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National Healthcare Disparities Report, 2013

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

Respiratory Diseases

Importance

Mortality
Number of deaths due to chronic lower respiratory diseases (2011 prelim.) 143,382 (Hoyert & Xu, 2012)
Number of deaths, influenza and pneumonia combined (2011 prelim.) 53,667 (Hoyert & Xu, 2012)
Cause of death rank for chronic lower respiratory diseases (2011 prelim.) 3rd (Hoyert & Xu, 2012)
Cause of death rank for influenza and pneumonia combined (2011 prelim.) 8th (Hoyert & Xu, 2012)
Prevalence
Adults age 18 and over with current asthma (2011) 18.7 million (Schiller, et al., 2012)
Children under age 18 with current asthma (2011) 7.0 million (Bloom, et al., 2012)
Incidence
Number of discharges attributable to pneumonia (2010) 1.1 million (Pfuntner, et al., 2013)
New cases of tuberculosis (2012) 9,945 (CDC, 2013c)
Cost
Total cost of upper respiratory infections (annual est.) $40 billion (Fendrick, et al., 2003)
Total cost of asthma (2007) $56 billion (Barnett & Nurmagambetov, 2011)
Cost-effectiveness of influenza immunization (2006) $0-$14,000/QALY (Maciosek, et al., 2006)

Measures

The NHQR and NHDR track several quality measures for prevention and treatment of this broad category of illnesses that includes pneumonia, tuberculosis, and asthma. The seven measures highlighted in this section are:

  • Pneumococcal immunization.
  • Influenza immunization among patients hospitalized with pneumonia.
  • Influenza immunization among nursing home residents.
  • Pneumococcal immunization among nursing home residents.
  • Completion of tuberculosis therapy.
  • Daily asthma medication.
  • Written asthma management plans.

Findings

Prevention: Pneumococcal Immunization

Immunization is a cost-effective strategy for reducing illness, death, and disparities associated with pneumonia and influenza.

  Figure 2.39. Adults age 65 and over who reported ever receiving pneumococcal immunization, by race and ethnicity, 2000-2011

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Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2000-2011.
Denominator: Civilian noninstitutionalized population age 65 and over.
Note: Age adjusted to the 2000 U.S. standard population. Benchmark is derived from the Behavioral Risk Factor Surveillance System; go to Chapter 1, Introduction and Methods, for details.

  • Overall, the percentage of adults age 65 and over who reported ever receiving pneumococcal immunization increased from 53.4% in 2000 to 62.7% in 2011 (Figure 2.39). In 2011, increases were observed among Whites and Blacks, but Asians who reported ever receiving pneumococcal immunization decreased.
  • In all years, Blacks and Asians were less likely than Whites and Hispanics were less likely than non-Hispanic Whites to receive pneumococcal immunization.
  • The 2008 top 5 State achievable benchmark was 67%.xxx At the current annual rate of increase, this benchmark could be attained overall in about 5 years. Whites could achieve the benchmark in about 2 years, while Blacks, Asians, and Hispanics would not reach the benchmark for 13, 23, and 19 years, respectively.

Also, in the NHQR:

  • In all years, adults with basic activity limitations were more likely than adults with neither basic nor complex activity limitations to receive pneumococcal immunization.

  Figure 2.40. State variation in disparities related to education: adults age 65 and over who reported ever receiving pneumococcal immunization, 2010

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Key: Biggest Disparity Quartile identifies States with the largest differences in rates of pneumococcal immunization between adults with less than a high school education and adults who graduated from college; Smallest Disparity Quartile identifies States with the smallest differences in rates of pneumococcal immunization between adults with less than a high school education and adults who graduated from college.
Source: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System, 2010.

  • The States in the biggest disparity quartile had differences of more than 11% between adults with less than a high school education and adults who graduated from college in the rate of pneumococcal immunization. In the States in the smallest disparity quartile, the differences were less than 4.7% (Figure 2.40).
  • States in the Middle Atlantic, East South Central, and West South Central census divisions tended to have larger education-related disparities in pneumococcal immunization while States in the New England, West North Central, and Mountain census divisions tended to have smaller education-related disparities in pneumococcal immunization.

Also, in the NHQR:

  • States in the East South Central and West South Central census divisions tended to have lower rates of pneumococcal immunization.

Prevention: Influenza Immunization Among Patients Hospitalized With Pneumonia

In 2011, overall compliance with most of these measures surpassed 95%, our threshold for retiring measures. One pneumonia care measure that has not yet been retired is influenza immunization status assessment or provision, and this measure is presented here.

