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National Healthcare Disparities Report, 2013

Chapter 9. Health System Infrastructure

In its report, Future Directions for the National Healthcare Quality and Disparities Reports, the Institute of Medicine (IOM, 2010) recommended that future editions of the National Healthcare Quality Report (NHQR) and National Healthcare Disparities Report (NHDR) include data on the health care system's infrastructure capabilities. According to the IOM:

These components are not necessarily health care aims/attributes in themselves, but are a means to those aims since they are elements of the health care system that better enable the provision of quality care. Care coordination and health systems infrastructure are of interest to the extent that they improve effectiveness, safety, timeliness, patient-centeredness, access, or efficiency.

Acknowledging that the measures and data required to assess the strength and capabilities of the health care infrastructure have not been well developed, the IOM identified structural elements that may affect quality improvement. Key elements include:

  • Information systems for data collection, quality improvement analysis, and clinical communication support.
  • An adequate and well-distributed workforce.
  • Organizational capacity to support emerging models of care, cultural competence services, and ongoing improvement efforts.

Of significance, inadequacies in health system infrastructure may limit access and contribute to poor quality of care and outcomes, particularly among vulnerable population groups that include racial and ethnic minority groups and people residing in areas with health professional shortages.

This chapter presents data to illustrate the strength of the U.S. health system infrastructure and how this infrastructure may influence quality of care. The chapter is divided into three sections, each addressing a unique aspect of the health care system:

  • Health information technology (IT).
  • Workforce diversity.
  • Health care safety net.

The chapter begins with data to describe the adoption and use of health IT. Use of health IT can be an effective way to manage health care costs and improve quality of care. The recently released report, Equity in the Digital Age: How Health Information Technology Can Reduce Disparitiesi points out that the use of health IT is an opportunity to dramatically improve patient understanding of their medication instructions and prescriptions. Having a limited understanding of English can increase the odds of misunderstanding English language prescription labels up to three times for Spanish-speaking Latinos and for those who speak Korean, and up to four times for those speaking dialects of Chinese. Documenting the patient's language as part of the electronic health record and electronic prescription can help providers ensure that medication instructions and prescription drug labels will be understandable.

Evidence has also shown that the adoption and effective use of health IT can help reduce medical errors and adverse events, enable better documentation and file organization, provide patients with information that assists their adherence to medication regimens and scheduled appointments, and assist doctors in tracking their treatment protocols (IOM, 2010).

After presenting measures on the use of health IT, we present data on health care workforce diversity. An adequate supply of health care providers is an important indicator of health care quality. Aside from a provider-to-population ratio that effectively meets demand for care, it is important that the workforce be appropriately distributed.

In previous quality and disparities reports, data have been presented on diversity in the nursing, dental, pharmacy, allied health, and primary care physician workforce. This year, the NHQR and NHDR present data on the geographic and racial/ethnic distribution of nurse practitioners and physician assistants.

The distribution and availability of a culturally competent health care workforce has significant repercussions for access to care, particularly among the Nation's most vulnerable populations—racial and ethnic minorities, low-income populations, and uninsured or underinsured people. People who cannot access health care services, either because of financial considerations or inadequacy in the local health care infrastructure, often rely on safety net providers for essential health care services. The final section of this chapter presents measures related to the performance of safety net providers, including people served, characteristics of selected safety net providers, and patient outcomes.

Measures

The IOM acknowledges that health system infrastructure measures such as adoption and effective use of health IT are likely to be in the developmental stage, and evidence of the impact on quality improvement has not yet been strongly established. The IOM highlighted three infrastructure capabilities that should be further evaluated for reporting. These capabilities include adoption and use of health IT, workforce distribution and its relevance to minority and other underserved populations, and care management processes.

Findings

Health Information Technology: Focus on Electronic Health Records

According to the Office of the National Coordinator for Health IT, an electronic health record (EHR) is a real-time patient health record with access to evidence-based decision support tools that can be used to aid clinicians in decisionmaking. The EHR can automate and streamline a clinician's workflow, ensuring that all clinical information is communicated. The EHR can also support the collection of data for uses other than clinical care, such as billing, quality management, outcome reporting, and disease surveillance and reporting for public health purposes.

