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National Healthcare Disparities Report, 2013

Chapter 5. Timeliness

Timeliness in health care is the system's capacity to provide care quickly after a need is recognized. It is one of the six dimensions of quality the Institute of Medicine established as a priority for improvement in the health care system (IOM, 2001). Measures of timeliness include time spent waiting in doctors' offices and emergency departments (EDs) and the interval between identifying a need for specific tests and treatments and actually receiving services.

Importance

Morbidity and Mortality

  • Lack of timeliness can result in emotional distress, physical harm, and higher treatment costs (Boudreau, et al., 2004).
  • Stroke patients' mortality and long-term disability are largely influenced by the timeliness of therapy (Kazley, et al., 2010).
  • Timely delivery of appropriate care can help reduce mortality and morbidity for chronic conditions such as kidney disease (Smart & Titus, 2011).
  • Timeliness in childhood immunizations helps maximize protection from vaccine-preventable diseases while minimizing risks to the child and reducing the chance of disease outbreaks (Luman, et al., 2005).
  • Timely antibiotic treatments are associated with improved clinical outcomes (Cartmill, et al., 2012).

Cost

  • Early care for comorbid conditions has been shown to reduce hospitalization rates and costs for Medicare beneficiaries (Himelhoch, et al., 2004).
  • Some research suggests that, over the course of 30 years, the costs of treating diabetic complications can approach $50,000 per patient (Caro, et al., 2002). Early care for complications in patients with diabetes can reduce overall costs of the disease (Ramsey, et al., 1999).
  • Timely outpatient care can reduce admissions for pediatric asthma, which account for more than $1.25 billion in total hospitalization charges annually (AHRQ, 2009; Schatz, et al., 2009).

Measures

This report includes three measures related to timeliness of primary, emergency, and hospital care:

  • Getting care for illness or injury as soon as wanted.
  • ED waiting times.
  • Timeliness of cardiac reperfusion for heart attack patients.

Findings

Getting Care for Illness or Injury As Soon As Wanted

A patient's primary care provider should be the first point of contact for most illnesses and injuries. A patient's ability to receive timely treatment for illness and injury is a key element in a patient-centered health care system.

Figure 5.1. Adults who needed care right away for an illness, injury, or condition in the last 12 months who sometimes or never got care as soon as wanted, by race/ethnicity and income, 2002-2010

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Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2010.
Denominator: Civilian noninstitutionalized population age 18 and over.
Note: For this measure, lower rates are better. White and Black are non-Hispanic. Hispanic includes all races.

  • From 2002 to 2010, the percentage of adults who needed care right away for an illness, injury, or condition in the last 12 months who sometimes or never got care as soon as wanted was significantly lower for Whites than for Blacks and Hispanics (Figure 5.1).
  • In all years, the percentage who reported not getting needed care as soon as wanted was significantly lower for high-income people than for poor, low-income, and middle-income people.
  • In 7 of 9 years, the percentage who reported not getting care as soon as wanted was significantly lower for people who spoke English most often at home than for people who spoke other languages (data not shown).

Also, in the NHQR:

  • In 2010, the percentage of adults who sometimes or never got care as soon as wanted was significantly lower for adults with neither basic nor complex activity limitations than for adults with complex activity limitations.

Figure 5.2. Children who needed care right away for an illness, injury, or condition in the last 12 months who sometimes or never got care as soon as wanted, by race/ethnicity and income, 2002-2010

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Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2010.
Denominator: Civilian noninstitutionalized population under age 18.
Note: For this measure, lower rates are better. White and Black are non-Hispanic. Hispanic includes all races. The 2009 and 2010 data for Blacks; the 2007, 2009, and 2010 data for high-income families; the 2009 and 2010 data for middle-income families; and the 2010 data for low-income families did not meet criteria for statistical reliability, data quality, or confidentiality.

