Chapter 2. Quality of Health Care (continued, 2)

National Healthcare Disparities Report, 2008

Effectiveness (continued) 

Mental Health and Substance Abuse

Type of statisticNumber
Highest cause of death rank-suicide (2005)11th4
Adults age 18 and over with any mental disorder or substance disorder in past year (2001-2003)32.4%44, x
Alcohol-related motor vehicle deaths (2006)17,60245
People age 12 and over with alcohol and/or illicit drug dependence or abuse (2006)22.6 million (9.2%)46
Adults age 18 and over with serious psychological distress (2006)24.9 million 46
Youths ages 12-17 with a major depressive episode during the past year (2006)2.0 million (7.9%)46
Adults age 18 and over with a major depressive episode during the past year (2006)15.8 million (7.2%)46
Adults with history of major depressive disorder (2006)30.4 million (13.9%)46
Total medical expenditures for substance abuse and mental disorders (2003 est.)$121 billion47
Cost effectiveness of problem drinking screening and brief counseling$14,000-$35,000/QALY7

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

In 2004, almost one-fourth of all stays in U.S. community hospitals for patients age 18 and over—7.6 million of nearly 32 million stays—involved mental disorders such as depression, bipolar disorder, schizophrenia, and substance use-related disorders.48 In a cross-national survey of adults in 14 countries (8 developed, 6 less developed) conducted from 2001 to 2003, the United States had the highest rate of any mental disorders, including substance abuse.49,x The 12month prevalence of anxiety disorders in the United States in 2001-2003 was 19.1%; mood disorders, 9.7%; impulse control disorder, 10.5%; and any substance disorder (including drug abuse, alcohol abuse, and nicotine dependencexi), 13.4%.

Socioeconomic factors and cultural factors can affect mental health. For example, poverty is both a risk factor for poor mental health and can be a consequence of poor mental health. Low-income individuals may be more likely to receive needed substance abuse treatment due to linkages in service delivery between substance abuse and public assistance services in many States.


x To some extent, this finding may be attributable to cross-national differences in how people respond to the mental health assessment tool used.
xi Nicotine dependence is a physical addiction to nicotine when delivered by various tobacco products.


Culturally and linguistically appropriate services can decrease the prevalence, incidence, severity, and duration of certain mental disorders. However, many factors adversely affect the mental health of racial and ethnic groups and present significant barriers to treatment. These include cost of care, social stigma, fragmented organization of services, discrimination,xii racism, and mistrust. One way to help meet the needs of racial and ethnic populations is to engage representatives from the community being served in the design, planning, and implementation of services. Providing services to meet the cultural and linguistic needs of more diverse populations may demand more of an initial investment than continuing services as usual. To date, there are no cost-effectiveness studies that provide information on the benefits of providing or failing to provide culturally and linguistically appropriate services.50

In rural and remote areas, many people with mental illnesses have inadequate access to care, limited availability of skilled care providers, lower family incomes, and greater societal stigma for seeking mental health treatment than their urban counterparts. In addition, rural Americans are less likely to have private health insurance benefits for mental health care. Lack of coverage often occurs because small employers and individual purchasers dominate the rural health insurance marketplace. Therefore, insurance policies are more likely to have limited or no mental health coverage. For racial and ethnic populations in rural areas, these problems are compounded by the dearth of culturally and linguistically competent providers. Finally, of the 1,669 federally designated mental health professional shortage areas, more than 85% are rural areas.51

Treatment: Receipt of Needed Treatment for Illicit Drug Use

Illicit drugxiii use is a medical problem that can have a direct toxic effect on a number of body organs, as well as exacerbate numerous health and mental health conditions. Treatment for illicit drug use at a specialty facility is an effective way to reduce the chances of future illicit drug use.


xiiThe Office for Civil Rights (OCR) (http://www.hhs.gov/ocr/) is the sole agency with the authority to enforce Title VI of the Civil Rights Act of 1964, 42 U.S.C. 2000d, which prohibits discrimination based on race, color, or national origin in programs and activities that receive Federal financial assistance, including most health care providers and human service agencies. Individuals and advocacy groups may file complaints with OCR to remedy such discrimination.

xiiiIllicit drugs included in this measure are marijuana/hashish, cocaine (including crack), inhalants, hallucinogens, heroin, and prescription-type psychotherapeutic drugs (nonmedical use).


Figure 2.20. People age 12 and over who needed treatment for illicit drug use and who received such treatment at a specialty facility in the last 12 months, by race (top left), ethnicity (top right), income (bottom left), and education (bottom right), 2003-2006.

Trend line chart. Healthy People 2010 Target: 24%. Race; 2003, Total, 15.0%, White, 14.0%, Black, 21.1%, AI/AN, NA; 2004, Total, 17.7%, White, 15.8%, Black, 26.2%, AI/AN, 5.8%. 2005, Total, 17.0%, White, 15.6%, Black, 24.7%, AI/AN, N/A; 2006, Total, 20.3%, White, 19.6%, Black, 25.8%, AI/AN: N/A. Ethnicity; 2003, Non-Hispanic White, 15.3%, Hispanic, 8.4%; 2004, Non-Hispanic White, 16.4%, Hispanic, 12.7%; 2005, Non-Hispanic White, 14.9%, Hispanic, 19.4%; 2006, Non-Hispanic White, 19.2%, Hispanic, 24%.

