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National Healthcare Disparities Report, 2013

Chapter 2. Effectiveness of Care for Common Clinical Conditions

As better understanding of health and sickness has led to superior ways of preventing, diagnosing, and treating diseases, the health of most Americans has improved dramatically. However, many Americans do not receive the full benefits of high-quality care.

This chapter is organized around eight common clinical areas: cancer, cardiovascular disease, chronic kidney disease, diabetes, HIV disease, mental health and substance abuse, musculoskeletal diseases, and respiratory diseases. One section in this chapter relates most closely to national priorities identified in the National Strategy for Quality Improvement in Health Care.i The Cardiovascular Disease section addresses the priority "promoting the most effective prevention and treatment of the leading causes of mortality, starting with cardiovascular disease."

In this chapter, process measures are organized into several categories related to the patient's need for preventive care, treatment of acute illness, and chronic disease management. These are derived from the original Institute of Medicine (IOM) categories: staying healthy, getting better, living with illness or disability, and coping with the end of life. There is sizable overlap among these categories, and some measures may be considered to belong in more than one category. Outcome measures are organized separately because prevention, treatment, and management can all play important roles in affecting outcomes.

Prevention

Caring for healthy people is an important component of health care. Educating people about health and promoting healthy behaviors can help postpone or prevent illness and disease. In addition, detecting health problems at an early stage increases the chances of effectively treating those problems, often reducing suffering and costs.

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 (ESRD), are chronic, which means they cannot simply be treated once; they must be managed over time. Management of chronic disease often involves promotion and maintenance of lifestyle changes and regular contact with a provider to monitor the status of the disease. For patients, effective management of chronic diseases can mean the difference between normal, healthy living and frequent medical problems.

Outcomes

Many factors other than health care influence health outcomes, including a person's genes, lifestyle, and social and physical environment. However, for many individuals, appropriate preventive services, timely treatment of acute illness and injury, and meticulous management of chronic disease can positively affect mortality, morbidity, and quality of life.

 Cancer

Importance

Mortality
Number of deaths (2010) 574,738 (USCS, 2014)
Cause of death rank (2011 prelim.) 2nd (Hoyert & Xu, 2012)
Prevalence
Americans diagnosed and living with cancer (2009) 13,027,914 (Howlader, et al., 2012)
Incidence
New cases of cancer (2010) 1,456,496 (USCS, 2014)
New cases of breast cancer (2010) 206,966 (USCS, 2014)
New cases of colorectal cancer (2010) 131,607 (USCS, 2014)
Cost
Total costii (2009.) $216.6 billion (NHLBI, 2012)
Direct costsiii (2009) $86.6 billion (NHLBI, 2012)
Indirect costs (2009) $130.0 billion (NHLBI, 2012)
Cost-effectivenessiv of breast cancer screening $35,000-$165,000/QALY (Maciosek, et al., 2006)

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 National Healthcare Quality Report (NHQR) and National Healthcare Disparities Report (NHDR). In even years, the reports focus on colorectal cancer, and in odd years, the reports focus on breast cancer. This year, the report measures are:

  • Breast cancer screening.
  • Breast cancer first diagnosed at advanced stage.
  • Axillary node dissection or sentinel lymph node biopsy at time of surgery for breast cancer.
  • Radiation therapy following breast-conserving surgery.
  • Breast cancer deaths.

Findings

Prevention: Breast Cancer Screening

Early detection of cancer allows more treatment options and often improves outcomes. Mammography, the most effective method for detecting breast cancer at its early stages, can identify malignancies before they can be felt and before symptoms develop. Previous reports tracked receipt of mammography among women age 50 and over. The breast cancer screening measure used in the 2013 NHQR and NHDR reflects a more recent recommendation of the U.S. Preventive Services Task Force for mammograms every 2 years for women ages 50-74.

 Figure 2.1. Women ages 50-74 who reported they had a mammogram within the past 2 years, by income and ethnicity, 2000, 2003, 2005, 2008, and 2010

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Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2000, 2003, 2005, 2008, and 2010.
Denominator: Civilian noninstitutionalized women ages 50-74.
Note: White and Black are non-Hispanic. Hispanic includes all races. Rates are age adjusted to the 2000 U.S. standard population.