The IOM report, Future Directions for the National Healthcare Quality and Disparities Reports highlights the adoption and use of health IT as a tool to manage cost and improve the quality of care delivered (IOM, 2010). Meaningful use of an EHR, for instance, is increasingly viewed as essential to improving both the efficiency of service delivery and health care quality (Resnick & Alwan, 2010).

The Medicare and Medicaid EHR Incentive Programs provide financial incentives for the "meaningful use" of certified EHR technology to improve patient care. One component of meaningful use is electronic prescribing (e-prescribing). An e-prescribing system enables electronic transmission of prescriptions to pharmacies from a provider's office. E-prescribing was intended to improve patient safety by eliminating the time gap between provider office and pharmacy, reducing medication errors, improving quality of care and patient satisfaction, and reducing illegible prescriptions (Kannry, 2011).

Poor adherence to medication therapy is a large and costly problem in the United States. The World Health Organization estimates that as many as 50% of patients do not adhere fully to their medication treatment, leading to 125,000 premature deaths and billions in preventable health care costs. Analysis suggests that an increase in first-filled medication adherence combined with other e-prescribing benefits could, over the next 10 years, lead to between $140 billion and $240 billion in health care savings and improved health outcomes (Health Manag Technol, 2012).

The recent report Equity in the Digital Age, noted above, highlights the importance of ensuring that everyone benefits from the tremendous potential of health IT to improve access to care, enhance health care quality, and create targeted strategies that promote health equity. Implementation of EHR advancements must respond to the needs of all populations, particularly racial and ethnic minority communities, immigrants, and people with limited English proficiency.

Electronic Health Records in Hospitals

The 2012 Commonwealth Fund report Using ElectronicHealth Records To Improve Quality and Efficiency: The Experience of Leading Hospitals found that successful implementation of EHRs depends on strong leadership, full involvement of clinical staff in design and implementation, and mandatory staff training. EHRs can improve health care quality and patient safety through the use of checklists and alerts and promotion of evidence-based practices. EHRs can increase efficiency by alerting physicians to duplicate orders and enabling faster prescribing and test ordering while reducing errors and redundancy. This year's NHDR tracks overall EHR use in hospitals and inclusion of several specific components.

EHRs can improve the quality and safety of care in all types of hospitals and in departments within hospitals. In emergency departments, for instance, electronic clinical documentation and decision support can help mitigate problems of treating new patients with complicated medical histories and gaps in their medical records. EHRs can also provide effective decision support and clinical reminders to facilitate a seamless transition of care by reducing communication breakdown between different providers.

Overall EHR use is presented by hospital ownership because many not-for-profit hospitals serve large populations who experience health care disparities, including racial and ethnic minorities and Medicaid recipients. The Government Accountability Office found that government and not-for-profit hospitals account for a larger percentage of total uncompensated costs compared with for-profit hospital groups (GAO, 2005).

Figure 9.1. Electronic health record use in hospitals, by hospital control and hospital type, 2011

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Key: CPOE = computerized provider order entry.
Source: American Hospital Association, 2011 Annual Survey Information Technology Supplement.
Note: Data were obtained from an average of 3,414 hospitals.

Fully Implemented EHR
  • In 2011, 80.3% of hospitals run by the Federal Government, 34.5% of not-for-profit, 23.7% of non-Federal, and 15.2% of investor-owned hospitals had a fully implemented EHR system (Figure 9.1).
  • More than 47% of children's general hospitals, 31.4% of general medical and surgical hospitals, 20.2% of acute long-term care hospitals, 18.8% of rehabilitation hospitals, and 12.2% of psychiatric hospitals had a fully implemented EHR system.
  • Nearly 52% of hospitals that are members of the Council of Teaching Hospitals (COTH) and 27.8% of non-COTH member hospitals had a fully implemented EHR system (data not shown).
Medication Lists
  • In 2011, 81.1% of hospitals run by the Federal Government, 50.2% of not-for-profit, 38.5% of non-Federal, and 22.9% of investor-owned hospitals had an EHR system that supports medication lists.
  • More than 73% of children's general hospitals, 47.2% of general medical and surgical hospitals, 17.4% of acute long-term care hospitals, 20.4% of rehabilitation hospitals, and 12.1% of psychiatric hospitals had an EHR system that supports medication lists.
  • About 64% of hospitals that are members of COTH and 41.8% of non-COTH member hospitals had an EHR system that supports medication lists (data not shown).
Drug Decision Support

In 2011, 97.6% of hospitals run by the Federal Government, 71.6% of not-for-profit, 52.2% of non-Federal, and 40.5% of investor-owned hospitals had an EHR system with a component for drug decision support.

