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National Healthcare Quality Report, 2013

Chapter 2. Effectiveness of Care for Common Clinical Conditions

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, many Americans do not receive the full benefits of high-quality care.

This chapter is organized around eight common clinical areas: cancer, cardiovascular disease, chronic kidney disease, diabetes, HIV disease, mental health and substance abuse, musculoskeletal diseases, and respiratory diseases. One section in this chapter relates most closely to national priorities identified in the National Strategy for Quality Improvement in Health Care.i The Cardiovascular Disease section addresses the priority "promoting the most effective prevention and treatment of the leading causes of mortality, starting with cardiovascular disease."

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.

Prevention

Caring for healthy people is an important component of health care. Educating people about health and promoting healthy behaviors can help postpone or prevent illness and disease. In addition, detecting health problems at an early stage increases the chances of effectively treating them, often reducing suffering and costs.

Treatment

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.

Management

Some diseases, such as diabetes and end stage renal disease (ESRD), are chronic, which means they cannot simply be treated once; they must be managed over time. 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.

Outcomes

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. 

Cancer

Importance

Mortality
Number of deaths (2010) 574,738 (USCS, 2014)
Cause of death rank (2011 prelim.) 2nd (Hoyert & Xu, 2012)
Prevalence
Americans diagnosed and living with cancer (2009) 13,027,914 (Howlader, et al., 2012)
Incidence
New cases of cancer (2010) 1,456,496 (USCS, 2014)
New cases of breast cancer (2010) 206,966 (USCS, 2014)
New cases of colorectal cancer (2010) 131,607 (USCS, 2014)
Cost
Total costii (2009) $216.6 billion (NHLBI, 2012)
Direct costsiii (2009) $86.6 billion (NHLBI, 2012)
Indirect costs (2009) $130.0 billion (NHLBI, 2012)
Cost-effectivenessiv of breast cancer screening $35,000-$165,000/QALY (Maciosek, et al., 2006)

Measures

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 National Healthcare Quality Report (NHQR) and National Healthcare Disparities Report (NHDR). In even years, the reports focus on colorectal cancer, and in odd years, the reports focus on breast cancer. This year, the report measures are:

  • Breast cancer screening.
  • Breast cancer first diagnosed at advanced stage.
  • Axillary node dissection or sentinel lymph node biopsy at time of surgery for breast cancer.
  • Radiation therapy following breast-conserving surgery.
  • Breast cancer deaths.

Findings

Prevention: Breast Cancer Screening

Early detection of cancer allows more treatment options and often improves outcomes. Mammography, the most effective method for detecting breast cancer at its early stages, can identify malignancies before they can be felt and before symptoms develop. Previous reports tracked receipt of mammography among women age 50 and over. The breast cancer screening measure used in the 2013 NHQR and NHDR reflects a more recent recommendation of the U.S. Preventive Services Task Force for mammograms every 2 years for women ages 50-74.

  Figure 2.1. Women who reported they had a mammogram within the past 2 years, by insurance (ages 50-64), 2000, 2003, 2005, 2008, and 2010, and activity limitations (ages 50-74), 2008 and 2010

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Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2000, 2003, 2005, 2008, and 2010.
Denominator: Civilian noninstitutionalized women ages 50-64 (left). Civilian noninstitutionalized women ages 50-74 (right).
Note: Rates are age adjusted to the 2000 U.S. standard population. Basic activity limitations include problems with mobility, self-care, domestic life, or activities that depend on sensory functioning. Complex activity limitations include limitations experienced in work or in community, social, and civic life. Data for activity limitations are not available for 2000, 2003, and 2005.

  • Overall, in 2010, 72.4% of women ages 50-74 had received a mammogram in the past 2 years (Figure 2.1).
  • In all years, among women ages 50-64, uninsured women were less likely to receive a mammogram compared with those with private insurance. Except in 2008, women with public insurance were less likely to receive a mammogram in all years compared with those with private insurance.
  • In 2008 and 2010, women with basic or complex activity limitations were less likely to receive a mammogram compared with those with neither basic nor complex activity limitations. While people with activity limitations often have more visits to health care providers, these may be more focused on managing chronic conditions than on delivering preventive care. Research shows that women with mobility limitations are less likely to receive breast examinations and mammograms (Allen, et al., 2009).
  • The 2008 top 5 State achievable benchmark was 88%.v There is no evidence of progress toward the benchmark by any activity limitation or insurance group.