  • Overall, in 2010, 72.4% of women ages 50-74 had received a mammogram in the past 2 years (Figure 2.1).
  • From 2000 to 2010, the percentage of women who received a mammogram declined for women from poor and low-income households and for non-Hispanic Whites.
  • In 2000, 2003, and 2005, Hispanic women were less likely to receive a mammogram compared with non-Hispanic White women. These differences were not statistically significant in other data years.
  • From 2000 to 2010, women from poor, low-income, and middle-income households were less likely to receive a mammogram compared with women from high-income households.
  • The 2008 top 5 State achievable benchmark was 88%.v There is no evidence of progress toward the benchmark by any income or racial group.

Also, in the NHQR:

  • In all years, among women ages 50-64, uninsured women were less likely to receive a mammogram compared with those with private insurance. Except in 2008, women with public insurance were less likely to receive a mammogram in all years compared with those with private insurance.
  • In 2008 and 2010, women with basic or complex activity limitations were less likely to receive a mammogram compared with those with neither basic nor complex activity limitations.

National data on cancer care for some underserved populations are not available from the national data sources in the NHDR. These populations include people with limited English proficiency; individuals who speak a language other than English at home; lesbian, gay, bisexual, and transgender individuals; and Asian and Hispanic subpopulations. To address some of these data gaps, additional data from the California Health Interview Survey (CHIS) are shown below. The sampling methods used in CHIS are an example of how important disparities can be examined when data are collected this way.

 Figure 2.2. Women ages 50-74 who reported they had a mammogram within the past 2 years, by English proficiency, preferred language, and ethnicity, California, 2009

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Source: University of California, Los Angeles, Center for Health Policy Research, California Health Interview Survey, 2009.
Denominator: Civilian noninstitutionalized women ages 50-74 in California.

  • In 2009, 86.3% of women ages 50-74 living in California had received a mammogram in the past 2 years (Figure 2.2).
  • In 2009, there were no statistically significant differences by English proficiency in the percentage of women who had received a mammogram.
  • In 2009, women who preferred to speak Korean (57%) were less likely to receive a mammogram than those who preferred to speak English (86.9%).
  • In 2009, Korean women (64.1%) were less likely to receive a mammogram compared with non-Hispanic Whites (87%). Vietnamese women (93.6%) were more likely to receive a mammogram compared with non-Hispanic Whites.

Outcome: Breast Cancer First Diagnosed at Advanced Stage

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 cancer cases diagnosed at advanced stages is a measure of the effectiveness of cancer screening efforts and of adherence to followup care after a positive screening test. Because many cancers often take years to develop, changes in rates of late-stage cancer may lag behind changes in screening rates.

 Figure 2.3. Age-adjusted rate of advanced stage breast cancer per 100,000 women age 40 and over, by ethnicity and race, 2000-2009

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Key: API = Asian or Pacific Islander; AI/AN = American Indian or Alaska Native.
Source: Centers for Disease Control and Prevention and National Cancer Institute, National Program of Cancer Registries (NPCR), United States Cancer Statistics. Includes NPCR and National Cancer Institute's Surveillance, Epidemiology, and End Results registries meeting United States Cancer Statistics publication criteria for every year. Covers 90.1% of the total U.S. population. States excluded are: Arkansas, District of Columbia, Mississippi, North Carolina, South Dakota, Tennessee, and Virginia.
Denominator: Women age 40 and over.
Note: For this measure, lower rates are better. Age adjusted to the 2000 U.S. standard population. Advanced stage breast cancer is defined as local stage with tumor size greater than 2 cm diameter, regional stage or distant stage.

  • In all years from 2000 to 2009, the rate of advanced stage breast cancer in Hispanic women was lower than in non-Hispanic White women (Figure 2.3).
  • In all years, advanced stage breast cancer rates were lower among Asian or Pacific Islander (API) and American Indian or Alaska Native (AI/AN) women compared with White women.vi
  • From 2002 to 2009, the rates of advanced stage breast cancer were higher for Black women compared with White women.
  • The 2008 top 5 State achievable benchmark was 81 per 100,000 women.vii AI/AN, API, and Hispanic women have achieved the benchmark, while Black women are moving away from the benchmark.

Also, in the NHQR:

  • In all years, women ages 50-64 and 65 and over had higher rates of advanced stage breast cancer than women ages 40-49.

