Chapter 2. Effectiveness
National Healthcare Quality Report, 2010
As better understanding of health and sickness has led to superior ways of preventing, diagnosing, and treating diseases, the health of most Americans has improved dramatically. However, ample evidence indicates that some Americans do not receive the full benefits of high-quality care.
This chapter is organized around eight clinical areas (cancer, diabetes, end stage renal disease [ESRD], heart disease, HIV and AIDS, maternal and child health, mental health and substance abuse, and respiratory diseases) and three types of health care services that typically cut across clinical conditions (lifestyle modification, functional status preservation and rehabilitation, and supportive and palliative care). The 11 sections of this chapter highlight a small number of core and supporting measures.
In this chapter, process measures are organized into several categories related to the patient's need for preventive care, treatment of acute illness, and chronic disease management. These are derived from the original Institute of Medicine (IOM) categories: staying healthy, getting better, living with illness or disability, and coping with the end of life. There is sizable overlap among these categories, and some measures may be considered to belong in more than one category. Outcome measures are organized separately because prevention, treatment, and management can all play important roles in affecting outcomes.
Caring for healthy people is an important component of health care. Educating people about health and promoting healthy behaviors can help postpone or avoid illness and disease. In addition, detecting health problems at an early stage increases the chances of effectively treating them, often reducing suffering and costs.
Even when preventive care is ideally implemented, it cannot entirely avert the need for acute care. Delivering optimal treatments for acute illness can help reduce the consequences of illness and promote the best recovery possible.
Some diseases, such as diabetes and ESRD disease, are chronic, which means they cannot simply be treated once; they must be managed across a lifetime. Management of chronic disease often involves promotion and maintenance of lifestyle changes and regular contact with a provider to monitor the status of the disease. For patients, effective management of chronic diseases can mean the difference between normal, healthy living and frequent medical problems.
Many factors other than health care influence health outcomes, including a person's genes, lifestyle, and social and physical environment. However, for many individuals, appropriate preventive services, timely treatment of acute illness and injury, and meticulous management of chronic disease can positively affect mortality, morbidity, and quality of life.
|Number of deaths (2007)||562,8751|
|Cause of death rank (2007)||2nd1|
|Number of living Americans who have been diagnosed with cancer (2007)||11,713,7362|
|New cases of cancer (2010)||1,529,5603|
|New cases of breast cancer (2010)||209,0603|
|Total costi (2010 est.)||$263.8 billion4|
|Direct costsii (2010 est.)||$102.8 billion4|
|Indirect costs (2010 est.)||$161.0 billion4|
|Cost-effectivenessiii of colorectal cancer screening||$35,000-$165,000/QALY5|
Evidence-based consensus defining good quality care and how to measure it currently exists for only a few cancers and a few aspects of care. Breast and colorectal cancers have high incidence rates and are highlighted in alternate years of the report. The 2009 National Healthcare Quality Report (NHQR) highlighted breast cancer; this year's focus is on colorectal cancer. The core report measures are:
- Colorectal cancer screening.
- Colorectal cancer first diagnosed at advanced stage.
- Colorectal cancer deaths.
As in previous reports, the 2010 NHQR includes one supporting measure for colorectal cancer care from the National Cancer Data Base that has been endorsed by the National Quality Forum:
- Surgical resection of colon cancer that includes at least 12 lymph nodes.
Prevention: Colorectal Cancer Screening
Colorectal cancer is the third most common cancer in adults.3 Prevention of colorectal cancer includes modifying risk factors such as weight, physical activity, smoking, and alcohol use, as well as screening for early disease. Screening is important because early stages of colorectal cancer may not present any symptoms, and screening can detect abnormal growths before they develop into cancer.3,6
Early detection increases treatment options and the chances for survival. The U.S. Preventive Services Task Force recommends colorectal cancer screening for men and women age 50 and over. The screening measured in the NHQR includes having a fecal occult blood test in the past 2 years or ever having received flexible sigmoidoscopy, colonoscopy, or proctoscopy.
Figure 2.1. Adults age 50 and over who reported receiving colorectal cancer screening (received fecal occult blood test in past 2 years or ever received colonoscopy, sigmoidscopy, or proctoscopy), by resident location, 2005 and 2008
Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey (NHIS), 2005 and 2008.
Denominator: Adults age 50 and over in the civilian noninstitutionalized population.
Note: Estimates are age adjusted to the standard population except where indicated. Benchmark is derived from the Behavioral Risk Factor Surveillance System (BRFSS); go to Introduction and Methods for details.