Also, in the NHDR:

  • In 2000, 2003, and 2005, Hispanic women were less likely to receive a mammogram compared with non-Hispanic White women.
  • From 2000 to 2010, women from poor, low-income, and middle-income households were less likely to receive a mammogram compared with women from high-income households.

Outcome: Breast Cancer First Diagnosed at Advanced Stage

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 diagnosed at advanced stages is a measure of the effectiveness of cancer screening efforts and of adherence to followup 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 screening rates.

  Figure 2.2. Age-adjusted rate of advanced stage breast cancer per 100,000 women age 40 and over, by age, 2000-2009

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Source:Centers for Disease Control and Prevention and National Cancer Institute, National Program of Cancer Registries (NPCR), United States Cancer Statistics. Includes NPCR and National Cancer Institute's Surveillance, Epidemiology, and End Results registries meeting United States Cancer Statistics publication criteria for every year. Covers 90.1% of the total U.S. population. States excluded are Arkansas, District of Columbia, Mississippi, North Carolina, South Dakota, Tennessee, and Virginia.
Denominator: Women age 40 and over.
Note: For this measure, lower rates are better. Age adjusted to the 2000 U.S. standard population. Advanced stage breast cancer is defined as local stage with tumor size greater than 2 cm diameter, regional stage or distant stage.

  • In all years, women ages 50-64 and 65 and over had higher rates of advanced stage breast cancer than women ages 40-49 (Figure 2.2).
  • The rate of advanced stage breast cancer was decreasing for women ages 50-64.

Also, in the NHDR:

  • In all years, advanced stage breast cancer rates were lower among Asian or Pacific Islander (API) and American Indian or Alaska Native (AI/AN) women compared with White women.
  • From 2002 to 2009, the rates of advanced stage breast cancer were higher for Black women compared with White women.

Treatment: Recommended Care for Breast Cancer

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 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 adequate examination of lymph nodes when surgery is performed.

  Figure 2.3. Women with clinical Stage I-IIb breast cancer who received axillary node dissection or sentinel lymph node biopsy at the time of lumpectomy or mastectomy, by insurance status (under age 65) and age, 2004-2010

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Source: Commission on Cancer, American College of Surgeons and American Cancer Society, National Cancer Data Base, 2004-2010.
Denominator: Women with Stage I-IIb breast cancer undergoing lumpectomy or mastectomy.

  • Overall in 2010, 94.5% of women with clinical Stage I-IIb breast cancer had received axillary node dissection or sentinel lymph node biopsy at the time of lumpectomy or mastectomy (Figure 2.3).
  • From 2004 to 2010, the percentage of women who received axillary node dissection or sentinel lymph node biopsy improved for all age and insurance groups.
  • In all years, women ages 70-79 and 80 and over were less likely than women under age 40 to receive axillary node dissection or sentinel lymph node biopsy. Breast cancer treatment for older women (80 and over) may be complicated by other chronic conditions they may be experiencing at the same time.
  • In all years, among women under age 65, those with public health insurance were less likely than those with private insurance to receive axillary node dissection or sentinel lymph node biopsy.
  • The 2008 top 5 State achievable benchmark was 97%.vi At the current rate of increase, women in all age and insurance groups could achieve the benchmark within 2 years, except those age 80 and over.

Also, in the NHDR:

  • From 2004 to 2010, the percentage of women who received axillary node dissection or sentinel lymph node biopsy improved for Cuban, Hispanic, Black, White, and Puerto Rican women and women from all income groups.
  • In all years, there were no statistically significant differences by ethnicity or income in the percentage of women with clinical Stage I-IIb breast cancer who received axillary node dissection or sentinel lymph node biopsy.