Treatment: Recommended Care for Breast Cancer

Different diagnostic and treatment options exist for various types of cancer. Some aspects of cancer care are well established as beneficial and are commonly recommended. The appropriateness of recommended care depends on different factors, such as the stage or extent of the cancer within the body (especially whether the disease has spread from the original site to other parts of the body). Other types of care are important for accurate diagnosis, such as ensuring adequate examination of lymph nodes when surgery is performed.

 Figure 2.4. Women with clinical Stage I-IIb breast cancer who received axillary node dissection or sentinel lymph node biopsy at the time of lumpectomy or mastectomy, by race/ethnicity and income, 2004-2010

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Source: Commission on Cancer, American College of Surgeons and American Cancer Society, National Cancer Data Base, 2004-2010.
Denominator: Women with Stage I-IIb breast cancer undergoing lumpectomy or mastectomy
Note: White and Black are non-Hispanic. Hispanic includes all races.

  • Overall, in 2010, 94.5% of women with clinical Stage I-IIb breast cancer had received axillary node dissection or sentinel lymph node biopsy at the time of lumpectomy or mastectomy (Figure 2.4).
  • From 2004 to 2010, the percentage of women who received axillary node dissection or sentinel lymph node biopsy improved for Cuban, Hispanic, Black, White, and Puerto Rican women and women from all income groups.
  • In all years, there were no statistically significant differences by race/ethnicity or income in the percentage of women with clinical Stage I-IIb breast cancer who received axillary node dissection or sentinel lymph node biopsy.
  • The 2008 top 5 State achievable benchmark was 97%.viii Puerto Ricans have achieved the benchmark. At the current rate of increase, most racial/ethnic and income groups could achieve this benchmark in 4 years.

Also, in the NHQR:

  • In all years, women ages 70-79 and 80 and over were less likely than women under age 40 to receive axillary node dissection or sentinel lymph node biopsy. 
  • In all years, among women under age 65, those with public health insurance were less likely than those with private insurance to receive axillary node dissection or sentinel lymph node biopsy.

 Figure 2.5. Women under age 70 treated for breast cancer with breast-conserving surgery who received radiation therapy within 1 year of diagnosis, by race/ethnicity and income, 2004-2010

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Source: Commission on Cancer, American College of Surgeons and American Cancer Society, National Cancer Data Base, 2004-2010.
Denominator: Women under age 70 undergoing breast-conserving surgery
Note: White and Black are non-Hispanic. Hispanic includes all races. Data for 2008 and 2009 may be lower due to the timing of data collected. Radiation can be administered 1 year from diagnosis, so registries may not complete radiation information at the time of case abstraction.

  • Overall, in 2010, 81.9% of women under age 70 treated for breast cancer with breast-conserving surgery had received radiation therapy within 1 year of diagnosis (Figure 2.5).
  • In all years, Black, Hispanic, and Mexican women were less likely to receive radiation therapy compared with White women. In 5 of 7 years, Cuban women were less likely to receive radiation therapy than non-Hispanic White women.
  • In 4 of 7 years, women from poor households were less likely to receive radiation therapy compared with those from high-income households.
  • The 2008 top 5 State achievable benchmark was 94%.ix There is no evidence of progress toward the benchmark by any racial/ethnic or income group.

Also, in the NHQR:

  • In all years, women ages 40-49, 50-59, and 60-69 were more likely than women under age 40 to receive radiation therapy.
  • In all years, among women under age 65, those with public insurance were less likely than those with private insurance to receive radiation therapy.

Outcome: Breast Cancer Deaths

The death rate from a disease is a function of many factors, including the causes of the disease; social forces; and the effectiveness of the health care system in providing prevention, treatment, and management of the disease. Breast cancer deaths reflect the impact of cancer screening, diagnosis, and treatment. Mortality is measured as the number of deaths per 100,000 population. Declines in breast cancer deaths can be attributed, in part, to improvements in early detection and treatment.

 Figure 2.6. Age-adjusted breast cancer deaths per 100,000 women, by race and ethnicity, 2000-2010

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Key: API = Asian or Pacific Islander; AI/AN = American Indian or Alaska Native.
Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System—Mortality, 2000-2010.
Denominator: U.S. female population.
Note: For this measure, lower rates are better. Total rate is age adjusted to the 2000 U.S. standard population.