  • From 2002 to 2010, the percentage of children who sometimes or never received care as soon as wanted decreased for Whites and Hispanics (Figure 5.2).
  • In 4 of 6 years where data were available, the percentage of children who did not receive care as soon as wanted was significantly lower for children from high-income families than for children from poor families. In 3 of 6 years where data were available, the percentage of children who did not receive care as soon as wanted was significantly lower for children from high-income families than for children from low-income families.

Also, in the NHQR:

  • From 2002 to 2010, the percentage of children who needed care right away for an illness, injury, or condition in the last 12 months who sometimes or never got care as soon as wanted decreased for children without special health care needs.
  • From 2002 to 2009, the percentage also decreased for children with special health care needs.

Emergency Department Visit Waiting Times

In 2010, an estimated 130 million visits were made to hospital EDs compared with almost 124 million visits in 2008 (CDC, 2010). The median waiting time for patients to be seen by a physician during an ED visit in the United States was 28 minutes (CDC, 2010). Not all patients seeking care in an ED need urgent care, and use of EDs for nonurgent care could lead to longer waiting times.

Figure 5.3. Emergency department visits where patient was transferred or admitted and length of visit was 6 hours or more, by insurance and race, 2010-2011

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Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Ambulatory Medical Care Survey, 2010-2011.
Note: For this measure, lower rates are better. Public insurance includes Medicare, Medicaid, and State Children's Health Insurance Program. Uninsured is defined as having "only self-pay" or "no charge/charity" as payment sources. For general information about survey methodology, reliability of estimates, and other technical information, refer to the National Hospital Ambulatory Medical Care Survey: 2006 emergency department summary (http://www.cdc.gov/nchs/data/nhsr/nhsr007.pdf [PDF File, 697 KB]).

  • In 2010-2011, a higher percentage of patients with public insurance had to wait 6 hours or more compared with patients with private insurance (Figure 5.3).
  • The percentage of patients who were transferred or admitted and had to wait 6 hours or more was significantly higher for Blacks than for Whites.

Also, in the NHQR:

  • In 2010-2011, the percentage of patients who were transferred or admitted and had to wait 6 hours or more was significantly higher for those ages 18-44 than for those under age 18 and those age 65 and over.
  • In 2010-2011, the percentage of ED patients who had to wait 6 hours or more was about 2½ times as high in metropolitan areas as in nonmetropolitan areas.

Timeliness of Cardiac Reperfusion for Heart Attack Patients

The capacity to treat hospital patients in a timely manner is especially important for emergency situations such as heart attacks. Some heart attacks are caused by blood clots. Early actions, such as percutaneous coronary intervention (PCI) or fibrinolytic medication, may open blockages caused by blood clots, reduce heart muscle damage, and save lives (Gerczuk & Kloner, 2012). To be effective, these actions need to be performed quickly after the start of a heart attack. In this report, we present two measures of timeliness of cardiac reperfusion:

  • PCI within 90 minutes among appropriate patients.
  • Fibrinolytic medication within 30 minutes among appropriate patients.

Figure 5.4. Hospital patients with heart attack given percutaneous coronary intervention within 90 minutes of arrival, 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: Discharged hospital patients with a principal diagnosis of acute myocardial infarction and documented receipt of percutaneous transluminal angioplasty or stent placement during the hospital stay.

  • Among heart attack patients, the percentage of patients receiving timely PCI improved for all racial/ethnic groups from 2005 to 2011 (Figure 5.4).
  • In all years, Blacks and Hispanics were less likely than Whites to receive timely PCI.
  • The 2010 top 5 State achievable benchmark was 96%.i At the current rates of improvement, the achievable benchmark could be attained overall and among all racial/ethnic groups in less than 1 year.

Also, in the NHQR:

  • From 2005 to 2011, the percentage of patients receiving PCI within 90 minutes improved significantly for both males and females.