  Figure 2.4. Women under age 70 treated for breast cancer with breast-conserving surgery who received radiation therapy within 1 year of diagnosis, by insurance (under age 65) and age, 2004-2010

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Source: Commission on Cancer, American College of Surgeons and American Cancer Society, National Cancer Data Base, 2004-2010.
Denominator: Women under age 70 undergoing breast-conserving surgery.
Note: Data for 2008 and 2009 may be lower due to the timing of data collected. Radiation can be administered 1 year from diagnosis, so registries may not complete radiation information at the time of case abstraction.

  • Overall, in 2010, 81.9% of women under age 70 treated for breast cancer with breast-conserving surgery had received radiation therapy within 1 year of diagnosis (Figure 2.4).
  • In all years, women ages 40-49, 50-59, and 60-69 were more likely than women under age 40 to receive radiation therapy.
  • In all years, among women under age 65, those with public insurance were less likely than those with private insurance to receive radiation therapy.
  • The 2008 top 5 State achievable benchmark was 94%.vii There is no evidence of progress toward the benchmark by any insurance or age group.

Also, in the NHDR:

  • In all years, Black, Hispanic, and Mexican women were less likely to receive radiation therapy compared with White women. In 5 of 7 years, Cuban women were less likely to receive radiation therapy than White women.
  • In 4 of 7 years, women from poor households were less likely to receive radiation therapy compared with those from high-income households.

Outcome: Breast 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. Breast cancer deaths reflect the impact of cancer screening, diagnosis, and treatment. Mortality is measured as the number of deaths per 100,000 population. Declines in breast cancer deaths can be attributed, in part, to improvements in early detection and treatment.

  Figure 2.5. Age-adjusted breast cancer deaths per 100,000 women, by age (2000-2010) and residence location (2004-2010)

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Key: MSA = metropolitan statistical area.
Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System—Mortality, 2000-2010.
Denominator: U.S. female population.
Note: For this measure, lower rates are better. Total rate is age adjusted to the 2000 U.S. standard population.

  • Overall, in 2010, the rate of breast cancer deaths was 22.1 per 100,000 population (Figure 2.5).
  • From 2000 to 2010, the rates of breast cancer deaths decreased for women from all age groups and residence locations.
  • In all years, women ages 45-64 and 65 and over had higher rates of breast cancer death compared with women ages 18-44. There were no statistically significant differences by residence location.
  • The 2008 top 5 State achievable benchmark was 17 per 100,000 population.viii At the current rate of decrease, women in all residence locations displayed could achieve the benchmark in 14 years.

Also, in the NHDR:

  • In all years, Hispanic women had lower breast cancer death rates than non-Hispanic White women.
  • In all years, API and AI/AN women had lower breast cancer death rates than White women, while Black women had higher rates than White women.

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Cardiovascular Disease

Importance

Mortality
Number of deaths from major cardiovascular disease (2010 prelim.) 777,548 (Murphy, et al., 2012)
Cause of death rank (2010 prelim.) 1st (Murphy, et al., 2012)
Prevalence
Number of cases of heart failure (2010 est.) 5.1 million (Go, et al., 2014)
Number of cases of high blood pressure among U.S. adults age 18 years and over (2003-2010 est.) 67 million (MMWR, 2012)
Incidence
Number of heart attacks or cases of fatal coronary heart disease (2010 est.) 915,000 (Go, et al., 2014)
Cost
Total cost of cardiovascular disease (2010 est.) $315.4 billion (Go, et al., 2014)
Total cost of heart disease (2010 est.) $204.4 billion (Go, et al., 2014)
Direct costs of cardiovascular disease (2010 est.) $193.4 billion (Go, et al., 2014)
Cost-effectiveness of hypertension screening $14,000-$35,000/QALY (Macosiek, et al., 2006)

Measures

The NHQR and NHDR track several quality measures for preventing and treating cardiovascular disease. Three measures are highlighted here:

  • Blood pressure monitoring.
  • Inpatient deaths following heart attack.
  • Hospitalization for congestive heart failure.