  • Overall, in 2010, the rate of breast cancer deaths was 22.1 per 100,000 population (Figure 2.6).
  • From 2000 to 2010, the rates of breast cancer deaths decreased overall and for all racial/ethnic groups except AI/ANs.
  • In all years, Hispanic women had lower breast cancer death rates than non-Hispanic White women.
  • In all years, API and AI/AN women had lower breast cancer death rates than White women, while Black women had higher rates than White women.x
  • The 2008 top 5 State achievable benchmark was 17 per 100,000 population.xi AI/AN, API, and Hispanic women have achieved the benchmark. White women could achieve the benchmark in 9 years, non-Hispanic White women in 10 years, and Black women in 28 years.

Also, in the NHQR:

  • In all years, women ages 45-64 and 65 and over had higher rates of breast cancer death compared with women ages 18-44. There were no statistically significant differences by residence location.

This year, the NHDR features findings from a report by the Department of Native Hawaiian Health and its Center for Native and Pacific Health Disparities Research. They are located at the John A. Burns School of Medicine at the University of Hawaii. The report is titled Assessment and Priorities for Health & Well-Being in Native Hawaiians and Other Pacific Peoples (Look, et al., 2013).

Cancer in Hawaii

Cancer is the second leading cause of death in the State of Hawaii. While rates vary by ethnic group, the four most common types of cancer in Hawaii are breast (female), colorectal, lung, and prostate cancers (Green, 2010). In general, Native Hawaiians tend to be diagnosed with cancer at a younger age and experience lower survival rates compared with other racial groups (Mau, 2010).

The recently reported incidence and mortality rates for both Native Hawaiian men and women were the highest of all ethnicities in Hawaii (Green, 2010). For Native Hawaiian males, the cancer incidence rate was comparable to all races, but a clear difference was found in the death rate: 231.7 per 100,000 population compared with 192.0 per 100,000 population for all races. For Native Hawaiian females, the incidence rate was 447.8 per 100,000 population compared with 382.2 per 100,000 population for all races. The cancer mortality rate was 171.0 per 100,000 population compared with 124.7 per 100,000 population for all races.

Patterns of cancer occurrence also differ between ethnic and racial groups in the Pacific region (Mishra, et al., 1996). For example, Samoan males residing in Hawaii have a relatively higher frequency of lung, prostate, thyroid, and liver cancers and a lower frequency of colon and rectal cancers compared with other Polynesians, such as Western Samoans and Native Hawaiians. Moreover, Samoan women have a higher frequency of leukemia and corpus uteri, thyroid, and pancreatic cancers than other Polynesian women (Mau, 2010). Throughout Micronesia, the Marshallese have the highest prevalence of breast, cervical, other genitourinary, and thyroid cancers compared with other Pacific Islanders, which may be due to effects of U.S. nuclear testing in the region between 1946 and 1958 (Palafox, et al., 2004).

Compared with their counterparts in the continental United States, Samoan and Native Hawaiian women have the highest overall cancer death rates—higher than the rates for non-Hispanic White women and all Asian women. This is accounted for in large part by the high lung cancer and breast cancer death rates for Native Hawaiian and Samoan women (Cook, et al., 2010). Higher mortality rates among Native Hawaiian and other indigenous or minority Americans are partially attributed to barriers to accessing good cancer care and timely diagnosis and treatment (Green, 2010). These effects may be compounded by higher prevalence of poor diet and tobacco use among Native Hawaiians, the two leading causes of cancer (Green, 2010).

 Figure 2.7. Female breast cancer incidence and mortality by race/ethnicity, Hawaii, 1995-2000

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Source: American Cancer Society, 2004.

