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National Healthcare Quality Report, 2013

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

Musculoskeletal Diseases

Importance

Prevalence
People who have arthritis, gout, lupus, or fibromyalgia (2010-2012) 52.5 million (22.7% of U.S. adults) (MMWR, 2013)
Number of people with low bone density 52 million (Crandall, et al., 2012)
Morbidity
Activity limitations attributable to arthritis, gout, lupus, or fibromyalgia (2010-2012) 22.7 million adults (MMWR, 2013)
Lifetime osteoporosis-related fractures among women over age 50 approx. 50% (NOF)
Lifetime osteoporosis-related fractures among men over age 50 approx. 25% (NOF)
Cost
Total cost of arthritis and other rheumatic conditions (2003) $128 billion (MMWR, 2007)
Direct medical cost of arthritis and other rheumatic conditions (2003) $81 billion (MMWR, 2007)
Indirect costs of arthritis and other rheumatic conditions (2003) $47 billion (MMWR, 2007)
Total cost of osteoporosis-related fractures (2005) $19 billion (NOF)

Measures

This section tracks several quality measures for prevention and management of musculoskeletal diseases. The arthritis measures are part of the Arthritis Foundation's Quality Indicator Set for Osteoarthritis. A multidisciplinary panel of experts on arthritis and pain reviewed scientific evidence to help develop the Quality Indicator Set (Pencharz & MacLean, 2004). The measures were tracked as part of Healthy People 2010 and continue to be tracked in Healthy People 2020. Osteoporosis measures are usually tracked in this section, but no new data are available for this year's reports.

This section highlights three measures related to quality of care for arthritis:

  • Arthritis education for adults with arthritis.
  • Counseling about physical activity for adults with arthritis.
  • Counseling about weight reduction for overweight and obese adults with arthritis.

Findings

Management: Arthritis Education for Adults With Arthritis

Osteoarthritis is the most common form of arthritis, affecting about 12% of the general population. Patients with symptomatic osteoarthritis who receive education about the natural history, treatment, and self-management of the disease have better knowledge and self-efficacy and experience less pain and functional impairment (Pencharz & MacLean, 2004).

Figure 2.28. Adults with doctor-diagnosed arthritis who reported they had effective, evidence-based arthritis education as an integral part of the management of their condition, by education and activity limitations, 2009

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Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2009.
Denominator: Civilian noninstitutionalized adults with doctor-diagnosed arthritis.
Note: Estimates 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.

  • Rates for all groups regardless of education level and activity limitation are low; only about 9% to 15% of adults diagnosed with arthritis reported they received education as part of the management of their condition (Figure 2.28).
  • Adults with any college education were more likely to receive effective, evidence-based arthritis education than high school graduates and adults with less than a high school education (13% compared with 8.8% and 9.7%, respectively).

Also, in the NHDR:

  • Male adults were less likely to receive education than female adults. However, there were no statistically significant differences between Black males and Black females.
  • The percentage of adults who received education was higher for White females and Black females than for Hispanic females. There were no statistically significant differences between White females and Black females.

Management: Counseling About Physical Activity for Adults With Arthritis

Patients with symptomatic osteoarthritis should also receive counseling about muscle strengthening and aerobic exercise programs. Such programs can reduce pain and improve functional ability (Pencharz & MacLean, 2004).

Figure 2.29. Adults with doctor-diagnosed arthritis who reported they received health care provider counseling about physical activity or exercise, by income and activity limitations, 2009

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Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2009.
Denominator: Civilian noninstitutionalized adults with doctor-diagnosed arthritis.
Note: Estimates 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 2009, overall, 57.2% of adults with doctor-diagnosed arthritis received health care provider counseling (Figure 2.29).
  • Poor, low-income, and middle-income adults were less likely than high-income adults to receive health care provider counseling about physical activity or exercise.
  • Adults with basic or complex activity limitations were more likely to receive health care provider counseling about physical activity or exercise than adults with neither limitation.

Also, in the NHDR:

  • Among adults ages 45-64, Hispanics were more likely than Whites to receive exercise counseling.

Management: Counseling About Weight Reduction for Overweight and Obese Adults With Arthritis

Weight is a risk factor for osteoarthritis and weight reduction can be used to prevent the development of osteoarthritis among overweight and obese people. Moreover, overweight and obese people with osteoarthritis who lose weight experience less joint pain and have improved function (Pencharz & MacLean, 2004).