Family income; 2003, Poor, 22.3%, Near Poor, 15.8%, Middle income, 15.8%, High income, 13.5%; 2004, Poor, 25.2%, Near Poor, 21.7%, Middle income, 18.0%, High income, 12.3%; 2005, Poor, 23.7%, Near Poor, 13.1%, Middle income, 17.3%, High income, 16.1%; 2006, Poor, 30.8%, Near Poor, 22.7%, Middle income, 19.1%, High income, 16.5%. Education; 2003, Less than high school, 19%, High school grad, 18%, Some college, 13%, ; 2004, Less than high school, 25%, High school grad, 22%, Some college, 14%; 2005, Less than high school, 22%, High school grad, 19%, Some college, 14%; 2006, Less than high school, 32%, High school grad, 22%, Some college, 16%.

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

Source: Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2006.

Reference population: U.S. population age 12 and over who needed treatment for illicit drug use in the past year.

Note: Estimates by education were available only for persons age 18 and over. "Received illicit drug treatment at a specialty facility" refers to treatment received at a hospital (inpatient), rehabilitation facility (inpatient or outpatient), or mental health center to reduce or stop the nonmedical use of prescription-type psychotherapeutic drugs or for medical problems associated with drug use. Respondents were classified as needing treatment for an illicit drug problem if they met at least one of these three criteria during the past year: (1) dependent on any illicit drug; (2) abuse of any illicit drug; or (3) received treatment for an illicit drug problem at a specialty facility (drug and alcohol rehabilitation facilities [inpatient or outpatient], hospitals [inpatient only], and mental health centers). Data were insufficient for this analysis for Asians, Native Hawaiians and Other Pacific Islanders, and American Indians and Alaska Natives.

  • From 2003 to 2006, the gap between Blacks and Whites decreased. In 2006, the disparity was eliminated between these groups in the percentage of people age 12 and over who needed treatment for illicit drug use and received it at a specialty facility in the past year (Figure 2.20); there was no statistically significant difference.
  • From 2003 to 2006, the gap between Hispanics and non-Hispanic Whites decreased. In 2006, the disparity between these groups in those who needed and received treatment for illicit drug use was eliminated; there was no statistically significant difference.
  • From 2003 to 2006, the gap between poor and high-income people remained the same. In 2006, a higher percentage of poor people needed and received treatment for illicit drug use than high-income people (30.8% compared with 16.5%).
  • From 2003 to 2006, the gap between people with less than a high school education and people with some college education decreased. In 2006, people with less than a high school education who needed treatment were significantly more likely to receive treatment for illicit drug use than people with some college education (31.7% compared with 15.9%).
  • In 2006, Blacks, Hispanics, poor people, and people with less than a high school education achieved the Healthy People 2010 target of 24% of people age 12 and over who needed treatment for illicit drug use actually receiving such treatment.

Treatment: Receipt of Treatment for Depression

Treatment for depression is an effective way to reduce the chances of future major depressive episodes. However, many people face significant barriers to treatment for depression, such as cost of care, societal stigma, and fragmented organization of services.50

Figure 2.21. Adults with a major depressive episode in the last 12 months who received treatment for depression in the last 12 months, by race, ethnicity, income, and education, 2006.

bar charts. percent. Total, 69.1%; White, 71.1%; Black, 58.9%; Non-Hispanic White, 73.3%; Hispanic, 51.8%; Poor , 66.3%; Low income, 67.8%; Middle Income, 69.9% ; High Income, 71.3%; < High School, 65.7%; High School Grad, 67.7%; At least some college, 71.1%.

Source: Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2006.

Reference population: U.S. population age 18 and over who had a major depressive episode in the past year.

Note: Major depressive episode is defined as a period of at least 2 weeks when a person experienced a depressed mood or loss of interest or pleasure in daily activities and had a majority of the symptoms for depression described in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSMIV). Treatment for depression is defined as seeing or talking to a medical doctor or other professional or using prescription medication in the past year for depression. Data were insufficient for this analysis for Asians, Native Hawaiians and Other Pacific Islanders, and American Indians and Alaska Natives.

  • The percentage of adults with a major depressive episode in the last 12 months who received any treatment for depression in the last 12 months was significantly lower for Blacks than for Whites (58.9% compared with 71.1%) and lower for Hispanics than for non-Hispanic Whites (51.8% compared with 73.3%; Figure 2.21).
  • There were no statistically significant differences by income level or education level for this measure.

 

Treatment: Receipt of Minimally Adequate Treatment for Mental Disorders

Receipt of any treatment for a major depressive episode is a relatively low standard against which to assess quality of mental health care. The Collaborative Psychiatric Epidemiology Surveys (CPES) allow more detailed examination of mental health care. The CPES join together three nationally representative surveys, the National Comorbidity Survey Replication (NCSR), the National Survey of American Life (NSAL), and the National Latino and Asian American Study (NLAAS). Together, these surveys provide national estimates of mental disorders and mental health care for majority and minority populations in the United States in much greater detail than other data sources.

To better assess quality of mental health care, a higher standard of care, minimally adequate treatment, has been specified using the CPES. This measure defines minimally adequate treatment as pharmacotherapy, including at least 60 days of an appropriate medication and 4 visits to a physician; or psychotherapy, including at least 8 visits to a health care or human services professional lasting an average of 30 minutes or more.52

Figure 2.22. Adults with a mood, anxiety, or impulse control disorder in the last 12 months who received minimally adequate treatment, by race/ethnicity, income, and education, 2001-2003.

Total, 29.4%; White, 32.3%; Black, 22.8%; Hispanic, 9%; Poor , 33.6%; Low income, 27.3%; Middle Income, 26.5%; High Income, 31.2%; < High School, 21.8%; High School Grad, 25.5%; Some college, 34.2%

Source: National Institute of Mental Health, Collaborative Psychiatric Epidemiology Surveys, 2001-2003.

Reference population: U.S. population age 18 and over who had a mood, anxiety, or impulse control disorder in the past year.