Return to Contents

Cardiovascular Disease

Importance

Mortality
Number of deaths from major cardiovascular disease (2010 prelim.) 777,548 (Murphy, et al., 2012)
Cause of death rank (2010 prelim.) 1st (Murphy, et al., 2012)
Prevalence
Number of cases of heart failure (2010 est.) 5.1 million (Go, et al., 2014)
Number of cases of high blood pressure among U.S. adults age 18 years and over (2003-2010 est.) 67 million (MMWR, 2012)
Incidence
Number of heart attacks or cases of fatal coronary heart disease (2010 est.) 915,000 (Go, et al., 2014)
Cost
Total cost of cardiovascular disease (2010 est.) $315.4 billion (Go, et al., 2014)
Total cost of heart disease (2010 est.) $204.4 billion (Go, et al., 2014)
Direct costs of cardiovascular disease (2010 est.) $193.4 billion (Go, et al., 2014)
Cost-effectiveness of hypertension screening $14,000-$35,000/QALY (Maciosek, et al., 2006)

Measures

The NHQR and NHDR track several quality measures for preventing and treating cardiovascular disease. Three measures are highlighted here:

  • Blood pressure monitoring.
  • Inpatient deaths following heart attack.
  • Hospitalization for congestive heart failure.

In addition, this chapter presents other measures focusing on Native Hawaiians and Other Pacific Islanders and the costs of disparities in hospitalizations for congestive heart failure. Several measures related to heart disease are also presented in other chapters of this report. Timeliness of cardiac reperfusion for heart attack patients is tracked in Chapter 5, Timeliness. Receipt of complete written discharge instructions by patients with heart failure is tracked in Chapter 7, Care Coordination.

Findings

Prevention: Blood Pressure Monitoring

National screening guidelines for hypertension are well established (USPSTF, 2007). However, since high blood pressure is asymptomatic in most cases, it is not surprising that many of those affected do not know they have this condition.

 Figure 2.8. Adults who reported receiving a blood pressure measurement in the last 2 years and can state whether their blood pressure was normal or high, by race/ethnicity and sex, 2008

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Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2008.
Denominator: Civilian noninstitutionalized population age 18 and over.
Note: Rates are age adjusted to the 2000 U.S. standard population. White and Black are non-Hispanic; Hispanic includes all races.

  • In 2008, 93.6% of White, 93.5% of Black, and 89.0% of Hispanic adults reported they had a blood pressure measurement in the past 2 years (Figure 2.8).
  • In 2008, Hispanic men were less likely to receive a blood pressure measurement than White men.
  • In 2008, Hispanic women were less likely to receive a blood pressure measurement than White women.

Also, in the NHQR:

  • In 2008, Hispanic adults with basic activity limitations were less likely to receive a blood pressure measurement than White adults with basic activity limitations.
  • In 2008, Hispanic adults with neither activity limitation were less likely to receive a blood pressure measurement than White adults with neither activity limitation.

National data on cardiovascular care for some underserved populations are not available from the national data sources in the NHDR. These populations include people with limited English proficiency; individuals who speak a language other than English at home; lesbian, gay, bisexual, and transgender individuals; and Asian and Hispanic subpopulations. To address some of these data gaps, additional data from the CHIS are shown below.

 Figure 2.9. Adults who were diagnosed with high blood pressure, by English proficiency, preferred language, ethnicity, and Asian ethnicity, California, 2011-2012

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Source: University of California, Los Angeles, Center for Health Policy Research, California Health Interview Survey, 2011-2012 combined.
Note: For this measure, lower rates are better. White and Black are non-Hispanic.

  • In 2011-2012, 27.2 % of adults living in California were diagnosed with high blood pressure (Figure 2.9).
  • In 2011-2012, adults who spoke English well or very well (19.9%) were less likely to be diagnosed with high blood pressure than those who spoke English only (30.4%).
  • In 2011-2012, adults who preferred to speak Vietnamese (33.8%) and Korean (35.4%) were more likely to be diagnosed with high blood pressure compared with those who preferred to speak English (27.3%). In the same period, adults who preferred to speak Chinese (20.6%) were less likely than those who preferred to speak English to be diagnosed with high blood pressure.
  • In 2011-2012, Black adults (40.5%) were more likely to be diagnosed with high blood pressure than White adults (30.3%). Mexican (23.5%) and South American (15.5%) adults were less likely to be diagnosed with high blood pressure than White adults.
  • In 2011-2012, Chinese (18.7%), Korean (24.9%), Vietnamese (25.1%), and South Asian (8.2%) adults were less likely to be diagnosed with high blood pressure than White adults (30.3%).