New!  Figure 2.41. Hospital patients age 50 and over with pneumonia who received influenza immunization status assessment or provision, by race/ethnicity, 2005-2011

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Key: AI/AN = American Indian or Alaska Native.
Source: Centers for Medicare & Medicaid Services, Medicare Quality Improvement Organization Program, 2005-2011.
Denominator: Patients age 50 and over discharged October-February with a principal discharge diagnosis of pneumonia or a principal discharge diagnosis of either septicemia or respiratory failure and secondary diagnosis of pneumonia.
Note: White, Black, AI/AN, and Asian are non-Hispanic; Hispanic includes all races.

  • From 2005 to 2011, the percentage of patients age 50 and over with pneumonia who received influenza immunization status assessment or provision increased from 55.2% to 94.1% (Figure 2.41). Improvements were observed among all racial/ethnic groups.
  • In all years since 2006, Black, Hispanic, AI/AN, and Asian patients were less likely than White patients to receive influenza immunization status assessment or provision.
  • In 2010, the 2008 top 5 State achievable benchmark of 91% was attained.
  • In 2011, the new top 5 State achievable benchmark was 97%.xxxi All racial/ethnic groups were on track to attain the benchmark in about a year.

Also, in the NHQR:

  • In all years, patients ages 65-74, 75-84, and 85 and over were more likely to receive influenza immunization status assessment or provision than patients ages 50-64.

Prevention: Influenza and Pneumococcal Immunization Among Nursing Home Residents

Long-stay residents typically enter a nursing facility because they can no longer care for themselves at home. They tend to stay in the facility for several months or years. They are at high risk for influenza infections, complications, and mortality because of advanced age, comorbid conditions, and increased exposure in institutional settings. Hence, routine immunization of nursing home residents and staff against influenza is strongly recommended. Pneumoccocal immunization is also appropriate for most long-stay nursing home residents based on age and comorbid conditions.

New!  Figure 2.42. Long-stay nursing home residents who were assessed and given influenza and pneumococcal immunization, by race/ethnicity, 2011

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Source: Centers for Medicare & Medicaid Services, Minimum Data Set, 2011. Data are from the third quarter of each calendar year.
Denominator: All long-stay residents in Medicare- or Medicaid-certified nursing home facilities.

  • In 2011, 89.5% of long-stay nursing home residents were assessed and given influenza immunization and 93.3% were assessed and given pneumococcal immunization (Figure 2.42).
  • Black, AI/AN, multiple-race, and Hispanic residents were less likely than White residents to receive both influenza and pneumococcal immunization. NHOPI residents were less likely than White residents to receive pneumococcal immunization.
  • In 2011, the top 5 State achievable benchmark for influenza immunization was 94%xxxii and the benchmark for pneumococcal immunization was 98%.xxxiii No racial/ethnic group has achieved the benchmarks.

Also, in the NHQR:

  • Residents ages 0-64, 65-74, and 75-84 were less likely than residents age 85 and over to receive both influenza and pneumococcal immunization.
  • Females were more likely than males to receive pneumococcal immunization.

Outcome: Completion of Tuberculosis Therapy

Failure to complete tuberculosis therapy puts patients at increased risk for treatment failure and for spreading the infection to others. Even worse, it may result in the development of drug-resistant strains of tuberculosis.

  Figure 2.43. Patients with tuberculosis who completed a curative course of treatment within 1 year of initiation of treatment, by race/ethnicity and place of birth, 2000-2009

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Key: API = Asian or Pacific Islander.
Source: Centers for Disease Control and Prevention, National Tuberculosis Surveillance System, 2000-2009.
Denominator: U.S. civilian noninstitutionalized population treated for tuberculosis.
Note: White, Black, and API are non-Hispanic; Hispanic includes all races.

  • The percentage of patients who completed tuberculosis therapy within 1 year increased from 80.2% in 2000 to 86.1% in 2009 (Figure 2.43). Improvements were observed among foreign-born patients and among all racial/ethnic groups.
  • In 8 of 10 years, Hispanics were less likely than Whites to complete tuberculosis treatment
  • The 2008 top 4 State achievable benchmark was 94%.xxxiv At the current annual rate of increase, this benchmark could not be attained overall for about 12 years. Whites, Blacks, and APIs could achieve the benchmark sooner while Hispanics would need about 18 years. Foreign-born people would need about 16 years.

Also, in the NHQR:

  • In all years, children ages 0-17 with tuberculosis were more likely than adults ages 18-44 to complete a curative course of treatment within 1 year of initiation of treatment.
  • From 2004 to 2009, males were less likely than females to complete tuberculosis treatment.

  Figure 2.44. Patients with tuberculosis who completed a curative course of treatment within 1 year of initiation of treatment, by Asian and Pacific Islander and Hispanic granular ethnicities, 2008-2009

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Source: Centers for Disease Control and Prevention, National Tuberculosis Surveillance System, 2008-2009.
Denominator: U.S. civilian noninstitutionalized population treated for tuberculosis.