Note: White and Black are non-Hispanic groups. Data for Asians and Pacific Islanders and American Indians and Alaska Natives were not statistically reliable for this analysis. The Composite International Diagnostic Interview (CIDI) was used to make psychiatric diagnoses consistent with the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSMIV). "Minimally adequate treatment" is defined as at least 60 days of an appropriate medication and 4 visits to a physician OR at least 8 visits to a health care or human services professional lasting an average of 30 minutes or more in the past year.

  • Nearly 30% of adults with mood, anxiety, or impulse control disorders received minimally adequate treatment (Figure 2.22).
  • The percentage of adults who received minimally adequate treatment was lower among Blacks and Hispanics compared with Whites, with Hispanics having the lowest percentage of all groups.
  • The percentage of adults who received minimally adequate treatment was also lower among individuals with less than a high school education and high school graduates compared with those with some college education.
  • There were no statistically significant differences by household income for this measure.

Respiratory Diseases

Type of statisticNumber
Number of deaths due to lung diseases (2004)226,37953
Number of deaths, influenza and pneumonia combined (2005)63,0014
Cause of death rank, influenza and pneumonia combined (2005)8th4
People age 18 and over with current asthma (2006)16 million54
People under age 18 with an asthma attack in past 12 months (2004)5.9 million55
Annual number of cases of the common cold (est.)>1 billion56
Number of discharges attributable to pneumonia (2003 est.)1.4 million57
Total cost of lung diseases (2007 est.)$153.6 billion6
Direct medical costs of lung diseases (2007 est.)$94.8 billion6
Total approximate cost of upper respiratory infections (annual)$40 billion58
Total cost of asthma (2007)$19.7 billion53
Direct medical costs of asthma (2007)$14.7 billion53
Cost effectiveness of influenza immunization$0-$ 14,000/QALY7

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

Prevention: Pneumococcal Vaccination

Vaccination is an effective strategy for reducing illness, death, and disparities associated with pneumococcal disease and influenza.59,60

Figure 2.23. Adults age 65 and over who ever received pneumococcal vaccination, by race (top left), ethnicity (top right), and income (bottom left), 1999-2006.

Trend line charts. Healthy People 2010 Target: 90%. Race: White, 1999, 51.9%, 2000, 55.8%, 2001, 56.7%, 2002, 58.8%, 2003, 57.9%, 2004, 59.2%, 2005, 58.4%, 2006, 59.9%; Black, 1999, 32.9%, 2000, 30.9%, 2001, 33.7%, 2002, 37.4%, 2003, 37.2%, 2004, 39.2%, 2005, 40.4%. 2006, 36.8%; asian, 1999, 41.5%, 2000, 42.2%, 2001, 28.2%, 2002, 32.5%, 2003, 35.4%, 2004, 34.7%, 2005, 37.0%, 2006, 37.8%. Ethnicity; Non-Hispanic White 1999, 53.2%, 2000, 56.9%, 2001, 57.9%, 2002, 60.4%, 2003, 59.6%, 2004, 60.9%, 2005, 60.5%, 2006, 61.9%; Hispanic, 1999, 28.6%, 2000, 30.5%, 2001, 33%, 2002, 27.6%, 2003, 31.5%, 2004, 34.1%, 2005, 29.0%, 2006, 33.2%.

Poor, 1999, 40.4%, 2000, 40.3%, 2001, 43%, 2002, 42.6%, 2003, 47.6%, 2004, 42.3%, 2005, 45.8%, 2006, 45.1%; Near Poor, 1999, 46.1%, 2000, 51%, 2001, 50.7%, 2002, 53.8%, 2003, 56.2%, 2004, 54.9%, 2005, 53.5%, 2006, 55%; Middle Income, 1999, 52.9%, 2000, 56.1%, 2001, 57.5%, 2002, 59.4%, 2003, 58%, 2004, 61.3%, 2005, 60.8%, 2006, 60%; High Income, 1999, 53.2%, 2000, 58.5%, 2001, 57.8%, 2002, 60.6%, 2003, 56%, 2004, 61.1%, 2005, 57.3%, 2006, 60.9%.

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 1999-2006.

Reference population: Civilian noninstitutionalized population age 65 and over.

Note: Data were insufficient for this analysis for Native Hawaiians and Other Pacific Islanders and for American Indians and Alaska Natives (go to Chapter 4 for data for Native Hawaiians and Other Pacific Islanders).

  • From 1999 to 2006, the overall percentage of adults age 65 and over who had received pneumococcal vaccination improved significantly, from 49.9% to 57.3% (data not shown). Improvements were observed for Whites, Hispanics (Figure 2.23), and people with less than a high school education (data not shown).
  • The gap between Blacks and Whites increased. In 2006, the percentage of adults age 65 and over who ever had pneumococcal vaccination was significantly lower for Blacks than for Whites (36.8% compared with 59.9%).
  • From 1999 to 2006, the gap between Hispanics and non-Hispanic Whites decreased. However, in 2006, the percentage of Hispanic adults age 65 and over who ever had pneumococcal vaccination was still about half that of non-Hispanic Whites (33.2% compared with 61.9%).
  • The gap between poor and high-income people remained the same. In 2006, the percentage was significantly lower for poor older adults than for high-income older adults (45.1% versus 60.9%).
  • In 2006, as in 2005, no group achieved the Healthy People 2010 target of 90% of adults age 65 and over having received pneumococcal vaccination.

Racial and ethnic minorities are disproportionately of lower SES. To distinguish the effects of race, ethnicity, income, and education on pneumococcal vaccination, this measure is stratified by income and education level.

Figure 2.24. Adults age 65 and over who ever received pneumococcal vaccination, by race (left) and ethnicity (right), stratified by income, 2006.

