all-States average (i.e., greater use of restraints in both years), with a combined average rate of 11.0% in 2005.
  • From 2004 to 2005, 10 Statesxxvii showed decreases in the use of physical restraints with chronic care nursing home residents. No State showed an increase.

xxv The States are Hawaii, Washington, Montana, North Dakota, South Dakota, Nebraska, Kansas, Minnesota, Iowa, Wisconsin, Illinois, Michigan, Indiana, Alabama, Virginia, West Virginia, Delaware, Pennsylvania, New Jersey, New York, Vermont, New Hampshire, Rhode Island, Maine, and the District of Columbia.
xxvi The States are California, Utah, Arizona, Oklahoma, Arkansas, Louisiana, Tennessee, Mississippi, North Carolina, South Carolina, Georgia, and Florida.
xxvii The States are Idaho, Texas, Kansas, Connecticut, Georgia, Virginia, Wisconsin, Minnesota, Louisiana, and Ohio.


Management: Presence of Pressure Ulcers Among Nursing Home Residents

A pressure ulcer, or pressure sore, is an area of broken down skin caused by sitting or lying in one position for an extended period of time. Pressure sores can be painful, take a long time to heal, and cause other complications such as skin or bone infections. Pressure sores are classified into four stages (stages 1 through 4, with stage 4 being the most severe) according to the depth or type of tissue damage. The measures presented here include all four stages.

Figure 2.40. Postacute and chronic care nursing home residents with pressure ulcers, by type of resident, 1999-2004

Figure 2.40. Postacute and chronic care nursing home residents with pressure ulcers, by type of resident, 1999-2004

Source: Centers for Medicare & Medicaid Services, Minimum Data Set, 1999-2004.

Denominator: All residents in Medicare or Medicaid certified nursing and long-term care facilities.

  • There were improvements in pressure sore measures for all three types of residents between 1999 and 2004.
  • From 1999 to 2004, the rate of postacute care residents with pressure ulcers fell from 22.4% to 21.2% (Figure 2.40).xxviii For high-risk chronic care residents, the rate fell from 14.3% to 13.5%, and for low-risk chronic care residents, the rate fell from 2.8% to 2.7%.xxix
  • High-risk chronic care residents have a fivefold greater risk of having pressure sores than low-risk chronic care residents.

xxviii Postacute refers to residents who are admitted to a facility and stay fewer than 30 days; these admissions typically follow an acute-care hospitalization and involve high-intensity rehabilitation or clinically complex care.
xxix Chronic refers to residents who enter a nursing facility typically because they are no longer able to care for themselves at home; they tend to remain in the facility from several months to several years. High-risk residents are those who are in a coma, who do not get or absorb the nutrients they need, or who cannot move or change position on their own. Conversely, low-risk residents can be active, can change positions, and are getting and absorbing the nutrients they need.


Management: Improvement in Ambulation in Home Health Episodes

Improvement in ambulation/locomotion is demonstrated by an increase in the percentage of patients who improve walking or mobility with a wheelchair. Many patients receiving home health care may need help to walk safely. This assistance can come from another person or from equipment (such as a cane). Patients who use a wheelchair may have difficulty moving around safely; but if they can perform this activity with little assistance, they are more independent, self-confident, and active. In cases of patients with some neurological conditions, such as progressive multiple sclerosis or Parkinson's disease, ambulation may not improve even when the nursing home or home health service provides good care.

Figure 2.41. Home health episodes showing ambulation/locomotion improvement, 2002-2004

Figure 2.41. Home health episodes showing ambulation/locomotion improvement, 2002-2004

Source: Centers for Medicare & Medicaid Services, Outcome and Assessment Information Set (OASIS), 2002-2004.

Denominator: U.S. adult nonmaternity patients receiving home health care.

  • From 2002 to 2004, the proportion of home health episodesxxx showing improvement in ambulation/locomotion increased, from 33.9% to 37.2% (Figure 2.41).
  • The proportion of home health episodes showing ambulation/locomotion improvement also increased for every age group.

xxx An “episode” is the time during which a patient is under the direct care of a home health agency. It starts with the beginning/resumption of care and finishes when the patient is discharged or transferred to an inpatient facility. The same patient may be involved in multiple episodes.


Management: Acute Care Hospitalization of Home Health Patients

Improvement in acute care hospitalization is demonstrated by a decrease in the percentage of patients who had to be admitted to the hospital. Patients may need to go into the hospital while they are getting care. Depending on the severity of the patient's condition, this may not be avoidable even with good home health care.

Figure 2.42. Home health episodes with acute care hospitalization, 2002-2004

Figure 2.42. Home health episodes with acute care hospitalization, 2002-2004

Source: Centers for Medicare & Medicaid Services, Outcome and Assessment Information Set (OASIS), 2002-2004.

Denominator: U.S. adult nonmaternity patients receiving home health care.

  • In 2004, 27.9% of home health episodes ended in hospitalization (Figure 2.42).
  • Between 2002 and 2004, the rate remained stable for the entire population and for every age group.
  • In all 3 data years, home health patients under 65 years of age were more likely than patients 65-74 to require hospitalization. This may be related to the fact that home health patients under the age of 65 tend to have different characteristics, such as greater degrees of disability and illness.
Management: Receipt of Right Amount of Pain Medicine by Hospice Patients

Addressing the comfort aspects of care, such as relief from pain, fatigue, and nausea, is an important component of hospice care.xxxi

Figure 2.43. Hospice patients age 18 and older who did not receive the right amount of medicine for pain, by age group, 2005

Figure 2.43. Hospice patients age 18 and older who did not receive the right amount of medicine for pain, by age group, 2005

Source: National Hospice and Palliative Care Organization Family Evaluation of Hospice Care, 2005.

Denominator: Adult hospice patients.

  • The proportion of hospice patients whose families reported that they did not receive the right amount of medicine for pain was 5.9% in 2005 (Figure 2.43).
  • Families of hospice patients ages 18-44 and ages 45-64 were more likely to report the patient did not receive the right amount of pain medicine (8.3% and 6.2%, respectively) compared with families of patients age 65 and older (4.9%).

xxxi This measure is based on responses from a family member of the deceased. In interpreting it, it should be noted that family members may or may not be able to determine whether the right amount of medicine for pain was administered.


Management: Receipt of Care Consistent With Patient's Stated End-of-Life Wishes

End-of-life care should respect a patient's stated end-of-life wishes. This includes shared communication and decisionmaking between providers and hospice patients and their family members and respect of cultural beliefs.

Figure 2.44. Hospice patients age 18 and older who did not receive care consistent with their stated end-of-life wishes, by age group, 2005

Figure 2.44. Hospice patients age 18 and older who did not receive care consistent with their stated end-of-life wishes, by age group, 2005

Source: National Hospice and Palliative Care Organization Family Evaluation of Hospice Care, 2005.

Denominator: Adult hospice patients.

  • The proportion of hospice patients whose families reported that they did not receive end-of-life care consistent with their stated wishes was 5.5% in 2005 (Figure 2.44).
  • Families of hospice patients ages 18-44 were more likely and families of patients ages 45-64 were less likely than families of patients age 65 and older to report patients did not receive end-of-life care consistent with their stated wishes.

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