  • There is considerable variation in completion of treatment for tuberculosis among API granular ethnicities and among Hispanic granular ethnicities (Figure 2.44).
  • Most groups are far from the 2008 top 4 State achievable benchmark of 94%. Only Koreans reached the benchmark in 2009.

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 asthma diagnosis and management (NHLBI, 2007). 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.

While not all patients with asthma need to take medications, patients with persistent asthma need daily long-term controller medication to prevent exacerbations and chronic symptoms. Preventive medications for people with persistent asthma include inhaled corticosteroids, inhaled long-acting beta-2 agonists, cromolyn, theophylline, and leukotriene modifiers.

  Figure 2.45. People with current asthma who report taking preventive asthma medicine daily or almost daily, by race/ethnicity and family income, 2003-2010

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Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2003-2010.
Denominator: Civilian noninstitutionalized population with current asthma.
Note: Age adjusted to the 2000 U.S. standard population using four age groups: 0-17, 18-44, 45-64, and 65 and over. People with current asthma reported that they still had asthma or had an asthma attack in the last 12 months. White and Black are non-Hispanic; Hispanic includes all races.

  • From 2003 to 2010, the percentage of people with current asthma who reported taking preventive asthma medicine daily or almost daily fell from 29.6% to 26.5% (Figure 2.45). Significant decreases were observed among Blacks, Hispanics, high-income people, and poor people.
  • In 5 of 8 years, Blacks were less likely than Whites to take daily preventive asthma medicine.
  • In 5 of 8 years, poor and low-income people were less likely than high-income people to take daily preventive asthma medicine.

Also, in the NHQR:

  • In all years, uninsured people under age 65 were less likely than people under age 65 with any private health insurance to take daily preventive asthma medicine.
  • In all years, people ages 18-44 were less likely than other age groups to take daily preventive asthma medicine.

Management: Written Asthma Management Plans

A successful partnership for asthma care requires providers to educate patients about daily management and how to recognize and handle worsening asthma. Hence, providers should develop written asthma management plans as part of educating patients regarding self-management, especially for patients with moderate or severe persistent asthma and those with a history of severe exacerbation.

  Figure 2.46. People with current asthma who received written asthma management plans from their health provider, by race/ethnicity and family income, 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 with current asthma.
Note: Estimates are age adjusted to the 2000 U.S. standard population. White and Black are non-Hispanic; Hispanic includes all races.

  • In 2008, only one-third of people with current asthma received written asthma management plans from their provider (data not shown).
  • Blacks were more likely than Whites to receive written asthma management plans (Figure 2.46). Black-White differences were most significant in middle- and high-income families.

Also, in the NHQR:

  • Children ages 0-17 were more likely to receive written asthma management plans than adults ages 18-44. This age effect was most significant in middle- and high-income families.
Focus on Asian and Hispanic Subgroups

National data on Asian and Hispanic subgroups are limited. In this section, we show the percentage of people with current asthma whose doctor helped them to develop an asthma management plan among Asian and Hispanic subgroups in California. Data come from the 2011-2012 California Health Interview Survey.

  Figure 2.47. People with current asthma whose doctor helped them to develop an asthma management plan, by Asian and Hispanic subgroups 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.

  • In 2011-2012, among Asian Californians, there was moderate variation among subgroups in the percentage of people with current asthma whose doctor helped them to develop an asthma management plan (Figure 2.47). Differences related to English proficiency were not statistically significant due in part to large standard errors for the subpopulations.
  • In 2011-2012, among Hispanic Californians, there also was moderate variation among subgroups in the percentage of people with current asthma whose doctor helped them to develop an asthma management plan. Hispanics who did not speak English well were less likely to report help with developing an asthma management plan compared with Hispanics who spoke English at home. Other differences were not statistically significant due in part to large standard errors for many subpopulations.

xxx The top 5 States that contributed to the achievable benchmark are Colorado, Delaware, Maine, New Hampshire, and Oklahoma.
xxxi The top 5 States that contributed to the achievable benchmark are Florida, Maine, New Hampshire, New Jersey, and South Carolina.
xxxii The top 5 States that contributed to the achievable benchmark are Alaska, Hawaii, New Hampshire, New Jersey, and South Dakota.
xxxiii The top 5 States that contributed to the achievable benchmark are Alaska, Iowa, New Hampshire, North Dakota, and Wisconsin.
xxxiv The top 4 States that contributed to the achievable benchmark are Colorado, Kansas, Mississippi, and Oregon.


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Page originally created May 2014

 

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