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National Healthcare Disparities Report, 2013

Chapter 2. Effectiveness of Care for Common Clinical Conditions (continued)

Chronic Kidney Disease

Importance

Mortality
Total ESRD deaths (2011) 92,221 (USRDS, 2013b)
Prevalence
Total ESRD cases (2011) 615,899 (USRDS, 2013b)
Incidence
Number of new ESRD cases (2011) 115,643 (USRDS, 2013b)
Cost
Total ESRD Medicare program expenditures (2011) $29.5 billion (USRDS, 2013b)
Overall Medicare expenditures for chronic kidney disease (all stages), including Part D (2011) $45.5 billion (USRDS, 2013b)

Measures

The NHQR and NHDR track several measures of chronic kidney disease management to assess the quality of care provided to patients who have progressed to chronic kidney disease stage 5, kidney failure, also known as ESRD. A previous core measure, adequacy of dialysis, was retired because it achieved a rate above 95%.

Two measures are highlighted here:

  • Nephrology care before kidney failure.
  • Registration for transplantation.

Findings

Management: Nephrology Care Before Kidney Failure

Early referral to a nephrologist is important for patients with progressive chronic kidney disease who are approaching kidney failure. Patients who begin nephrology care more than a year before kidney failure are less likely to begin dialysis with a catheter, experience infections related to vascular access, or die during the months after dialysis initiation (USRDS, 2013a).

Mindful management during the transition to ESRD permits informed selection of a renal replacement therapy from the range of options, including conservative management (no dialysis), hemodialysis, peritoneal dialysis, and kidney transplantation. Early and mindful management also permits, as applicable, timely placement and maturation of vascular access for dialysis and workup for kidney transplantation.

Figure 2.17. New end stage renal disease patients age 18 and over who saw a nephrologist at least 12 months prior to initiation of renal replacement therapy, by race and ethnicity, 2005-2010

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Key: API = Asian or Pacific Islander; AI/AN = American Indian or Alaska Native.
Source: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, U.S. Renal Data System, 2005-2010.
Note: Hispanic and non-Hispanic include all races.

  • In 2010, only 29% of total new ESRD patients age 18 and over began nephrology care at least 12 months prior to initiation of renal replacement therapy. However, this was an increase from 2005, when the total percentage was 25% (Figure 2.17).
  • In all years, the percentage of new ESRD patients who began nephrology care at least 12 months prior to initiation of renal replacement therapy was higher for non-Hispanics than for Hispanics.
  • The percentage of AI/AN patients who began nephrology care at least 12 months prior to initiation of renal replacement therapy fluctuated slightly from year to year, from a low of 24.5% in 2005 to a high of 24.7% in 2010.
  • In all years, Whites were more likely than Blacks and non-Hispanics were more likely than Hispanics to begin nephrology care at least 12 months prior to initiation of renal replacement therapy.
  • The 2010 top 5 State achievable benchmark was 51%.xiv Whites, Blacks, and APIs show only slight progress toward the benchmark, with time to achieve the benchmark ranging from 19 years for APIs to 37 years for Blacks. AI/AN patients, however, show virtually no progress toward the benchmark and would take more than a century to reach it.

Also, in the NHQR:

  • In all years, the percentage of ESRD patients who began nephrology care at least 12 months prior to initiation of renal replacement therapy was higher for patients age 45 and over than for patients ages 18-44.

Management: Registration for Transplantation

Kidney transplantation is a renal replacement therapy that replaces the failing kidney with a healthy donor kidney. ESRD patients who receive a kidney transplant have lower mortality and hospitalization rates than those on dialysis. First-year all-cause mortality rates in hemodialysis patients, for example, are nearly five times higher than rates among transplant patients (USRDS, 2013a).

If a patient is determined to be a good candidate for transplant, he or she is registered with a transplant program to wait for a match with the most suitable donor. The supply of donor kidneys, however, continues to lag behind demand. While there were 17,671 kidney transplants in 2011, by the end of the year, 55,371 active adult candidates remained on the waiting list. Waiting times continue to increase, with the median waiting time reaching 4.3 years for patients newly listed in 2007 (USRDS, 2013a). Despite these challenges, registration is a vital first step toward kidney transplantation.

Figure 2.18. Dialysis patients under age 70 who were registered for transplantation within a year of ESRD initiation, by race and ethnicity, 2001-2009

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Key: API = Asian or Pacific Islander; AI/AN = American Indian or Alaska Native.
Source: National Institute of Diabetes and Digestive and Kidney Diseases, U.S. Renal Data System, 2001-2009.
Denominator: New end stage renal disease patients (receiving hemodialysis or peritoneal dialysis) in the given year who were under age 70 and had a known State of residence in the 50 States or the District of Columbia.
Numerator: Patients who were either wait-listed or received a deceased-donor kidney within 1 year of their ESRD initiation date.
Note: Patients who received a transplant at any time from a live donor or residing in American territories were excluded. Percentages are estimated using the Kaplan-Meier methodology. Hispanic and non-Hispanic include all races.