Nearly 77% of children's general hospitals, 66.7% of general medical and surgical hospitals, 34.1% of acute long-term care hospitals, 27.5% of rehabilitation hospitals, and 26.4% of psychiatric hospitals had an EHR system with a component for drug decision support.

  • Eighty-three percent of hospitals that are members of COTH and 60.3% of non-COTH member hospitals had an EHR system with a component for drug decision support (data not shown).
Computerized Provider Order Entry of Medications
  • In 2011, 92.8% of hospitals run by the Federal Government, 55.3% of not-for-profit, 43.9% of non-Federal, and 25.4% of investor-owned hospitals had an EHR system that supports CPOE of medications.
  • About 77% of children's general hospitals, 50.6% of general medical and surgical hospitals, 31.1% of acute long-term care hospitals, 28.8% of rehabilitation hospitals, and 28.2% of psychiatric hospitals had an EHR system that supports CPOE of medications.
  • More than 80% of hospitals that are members of COTH and 45.7% of non-COTH member hospitals had an EHR system that supports CPOE of medications (data not shown).
Pharmaceutical Bar Coding
  • In 2011, 79.5% of hospitals run by the Federal Government, 52.4% of not-for-profit, 36.6% of non-Federal, and 33.2% of investor-owned hospitals had an EHR system that supports pharmaceutical bar coding.
  • About 53% of children's general hospitals, 50.0% of general medical and surgical hospitals, 23.3% of acute long-term care hospitals, 29.7% of rehabilitation hospitals, and 13.2% of psychiatric hospitals had an EHR system that supports pharmaceutical bar coding.
  • More than half (54%) of hospitals that are members of COTH and 45.3% of non-COTH member hospitals had an EHR system that supports pharmaceutical bar coding (data not shown).

Also, in the NHQR:

  • In 2011, 29.6% of hospitals had a fully implemented EHR system, and the Midwest had the highest implementation rate (36.8%). Nearly 30% of hospitals in the West, 27.2% of hospitals in the South, and 18.3% of hospitals in the Northeast had a fully implemented EHR system.
  • In 2011, 32.2% of urban hospitals and 26.5% of rural hospitals had a fully implemented EHR system.

Electronic Health Records in Physician Practices

In addition to alerts, guidelines, and electronic ordering, efficient exchange of health information between providers can lead to better care and improved patient safety. Many factors outside of the physician's control may help determine his or her ability to adopt an EHR system. Unfortunately, practice size and availability of resources affect EHR adoption rates. Thus, the potential quality and efficiency benefits of an EHR system may be unavailable to resource-constrained organizations that are constantly challenged to "do more with less" (McAlearney, et al., 2010).

The most frequent reasons cited for not adopting health IT are cost and potential loss of productivity. EHRs cost almost $44,000 per full-time-equivalent provider, with ongoing costs of $8,400 annually (Samantaray, et al., 2011).

 

Figure 9.2. Office-based physicians with an electronic health record system, by region, metropolitan status, and specialty, 2012

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Key: MSA = metropolitan statistical area.
Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Ambulatory Medical Care Survey (NAMCS), 2012 NAMCS National Electronic Health Records Survey.
Denominator: Non-federally employed physicians who provide direct patient care in the 50 States and the District of Columbia, excluding radiologists, anesthesiologists, and pathologists.

  • In 2012, 78.9% of physician offices in the West, 71% in the Midwest, 70.2% in the Northeast, and 68.6% in the South had an EHR system (Figure 9.2).
  • In 2012, 72.0% of physician offices in metropolitan areas and 69.5% of physician offices in nonmetropolitan areas had an EHR system.
  • In 2012, 74.9% of primary care specialists, 70.7% of medical specialists, and 66.5% of surgical specialists had an EHR system.