 Figure 2.10. Adults currently diagnosed with heart disease who had emergency room visits in the past 12 months, by English proficiency, preferred language, and ethnicity, California, 2011-2012

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Source: University of California, Los Angeles, Center for Health Policy Research, California Health Interview Survey, 2011-2012 combined.
Note: For this measure, lower rates are better. White and Black are non-Hispanic.

  • In 2011-2012, 17.9% of adults living in California with heart disease had an emergency room visit (Figure 2.10).
  • In 2011-2012, there were no statistically significant differences by English proficiency, preferred language, or ethnicity in the percentage of adults with heart disease who had an emergency room visit.

Outcome: Inpatient Deaths Following Heart Attack

Heart attack, or acute myocardial infarction, is a common life-threatening condition that requires rapid recognition and efficient treatment in a hospital to reduce the risk of serious heart damage and death. Measuring processes of heart attack care can provide information about whether a patient received specific needed services, but these processes make up a very small proportion of all the care that a heart attack patient needs. Measuring outcomes of heart attack care, such as mortality, can provide a more global assessment of all the care a patient receives and usually is the aspect of quality that matters most to patients.

Significant improvements in process measures of quality of care for heart attack have occurred in recent years. All process measures tracked in past reports have attained overall performance levels exceeding 95% and have been retired. Therefore, the 2013 NHQR and NHDR focus on outcome measures. Survival following admission for 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 patients to other hospitals for services. It also may partly reflect receipt of appropriate health services.

 Figure 2.11. Inpatient deaths per 1,000 adult hospital admissions with heart attack, by race/ethnicity and area income, 2001-2010

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Key: API = Asian or Pacific Islander; Q1 represents the lowest income quartile and Q4 represents the highest income quartile based on the median income of a patient's ZIP Code of residence.
Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, State Inpatient Databases disparities analysis file; and AHRQ Quality Indicators, modified version 4.1, 2001-2010.
Denominator: Adults age 18 and over admitted to a non-Federal community hospital in the United States with acute myocardial infarction as principal discharge diagnosis.
Note: For this measure, lower rates are better. Rates are adjusted by age, major diagnostic category, all payer refined-diagnosis related group risk of mortality score, and transfers into the hospital. White, Black, and API are non-Hispanic; Hispanic includes all races.

  • From 2001 to 2010, the risk-adjusted inpatient mortality rate for hospital admissions with heart attack decreased significantly for each racial/ethnic and area income group (Figure 2.11).
  • From 2005 to 2009, Blacks had lower inpatient mortality rates than Whites.
  • In 5 of 10 years, residents of the lowest area income quartile had higher inpatient mortality rates than residents of the highest area income quartile.
  • The 2008 top 4 State achievable benchmark for inpatient heart attack mortality was 48 per 1,000 admissions.xii At current rates of improvement, all racial/ethnic and area income groups would attain the benchmark within the next 2 years.

Also, in the NHQR:

  • In all years, women had higher rates of inpatient heart attack deaths than men and uninsured patients had higher rates than privately insured patients.

Outcome: Hospitalization for Congestive Heart Failure

Some hospitalizations for heart failure are unavoidable, but rates of hospitalization can be influenced by the quality of outpatient care.

 Figure 2.12. Adult admissions for congestive heart failure per 100,000 population, by race/ethnicity and area income, 2001-2010

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Key: API = Asian or Pacific Islander; Q1 represents the lowest income quartile and Q4 represents the highest income quartile based on the median income of a patient's ZIP Code of residence.
Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, State Inpatient Databases disparities analysis file; and AHRQ Quality Indicators modified version 4.1, 2001-2010.
Denominator: U.S. resident population age 18 and over.
Note: For this measure, lower rates are better. Rates are adjusted by age and sex. White, Black, and API are non-Hispanic; Hispanic includes all races.

  • From 2001 to 2010, the hospitalization rate for congestive heart failure decreased significantly overall and for each racial/ethnic and area income group (Figure 2.12).
  • In all years, Blacks had higher rates of admission for congestive heart failure compared with Whites while APIs had lower rates than Whites.
  • In all years, residents of the highest area income quartile had lower rates than residents of the two lower area income quartiles.
  • The 2008 top 4 State achievable benchmark for congestive heart failure admissions was 195 per 100,000 population.xiii At current rates of improvement, Whites could achieve the benchmark in 6 years. APIs, Hispanics, and Blacks could achieve the benchmark in 1, 4, and 9 years, respectively. Residents of the lowest income quartile would need 13 years while residents of other income quartiles could achieve the benchmark in 7 years.