In addition, this chapter presents a measure focusing on the costs of hospitalizations for congestive heart failure. Several measures related to heart disease are also presented in other chapters of this report. Timeliness of cardiac reperfusion for heart attack patients is tracked in Chapter 5, Timeliness. Receipt of complete written discharge instructions by patients with heart failure is tracked in Chapter 7, Care Coordination.

Findings

Prevention: Blood Pressure Monitoring

National screening guidelines for hypertension are well established (USPSTF, 2007). However, since high blood pressure is asymptomatic in most cases, it is not surprising that many of those affected do not know they have this condition.

  Figure 2.6. Adults who reported receiving a blood pressure measurement in the last 2 years and can state whether their blood pressure was normal or high, by race/ethnicity and activity limitations, 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 age 18 and over.
Note: White and Black are non-Hispanic; Hispanic includes all races. Rates are age adjusted to the 2000 U.S. standard population. Basic activity limitations include problems with mobility, self-care, domestic life, or activities that depend on sensory functioning. Complex activity limitations include limitations experienced in work or in community, social, and civic life.

  • In 2008, 93.6% of White, 93.5% of Black, and 89.0% of Hispanic adults reported they had a blood pressure measurement in the past 2 years (Figure 2.6).
  • In 2008, Hispanic adults with basic activity limitations were less likely to receive a blood pressure measurement than White adults with basic activity limitations.
  • In 2008, Hispanic adults with neither activity limitation were less likely to receive a blood pressure measurement than White adults with neither activity limitation.

Also, in the NHDR:

  • In 2008, Hispanic women were less likely to receive a blood pressure measurement than White women.
  • In 2008, Hispanic men were less likely to receive a blood pressure measurement than White men.

Outcome: Inpatient Deaths Following Heart Attack

Heart attack, or acute myocardial infarction, is a common life-threatening condition that requires rapid recognition and efficient treatment in a hospital to reduce the risk of serious heart damage and death. Measuring processes of heart attack care can provide information about whether a patient received specific needed services, but these processes make up a very small proportion of all the care that a heart attack patient needs. Measuring outcomes of heart attack care, such as mortality, can provide a more global assessment of all the care a patient receives and usually is the aspect of quality that matters most to patients.

Significant improvements in process measures of quality of care for heart attack have occurred in recent years. All process measures tracked in past reports have attained overall performance levels exceeding 95% and have been retired. Therefore, the 2013 NHQR and NHDR focus on outcome measures. Survival following admission for heart attack reflects multiple patient factors, such as a patient's comorbidities, as well as health care system factors, such as the possible need to transfer patients to other hospitals for services. It also may partly reflect receipt of appropriate health services.

  Figure 2.7. Inpatient deaths per 1,000 adult hospital admissions with heart attack, by expected payment source and sex, 2004-2010

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Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample and AHRQ Quality Indicators, modified version 4.1, 2004-2010.
Denominator: Adults age 18 and over admitted to a non-Federal community hospital in the United States with acute myocardial infarction as principal discharge diagnosis.
Note: For this measure, lower rates are better. Rates are adjusted by age, major diagnostic category, all payer refined-diagnosis related group risk of mortality score, and transfers into the hospital.

  • From 2004 to 2010, the risk-adjusted inpatient mortality rate for hospital admissions with heart attack decreased significantly overall and for both sexes and all expected payment sources (Figure 2.7).
  • In all years, women had higher rates of inpatient heart attack deaths than men and uninsured patients had higher rates than privately insured patients.
  • The 2008 top 4 State achievable benchmark for inpatient heart attack mortality was 48 per 1,000 admissions.ix Men have achieved the benchmark. At current rates of improvement, women would need 2 years to achieve it. Patients with private insurance and Medicare could achieve the benchmark in less than a year, and it would take those with Medicaid 1 year to achieve it. Uninsured patients would need 7 years to achieve the benchmark.

Also, in the NHDR:

  • From 2005 to 2009, Blacks had lower inpatient mortality rates than Whites.
  • In 5 of 10 years, residents of the lowest area income quartile had higher inpatient mortality rates than residents of the highest area income quartile.