Also, in the NHQR:

  • In 2012, 71.8% of physicians had an EHR system.
  • Nearly 84% of physicians under age 35 had an EHR system, which is significantly higher than the 62.8% of physicians age 55 and over who had an EHR system.

E-prescribing is widely recognized as a component of the prescribing process that facilitates handoffs, improves clinical decisionmaking, and may improve medication adherence (Johnson & Lehmann, 2013). Also, in the outpatient setting, e-prescribing is critical given the high rate of prescribing errors and adverse drug events, as well as the frequency with which medications are prescribed (Abramson, et al., 2013). In 2011, 570 million electronic prescriptions were written, compared with 326 million in 2010 and 191 million in 2009 (Jariwala, et al., 2013).

Figure 9.3. Office-based physicians with a computerized system for ordering prescriptions, by region and specialty, 2009-2012

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Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Ambulatory Medical Care Survey (NAMCS), 2009-2010 NAMCS Core and Electronic Medical Record Supplement and 2011-2012 NAMCS National Electronic Health Records Survey.
Denominator: Non-federally employed physicians who provide direct patient care in the 50 States and the District of Columbia, excluding radiologists, anesthesiologists, and pathologists.

  • From 2009 to 2012, the percentage of physician offices with an e-prescribing system improved from 39.0% to 77.1% in the South, from 41.1% to 80.3% in the Midwest, from 42.5% to 81.3% in the Northeast, and from 49.2% to 80.7% in the West (Figure 9.3).
  • During this same period, the percentage of surgical practices with an e-prescribing system improved from 35.9% to 78.9%. For medical specialty practices, the percentage improved from 40.3% to 76.9%, and for primary care practices, the percentage improved from 46.0% to 81.4%.
  • The percentage of physician offices with an e-prescribing system improved from 43.4% to 80.0% in metropolitan areas and from 36.6% to 75.4% in nonmetropolitan areas (data not shown).

Also, in the NHQR:

  • In all years, the percentage of practices using e-prescribing was significantly higher for practices with more than 10 physicians than for practices with 10 or fewer physicians.

Figure 9.4. Office-based physicians with a computerized system for sending prescriptions electronically to pharmacies, by region and specialty, 2009-2010 and 2012

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Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Ambulatory Medical Care Survey (NAMCS), 2009-2010 NAMCS Core and Electronic Medical Record Supplement and 2012 NAMCS National Electronic Health Records Survey.
Denominator: Non-federally employed physicians who provide direct patient care in the 50 States and the District of Columbia, excluding radiologists, anesthesiologists, and pathologists.
Note: The 2011 data were not available.

  • From 2009 to 2012, the percentage of physician offices with a computerized system for sending prescriptions electronically to pharmacies improved from 27.4% to 70.1% in the South, from 33.0% to 76.1% in the Northeast, from 33.2% to 75.6% in the Midwest, and from 40.8% to 73.2% in the West (Figure 9.4).
  • During this same period, the percentage of surgical practices with a computerized system for sending prescriptions electronically to pharmacies improved from 24.4% to 72.9%. For medical specialty practices, the percentage increased from 28.8% to 69.5%, and for primary care practices, from 38.4% to 75.7%.
  • The percentage of physician offices with a computerized system for sending prescriptions electronically to pharmacies improved from 33.4% to 73.8% in metropolitan areas and from 30.4% to 69.2% in nonmetropolitan areas (data not shown).

Also, in the NHQR:

  • From 2009 to 2012, the overall adoption of computerized systems for sending prescriptions electronically to pharmacies showed significant improvement from 33.0% to 73.3%. All physician age groups and practice sizes showed improvement.

Figure 9.5. Office-based physicians with an e-prescribing system with a component for providing warnings of drug interactions or contraindications, by region and specialty, 2009-2010 and 2012

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Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Ambulatory Medical Care Survey (NAMCS), 2009-2010 NAMCS Core and Electronic Medical Record Supplement and 2012 NAMCS National Electronic Health Records Survey.
Denominator: Non-federally employed physicians who provide direct patient care in the 50 States and the District of Columbia, excluding radiologists, anesthesiologists, and pathologists.
Note: The 2011 data were not available.