Also, in the NHQR:

  • In all years, patients ages 45-64 and 65 and over had higher hospitalization rates for congestive heart failure than patients ages 18-44, and men had higher rates than women.

Focus on Native Hawaiians and Other Pacific Islanders

The ability to assess disparities among Native Hawaiians and Other Pacific Islanders (NHOPIs) has been a challenge for two main reasons. First, the NHOPI racial category is relatively new to Federal data collection. Before 1997, NHOPIs were classified as part of the API racial category and could not be identified separately in most Federal data. In 1997, the Office of Management and Budget promulgated new standards for Federal data on race and ethnicity and mandated that information about NHOPIs be collected separately from information about Asians. However, these standards have not yet been incorporated into all databases. Second, when information about this population was collected, databases often included insufficient numbers of NHOPIs to allow reliable estimates to be made.

Cardiovascular disease is a leading cause of death among Native Hawaiians. To supplement information in the reports on quality of care received by NHOPIs for heart disease, we feature data from additional data sources. Here we present data from the Behavioral Risk Factor Surveillance System (BRFSS) on cholesterol screening among NHOPIs, including people of mixed race who identify primarily as NHOPI. Note that the 2011 BRFSS cannot be compared with previous years because of the addition of cell phone data and the use of a new weighting methodology.

 Figure 2.13. Adults who reported receiving a cholesterol check in the last 5 years, by race and insurance, 2011

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Key: NHOPI = Native Hawaiian or Other Pacific Islander.
Source: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System, 2011.
Denominator: Adults age 18 and over.

  • In 2011, among adults with health insurance, the percentage of adults who received a cholesterol check in the last 5 years was lower among NHOPIs compared with Whites (Figure 2.13).
  • Among adults without health insurance, the percentage of adults who received a cholesterol check in the last 5 years was also lower among NHOPIs compared with Whites.

Hawaii, home to more than half of Native Hawaiians in the United States, is a leader in collecting health information on NHOPI and Asian populations. Here we provide information from the Hawaii State Inpatient Databases on admissions for congestive heart failure among NHOPI and Asian subpopulations.

 Figure 2.14. Adult admissions for congestive heart failure per 100,000 population, State of Hawaii, by granular ethnicity, 2010

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Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Hawaii State Inpatient Databases and AHRQ Quality Indicators, modified version 4.1, 2010.
Denominator: Adults age 18 and over in Hawaii based on the Hawaii Health Survey.
Note: For this measure, lower rates are better. Rates are adjusted by age and gender using the total U.S. population for 2000 as the standard population.

  • In Hawaii, in 2010, Native Hawaiians, Samoans, Other Pacific Islanders, and Filipinos had higher rates of hospital admissions for congestive heart failure than Whites (Figure 2.14).
  • NHOPI and Asian subpopulations are quite diverse. Considerable variation in rates was observed among the different subgroups.

Outcome: Costs of Disparities in Hospitalizations for Congestive Heart Failure

The following analysis estimates numbers of excess hospitalizations for congestive heart failure in 2010 by comparing adjusted rates of hospitalizations for congestive heart failure for different populations with the 2010 top 4 State achievable benchmark rate of 182 hospitalizations per 100,000 population. The benchmark rate was set based on the States with rates in the top 10%. For excess hospitalizations for congestive heart failure to be calculated, the difference between a group's rate and the benchmark rate was multiplied by the number of people in the group (for example, for Hispanics, the difference between the Hispanic rate and the benchmark rate was multiplied by the number of Hispanics).

 Figure 2.15. Excess number of hospitalizations for congestive heart failure, by race/ethnicity, 2010
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Key: API = Asian or Pacific Islander.
Source: Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project, Nationwide Inpatient Sample; and AHRQ Quality Indicators, modified version 4.1, 2010.
Note: White, Black, and API are non-Hispanic. Hispanic includes all races.