  • From 2001 to 2009, the total percentage of dialysis patients under age 70 who were registered for transplantation within 1 year of progressing to ESRD increased from 14.3% to 17.4% (Figure 2.18).
  • In 2009, improvements were observed across all racial and ethnic groups except AI/AN patients.
  • From 2001 to 2004, the percentage of dialysis patients registered for transplantation within 1 year of progressing to ESRD was lower for Hispanics than for non-Hispanics. In 2005, the disparity was eliminated and after that, the percentage of dialysis patients registered for transplantation within 1 year of progressing to ESRD was higher for Hispanics than for non-Hispanics.
  • In all years, Blacks and AI/ANs were less likely than Whites to be registered for transplantation within 1 year of progressing to ESRD. However, APIs were more likely than Whites to be registered.
  • The 2008 top 5 State achievable benchmark for registration for transplantation within 1 year of progressing to ESRD was 27%.xv Although APIs have already surpassed the 2008 achievable benchmark, Blacks and AI/ANs could not attain the benchmark for 26 and 22 years, respectively, and Whites could not attain it for 27 years.

Also, in the NHQR:

  • In 2009, as in all previous years, patients ages 20-69 were less likely than patients ages 0-19 to be registered for transplantation within 1 year of progressing to ESRD, and females were less likely than males to be registered for transplantation within 1 year of progressing to ESRD.

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Diabetes

Importance

Mortality
Number of deaths (2011) 73,282 (Hoyert & Xu, 2012)
Cause of death rank (2011 prelim.) 7th (Hoyert & Xu, 2012)
Prevalence
Total number of people with diabetes (all ages, 2010)xvi 25.8 million (CDC, 2011c)
Number of people with diagnosed diabetes (all ages, 2010) 18.8 million (CDC, 2011c)
Number of people with undiagnosed diabetes (age 20 years and over, 2010) 7.0 million (CDC, 2011c)
Incidence
New cases (age 20 and over, 2010) 1.9 million (CDC, 2011c)
Cost
Total cost (2012) $245 billion (ADA, 2013)
Direct medical costs (2012) $176 billion (ADA, 2013)
Indirect costs (2012) $68.6 billion (ADA, 2013)

Measures

Diabetes is one of the leading causes of hospitalization in the United States, with more than 600,000 discharges in 2009 (CDC, 2011a). With appropriate and timely ambulatory care, it may be possible to prevent many hospitalizations for diabetes and related complications. Routine monitoring of blood glucose levels, along with foot and dilated eye examinations and tests for hemoglobin A1c (HbA1cxvii ), has been shown to help prevent or mitigate complications of diabetes, such as diabetic neuropathy, retinopathy, and vascular and kidney disease.

The NHQR and NHDR track several measures of diabetes management and outcomes to assess the quality of care provided to patients with diabetes. These measures examine the extent to which patients receive care needed to prevent complications, including serious problems such as the development of kidney failure.

Three measures are highlighted here:

  • Receipt of four recommended diabetes services.
  • Hospital admissions for uncontrolled diabetes.
  • End stage renal disease due to diabetes.

In addition, this year we are highlighting a measure from the 2011-2012 California Health Interview Survey, with a focus on Asian and Hispanic subgroups:

  • Written diabetes management plan.

Findings

Management: Receipt of Four Recommended Diabetes Services

A composite measure is used to track the national rate of receipt of four recommended annual diabetes interventions: at least two HbA1c tests, a foot examination, a dilated eye examination, and a flu shot. These are basic process measures that provide an assessment of the quality of diabetes care. In 2011, to be more consistent with current recommendations, the frequency of HbA1c tests was increased to two per year and receipt of a flu shot was added to the measure.

Figure 2.19. Adults age 40 and over with diagnosed diabetes who reported receiving four recommended services for diabetes in the calendar year (2+ hemoglobin A1c tests, foot exam, dilated eye exam, and flu shot), by race/ethnicity and income, 2008-2010

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Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2008-2010.
Denominator: Civilian noninstitutionalized population with diagnosed diabetes, age 40 and over.
Note: Data include people with both type 1 and type 2 diabetes. Rates are age adjusted to the 2000 U.S. standard population using two age groups: 40-59 and 60 and over. White and Black are non-Hispanic; Hispanic includes all races.

  • In 2010, overall, among adults age 40 and over with diagnosed diabetes, only about one-fourth reported receiving all four recommended services (Figure 2.19).
  • In 2009, Blacks and Hispanics were less likely than Whites to report receiving recommended care for diabetes. In 2010, however, there were no statistically significant differences by race.
  • In 2008 and 2009, poor, low-income, and middle-income adults were less likely to receive recommended care for diabetes than high-income adults. In 2010, there were no statistically significant differences by income.

Also, in the NHQR:

  • In 2009, residents of micropolitan (small town) and noncore (the most rural) areas were less likely than residents of large fringe metropolitan (suburban) areas to report receiving recommended care for diabetes. This finding is consistent with what we know about the relationship between a variety of health measures and the level of urbanization, that residents of suburban areas tend to have, for example, better access to care and report better health status than residents living in more urban or more rural areas (Ingram & Franco, 2012). In 2010, however, residents of micropolitan and noncore areas were just as likely as residents of large fringe metropolitan areas to report receiving recommended care for diabetes.