  • From 2009 to 2012, the percentage of physician offices with an e-prescribing system with a component for providing warnings of drug interactions or contraindications improved from 33.7% to 62.2% in the South, from 36.2% to 68.5% in the Midwest, from 36.5% to 70.2% in the Northeast, and from 43.7% to 67.7% in the West (Figure 9.5).
  • During this same period, the percentage of surgical practices with an e-prescribing system with a component for providing warnings of drug interactions or contraindications improved from 31.4% to 59.6%. For medical specialty practices, the percentage improved from 34.7% to 63.0%, and for primary care practices, from 40.2% to 71.9%.
  • The percentage of physician offices with an e-prescribing system with a component for providing warnings of drug interactions or contraindications improved from 37.9% to 67.0% in metropolitan areas and from 32.2% to 63.0% in nonmetropolitan areas (data not shown).

Also, in the NHQR:

  • In 2012, 74.8% of physicians under age 35, 72.3% of physicians ages 45-54, and 71.7% of physicians ages 35-44 had an e-prescribing system with a component for providing warnings of drug interactions or contraindications. Only 59.2% of physicians age 55 and over had an e-prescribing system with a component for providing warnings of drug interactions or contraindications, which was significantly lower than the percentage for physicians under age 35.

Workforce Diversity

Diversity in the composition of the health care workforce is important because it affects outcomes, quality, safety, and satisfaction.

Racial and ethnic disparities in health outcomes and the lack of health providers highlight the need for primary care providers. Members of racial and ethnic minority groups, who make up the majority of inner-city residents, are less likely than others to receive needed services, including treatment for HIV infection, mental health problems, cardiovascular disease, and cancer.

Health disparities affecting minorities have been traced to many causes, including language and cultural barriers that can deter minorities from seeking care or lead to suboptimal care. Racial and ethnic concordance in health care provider-patient relationships has been shown to improve care. Race-concordant patient-provider relationships, as opposed to race-discordant, have been found to result in longer medical visits with higher ratings of positive affect, shared decisionmaking, and satisfaction (Schoenthaler, et al., 2012).

Additional research has found that health care providers from groups underrepresented in the health professions are more likely to serve minority and economically disadvantaged patients. It has also been found that Black and Hispanic physicians practice in areas with larger Black and Hispanic populations than other physicians (Brown, et al., 2009).

Language differences between patients and clinicians jeopardize communication, leading to compromised care, increased health disparities and inequalities, dissatisfaction with care, and inefficiency in the health care system (Tang, et al., 2011). Research has also shown that linguistic minorities suffer more serious adverse outcomes from medical errors and receive worse care than English-speaking patients (Tang, et al., 2011).

Patient-clinician language concordance can enhance health care quality and equity, patient safety and satisfaction, and resource stewardship. Workforce diversity has been associated with both greater satisfaction with care received and improved provider-patient communication. Conversely, the lack of a diverse workforce may foster linguistic and cultural barriers, bias, and clinical uncertainty within the provider-patient relationship (Mitchell & Lassiter, 2012).

The adequacy and distribution of the primary care workforce to meet the current and future needs of Americans continue to be a cause for concern. Nurse practitioners, along with physicians and physician assistants, provide most of the primary care in the United States, with nurse practitioners accounting for 19% of the U.S. primary care workforce and physician assistants accounting for 7% (O'Neil & Dower, 2011).

Nurse practitioners provide an extensive range of care that includes taking health histories and providing complete physical exams. They diagnose and treat acute and chronic illnesses, provide immunizations, prescribe and manage medications and other therapies, order and interpret lab tests and x rays, and provide health education and supportive counseling.

Nurse practitioners deliver primary care in small and large, private and public practices and in clinics, schools, and workplaces. They function in both independent and collaborative practice arrangements, often taking the lead clinical, management, and accountability roles in innovative primary care models such as nurse-managed health centers and retail clinics (Naylor and Kurtzman, 2010).