- The overall percentage of adults age 50 and over who reported having received colorectal cancer screening significantly increased from 51.9% in 2005 to 56.3% in 2008 (data not shown).
- In 2005 and 2008, the percentage of adults age 50 and over residing in large fringe metropolitan areas who reported having received colorectal cancer screening was significantly higher than it was for adults residing in large central metropolitan and noncoreiv areas (Figure 2.1).
- Between 2005 and 2008, the percentage of adults age 50 and over who reported they ever received colorectal cancer screening increased significantly for residents of large central and medium metropolitan areas.
- The top 5 State achievable benchmark was 67.1%.v The available data are not sufficient to calculate time to benchmark.
Also, in the NHDR:
- In all years, the percentage of high-income individuals who reported having received colorectal cancer screening was significantly higher than the percentage for poor, low-income, and middle-income individuals.
Outcome: Advanced Stage Colorectal Cancer
Cancers can be diagnosed at different stages of development. Cancers diagnosed early before spread has occurred are generally more amenable to treatment and cure; cancers diagnosed late with extensive spread often have poor prognoses. The rate of cancer cases that are diagnosed at advanced stages is a measure of the effectiveness of cancer screening efforts and of adherence to follow-up care after a positive screening test. Because many cancers often take years to develop, changes in rates of late-stage cancer may lag behind changes in rates of screening.
Figure 2.2. Colorectal cancer diagnosed at advanced stage (tumors diagnosed at regional or distant stage) per 100,000 population age 50 and over, by age and gender, 2000-2007
Source: National Cancer Institute, Surveillance, Epidemiology, and End Results Program, 2000-2007.
Denominator: Adults ages 50 and over in the civilian noninstitutionalized population.
Note: Age adjusted to the 2000 U.S. standard population. Advanced stage colorectal cancer is defined as local stage with tumor size greater than 2 cm diameter, regional stage or distant stage.
- Between 2000 and 2007, the overall rate of advanced stage colorectal cancer diagnosis in adults age 50 and over significantly decreased, from 95.3 to 76.3 per 100,000 population (Figure 2.2).
- From 2000 to 2007, the rate of advanced stage colorectal cancer in adults ages 50-64 significantly decreased, from 45.7 to 40.1 per 100,000 population. During the same period, adults age 65 and over also saw a significant decrease, from 154.2 to 119.2 per 100,000 population. In all years, adults age 65 and over had significantly higher rates of advanced stage colorectal cancer than adults ages 50-64.
- From 2000 to 2007, the rate of advanced stage colorectal cancer in males age 50 and over decreased significantly, from 111.4 to 88.0. During the same period, rates for females age 50 and over also showed a significant decrease, from 83.2 to 67.0. In all years, males had significantly higher rates of advanced stage colorectal cancer compared with females.
Also, in the NHDR:
- From 2000 to 2007, the rate of advanced stage colorectal cancer was significantly lower for Asians and Pacific Islanders (APIs) and American Indians and Alaska Natives (AI/ANs) than for Whites.
Treatment: Recommended Care for Colorectal Cancer Patients
Different diagnostic and treatment options exist for various types of cancer. Some aspects of cancer care are well established as beneficial and are commonly recommended. The appropriateness of recommended care depends on different factors, such as the stage or the extent of the cancer within the body (especially whether the disease has spread from the original site to other parts of the body). Other types of care are important for accurate diagnosis, such as ensuring the adequate examination of lymph nodes when surgery (e.g., to remove color cancer) is performed.
Figure 2.3. Patients who received surgical resection of colon cancer that included at least 12 lymph nodes pathologically examined, by residence location, age, and insurance status, 2003-2007
Source: Commission on Cancer, American College of Surgeons and American Cancer Society, National Cancer Data Base, 2000-2007
Denominator: U.S. population age 50 and over.
- The overall percentage of adults diagnosed with colorectal cancer who received recommended care significantly increased, from 51.7% in 2003 to 77.0% in 2007 (Figure 2.3). Significant improvement was observed among all insurance groups during this period.
- From 2003 to 2007, the percentage of colorectal cancer patients who received recommended care significantly increased in all residence locations. The percentage of colorectal cancer patients in large metropolitan areas who received recommended care was significantly higher in all years than that of patients in micropolitan and noncore areas and significantly higher than the percentage of patients in small metropolitan areas in 4 of 5 years.
- Between 2003 and 2007, the percentage of colorectal cancer patients who received recommended care increased significantly for all age groups.