Bar chart by race. White: Income: Poor, 48.4; Near poor, 58; Middle income, 61.5; High Income, 63.2; Black; Poor, 38.6; Near poor, 36.4; Middle income, 41.5; High Income, 32.7. Bar chart by ethnicity. Non-Hispanic White: Poor, 54.8; Near poor, 60.5; Middle income, 62.5; High Income, 64.1; Hispanic: Poor, 24.2; Near poor, 31; Middle income, 41.7; High Income: No data.

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2005.

Reference population: Civilian noninstitutionalized population age 65 and over.

Note: Age adjusted to the 2000 U.S. standard population. Data were insufficient for this analysis for Asians, Native Hawaiians and Other Pacific Islanders, American Indians and Alaska Natives, and high-income Hispanics.

Figure 2.25. Adults age 65 and over who ever received pneumococcal vaccination, by race (left) and ethnicity (right), stratified by education, 2006.

Bar chart by race. White: Less than high school, 50.6, High school, 62.9, At least some college, 63.8; Black, Less than high school, 31.8, High school, 37.3, At least some college, 48.5. Ethnicity, Non-Hispanic White: Less than high school, 56, High school, 63.3, At least some college, 64.4; Hispanic: Less than high school, 23.1, High school, 51.9, At least some college, 46.1.

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2006.

Reference population: Civilian noninstitutionalized population age 65 and over.

Note: Age adjusted to the 2000 standard population. Data were insufficient for this analysis for Asians, Native Hawaiians or Other Pacific Islanders, and American Indians and Alaska Natives.

  • With the exception of the poor group, Blacks at all income levels were less likely than Whites of the same income level to ever have had a pneumococcal vaccination (Figure 2.24). High-income Blacks were almost half as likely as Whites of the same income level to receive this preventive care.
  • Hispanics at all income levels were less likely than non-Hispanic Whites of the same income level to have ever had a pneumococcal vaccination. Poor Hispanics were less than half as likely as Whites of the same income level to receive this preventive care.
  • With the exception of Hispanic high school graduates, Blacks and Hispanics at all education levels were less likely than Whites to have ever had a pneumococcal vaccination (Figure 2.25).

Treatment: Receipt of Recommended Hospital Care for Pneumonia

The elderly are at high risk for pneumonia. The highest rate of hospitalizations for pneumonia occurs in the population 65 and over—220.4 per 10,000 population for this group in 2004, compared with 45.5 per 10,000 for the overall population.57 The Centers for Medicare & Medicaid Services tracks a set of measures for quality of pneumonia care for hospitalized patients from the CMS Quality Improvement Organization (QIO) program. This set of measures has been adopted by the Hospital Quality Alliance (HQA).

Figure 2.26. Composite measure; Hospital patients with pneumonia who received recommended hospital care, by race/ethnicity, Medicare only, 2002-2004 (left) and All payer, 2005-2006 (right).

2002-2004 trend line chart by race/ethnicity. Total, 2002, 54.3%, 2003, 59.0%, 2004, 64.4%, White, 2002, 55.1%, 2003, 59.9%, 2004, 65.6%, Black, 2002, 47.6%, 2003, 52.3%, 2004, 58.2%, Asian, 2002, 56.1%, 2003, 56.7%, 2004, 61.1%, AI/AN, 2002, 54.7%, 2003, 57.8%, 2004, 62.8%, Hispanic, 2002, 45.3%, 2003, 58.5%, 2004, 54.5%. 2005, Total, 74.1, White, 74.6, Black, 69.5, Asian, 68.7, AI/AN, 73.3, Hispanic, 66.2; 2006, Total, 80.4, White, 81.5, Black, 76.9, Asian, 75.8, AI/AN, 76.8, Hispanic, 74.2.

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

Source: Centers for Medicare & Medicaid Services, Quality Improvement Organization program, 2002-2006.

Denominator: Patients with pneumonia who are hospitalized, all ages.

Note: Whites, Blacks, Asians, and AI/ANs are non-Hispanic groups. Composite includes the following five measures: (1) receipt of antibiotics within 4 hours, (2) receipt of appropriate antibiotics, (3) receipt of blood culture before antibiotics, (4) receipt of influenza screening (i.e., person is assessed as to whether he or she would be a good candidate for vaccination) or vaccination, and (5) receipt of pneumococcal screening or vaccination. Composite is calculated by averaging the percentage of opportunities for care in which the patient received all five incorporated components of care. For further details on composite measures, go to Chapter 1, Introduction and Methods. The denominator used to calculate these measures was refined in 2005 to exclude patients with health care-associated pneumonia. The percentage of Medicare beneficiaries with blood cultures within 24 hours of hospital arrival was changed to include in the denominator only patients who were admitted to the intensive care unit within 24 hours of hospital arrival.

  • In all 3 years, from 2002 to 2004, the percentage of patients with pneumonia who received recommended hospital carexiv was significantly lower for Blacks and Hispanics compared with Whites (Figure 2.26). In 2004, the percentage was also significantly lower for Asians compared with Whites.
  • In 2006, the percentage was lower for Blacks (76.9%), Asians (75.8%), and Hispanics (74.2%) than for Whites (81.5%) (Figure 2.26).
  • From 2002 to 2004 and from 2005 to 2006, the percentage of patients with pneumonia who received recommended hospital care improved significantly for the total population and for all racial and ethnic groups.

xiv "Recommended hospital care" is a composite of five separate measures. (The note for Figure 2.26 lists these measures.) For further details on composite measures, go to Chapter 1, Introduction and Methods.