  • In 2010, if Whites had the benchmark rate of congestive heart failure hospitalizations, they would have had 170,000 fewer hospitalizations (Figure 2.15). Instead of costing $3.9 billion, preventable hospitalization among Whites would have cost $2.5 billion, saving $1.4 billion.
  • If Blacks had the benchmark rate of congestive heart failure hospitalizations, they would have had 150,000 fewer hospitalizations. Instead of costing $1.7 billion, preventable hospitalizations among Blacks would have cost $400 million, saving $1.3 billion.
  • If Hispanics had the benchmark rate of congestive heart failure hospitalizations, they would have had 50,000 fewer hospitalizations. Instead of costing $1.2 billion, preventable hospitalizations among Hispanics would have cost $600 million, saving $600 million.
  • Because the overall rate among APIs was very close to the benchmark rate, there are almost no estimated excess congestive heart failure hospitalizations for this group.

Comparisons with the 4 State achievable benchmark for the composite rate of preventable hospitalizations in 2010 are also used to estimate excess preventable hospitalizations by area income. Area income refers to the median income of the ZIP Code in which the patient resides.

 Figure 2.16. Excess number of hospitalizations for congestive heart failure, by area income, 2010
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Source: Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project, Nationwide Inpatient Sample; and AHRQ Quality Indicators, modified version 4.1, 2010.

  • In 2010, if residents of the neighborhoods in the lowest income quartile had the benchmark rate of preventable hospitalizations, they would have had 160,000 fewer hospitalizations (Figure 2.16). Instead of costing $2.2 billion, preventable hospitalizations among income quartile 1 residents would have cost $900 million, saving $1.3 billion.
  • If residents of income quartile 2 neighborhoods had the benchmark rate of preventable hospitalizations, they would have had 90,000 fewer hospitalizations. Instead of costing $1.6 billion, preventable hospitalizations would have cost $900 million, saving $700 million.
  • If residents of income quartile 3 neighborhoods had the benchmark rate of preventable hospitalizations, they would have had about 70,000 fewer hospitalizations. Instead of costing $1.6 billion, preventable hospitalizations would have cost $1.0 billion, saving $600 million.
  • If residents of the highest income quartile neighborhoods had the benchmark rate of preventable hospitalizations, they would have had about 40,000 fewer hospitalizations. Instead of costing $1.5 billion, preventable hospitalizations would have cost $1.1 billion, saving $400 million.

i Available at https://www.ahrq.gov/workingforquality/reports.htm.
ii Throughout this report, 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."
iv Cost-effectiveness is measured here 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.
v The top 5 States that contributed to the achievable benchmark are Connecticut, Delaware, Massachusetts, New Hampshire, and Rhode Island.
vi According to Wingo, et al. (2008), breast cancer incidence rates among AI/AN women varied nearly threefold across Indian Health Service regions. The highest rates were in Alaska (134.8/100,000), the northern Plains (115.9/100,000), and the southern Plains (115.7/100,000). The Southwest had the lowest rate (50.8/100,000). In Alaska, the AI/AN and non-Hispanic White rates were similar. Overall, AI/AN women had lower rates of breast cancer than non-Hispanic White women but were more likely to be diagnosed with late stage disease.
vii The top 5 States that contributed to the achievable benchmark are Maine, Nevada, North Dakota, Vermont, and West Virginia.
viii The top 5 States that contributed to the achievable benchmark are Alaska, Arkansas, Mississippi, Montana, and Oklahoma.
ix The top 5 States that contributed to the achievable benchmark are Kansas, Minnesota, Montana, North Dakota, and Wisconsin.
x Racial/ethnic data on death certificates are underreported, especially for Hispanics, AI/ANs, and APIs. For more information, see Arias E, Schauman WS, Eschbach K, et al. The validity of race and Hispanic origin reporting on death certificates in the United States. Vital Health Stat 2008;2(148).
xi The top 5 States that contributed to the achievable benchmark are Alaska, Hawaii, Montana, Vermont, and Wyoming.
xii The top 4 States that contributed to the achievable benchmark are Arizona, Florida, Michigan, and Ohio.
xiii The top 4 States that contributed to the achievable benchmark are Colorado, Oregon, Utah, and Vermont.


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Page last reviewed May 2014
Page originally created May 2014
Internet Citation: Chapter 2. Effectiveness of Care for Common Clinical Conditions. Content last reviewed May 2014. Agency for Healthcare Research and Quality, Rockville, MD. https://archive.ahrq.gov/research/findings/nhqrdr/nhdr13/chap2.html

 

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