- In all years, patients age 65 and over with Medicare only and with Medicare and supplemental insurance had similar rates of recommended treatment.
Also, in the NHDR:
- Between 2003 and 2007, all racial and ethnic groups showed significant improvement in the percentage of patients diagnosed with colorectal cancer who received recommended care.
Outcome: Colorectal Cancer Deaths
The death rate from a disease is a function of many factors, including the causes of the disease; social forces; and the effectiveness of the health care system in providing prevention, treatment, and management of the disease. Colorectal cancer deaths reflect the impact of colorectal cancer screening, diagnosis, and treatment. Mortality is measured as the number of deaths per 100,000 population. Declines in colorectal cancer deaths can be attributed, in part, to improvements in early detection and treatment.
Figure 2.4. Age-adjusted colorectal cancer deaths per 100,000 population, by residence location, 2004-2007, and age, 2000-2007
Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System—Mortality, 2000-2007.
Denominator: U.S. population.
Note: Total rate is age adjusted to the 2000 U.S. standard population.
- Between 2004 and 2007, the rate of colorectal cancer deaths significantly decreased, from 18.0 to 16.9 per 100,000 population (Figure 2.4).
- In all years, residents of noncore and micropolitan areas had significantly higher rates of colorectal cancer deaths compared with residents of large fringe metropolitan areas.
- From 2004 to 2007, the rate of colorectal cancer deaths for adults ages 65 and over significantly decreased, from 109.2 to 100.6 per 100,000 population.
|Number of deaths (2007)||71,8321|
|Cause of death rank (2007)||7th1|
|Total number of Americans with diabetes (2007)||23.6 million7|
|Number of people with diagnosed diabetes (2007)||17.9 million7|
|Number of people with undiagnosed diabetes (2007)||5.7 million7|
|New cases (age 20 and over, 2007)||1.6 million7|
|Total cost (2007 est.)||$174 billion8|
|Direct medical costs (2007 est.)||$116 billion8|
Routine monitoring of blood glucose levels with hemoglobin A1c (HbA1c) tests and dilated eye and foot examinationsvi have been shown to help prevent or mitigate complications of diabetes, such as diabetic neuropathy, retinopathy, and vascular and kidney disease.9 With more than half a million discharges in 2006, diabetes is one of the leading causes of hospitalization in the United States.10 However, with appropriate and timely ambulatory care, it may be possible to prevent many hospitalizations for diabetes and related complications.
The core measure reported in this section examines the extent to which individuals with diabetes receive care needed to prevent complications or slow the disease's progression:
- Receipt of three recommended diabetes services.
In addition, three supporting outcome measures are presented. Two of these measures are included in AHRQ's Prevention Quality Indicators (PQIs).vii PQIs may be used to estimate rates of potentially avoidable hospitalizations among ambulatory care-sensitive conditions. These are hospitalizations that may have been prevented with high-quality ambulatory care and treatment.
The supporting measures from the PQIs are:
- Hospitalization for short-term diabetes complications (PQI 1).
- Hospitalization for lower extremity amputation (PQI 16).
The final supporting measure also offers insight into the adequacy of diabetes management:
- Control of HbA1c, cholesterol, and blood pressure.
Management: Receipt of Three Recommended Diabetes Services
The NHQR uses a composite measure to track the national rate of the receipt of all three recommended annual diabetes interventions: an HbA1c test, an eye examination, and a foot examination. These are basic process measures that provide an assessment of the quality of diabetes management.
Figure 2.5. Composite measure: Adults age 40 and over with diagnosed diabetes who received three recommended services for diabetes in the calendar year (hemoglobin A1c test, dilated eye examination, and foot examination), by residence location, 2002-2007
Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2007.
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. Data were statistically unreliable for the noncore population in 2007. Benchmark is derived from the Behavioral Risk Factor Surveillance System (BRFSS); refer to Introduction and Methods for details.
- The percentage of adults age 40 and over with diagnosed diabetes who received three recommended services showed a significant decrease, from 43.2% in 2002 to 37.5% in 2007 (Figure 2.5).
- Between 2002 and 2007, residents of large central metropolitan and medium metropolitan areas all showed a significant decrease in the percentage of adults diagnosed with diabetes who received recommended care.
- With the exception of 2004 and 2007, adults age 40 and over living in large fringe metropolitan areas were significantly more likely than those in noncore areas to receive recommended services.