Management: Daily Asthma Medication

Improving quality of care for people with asthma can reduce the occurrence of asthma attacks and avoidable hospitalizations. The National Asthma Education and Prevention Program, coordinated by the National Heart, Lung, and Blood Institute, develops and disseminates science-based guidelines for the diagnosis and management of asthma.61 These recommendations are built around four essential components of asthma management critical for effective long-term control of asthma: assessment and monitoring, control of factors contributing to symptom exacerbation, pharmacotherapy, and education for partnership in care.62

Daily long-term control medication is necessary to prevent exacerbations and chronic symptoms for all patients with persistent asthma. Appropriate controller medications for people with mild persistent asthma63,xv include inhaled corticosteroids, cromolyn, nedocromil, theophylline, and leukotriene modifiers.64


xv"Mild persistent asthma" refers to cases in which people experience asthma symptoms more than 2 days per week, more than 2 nights per month, and other clinical indicators.


Figure 2.27. People with current asthma who are now taking preventive medicine daily or almost daily (either oral or inhaler), by race (top left), ethnicity (top right), income (bottom left), and education (bottom right), 2003-2005.

Trend line charts. Race: Total, 2003, 30.1%, 2004, 30.3%, 2005, 32.2%; White, 2003, 30.4%, 2004, 31.1%, 2005, 34% Black, 2003, 29.4%, 2004, 31.8%, 2005, 27.4%; Non-Hispanic White, 2003, 30.8%, 2004, 31.8%, 2005, 35.9%; Hispanic, 2003, 28%, 2004, 27.4%, 2005, 21.1%.

Trend line chart by income. Poor, 2003, 26%, 2004, 29.4%, 2005, 27.1%; Low income, 2003, 26.5%, 2004, 28.6%, 2005, 29.3%; Middle Income, 2003, 29.2%, 2004, 27.1%, 2005, 30.1%; High Income, 2003, 35.7%, 2004, 34.8%, 2005, 38.5%. Education: Less than high school, 2003, 25.4%, 2004, 27.1%, 2005, 28.3%; High School, 2003, 29.4%, 2004, 28.8%, 2005, 33%; Some college, 2003, 34%, 2004, 30.8%, 2005, 34.5%.

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

Reference population: Noninstitutionalized population with asthma as defined below.

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2003-2005.

Note: People with current asthma are defined as people who report they either still have asthma or had an episode or attack in the last 12 months. Data were insufficient for Asians, Native Hawaiians and Other Pacific Islanders, and American Indians and Alaska Natives for this analysis.

  • From 2003 to 2005, there were no statistically significant changes over time in the percentage of people with current asthma who are taking daily preventive medicine for any group except for non-Hispanic Whites (Figure 2.27).
  • From 2003 to 2005, the gap between Blacks and Whites remained the same. In 2005, Blacks with current asthma were less likely than Whites with current asthma to take daily preventive medicine (27.4% compared with 34.0%).
  • From 2003 to 2005 the gap between Hispanics and non-Hispanic Whites increased. In 2005, Hispanics with current asthma were less likely than non-Hispanic Whites with current asthma to take daily preventive medicine (21.1% compared with 35.9%).
  • From 2003 to 2005, there were no statistically significant changes overall by income or education status in the percentage of people with current asthma who took daily preventive medicine (Figure 2.26).
  • In 2005, people with current asthma who were poor (27.1%), low income (29.3%), and middle income (30.1%) were less likely than high-income people (38.5%) to take daily preventive medicine.
  • There were no statistically significant differences by education status in 2005.

 

Nursing Home, Home Health, and Hospice Care

Type of statisticNumber
Number of nursing home residents ever admitted during the calendar year (2006)3,176,11965
Medicare fee-for-service (FFS) admissions to skilled nursing facilities (2005)2,543,13366
Number of Medicare FFS home health patients (2006)3,031,81467
Number of Medicare FFS beneficiaries using Medicare hospice services (2006)935,56568
Total cost of nursing home care (2006)124.9 billion69
Medicare expenditures for nursing home care (2006)$20.8 billion69
Total cost of home health care (2006)$52.7 billion69
Medicare expenditures for home health care (2006)$19.8 billion69
Medicare FFS payments for hospice services (2006)9.2 billion%70

Note: Statistics may vary from previous years due to revised and updated source statistics or addition of new data sources. Cost estimates for nursing home and home health services include costs only for free-standing skilled nursing facilities, nursing homes, and home health agencies, and not facilities that are hospital based.

This section highlights two core measures of nursing home quality of care—use of physical restraints and presence of pressure sores—and two measures of home health care quality—improvement in walking or moving around and episodes with acute care hospitalization. In addition, this section includes supplemental measures on management of pain in hospice care, receipt of care consistent with patient's stated end-of-life wishes, and referral to hospice at the right time.

Management: Use of Physical Restraints on Nursing Home Residents

Although restraining nursing home residents is sometimes a component of keeping residents safe and well cared for, residents who are restrained daily can become weak, lose their ability to go to the bathroom by themselves, and develop pressure sores or other medical complications. Restraints should be used only when they are necessary as part of the medical treatment.

Figure 2.28. Long-stay nursing home residents with physical restraints, by race/ethnicity, 1999-2006.

Race: Total, 1999, 10.7%, 2000, 10.4%, 2001, 10.3%, 2002, 9.3%, 2003, 7.8%, 2004, 7.3%, 2005, 6.6%, 2006, 6.0% White, 1999, 10.6%, 2000, 10.3%, 2001, 10.2%, 2002, 9.2%, 2003, 7.8%, 2004, 7.2%, 2005, 6.6%, 2006, 6.0% Black, 1999, 10.1%, 2000, 9.7%, 2001, 9.3%, 2002, 8.5%, 2003, 6.9%, 2004, 6.4%, 2005, 5.8%, 2006, 5.4% API, 1999, 15.7%, 2000, 15.3%, 2001, 15.1%, 2002, 13.1%, 2003, 10.2%, 2004, 10.6%, 2005, 9.8%, 2006, 9.1% AI/AN, 1999, 10.2%, 2000, 10.5%, 2001, 10.3%, 2002, 9.4%, 2003, 7.6%, 2004, 7.9%, 2005, 7.7%, 2006, 6.9% Hispanic, 1999, 15.4%, 2000, 15.1%, 2001, 14.6%, 2002, 13.5%, 2003, 10.7%, 2004, 9.5%, 2005, 8.7%, 2006, 8.1%

Key: AI/AN = American Indian or Alaska Native; API = Asian or Pacific Islander.