Management: Written Diabetes Management Plan

A successful partnership for diabetes care requires providers to educate patients about daily management of their diabetes. Hence, providers should develop a written diabetes management plan, especially for patients with a history of uncontrolled diabetes.

Focus on Asian and Hispanic Subpopulations

National data on diabetes management and outcomes 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 CHIS are shown below.

In this section, we show the percentage of people with diabetes among Asian and Hispanic subpopulations in California whose doctor helped them to develop a diabetes management plan.

Figure 2.20. People with current diabetes whose doctor helped to develop a diabetes management plan, by Asian and Hispanic subpopulations and English proficiency, California, 2011-2012

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Source: UCLA, Center for Health Policy Research, California Health Interview Survey, 2011-2012.
Denominator: Civilian noninstitutionalized population in California.
Note: The Asian subpopulation sample size for "English Only" speakers did not meet requirements for statistical reliability, data quality, or confidentiality and is not included.

  • In 2011-2012, among Asian Californians, there was moderate variation among subgroups in the percentage of people with current diabetes whose doctor helped them to develop a diabetes management plan (Figure 2.20), from 46.2% of South Asian respondents to 74.3% of Vietnamese respondents.
  • Asian respondents who speak English well/very well were more likely to have a doctor help them develop a diabetes management plan than Asian respondents who speak English not well/not at all.
  • In 2011-2012, among Hispanic Californians, there was less variation among subgroups in the percentage of people with current diabetes whose doctor helped them to develop a diabetes management plan.
  • Hispanic respondents who speak English only were more likely to have a doctor help them develop a diabetes management plan than Hispanic respondents who speak English not well/not at all.
Focus on Native Hawaiians

Various studies have found that one-third of Native Hawaiian adults have or are at risk for diabetes or prediabetes (Aluli, et al., 2009; Grandinetti, et al., 1998). The Hawaii State Department of Health reported in 2007 that NHOPIs in Hawaii had the highest age-adjusted percentage of people with diabetes (20.6%) among all racial groups, more than three times as high as Whites (6.8%), nearly twice as high as Hispanics/Latinos (11.1%), and more than double Asians (8.9%). Among older Native Hawaiian adults, 19.6% have diabetes, twice the rate among older White adults (9.4%) (Salvail, et al., 2007).

Diabetes is rising among Polynesians, Micronesians, and Melanesians, who have prolonged exposure to more westernized lifestyles (e.g., access to calorie-dense, high-fat foods and less physical activity) compared with more traditional subsistence-based lifestyles (Okihiro & Harrigan, 2005; Papoz, et al., 1996).

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 (Look, et al., 2013). In this section, we show the percentage of adults in Hawaii with diabetes who reported receiving diabetes management education, by ethnicity.

Figure 2.21. Adults with diabetes receiving diabetes management education, by ethnicity, Hawaii, 2011

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Source: Hawaii State Department of Health, 2011.
Note: All rates are 3-year averages.

  • With increased attention to diabetes management efforts on the part of community health clinics, the Native Hawaiian Health Care Systems, and private physicians, a growing number of Native Hawaiians are reporting increased diabetes awareness and access to diabetes management education (Figure 2.21).
  • Between 2000 and 2010, the number of Native Hawaiians who reported receiving diabetes management education increased from 47% to 57%, a rate higher than the rate for the State as a whole.

The increased efforts to provide diabetes self-management education has not necessarily led to improved diabetes outcomes, which suggest that different approaches or strategies may be needed. A recent analysis of health insurance data in Hawaii found that Native Hawaiians and Filipinos are at greatest risk for poorly controlled diabetes, and these patients seem to be the least likely to achieve sustained appropriate long-term self-management of their disease (Juarez, et al., 2012).

Outcome: Admissions for Uncontrolled Diabetes

Individuals who do not achieve good control of their diabetes may develop symptoms that require correction through hospitalization. Admission rates for uncontrolled diabetes may be reduced by better outpatient treatment and patients' tighter adherence to diet and medication.

Figure 2.22. Hospital admissions for uncontrolled diabetes per 100,000 population, age 18 and over, by race/ethnicity and area income, 2004-2010

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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 (AHRQ), Healthcare Cost and Utilization Project, Nationwide Inpatient Sample and AHRQ Quality Indicators, version 4.1, 2004-2010.
Denominator: U.S. resident population age 18 and over.
Note: For this measure, lower rates are better. White, Black, and API are non-Hispanic; Hispanic includes all races

  • In all years, the rate of hospital admissions for uncontrolled diabetes was higher for Blacks and Hispanics and lower for APIs and Whites (Figure 2.22).
  • In all years, the rate of hospital admissions for uncontrolled diabetes was higher for adults living in communities with median household incomes in the first (lowest), second, and third quartiles than for people living in communities in the fourth quartile (highest).
  • The 2008 top 4 State achievable benchmark was 5 admissions per 100,000 population.xviii Most racial/ethnic groups could not achieve the benchmark for about 20 years. However, APIs and Hispanics would need 9 years and 11 years, respectively, to achieve the benchmark. Adults living in the lowest income quartile (Q1) would need 51 years to achieve the benchmark.