- The 2008 top 4 State achievable benchmark was 51.4%.viii At the current overall rate of decrease of 1.2%, there is no indication of progress toward the benchmark. The benchmark was achieved by residents of large fringe metropolitan areas in 2003 but since then, the percentage of residents receiving recommended care has decreased and is therefore moving away from the benchmark. A similar trend is shown for large central and medium metropolitan areas, micropolitan areas, and noncore areas. Small metropolitan areas, with an annual rate of increase of 1.7%, could achieve the benchmark in 2 years.
- In 2007, 88% of adults diagnosed with diabetes had HbA1c measurement in the calendar year, 61% had dilated eye examination, and 66.5% their feet checked. HbA1c measurement and foot examination have significantly decreased since 2002.
Also, in the NHDR:
- In 5 of 6 years, the percentage of adults age 40 and over with diabetes who received recommended services was significantly lower for Hispanics than for non-Hispanic Whites.
Outcome: Admissions for Short-Term Diabetes Complications
Individuals who do not achieve good control of their diabetes are more prone to short-term complications that can reduce quality of life, increase chances of death, and increase health care costs both directly and indirectly. The acute metabolic complications of diabetes consist of diabetic ketoacidosis (DKA), hyperosmolar nonketotic coma (HNC), lactic acidosis (LA), and hypoglycemia.11
Patients with DKA, HNC, and LA require hospitalization for treatment, which results in the use of significant health care resources with increased health care costs. Patients with hypoglycemia often do not require hospitalization but can still incur costs for treatment in an ambulatory setting, as well as loss of productivity. Prevention is an important component in reducing health care costs for these disorders11 and helping people with diabetes maintain optimal function.
Figure 2.6. Hospital admissions for diabetes with short-term complications per 100,000 population, age 18 and over, by residence location and age, 2004-2007
Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample and AHRQ Quality Indicators, version 3.1.
Denominator: U.S. resident population age 18 and over.
Note: Short-term complications include ketoacidosis, hyperosmolarity, or coma and exclude obstetric admissions and transfers from other institutions.
- In all years, residents of large fringe metropolitan areas had significantly lower hospital admissions for short-term complications than residents of micropolitan areas (Figure 2.6). Residents of large fringe metropolitan areas also had significantly lower hospital admissions than residents of large central metropolitan areas in 3 of 4 years.
- Between 2004 and 2007, the overall rates of admission for adults who experienced short-term complications significantly increased, from 55.2 to 59.9.
- Between 2004 and 2007, adults ages 18-44 had a significant increase in the rates of admission for short-term complications while adults age 65 and over had a significant decrease in admission rates.
- In all years, adults age 65 and over had significantly lower rates of admission for short-term complications than adults ages 18-64.
- The 2008 top 4 State achievable benchmark was 37.8 per 100,000 population.ix At the current annual rate of increase of 1.7%, there is no indication of progress toward the benchmark by residents of any location. Adults age 65 and over have already achieved the benchmark but adults ages 18-64 show no progress toward the benchmark.
Also, in the NHDR:
- In all years, the rate of hospital admissions for short-term complications was significantly higher for adults living in communities with median household incomes in the first quartile (lowest) than it was for people living in communities with median household incomes in the fourth quartile (highest).
- In all years, the rates of admission were 2.5 times as high for adults living in communities with median household incomes in the first quartile compared with adults living in communities with median household incomes in the fourth quartile.
Outcome: Controlled Hemoglobin, Cholesterol, and Blood Pressure
People diagnosed with diabetes are often at higher risk for other cardiovascular risk factors, such as high blood pressure and high cholesterol. Having these conditions in combination with diagnosed diabetes increases the likelihood of complications, such as heart and kidney diseases, blindness, nerve damage, and stroke. Patients who manage their diabetes and maintain an HbA1c level of <7%, total cholesterol of <200 mg/dL, and blood pressure of <140/80 mm Hgx can decrease these risks.
Figure 2.7. Adults age 40 and over with diagnosed diabetes with hemoglobin A1c, total cholesterol, and blood pressure under control, by age, 2001-2004 and 2005-2008
Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health and Nutrition Examination Survey.
Denominator: Civilian noninstitutionalized population with diagnosed diabetes, age 40 and over.
Note: Age adjusted to the 2000 standard population using two age groups: 40-59 and 60 and over.
- In 2005-2008, only 54.1% of adults age 40 and over with diabetes had achieved control of their HbA1c level, 65.2% had their cholesterol under control, and 58.6% had their blood pressure under control (Figure 2.7). Although the percentage of adults with controlled HbA1c and blood pressure does not differ markedly from that in the 2001-2004 period, a significant increase in the percentage who had their cholesterol under control was observed over time, from 48.5% in 2001-2004 to 65.2% in 2005-2008.