Source: Centers for Medicare & Medicaid Services, Minimum Data Set, 1999-2006. Data are from the third quarter of each calendar year.

Denominator: Long-stay nursing home residents, all ages.

Note: White, Black, API, and AI/AN are non-Hispanic groups. Long-stay residents are persons in an extended/permanent nursing home stay.

  • From 1999 to 2006, the percentage of residents who were physically restrained decreased from 10.7% to 6.0% (Figure 2.28).
  • From 1999 to 2006, the gap between APIs and Whites in the percentage of residents who were physically restrained decreased. However, in 2006 the percentage of residents who were physically restrained was higher for APIs than for Whites (9.1% compared with 6.0%).
  • From 1999 to 2006, the gap between Hispanics and Whites decreased. However, in 2006, the percentage of residents who were physically restrained was still higher for Hispanics than for Whites (8.1% compared with 6.0%).

Management: Presence of Pressure Sores in 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 time. Residents should be assessed by nursing home staff for presence or risk of developing pressure sores. Nursing homes can help to prevent or heal pressure sores by keeping residents clean and dry and by changing their position frequently or helping them move around, making sure residents get proper nutrition, and using soft padding to reduce pressure on the skin. However, some residents may get pressure sores even when a nursing home provides good preventive care.

Figure 2.29. High-risk, long-stay nursing home residents (left), and short-stay residents (right) with pressure sores, by race/ethnicity, 1999-2006.

Trend line chart. Total, 1999, 14.3%, 2000, 13.9%, 2001, 13.8%, 2002, 13.7%, 2003, 13.9%, 2004, 13.5%, 2005, 13.1%, 2006, 12.5%; White, 1999, 13.8%, 2000, 13.3%, 2001, 13.2%, 2002, 13.1%, 2003, 13.3%, 2004, 12.9%, 2005, 12.5%, 2006, 11.9%; Black, 1999, 18.1%, 2000, 17.6%, 2001, 17.7%, 2002, 17.5%, 2003, 17.3%, 2004, 16.8%, 2005, 16.7%, 2006, 16.3%; API, 1999, 12.4%, 2000, 12.5%, 2001, 12.2%, 2002, 12.1%, 2003, 12.1%, 2004, 11.2%, 2005, 11.4%, 2006, 11.3%; AI/AN, 1999, 16.1%, 2000, 16.9%, 2001, 15.4%, 2002, 15.5%, 2003, 16.7%, 2004, 15.5%, 2005, 13.4%, 2006, 14.4% ; Hispanic, 1999, 15.6%, 2000, 15.2%, 2001, 15.4%, 2002, 15.1%, 2003, 14.8%, 2004, 14.6%, 2005, 14.2%, 2006, 13.5% Pressure sores; Total, 1999, 23.4%, 2000, 22.6%, 2001, 22.0%, 2002, 21.6%, 2003, 21.7%, 2004, 21.2%, 2005, 20.7%, 2006, 20.1%; White, 1999, 22.7%, 2000, 21.8%, 2001, 21.4%, 2002, 21.0%, 2003, 21.1%, 2004, 20.6%, 2005, 20.2%, 2006, 19.6%; Black, 1999, 29.4%, 2000, 28.2%, 2001, 27.3%, 2002, 26.5%, 2003, 25.8%, 2004, 25.0%, 2005, 24.5%, 2006, 23.8%; API, 1999, 24.1%, 2000, 23.0%, 2001, 22.3%, 2002, 22.5%, 2003, 21.7%, 2004, 22.7%, 2005, 22.2%, 2006, 22.3%; AI/AN, 1999, 26.1%, 2000, 24.8%, 2001, 20.8%, 2002, 22.6%, 2003, 22.5%, 2004, 22.4%, 2005, 21.4%, 2006, 21.0%; Hispanic, 1999, 27.2%, 2000, 27.2%, 2001, 26.4%, 2002, 25.4%, 2003, 25.0%, 2004, 24.7%, 2005, 23.8%, 2006, 24.1%.

Key: AI/AN = American Indian or Alaska Native; API = Asian or Pacific Islander.

Source: Centers for Medicare & Medicaid Services, Minimum Data Set, 1999-2006. Data for long-stay residents are from the third quarter of each calendar year. Data for short-stay residents are full calendar-year estimates.

Denominator: Long-stay nursing home residents (left), and short-stay nursing home residents (right).

Note: White, Black, API, and AI/AN are non-Hispanic groups. Long-stay residents are people in an extended/permanent nursing home stay. Short-stay residents are people who need skilled nursing care or rehabilitation services following a hospital stay but are expected to return home.

High-risk, long-stay nursing home residents
  • From 1999 to 2006, the percentage of high-risk, xvi long-stay residents who developed pressure sores decreased from 14.3% to 12.5% (Figure 2.29). While improvements were observed for all groups except for AI/ANs, the gap between Blacks, AI/ANs, and Hispanics compared with Whites remained the same.
  • In 2006, the percentage of high-risk, long-stay residents who developed pressure sores was significantly higher for Blacks (16.3%), AI/ANs (14.4%), and Hispanics (13.5%) than for Whites (11.9%).

xvi"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.