Physician assistants practice collaboratively with physicians to address the health needs of the population served. Multiple studies have compared the scope of patient care services provided by physician assistants and physicians in primary care settings and have concluded that physician assistants can perform 85% to 90% of services traditionally provided by primary care physicians (Hooker & Everett, 2012). Physician assistants practicing in primary care are more likely to be female, older, and Hispanic (Coplan, et al., 2013).

Figure 9.6. Rate of nurse practitioners per 100,000 population, by race and ethnicity, 2010-2011

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Source: U.S. Census Bureau, American Community Survey, 2010-2011.

  • In 2010 and 2011, the rate of nurse practitioners was significantly higher for Whites than for other racial groups (Figure 9.6).
  • The rate of nurse practitioners for non-Hispanic Whites was nearly six times the rate for Hispanics.

Also, in the NHQR:

  • In 2011, there were 31.2 nurse practitioners per 100,000 population.
  • The Northeast tended to have higher rates of nurse practitioners while the West tended to have lower rates.

Figure 9.7. Rate of physician assistants per 100,000 population, by race and ethnicity, 2006-2011

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Source: U.S. Census, American Community Survey, 2006-2011.

  • From 2006 to 2011, White had significantly higher rates of physician assistants than Blacks (Figure 9.7).
  • In all years, physician assistants were significantly more likely to be Asian than Black; in 4 of 6 years, physician assistants were significantly more likely to be Asian than of multiple races. In 2011, the rate for Asians was more than twice the rate for Blacks.
  • In all years, physician assistants were significantly more likely to be non-Hispanic White than Hispanic.

Also, in the NHQR:

  • The Northeast tended to have higher rates of physician assistants while the Midwest tended to have lower rates.
  • There was considerable variation by State, ranging from 23.6 to 64.1 per 100,000 population.

Organizational Capacity: Focus on the Health Care Safety Net

Concern has arisen about the composition and distribution of the health workforce and whether the Nation's health workforce will be able to meet the increasing demand for care that a growing and aging U.S. population will have. In his seminal work on health care quality, Donabedian (1980) describes a robust health care "structure"—the setting or infrastructure supporting the delivery of care (e.g., hospitals, providers)—as necessary to ensure that processes of care contribute to good outcomes. Structural deficiencies in the United States health care delivery system resulting from shortages of providers, growing demand, and a high rate of uninsurance and underinsurance have contributed to unmet need and could result in increased morbidity and health care costs.

Safety net providers play an integral role in relieving unmet needs. As defined in an IOM report, the U.S. health care safety net is composed of "[t]hose providers that organize and deliver a significant level of health care and other health-related services to the uninsured, Medicaid, and other vulnerable populations" (IOM, 2010). Safety net providers act as a default system, or providers "of last resort," by ensuring access to care for millions of Americans lacking medical coverage or provider access, regardless of education, social status, language competency, or ability to pay.

The safety net includes many different types of providers, including public health departments, hospitals, and Health Resources and Services Administration (HRSA)-supported health centers (HSHCs). For the nearly 50 million uninsured people and for individuals with low income, safety net providers serve an essential function, eliminating financial barriers to care and enhancing access to services. As workforce shortages escalate, demand for safety net services is likely to increase.

The National Health Service Corps (NHSC) helps bring health care to patients in communities with limited access to health care. About one in five people in the United States (21 percent) live in a Health Professional Shortage Area. In 2009, the American Recovery and Reinvestment Act provided a significant infusion of $300 million over 3 years to grow the NHSC. The Affordable Care Act built on these efforts and provided $1.5 billion of support over 5 years (HRSA, 2013).

This section includes measures that show how well the health care safety net is meeting the needs of the Nation's vulnerable populations, particularly low-income populations and racial and ethnic subgroups. The measures focus on two types of safety net providers: hospitals and HSHCs. The first measure focuses on trauma center utilization for severe injuries. Trauma centers often provide care unavailable elsewhere in the community and thus can become part of the safety net. The second measure highlights the role of HSHCs as safety net providers by describing the characteristics of people with an HSHC visit in 2010.