- In 2001-2004, 56.9% of adults age 60 and over diagnosed with diabetes had cholesterol at optimal levels; this is significantly higher than the 43.3% of adults ages 40-59. In 2005-2008, the percentage of adults age 60 and over diagnosed with diabetes who had optimal cholesterol levels increased to 74.5% while adults ages 40-59 saw an increase to only 59.5%. Adults age 60 and over continued to have significantly higher percentages of people with optimal cholesterol levels compared with adults ages 40-59.
Also, in the NHDR:
- In 2001-2004, the percentage of non-Hispanic Whites with their blood pressure under optimal control was significantly higher than the percentage of non-Hispanic Blacks. However, in 2005-2008, the percentage of non-Hispanic Whites age 40 years and over who had their blood pressure under optimal control had decreased and the percentage of non-Hispanic Blacks with optimal control had increased. There was no statistically significant difference between the two groups.
Prevention: Lower Extremity Amputations
People living with diabetes represent more than 60% of nontraumatic lower extremity amputations12 even though amputations can be avoided through proper care on the part of patients and providers. Hospital admissions for lower extremity amputations for patient with diagnosed diabetes reflect poorly controlled diabetes. Better management of diabetes would prevent the need for lower extremity amputations. Differences in rates may also vary across racial and ethnic groups due to differences in prevalence.
Figure 2.8. Hospital admissions for lower extremity amputations per 1,000 adult patients with diagnosed diabetes, by age, 1999-2007
Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Discharge Survey and National Health Interview Survey.
Denominator: Civilian noninstitutionalized population 18 years and over who report they have ever been told they have diabetes.
Note: Data are age adjusted to the 2000 standard population using three age groups: 0-64, 65-74, and 75 and over.
- From 1999-2001 to 2005-2007, the overall rate of hospital admissions for lower extremity amputations significantly decreased, from 5.6 per 1,000 population to 3.5 per 1,000 population (Figure 2.8).
- From 1999-2001 to 2005-2007, rates significantly decreased for adults ages 45-64, from 6.2 per 1,000 population to 3.7 per 1,000 population. Adults age 65 and over diagnosed with diabetes also had admissions significantly decrease, from 9.4 per 1,000 population to 4.5 per 1,000 population.
- In all years, adults ages 18-44 had significantly lower rates of hospital admissions for lower extremity amputation than the overall population and adults age 45 and over. The rate of admission for adults age 65 and over was more than twice the rate of adults ages 18-44 in the first 2 data years and almost twice the rate in the third data year.
Also, in the NHDR:
- In 2002-2004 and 2005-2007, Blacks had significantly higher rates of hospitalization for lower extremity amputations compared with White adults.
- Males had similarly higher rates of admissions, twice the rate of females.
i Throughout this report, total cost equals cost of medical care (direct cost) and economic costs of morbidity and mortality (indirect cost).
ii Direct costs are defined as "personal health care expenditures for hospital and nursing home care, drugs, home care, and physician and other professional services."
iii Cost-effectiveness is measured here by the average net cost of each quality-adjusted life year (QALY) that is saved by the provision of a particular health intervention. QALYs are a measure of survival adjusted for its value: 1 year in perfect health is equal to 1.0 QALY, while a year in poor health would be something less than 1.0. A lower cost per QALY saved indicates a greater degree of cost-effectiveness.
iv Noncore areas are outside of metropolitan or micropolitan statistical areas. Micropolitan and noncore areas are typically regarded as rural.
v The top 5 States that contributed to the benchmark are Delaware, Maine, Maryland, Massachusetts, and New Hampshire.
vi HbA1c, or glycosylated hemoglobin, is a measure of average levels of glucose in the blood.
vii More information on the PQIs is available at: http://www.qualityindicators.ahrq.gov/downloads/pqi/word/pqi_guide_v31.doc. [Plugin Software Help]
viii The top 4 States contributing to the achievable benchmark are Alaska, New Hampshire, Vermont, and the District of Columbia.
ix The top 4 States that contributed to the achievable benchmark are Hawaii, Nebraska, Utah, and Vermont.
x Blood pressure control guidelines were updated in 2005. Previously, having a blood pressure reading of <140/90 mm Hg was considered under control. For this measure, the new threshold of <140/80 mm Hg has been applied to historic data for the sake of consistency and comparability.