Also, in the NHQR:

  • From 2004 to 2009, there were no statistically significant changes in the annual overall adult admission rate for uncontrolled diabetes. In 2010, the rate decreased to 19.2 admissions per 100,000 population.
Focus on Indian Health Service Facilities

AI/ANs who are members of federally recognized Tribes are eligible for services provided by the Indian Health Service (IHS). About 2 million AI/ANs in the United States receive care directly from IHS, through tribally contracted and operated health programs or through services purchased by IHS from other providers (IHS, 2011). Due to low numbers and lack of data, information about AI/AN hospitalizations is difficult to obtain in most Federal and State hospital utilization data sources. The NHDR addresses this gap by examining utilization data from IHS, Tribal, and contract hospitals.

Diabetes is one of the leading causes of morbidity and mortality among AI/AN populations (IHS, 2011). Its prevention and control are a major focus of the IHS Director's Chronic Disease Initiative and the IHS Health Promotion/Disease Prevention Initiative. Addressing barriers to health care is a large part of the overall IHS goal of ensuring that comprehensive, culturally acceptable personal and public health services are available and accessible to AI/ANs.

In this section, we show the rate of hospital admissions for uncontrolled diabetes per 100,000 population in IHS, Tribal, and contract hospitals, by age group.

Figure 2.23. Hospital admissions for uncontrolled diabetes per 100,000 population in IHS, Tribal, and contract hospitals, age 18 and over, by age group, 2003-2011

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Source: Indian Health Service, Office of Information Technology/National Patient Information Reporting System, National Data Warehouse, Workload and Population Data Mart, 2003-2011.
Note: For this measure, lower rates are better. Total estimates are age adjusted using the total U.S. population for 2000 as the U.S. standard population. Service population does not include the Portland and California regions.

  • From 2003 to 2011, the age-adjusted rate of total hospitalizations for uncontrolled diabetes in IHS, Tribal, and contract hospitals decreased from 37.8 to 18.3 per 100,000 population (Figure 2.23). Rates decreased among all age groups.
  • In all years, patients ages 18-44 had lower rates than patients age 65 and over.
Outcome: End Stage Renal Disease Due to Diabetes

Diabetes is the most common cause of kidney failure. Keeping blood glucose levels under control can prevent or slow the progression of kidney disease due to diabetes. In addition, when kidney disease is detected early, medication can slow the disease's progress. If kidney disease is detected late, however, it commonly progresses to chronic kidney disease stage 5, also known as ESRD.

Once the patient has progressed to ESRD, some type of renal replacement therapy is necessary, either conservative management (no dialysis), hemodialysis, peritoneal dialysis, or kidney transplantation. While some cases of kidney failure due to diabetes cannot be avoided, other cases reflect inadequate control of blood glucose or delayed detection and treatment of early kidney disease due to diabetes.

Figure 2.24. Adults age 20 and over with end stage renal disease due to diabetes, per million population, by race and ethnicity, 2003-2010

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Key: API = Asian or Pacific Islander; AI/AN = American Indian or Alaska Native.
Source: National Institute of Diabetes and Digestive and Kidney Diseases, U.S. Renal Data System, 2003-2010.
Denominator: U.S. resident population.
Note: For this measure, lower rates are better. Rates are adjusted by age, sex, race, and interactions of age, sex, and race. When reporting is by race and ethnicity, the adjustment is by age, sex, and interactions of age and sex. Hispanic and non-Hispanic include all races.

  • From 2003 to 2010, there were no statistically significant changes in the overall rate of new cases of ESRD due to diabetes (Figure 2.24). From 2009 to 2010, however, the rate decreased among Blacks, Hispanics, and AI/ANs.
  • In all years, AI/ANs, APIs, and Blacks had higher rates than Whites, and Hispanics had higher rates than non-Hispanics.
  • The 2010 top 5 State achievable benchmark was 71 per million population.xix Among all racial groups, AI/ANs are progressing toward the benchmark but would not achieve it for 17 years. At their current rate of improvement, Blacks would take 77 years. Rates among non-Hispanics and Hispanics are improving slowly; neither group could achieve the benchmark for more than 60 years.

Also, in the NHQR:

  • In all years, adults age 45 and over had higher rates of ESRD due to diabetes than adults ages 20-44. In addition, males had higher rates than females.