Outcome: Hospitalization for Congestive Heart Failure

Some hospitalizations for heart failure are unavoidable, but rates of hospitalization can be influenced by the quality of outpatient care.

  Figure 2.8. Adult admissions for congestive heart failure per 100,000 population, by age and sex, 2004-2010

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Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample and AHRQ Quality Indicators, modified version 4.1, 2004-2010.
Denominator: U.S. resident population age 18 and over.
Note: For this measure, lower rates are better. Age rates are adjusted by sex; sex rates are adjusted by age.

  • From 2004 to 2010, the hospitalization rate for congestive heart failure decreased significantly overall and for each age group and both sexes (Figure 2.8).
  • In all years, patients ages 45-64 and 65 and over had higher hospitalization rates for congestive heart failure than patients ages 18-44, and men had higher rates than women.
  • The 2008 top 4 State achievable benchmark for heart failure admissions was 195 per 100,000 population.x Women could achieve the benchmark in 5 years while men would take 12 years.

Also, in the NHDR:

  • In all years, Blacks had higher rates of admission for congestive heart failure compared with Whites while APIs had lower rates than Whites.
  • In all years, residents of the highest area income quartile had lower rates than residents of the two lower area income quartiles.

Outcome: Costs of Hospitalizations for Congestive Heart Failure

The Efficiency chapter examines the costs across potentially avoidable conditions; this section focuses on hospitalization costs for congestive heart failure. Hospitalizations for congestive heart failure are expensive. Preventing avoidable hospitalizations for congestive heart failure could improve the efficiency of health care delivery. For this analysis, total hospital charges were converted to costs using Healthcare Cost and Utilization Project (HCUP) cost-to-charge ratios based on hospital accounting reports from the Centers for Medicare & Medicaid Services. Therefore, cost estimates in this section refer to hospital costs for providing care but do not include either payers' costs or costs for physician care that are billed separately.

  Figure 2.9. Total national costs of hospitalizations for congestive heart failure, 2000-2010

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Source: Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project, Nationwide Inpatient Sample and AHRQ Quality Indicators, modified version 4.1, 2000-2010.
Denominator: Civilian noninstitutionalized adults age 18 and over.
Note: For this measure, lower rates are better. Annual rates are adjusted for age and sex. Costs are adjusted for inflation and are represented in 2010 dollars.

  • From 2000 to 2002, total national hospital costs associated with congestive heart failurexi increased from $8.1 billion to $8.8 billion. Since then, costs have been gradually declining, to $7.4 billion in 2010 (Figure 2.9).

i Available at http://www.ahrq.gov/workingforquality/reports.htm.
ii Throughout this report, total cost equals cost of medical care (direct cost) and economic costs of morbidity and mortality (indirect cost).
iii Direct costs are defined as "personal health care expenditures for hospital and nursing home care, drugs, home care, and physician and other professional services."
iv 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.
v The top 5 States that contributed to the achievable benchmark are Connecticut, Delaware, Massachusetts, New Hampshire, and Rhode Island.
vi The top 5 States that contributed to the achievable benchmark are Alaska, Arkansas, Mississippi, Montana, and Oklahoma.
vii The top 5 States that contributed to the achievable benchmark are Kansas, Minnesota, Montana, North Dakota, and Wisconsin.
viii The top 5 States that contributed to the achievable benchmark are Alaska, Hawaii, Montana, Vermont, and Wyoming.
ix The top 4 States that contributed to the achievable benchmark are Arizona, Florida, Michigan, and Ohio.
x The top 4 States that contributed to the achievable benchmark are Colorado, Oregon, Utah, and Vermont.
xi Adjusted for inflation using the gross domestic product implicit price deflator.


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Page last reviewed May 2014
Page originally created May 2014
Internet Citation: Chapter 2. Effectiveness of Care for Common Clinical Conditions. Content last reviewed May 2014. Agency for Healthcare Research and Quality, Rockville, MD. https://archive.ahrq.gov/research/findings/nhqrdr/nhqr13/chap2.html

 

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