Short-stay nursing home residents
  • From 1999 to 2006, the percentage of short-stay residents who had pressure sores decreased significantly for all groups (Figure 2.29).
  • From 1999 to 2006, the gap between Blacks and Whites decreased. However, in 2006, Black short-stay residents were still more likely than Whites to have pressure sores (23.8% compared with 19.6%).
  • From 1999 to 2006, the gap between APIs and Whites increased. In 2006, API short-stay residents were still more likely than Whites to have pressure sores (22.3% compared with 19.6%).
  • From 1999 to 2006, the gap between AI/ANs and Whites decreased. There were no statistically significant differences between AI/ANs and Whites in 2006.
  • From 1999 to 2006, the gap between Hispanics and Whites remained the same. In 2006, Hispanic short-stay residents were still more likely than Whites to have pressure sores (24.1% compared with 19.6%).
  • In 2006, the percentage of short-stay residents who had pressure sores was higher for males than for females (22.4% compared with 19%; data not shown).

Management: Improvement by Home Health Care Patients in Walking or Moving Around

How well a patient improves in ability level while getting home health care is a reflection of the provider's quality of service; patient factors, such as mobility and fear of falling; and the patient's available support system. Improved ambulation (i.e., getting better at walking or using a wheelchair) is a measure of improved outcomes.xvii

Figure 2.30. Adult home health care patients whose ability to walk or move around improved, by race (left) and ethnicity (right), 2002-2006.

Trend line chart. Total, 2002, 33.9%, 2003, 35.1%, 2004, 37.2%, 2005, 38.8%, 2006, 41.2%; White, 2002, 33.8%, 2003, 35.0%, 2004, 37.2%, 2005, 38.9%, 2006, 41.4%; Black, 2002, 32.7%, 2003, 33.6%, 2004, 36.7%, 2005, 36.8%, 2006, 38.7%; Asian, 2002, 38.0%, 2003, 39.4%, 2004, 40.9%, 2005, 42.7%, 2006, 44.7%; NHOPI, 2002, 39.2%, 2003, 40.3%, 2004, 41.3%, 2005, 42.5%, 2006, 44.9%; AI/AN, 2002, 35.4%, 2003, 36.3%, 2004, 37.0%, 2005, 38.5%, 2006, 41.1%; > 1 Race, 2002, 33.8%, 2003, 36.0%, 2004, 39.3%, 2005, 40.3%, 2006, 42.9%. Ethnicity; Non-Hispanic White, 2002, 33.8%, 2003, 35.0%, 2004, 37.2%, 2005, 38.9%, 2006, 41.4%; Hispanic, 2002, 37.1%, 2003, 37.8%, 2004, 39.1%, 2005, 39.4%, 2006, 41.2%.

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

Source: Centers for Medicare & Medicaid Services, Outcome and Assessment Information Set, 2002-2006.

Denominator: Episodes for adult nonmaternity patients receiving at least some skilled home health care.

Note: An episode is a 60-day period 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 from home health care or is transferred to an inpatient facility. Some patients have multiple episodes in a year. Data are reported only for those patients who were not already performing at the highest level of ambulation.

  • From 2002 to 2006, the percentage of home health care patients who got better at walking and moving around improved for Whites (from 33.8% to 41.4%; Figure 2.30) and the total population (from 33.9% to 41.2%). There were no statistically significant changes for other groups.
  • In 2006, there were no statistically significant differences between minority groups and Whites (Figure 2.30).

xvii In cases of patients with some neurological conditions, such as progressive multiple sclerosis or Parkinson's disease, ambulation may not improve even when the home health service provides good care.


Management: Acute Care Hospitalization of Home Health Care Patients

Improvement in the acute care hospitalization outcome is demonstrated by a decrease in the percentage of patients who had to be admitted to the hospital; lower percentages are the desirable outcome. Acute care hospitalization may be avoided if home health staff adequately check the patient's health condition at each visit to detect problems early. However, patients may need to go into the hospital while they are getting care. In some cases, this may not be avoidable even with good home health care.

Figure 2.31. Adult home health care patients who were admitted to the hospital, by race (left) and ethnicity (right), 2002-2006.

Trend line chart. White, 2002, 26.6%, 2003, 26.7%, 2004, 26.8%, 2005, 26.9%, 2006, 27.3%; Black, 2002, 33.9%, 2003, 33.9%, 2004, 34.1%, 2005, 33.9%, 2006, 33.9%; Asian, 2002, 21.7%, 2003, 21.5%, 2004, 22.5%, 2005, 23.0%, 2006, 23.1%; NHOPI, 2002, 27.6%, 2003, 26.0%, 2004, 26.3%, 2005, 25.6%, 2006, 27.1%; AI/AN, 2002, 30.7%, 2003, 31.2%, 2004, 32.3%, 2005, 33.6%, 2006, 34.2%; > 1 Race, 2002, 31.1%, 2003, 29.0%, 2004, 29.7%, 2005, 29.1%, 2006, 30.7%. Ethnicity; Non-Hispanic White, 2002, 26.6%, 2003, 26.7%, 2004, 26.8%, 2005, 26.9%, 2006, 27.3%; Hispanic, 2002, 30.6%, 2003, 30.3%, 2004, 30.7%, 2005, 31.0%, 2006, 31.0%.

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

Source: Centers for Medicare & Medicaid Services, Outcome and Assessment Information Set, 2002-2006.

Denominator: Episodes for adult nonmaternity patients receiving at least some skilled home health care.

Note: 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 from home health care or is transferred to an inpatient facility. Some patients have multiple episodes in a year.