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HIV and AIDS

Importance

Mortality
Number of deaths of people with AIDS (2010) 15,529 (CDC, 2013b)
Prevalence
Number of people living with HIV infection (2010) 872,990 (CDC, 2013b)
Number of people living with AIDS (2010) 487,692 (CDC, 2013b)
Incidence
Number of new HIV diagnoses (2010) 49,273 (CDC, 2013b)
Number of new AIDS diagnoses (2010) 32,052 (CDC, 2013b)
Cost
Federal spending on HIV/AIDS care, cash and housing assistance, prevention, and research (fiscal year 2014 est.) $23.2 billion (KFF, 2013)

 

HIV is a virus that kills or damages cells of the body's immune system. AIDS is the most advanced stage of HIV infection. HIV can be spread through unprotected sex with an infected person, sharing of drug needles, or contact with the blood of an infected person. In addition, women with HIV can pass the virus to their babies during pregnancy, childbirth, or breastfeeding.

The impact of HIV infection and AIDS is disproportionately higher for racial and ethnic minorities and people of lower income and education levels. Although access to care has improved, Blacks, Hispanics, women, and uninsured people with HIV remain less likely to have access to care and less likely to have optimal patterns of care (Tobias, et al., 2007).

The spread of HIV is linked to complex social and economic factors, including:

  • Poverty.
  • Concentration of the virus in specific geographic areas and smaller sexual networks.
  • Sexual risk behaviors (e.g., unprotected anal intercourse).
  • Sexually transmitted co-infections.
  • Unawareness of infection (people who do not know they are infected contribute to spreading this disease).
  • Stigma (negative attitudes, beliefs, and actions directed at people living with HIV/AIDS or directed at people who engage in behaviors that might put them at risk for HIV).
  • Alcohol, injection and noninjection drug use, and associated behaviors (CDC, 2010).

According to the Centers for Disease Control and Prevention (CDC), HIV and AIDS disproportionately affect Blacks in the United States. In 2010, Blacks represented 14% of the U.S. population but accounted for 44% of all diagnoses of new HIV infections (CDC, 2013b). The HIV/AIDS epidemic is also a serious threat to the Hispanic community. An estimated 21% of new HIV infections occurred among Hispanics in 2009, which is three times the infection rate of Whites (CDC, 2013b). In addition to being seriously affected by HIV, Hispanics continue to face challenges in accessing health care, especially preventive services and HIV treatment.

Undocumented immigrants face an even greater challenge in accessing care and information regarding HIV and AIDS, but data are limited on their HIV infection rates (Carrillo & DeCarlo, 2003). In 2007, HIV/AIDS was the fourth leading cause of death among Hispanic men and women ages 35-44 (CDC, 2011b). Having Medicaid and a usual source of care decreased the likelihood of delaying care for HIV, but research shows that delay in care is still greater for Hispanics and Blacks (Cunningham, et al., 2006).

Another group that is severely affected by HIV includes gay, bisexual, and other men who have sex with men (MSM). MSM represent 2% of the U.S. population and is the only risk group in which new HIV infections have been gradually increasing since the 1990s. MSM have constantly represented the largest percentage of people diagnosed with AIDS and people with an AIDS diagnosis who have died.

In 2010, MSM accounted for more than half (63%) of all new HIV infections in the United States and 78% of infections among all newly infected men. Black MSM accounted for 36% of new HIV infections in 2010. Young MSM are disproportionately affected, with those ages 13-24 accounting for 72% of new HIV infections among all persons ages 13-24 and 30% of new infections among all MSM in 2010 (CDC, 2013a).

The White House Office of National AIDS Policy launched the National HIV/AIDS Strategy (NHAS) in July 2010. The NHAS is a comprehensive plan focused on: (1) reducing the number of people who become infected with HIV, (2) increasing access to care and optimizing health outcomes for people living with HIV, and (3) reducing HIV-related health disparities. The plan serves as a roadmap for policymakers, partners in prevention, and the public on steps the United States must take to lower HIV incidence, get people living with HIV into care, and reduce HIV-related health disparities.

Measures

One measure is presented focusing on the quality of preventive care for HIV-infected individuals:

  • New AIDS cases.

Five measures are presented on access to care, retention in care, and treatment and prevention of opportunistic infections in HIV patients:

  • Adult HIV patients who had at least two outpatient visits during the year.
  • Adult HIV patients who received two or more CD4 tests during the year.
  • Adult HIV patients who received highly active antiretroviral therapy (HAART).
  • Eligible patients receiving prophylaxis for Pneumocystis pneumonia (PCP).
  • Eligible patients receiving prophylaxis for Mycobacterium avium complex (MAC).

This year, the report presents one measure on viral load:

  • HIV viral load less than 400.

In addition, one measure is presented on HIV infection deaths.

New! This year, we present data from the Ryan White HIV/AIDS Program (Ryan White Program).xx  It is important to note that not all people living with HIV use the Ryan White Program, so the data are not representative of the entire HIV population, which is estimated to be about 1.4 million people in the United States.

The two measures from the Ryan White Program are:

  • Rate of HIV patients in Ryan White-funded care who were virally suppressed (HIV RNA <200 copies/mL).
  • Rate of HIV patients in Ryan White-funded care who were retained in care (at least two ambulatory visit dates 90 days apart).

Findings

HIV Patients Receiving Care

Management of chronic HIV disease includes outpatient and inpatient services. Without adequate treatment, as HIV disease progresses, CD4 cell counts fall and patients become increasingly susceptible to opportunistic infections.