Trauma Center Utilization for Severe Injuries

Trauma remains a considerable cause of mortality and morbidity worldwide, constituting a tangible public health burden with significant associated social and economic cost (Mansoor & DuBose, 2012). Trauma care systems, which were developed because it was recognized that trauma requires complex medical care, include a network of care facilities that provides a range of care for all injured patients.

Trauma systems usually have a lead hospital, which should be the highest level available within the system. Levels range from level I to level III, with level I denoting the most clinically sophisticated hospitals:

  • Level I facilities are required to have a specific number of surgeons and anesthesiologists on duty at all times, as well as education, prevention, and outreach programs. The 24-hour coverage of surgery also provides trauma patients with many surgical specialties, including neurosurgery, as well as radiology, internal medicine, and critical care.
  • Level II trauma centers provide initial definitive trauma care regardless of the severity of the injury. When a level II center cannot provide the required care, the patient is transferred to a level I center.
  • Level III trauma centers are often considered community or rural-based hospitals and provide prompt assessment, resuscitation, emergency operations, and stabilizations and arrange for transfer to a facility that can provide necessary care.

Figure 9.8. Distribution of trauma center utilization for severe injuries in the United States, by sex and area income, 2010

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Key: Q = quartile.
Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Emergency Department Sample, 2010.

  • In 2010, males were more likely to use level I and II trauma centers than females (Figure 9.8).
  • In 2010, there were no statistically significant differences by area income in the percentage of injuries treated at level I and II trauma centers.

Also, in the NHQR:

  • In 2010, people ages 25-44 were more likely to use level I and II trauma centers than people age 45 and over. Adults age 65 and over were more likely than people under age 65 to use nontrauma centers.
  • In 2010, the percentage of injuries treated at level I and II trauma centers was significantly higher in large fringe metropolitan areas than in small metropolitan and micropolitan areas.

Patients Using HRSA-Supported Health Centers

HSHCs include health care organizations that receive a grant under Section 330 of the Public Health Service Act, including community health centers, migrant health centers, Health Care for the Homeless programs, and Public Housing Primary Care programs. These organizations typically render services to low-income populations, uninsured people, people with limited English proficiency, migratory and seasonal agricultural workers, individuals and families experiencing homelessness, and public housing residents.

To obtain Federal grant funding, these public and nonprofit organizations agree to provide a minimum set of services, including primary and preventive care, referrals to mental health care, and dental services. Access to care is available to all persons, regardless of ability to pay. Charges for services rendered are based on a sliding scale linked to patients' family income. More than 21 million people visited an HSHC in 2012.

Figure 9.9. Race, ethnicity, and income of patients receiving care in an HSHC, United States, 2012

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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, Bureau of Primary Health Care, Uniform Data System, 2012.
Note: Racial groups shown are non-Hispanic. Data were obtained from 1,128 Section 330 grantees. Income shown only includes known income. Income for nearly 23% of patients is unknown.

  • In 2012, approximately two-thirds (65.6%) of patients seen at an HSHC were White (Hispanic and non-Hispanic), and about one-quarter were Black (Figure 9.9).
  • In 2012, 34.4% of HSHC patients were Hispanic and nearly one-quarter of patients were determined by the HSHC to be best served in a language other than English.
  • For those for whom income is known, almost three-quarters of patients seen in an HSHC in 2012 had income at or below the Federal poverty level but only 7.4% of patients had an income over 200% of the poverty level.

Also, in the NHQR:

  • In 2012, 36.0% of patients seen at an HSHC were uninsured and 40.8% had Medicaid/CHIP.

Hawaiian Patients Using Federally Qualified Health Centers

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 at the John A. Burns School of Medicine of the University of Hawaii. The report is Assessment and Priorities for Health & Well-Being in Native Hawaiians and Other Pacific Peoples (Look, et al., 2013).

While the network of community health centers has helped to improve access to health services, the shortage of health professionals continues to be a primary challenge for many communities across the State. According to the State of Hawaii Primary Care Needs Assessment Data Book 2009, all of the islands except for some portions of Oahu are federally designated as medically underserved areas, indicating that the population has a shortage of personal health services. In addition, there is a shortage of mental health professionals on Molokai and in some areas on the other islands, including West Kauai, the North Shore of Oahu, East Maui, and in the Hāmākua, Puna, and Kaū communities of Hawaii Island.