  • From 2002 to 2006, the gap between Blacks and Whites in the percentage of home health care patients who were admitted to the hospital remained the same. In 2006, the percentage was higher for Blacks than for Whites (33.9% compared with 27.3%; Figure 2.31).
  • The gap between AI/ANs and Whites in the percentage of home health care patients who were admitted to the hospital increased. In 2006, the percentage was higher for AI/ANs than for Whites (34.2% compared with 27.3%).
  • The gap between Asians and Whites in the percentage of home health care patients who were admitted to the hospital remained the same. In 2006, the percentage was lower for Asians than for Whites (23.1% compared with 27.3%).
  • During the same period, the gap between Hispanics and non-Hispanic Whites in the percentage of home health care patients who were admitted to the hospital remained the same. In 2006, the percentage was higher for Hispanics than for non-Hispanic Whites (31.0% compared with 27.3%).

Management: Hospice Care

Hospice care is generally delivered at the end of life to patients with a terminal illness or condition who desire palliative medical care; it also includes 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 (IOM) 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."71 The National Hospice and Palliative Care Organization's Family Evaluation of Hospice Care survey examines the quality of hospice care for patients and their family members.xviii 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.72

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


xviii This annual survey provides unique insight into end-of-life care and captures information about a large percentage of hospice patients but is limited by nonrandom data collection and a response rate of about 40%. In addition, race and ethnicity were not reported by large numbers of respondents. These limitations should be considered when interpreting these findings.
xix This measure is based on responses from a family member of the deceased. 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.


Figure 2.32. Hospice patients who did NOT receive the right amount of medicine for pain, by race, ethnicity, and education, 2007.

Bar chart. Total, 5.7, White, 5.7, Black, 7.6, API, 11.3, AI/AN, 6.3, Non-Hispanic White, 5.7, Hispanic, 6.9, Less than high school, 6.1; High school, 5.1; Any college, 6.3.

Key: AI/AN=American Indian or Alaska Native; API=Asian or Pacific Islander.

Source: National Hospice and Palliative Care Organization Family Evaluation of Hospice Care, 2007.

Denominator: Adult hospice patients.

  • The percentage of hospice patients whose families reported that they did not receive the right amount of medicine for pain was 5.7% in 2007 (Figure 2.32).
  • The percentage of hospice patients whose families reported that they did not receive the right amount of medicine for pain was significantly higher for Blacks (7.6%) and APIs (11.3%) than for Whites (5.7%).
  • The percentage of hospice patients whose families reported that they did not receive the right amount of medicine for pain was also higher for Hispanics than for non-Hispanic Whites (6.9% compared with 5.7%).

End-of-life care. End-of-life care should respect a patient's stated end-of-life wishes. This includes shared communication and decision-making between providers, patients, and family members and respect for cultural beliefs.

Figure 2.33. Hospice patients age 18 and over who did NOT receive care consistent with their stated end-of-life wishes, by race, ethnicity, and education, 2007.

Bar chart. Total, 5.6, White, 5.2, Black, 10, API, 14.9, AI/AN, 11.4, Non-Hispanic White, 5.1, Hispanic, 10.8, < High School, 10.1, High School Grad, 6.4, Any College, 4.6. 

Key: AI/AN=American Indian or Alaska Native; API=Asian or Pacific Islander.

Source: National Hospice and Palliative Care Organization Family Evaluation of Hospice Care, 2007.

Denominator: Adult hospice patients.

  • The overall percentage of hospice patients whose families reported that they did not receive end-of-life care consistent with their wishes was 5.6% in 2007 (Figure 2.33).
  • The percentage whose families reported that they did not receive care consistent with their wishes was almost two times higher for Blacks (10.0%), almost three times higher for APIs (14.9%), and more than two times higher for AI/ANs (11.4%) compared with Whites (5.2%).
  • This percentage was more than two times higher for Hispanics than for non-Hispanic Whites (10.8% compared with 5.1%).
  • The percentage of patients whose families reported that they did not receive care consistent with their wishes was higher for hospice patients with less than a high school education compared with those who had any college education (10.1% compared with 4.6%).

Timeliness of hospice care. Research suggests that late referral to hospice results in unmet needs for some patients and caregivers.73 Therefore, the perception of timeliness of referral is an indicator of adequacy of access to hospice care.

Figure 2.34. Hospice patient caregivers who perceived patient was NOT referred to hospice at the right time, by race, ethnicity, and education, 2007.

Bar chart. Total, 11.3, White, 11.7, Black, 8.9, API, 12.4, AI/AN, 12.7, Non-Hispanic White, 11.7, Hispanic, 11.5, Less than high school, 8.4; High school, 9.7; Any college, 13.1.

Key: AI/AN = American Indian or Alaska Native; API = Asian or Pacific Islander.

Source: National Hospice and Palliative Care Organization Family Evaluation of Hospice Care, 2007.

Denominator: Adult hospice patients.

Note: Caregivers were family members who interacted with hospice providers.

  • Overall in 2007, 11.3% of hospice patient caregivers perceived hospice care was not referred at the right time (Figure 2.34).
  • The percentage of caregivers who perceived hospice care was not referred at the right time was lower for Blacks than for Whites (8.9% compared with 11.7%).
  • The percentage of caregivers who perceived hospice care was not referred at the right time was higher for AI/ANs than for Whites (12.7% compared with 11.7%).
  • The percentage of caregivers who perceived hospice care was not referred at the right time was lower for caregivers with less than a high school education (8.4%) and high school education (9.7%) than for caregivers with any college education (13.1%).
  • The percentage of caregivers who perceived hospice care was not referred at the right time was higher for females than for males (12.7% compared with 8.8%; data not shown).
Current as of March 2009
Internet Citation: Chapter 2. Quality of Health Care (continued, 2): National Healthcare Disparities Report, 2008. March 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://archive.ahrq.gov/research/findings/nhqrdr/nhdr08/Chap2b.html