HIV/AIDS clinical performance measures are indicators for use in monitoring the quality of care provided to adults and adolescents living with HIV. Based on the set of quality measures developed by the HIV/AIDS Bureau (HAB) of the Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services (HHS), performance can be measured for various HIV prevention and treatment services. Services needed by patients with HIV include:

  • Two or more medical visits in an HIV care setting in the measurement year.
  • Two or more CD4 cell counts performed in the measurement year.
  • HAART for patients with HIV disease.
  • PCP prophylaxis for patients with CD4 cell count under 200.
  • MAC prophylaxis for patients with CD4 cell count under 50.

Outcome: 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, screening and early detection of HIV disease, and availability of appropriate treatments for HIV-infected individuals.

Figure 2.25. New AIDS cases per 100,000 population age 13 and over, by race/ethnicity, 2000-2010

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Key: AI/AN = American Indian or Alaska Native, NHOPI= Native Hawaiian or Other Pacific Islander.
Source: Centers for Disease Control and Prevention, National Center for HIV, STD, and TB Prevention, HIV/AIDS Surveillance System, 2000-2010.
Denominator: U.S. population age 13 and over.
Note: For this measure, lower rates are better. White, Black, AI/AN, API and NHOPI are non-Hispanic. Hispanic includes all races.

  • Overall, in 2010, the total rate of new AIDS cases was 11.5 per 100,000 population (Figure 2.25).
  • Overall, in 2010, the total rate of new AIDS cases was 11.5 per 100,000 population.
  • In all years, Asians had lower rates of new AIDS cases than Whites.
  • In 2010, Blacks (47.4 per 100,000 population), AI/ANs (7.8 per 100,000 population), NHOPIs (9.1 per 100,000), and Hispanics (15.5 per 100,000 population) had higher rates of new AIDS cases than Whites (4.5 per 100,000 population).
  • The 2010 top 5 State achievable benchmark for new AIDS cases was 2.8 per 100,000 population.xxi  Asians have nearly achieved the benchmark. At the current rate, Whites could achieve the benchmark in 7 years, Hispanics in 10 years, Blacks in 15 years, and AI/ANs in 16 years.

Also, in the NHQR:

  • From 2000 to 2010, rates of new AIDS cases decreased overall, for ages 18-44 and 45-64, and for both sexes.
  • In all years, people ages 18-44 had a higher rate of new AIDS cases than other age groups, and males had a higher rate than females.

Management: Recommended Care for HIV

HIV measures tracked in the NHDR are from the HIV Research Network, which consists of 18 medical practices across the United States that treat large numbers of patients living with HIV. Data from the voluntary HIV Research Network are not nationally representative of the level of care received by everyone in the United States living with HIV.

HIV Research Network data represent only patients with HIV who are actually receiving care (about 14,000 patients per year) and do not represent patients who do not receive care. Furthermore, data shown below are not representative of the HIV Research Network as a whole because they represent only a subset of network sites that have the most complete data.

Below are data from the HIV Research Network that capture four of the HRSA quality measures. In addition, when CD4 cell counts fall below 50, medicine to prevent development of disseminated MAC infection is routinely recommended (Yeargin, et al., 2003), which is also tracked in the reports.

Figure 2.26. HIV patients who received recommended care, by race/ethnicity and sex, 2010

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Key: HAART = highly active antiretroviral therapy; PCP = Pneumocystis pneumonia; MAC = Mycobacterium avium complex.
Source: Agency for Healthcare Research and Quality, HIV Research Network, 2010.
Note: For HAART measure, adult HIV patients had to be enrolled in an HIV Network clinic, receive at least one CD4 test, and have at least one outpatient visit in addition to having at least one CD4 test result of 350 or less.

  • Overall, in 2010, 89.5% of people with HIV had two or more outpatient visits during the year, and 81.2% of people with HIV had two or more CD4 tests during the year (Figure 2.26). In addition, 94.6% of people with HIV received HAART, 93.6% of people with HIV received PCP prophylaxis, and 91.4% of people with HIV received MAC prophylaxis.
  • In 2010, there were no statistically significant differences by race/ethnicity or sex in the percentage of people with HIV receiving recommended services.

Also, in the NHQR:

  • In 2010, the percentage of adults with HIV who had two or more outpatient visits, two or more CD4 tests, and HAART was higher for those age 45 and over compared with those ages 18-44.
  • In 2010, the percentage of adults with HIV who had two or more outpatient visits and two or more CD4 tests was higher for those with Medicaid and Medicare/Dual Eligible insurance compared with those with private insurance.

New! Outcome: HIV Viral Load Suppression

Low levels of HIV viral load are desired, as they decrease the chances of spreading HIV. Even if an HIV patient's viral load is low, the risk of HIV transmission is not completely prevented. Thus, it is essential for HIV patients to continue to adequately manage the disease, by getting tested and taking any necessary medication.

Figure 2.27. Adult HIV patients with viral suppression for first test in the year, by ethnicity and sex, 2008-2010.