Hawaii has 19 federally qualified community health centers (Hawaii Primary Care Association, 2010). While they are diverse in many ways, they are all independent community-run, nonprofit health organizations with the commitment to serving the health needs of their respective communities, regardless of an individual's ability to pay. These rural and urban clinics are purposefully located in areas with limited access to medical services and thus receive annual supplemental Federal funds for clinical service support.

Collectively, these clinics provide primary care to 10% of Hawaii's population, 50% of whom are Medicaid patients and 25% of whom are uninsured. More than 40% of their patients are NHOPI (Figure 9.10). Most have diversified their health services to include behavioral health, dental care, and vision care. The number of patients they serve has more than doubled over the past 10 years (Hawaii Primary Care Association, 2011).

Figure 9.10. Ethnicity of patients served by community health centers, Hawaii, 2010

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Source: Hawaii Primary Care Association, Community health centers in Hawaii, 2010.

The Native Hawaiian Health Care Systems (NHHCS) is primarily funded by Federal appropriations through HRSA. The NHHCS works to improve the health status of Native Hawaiians. They use a combination of outreach, referral, and linkage mechanisms to provide a range of services that include nutrition programs, enabling services, screening and control of hypertension and diabetes, immunizations, and basic primary care services. They are composed of five nonprofit organizations created under the Native Hawaiian Health Care Act of 1988 and recently reauthorized under the Affordable Care Act. They include Hō‘ola Lāhui Hawai‘i on Kauai, Ke Ola Mamo on Oahu, Nā Pu‘uwai on Molokai, Hui No Ke Ola Pono on Maui, and Hui Mālama Ola Nā ‘Ōiwi on Hawaii Island.

Hospital Admissions of Vulnerable Populations

Hospitals continue to play a major role in the health care safety net and, increasingly, safety net hospitals are defined by their low-income population as opposed to control or governance (e.g., public hospitals).ii This section includes one measure suggestive of hospitals' willingness or ability to provide care to low-income populations: hospital inpatient discharges and aggregate cost accounted for by Medicaid and uninsured patients.

This measure offers insight into hospitals' contribution to the health care safety net, by selected hospital characteristics. These measures were estimated as follows:

  • (Number of Medicaid and uninsured discharges ÷ total number of discharges) × 100
  • (Total Medicaid and uninsured costs ÷ total costs across all payers) × 100

As indicated in Figure 9.11, the proportion of inpatient days and discharges provided to these vulnerable groups varied by hospital characteristics.

Figure 9.11. Medicaid and uninsured discharges, by facility characteristics, U.S. short-term acute hospitals, 2011

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[D] Select for Text Description.

Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, HCUPnet, 2011. Available at http://hcupnet.ahrq.gov.

  • On average, Medicaid recipients and medically uninsured people accounted for about one in four discharges from acute care hospitals in 2011 (Figure 9.11).
  • Twenty-five percent of Medicaid and uninsured patients were discharged from private, investor-owned hospitals compared with 35.4% from government hospitals.
  • Compared with hospitals with 500 or more beds, hospitals with bed sizes under 300 had a smaller percentage of Medicaid or uninsured patients.
  • About 27% of patients discharged from teaching hospitals were uninsured or covered by Medicaid, compared with 22.8% of patients in non-teaching hospitals.
  • Hospitals in the West discharged a greater proportion of Medicaid and uninsured patients (26.9%), while hospitals in the Midwest discharged the lowest percentage of these patients (22.7%).

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i Available at http://cpehn.org/resource/equity-digital-age-how-health-information-technology-can-reduce-disparities-0.
ii Concerned with the impact of hospital closures on the health care safety net, the Department of Health and Human Services Office for Civil Rights has expanded its enforcement efforts to prevent ethnic and racial minority communities from suffering race or national origin discrimination when local hospital facilities close or relocate.


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Page last reviewed May 2014
Page originally created May 2014
Internet Citation: Chapter 9. Health System Infrastructure. Content last reviewed May 2014. Agency for Healthcare Research and Quality, Rockville, MD. https://archive.ahrq.gov/research/findings/nhqrdr/nhdr13/chap9.html

 

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