Figure 5.5. Hospital patients with heart attack give fibrinolytic medication within 30 minutes of arrival, by race/ethnicity, 2005-2011

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Source: Centers for Medicare & Medicaid Services, Medicare Quality Improvement Organization Program, 2005-2011.
Denominator: Discharged hospital patients with a principal diagnosis of acute myocardial infarction and documented receipt of thrombolytic therapy during the hospital stay.

  • Among heart attack patients, the percentage of patients receiving timely fibrinolytic medication improved for all racial/ethnic groups from 2005 to 2011 (Figure 5.5). In 6 of 7 years, Blacks were less likely to receive timely fibrinolytic medication compared with Whites.
  • In 2010, the top 5 State achievable benchmark was 68%.ii At the current rate of improvement, the achievable benchmark could be attained overall in less than 3 years. At their current rate of improvement, Whites should reach the achievable benchmark in about 3 years, Blacks in about 2 years, and Hispanics in about 3 years. Asians have already achieved the benchmark.

Also, in the NHQR:

  • In all years, the percentage of patients who received fibrinolytic medication was significantly higher for males than for females.

References

Agency for Healthcare Research and Quality. Calculated from Healthcare Cost and Utilization Project. Kids' Inpatient Database. Available at: http://hcupnet.ahrq.gov. Accessed April 24, 2009.

Boudreau RM, McNally C, Rensing EM, et al. Improving the timeliness of written patient notification of mammography results by mammography centers. Breast J 2004 Jan-Feb;10(1):10-9.

Caro JJ, Ward AJ, O'Brien JA. Lifetime costs of complications resulting from type 2 diabetes in the U.S. Diabetes Care 2002 Mar;25(3):476-81.

Cartmill RS, Walker JM, Blosky MA, et al. Impact of electronic order management on the timeliness of antibiotic administration in critical care patients. Int J Med Inform 2012;81(11):782-91.

Centers for Disease Control and Prevention. National Hospital Ambulatory Medical Care Survey: 2010 emergency department summary tables. Available at http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2010_ed_web_tables.pdf (PDF File, 525 KB). Accessed March 8, 2013.

Gerczuk PZ, Kloner, RA. An update on cardioprotection: a review of the latest adjunctive therapies to limit myocardial infarction size in clinical trials. J Am Coll Cardiol 2012;59:969-78.

Himelhoch S, Weller WE, Wu AW, et al. Chronic medical illness, depression, and use of acute medical services among Medicare beneficiaries. Med Care 2004 Jun;42(6):512-21.

Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press; 2001.

Kazley AS, Hillman DG, Johnston KC, et al. Hospital care for patients experiencing weekend vs. weekday stroke: a comparison of quality and aggressiveness of care. Arch Neurol 2010 Jan;67(1):39-44.

Luman ET, Barker LE, Shaw KM, et al. Timeliness of childhood vaccinations in the United States: days undervaccinated and number of vaccines delayed. JAMA 2005 Mar 9;293(10):1204-11.

Ramsey SD, Newton K, Blough D, et al. Patient-level estimates of the cost of complications in diabetes in a managed-care population. Pharmacoecon 1999 Sep;16(3):285-95.

Schatz M, Rachelefsky G, Krishnan JA. Followup after acute asthma episodes: what improves future outcomes? Proc Am Thorac Soc 2009;6: 386-93.

Smart NA, Titus TT. Outcomes of early versus late nephrology referral in chronic kidney disease: a systematic review. Am J Med 2011 Nov;124(11):1073-80e2.


i The top 5 States that contributed to the achievable benchmark are Maine, Minnesota, North Carolina, Rhode Island, and South Carolina.
ii The top 5 States that contributed to the achievable benchmark are Arkansas, California, Georgia, Mississippi, and Texas.


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Page last reviewed May 2014
Page originally created May 2014
Internet Citation: Chapter 5. Timeliness. Content last reviewed May 2014. Agency for Healthcare Research and Quality, Rockville, MD. https://archive.ahrq.gov/research/findings/nhqrdr/nhdr13/chap5.html

 

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