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Source: Agency for Healthcare Research and Quality, HIV Research Network, 2008-2010.
Denominator: Includes adult HIV patients enrolled in an HIV Research Network medical practice prior to the year. Patients who died, didn't have an outpatient visit, or didn't have a CD4 test in the year are excluded.
Note: Viral load suppression means HIV RNA <400 copies/mL. White and Black are non-Hispanic. Hispanic includes all races.

  • Overall in 2010, 73% of adult HIV patients had viral suppression for the first test in the year (Figure 2.27).
  • In all years, the percentage of adult HIV patients with viral load suppression was lower for Blacks and Hispanics compared with Whites.
  • In all years, the percentage of adult HIV patients with viral load suppression was higher for males compared with females.

Also, in the NHQR:

  • In all years, the percentage of adult HIV patients with viral load suppression was higher for those age 45 and over compared with those ages 18-44.
  • In all years, the percentage of adult HIV patients with viral load suppression was lower for those with Medicaid compared with those with private insurance.

Outcome: Deaths of People With HIV Infection

Improved management of HIV infection has contributed to declines in the number of new AIDS cases in the United States since the 1990s (CDC, 2005). HIV infection deaths reflect a number of factors, including underlying rates of HIV risk behaviors, prevention of HIV transmission, early detection and treatment of HIV disease, and management of AIDS and its complications.

Figure 2.28. HIV infection deaths per 100,000 population, 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.
Note: For this measure, lower rates are better. Rates are age adjusted to the 2000 U.S. standard population.

  • Overall, in 2010, the total rate of HIV infection deaths was 2.6 per 100,000 population (Figure 2.28).
  • HIV infection death rates are decreasing overall and for all racial/ethnic groups.
  • From 2000 to 2010, HIV infection death rates were higher for Blacks than for Whites. APIs had lower rates than Whites in all years.xxii
  • In all years, HIV infection death rates were higher for Hispanics than for Whites.
  • The 2008 top 4 State achievable benchmark for HIV deaths was 0.9 per 100,000.xxiii At the current rate, Whites, non-Hispanic Whites, Hispanics, Blacks, and AI/ANs could achieve the benchmark in 3, 2, 4, 9, and 12 years, respectively. APIs have already reached the benchmark.

Also, in the NHQR:

  • In all years, the rate of HIV infection deaths was higher for males than for females.
  • From 2000 to 2010, the rate of HIV infection deaths was higher for adults ages 45-64 than for those ages 18-44. The rate was lower for those 65 and over compared with those ages 18-44.

New! Ryan White Program Overview

Over the past 23 years, the Ryan White Program has provided funds for primary care and support services for people living with and affected by HIV disease. Working with States, cities, and local community organizations, the Ryan White Program strives to improve the quality of HIV-related care to those who do not have sufficient health care coverage or financial resources for coping with HIV disease. In 2010, the Ryan White Program served a total of 556,175 non-ADAP clients.

The Ryan White Program, as authorized by the Ryan White HIV/AIDS Treatment Extension Act of 2009 (Public Law 111-87), is administered by HHS, HRSA, HAB. HRSA and HAB support the NHAS and its goals to reduce HIV incidence, increase access to care, optimize health outcomes, and reduce HIV-related health disparities.

Annually, Ryan White-funded programs are required to report to HRSA HAB how the funds have been used to provide services to HIV-positive individuals and their families who lack sufficient health care coverage or financial resources. The Ryan White Program Services Report (RSR) is the annual reporting instrument that agencies and organizations receiving funds complete to describe organizational characteristics, number and characteristics of clients served, types of services provided, number of clients receiving services, and number of client visits by type of service.

All clients served by the Ryan White Program received some type of Ryan White service, not just medical care. Of the 556,175 clients served in 2010, 68.5% were male, 30.7% female, and 0.8% transgenderxxiv (including male-to-female and female-to-male). Individuals under age 13 years accounted for 2.1% of the Ryan White population, followed by age 65 and over (2.9%), 13-24 (6.6%), 55-64 (13.7%), 25-34 (15.0%), 35-44 (25.7%), and 45-54 (33.9%). The racial/ethnic groups represented most commonly include non-Hispanic Black (47.2%), non-Hispanic White (28%), and Hispanic/Latino (22.1%); all other racial/ethnic groups are 1% or less.

In the RSR, HIV status is reported only for individuals who receive case management or medical care services. There were 313,170 HIV-positive individuals (56% of Ryan White clients) who received Ryan White-funded HIV medical care. Due to missing data on HIV medical care visits, viral load tests, and antiretroviral therapy for some of the 313,170 HIV-positive individuals, the following data have different denominators.

The number of HIV-positive clients with at least one HIV medical care visit and at least one viral load available was 255,172. The number of HIV-positive clients with at least one HIV medical service and at least one HIV medical care visit date available during the year was 297,042.

Figure 2.29. HIV clients in Ryan White-funded care who were virally suppressed (most recent HIV RNA <200 copies/mL), by race/ethnicity and household income, 2010

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Key: AI/AN = American Indian or Alaska Native; NHOPI = Native Hawaiian or Other Pacific Islander.
Source: Health Resources and Services Administration, 2010.
Denominator: HIV-positive clients all ages who received Ryan White-funded HIV care during the year and had visit date and viral load data available. Clients with missing viral load are excluded.
Note: White, Black, AI/AN, Asian, NHOPI are non-Hispanic. Hispanic includes all races. Poor refers to household incomes below the Federal poverty line; low income, from the poverty line to just below 200% of the poverty line; middle income, 200% to just below 300% of the poverty line; and high income, 300% of the poverty line and over.

  • In 2010, 69.5% of HIV-positive clients in Ryan White-funded care were virally suppressed (Figure 2.29).
  • In 2010, Black (63.3%), NHOPI (70.5%), AI/AN (70.4%), and Hispanic (73.6%) HIV-positive clients were less likely to be virally suppressed compared with White (76.3%) HIV-positive clients. Asian HIV-positive clients (78.8%) were more likely than White HIV-positive clients to be virally suppressed.
  • In 2010, HIV-positive clients from poor households (67.3%) were less likely to be virally suppressed than those from high-income households (72.1%). HIV-positive clients from low-income (76%) and middle-income (79.2%) households were more likely to be virally suppressed than those from high-income households.

Also, in the NHQR:

  • In 2010, female and transgender HIV-positive clients were less likely to be virally suppressed than male HIV-positive clients.
  • In 2010, HIV-positive clients with Medicaid and those without insurance were less likely to be virally suppressed than those with private insurance.

Figure 2.30. HIV-positive clients in Ryan White-funded care who were retained in HIV care (at least 2 ambulatory visit dates at least 90 days apart), by race/ethnicity and household income, 2010

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Key: AI/AN = American Indian or Alaska Native; NHOPI = Native Hawaiian or Other Pacific Islander.
Source: Health Resources and Services Administration, 2010.
Denominator: Total estimated number of HIV-positive clients all ages who received at least one Ryan White-funded care visit during the year and have visit dates available.
Note: White, Black, AI/AN, Asian, NHOPI are non-Hispanic. Hispanic includes all races. Poor refers to household incomes below the Federal poverty line; low income, from the poverty line to just below 200% of the poverty line; middle income, 200% to just below 300% of the poverty line; and high income, 300% of the poverty line and over.

  • In 2010, 75.7% of HIV-positive clients in Ryan White-funded care were retained in care (Figure 2.30).
  • In 2010, NHOPI (69.8%) and AI/AN (73.6%) HIV-positive clients were less likely to be retained in care compared with White HIV-positive clients (76.6%).
  • In 2010, HIV-positive clients from poor households (76.1%) were less likely to be retained in care than those from high-income households (78.8%).

Also, in the NHQR:

  • In 2010, transgender HIV-positive clients were less likely to be retained in care compared with male HIV-positive clients.
  • In 2010, HIV-positive clients with Medicaid and those without insurance were less likely to be retained in care compared with those with private insurance.

xiv The top 5 States that contributed to the achievable benchmark are Hawaii, Maine, Montana, North Dakota, and Vermont.
xv The top 5 States that contributed to the achievable benchmark are Delaware, Iowa, Minnesota, Montana, and Vermont.
xvi The total number of people with diabetes is the sum of the estimated number of those age 20 years and over with diagnosed or undiagnosed diabetes and the number of those younger than 20 years with diagnosed diabetes. The estimated number of adults age 20 years and over with diabetes (diagnosed or undiagnosed) was obtained using the fasting subsample from the 2005-2008 National Health and Nutrition Examination Survey (NHANES) data. The diabetes estimates from NHANES were applied to the 2010 U.S. resident population estimates to derive the estimated number of adults with diabetes. People who self-reported having been told by a doctor or health professional that they had diabetes were classified as having diagnosed diabetes. Those without a history of diabetes but with a fasting plasma glucose greater than or equal to 126 mg/dL or an HbA1c level greater than or equal to 6.5% were classified as having undiagnosed diabetes. Estimates of undiagnosed diabetes for people younger than 20 years are not available.
xvii The laboratory test for HbA1c, also known as "glycosylated hemoglobin," shows a patient's average blood glucose (in percent) over the previous 2 to 3 months.
xviii The top 4 States that contributed to the achievable benchmark are Colorado, Hawaii, Utah, and Vermont.
xix The top 5 States that contributed to the achievable benchmark are District of Columbia, Montana, New Hampshire, Vermont, and Wyoming.
xx Data on clients who solely receive assistance from the AIDS Drug Assistance Program (ADAP) were not included in this analysis because they are reported into a different data system.
xxi The top 5 States that contributed to the achievable benchmark are Iowa, Maine, South Dakota, Utah, and Wisconsin.
xxii 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).
xxiii The top 4 States that contributed to the achievable benchmark are Kansas, Minnesota, Oregon, and Wisconsin.
xxiv Transgender is defined as an individual whose gender identity is not congruent with his or her biologic gender, regardless of the status of surgical and hormonal gender reassignment processes.


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