Figure 2.30. Overweight and obese adults with doctor-diagnosed arthritis who reported they received health care provider counseling about weight reduction, by insurance (under age 65) and activity limitations, 2009

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Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2009.
Denominator: Civilian noninstitutionalized overweight and obese adults with doctor-diagnosed arthritis.
Note: Estimates 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. People were considered to have doctor-diagnosed arthritis if they answered yes to "Have you ever been told by a doctor or other health professional that you have some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?" For both men and women, overweight is BMI ≥25 to <30; obese is BMI ≥30.

  • In 2009, overall and in each insurance group, less than 50% of overweight and obese adults received provider counseling about weight reduction (Figure 2.30).
  • There were no statistically significant differences by insurance status in the percentage of overweight and obese adults who received weight reduction counseling.
  • Overweight and obese adults with basic or complex activity limitations were more likely to receive weight reduction counseling than overweight and obese adults with neither limitation (52.3% and 48.8%, respectively, compared with 36.1%).

Also, in the NHDR:

  • Poor overweight and obese adults were more likely than high-income overweight and obese adults to report they received health care provider counseling about weight reduction.

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Respiratory Diseases

Importance

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

Measures

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

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

Findings

Prevention: Pneumococcal Immunization

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

Figure 2.31. Adults age 65 and over who reported ever receiving pneumococcal immunization, by activity limitations and residence location, 2006-2011

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Key: MSA = metropolitan statistical area.
Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2006-2011.
Denominator: Civilian noninstitutionalized population age 65 and over.
Note: 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. Benchmark is derived from the Behavioral Risk Factor Surveillance System; see Chapter 1, Introduction and Methods, for details.

  • Overall, the percentage of adults age 65 and over who reported ever receiving pneumococcal immunization increased from 53.4% in 2000 to 62.7% in 2011 (data not shown).
  • Improvements were observed among adults with complex activity limitations (Figure 2.31). Improvements were also observed among residents of large central, large fringe, and medium metropolitan areas, micropolitan areas, and noncore areas.
  • In all years, adults with basic activity limitations were more likely than adults with neither basic nor complex activity limitations to receive pneumococcal immunization.
  • Except in 2009, residents of large central metropolitan areas were less likely than residents of large fringe metropolitan areas to receive pneumococcal immunization.
  • The 2008 top 5 State achievable benchmark was 67%.xxvi At the current annual rate of increase, this benchmark could be attained overall in about 5 years. Adults with basic or complex activity limitations and residents of large fringe metropolitan, medium metropolitan, micropolitan, and noncore areas could achieve the benchmark sooner. Adults with neither basic nor complex activity limitations would need 9 years to reach the benchmark.

Also, in the NHDR:

  • In all years, Blacks and Asians were less likely than Whites and Hispanics were less likely than non-Hispanic Whites to receive pneumococcal immunization.

Figure 2.32. State variation: adults age 65 and over who reported ever receiving pneumococcal immunization, 2010

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Key: Lowest Quality Quartile identifies States with the lowest rates of pneumococcal immunization; Highest Quality Quartile identifies States with the highest rates of pneumococcal immunization.
Source: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System, 2010.

  • The States in the lowest quality quartile had pneumococcal immunization rates under 67.4% while the States in the highest quality quartile had pneumococcal immunization rates above 71.3%.
  • States in the East South Central and West South Central census divisions tended to have lower rates of pneumococcal immunization while States in the New England and West North Central census divisions tended to have higher rates of pneumococcal immunization (Figure 2.32).

Also, in the NHDR:

  • States in the Middle Atlantic, East South Central, and West South Central census divisions tended to have larger education-related disparities in pneumococcal immunization.

Prevention: Influenza Immunization Among Patients Hospitalized With Pneumonia

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

New! Figure 2.33. Hospital patients age 50 and over with pneumonia who received influenza immunization status assessment or provision, by age and sex, 2005-2011

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Source: Centers for Medicare & Medicaid Services, Medicare Quality Improvement Organization Program, 2005-2011.
Denominator: Patients age 50 and over discharged October-February with a principal discharge diagnosis of pneumonia or a principal discharge diagnosis of either septicemia or respiratory failure and secondary diagnosis of pneumonia.

  • From 2005 to 2011, the percentage of patients age 50 and over with pneumonia who received influenza immunization status assessment or provision increased from 55.2% to 94.1% (Figure 2.33). Improvement was observed among all age groups and both sexes.
  • In all years, patients ages 65-74, 75-84, and 85 and over were more likely to receive influenza immunization status assessment or provision than patients ages 50-64.
  • In 2010, the 2008 top 5 State achievable benchmark of 91% was attained.
  • In 2011, the new top 5 State achievable benchmark was 97%.xxvii All age groups and both sexes were within 1 year of the benchmark.

Also, in the NHDR:

  • In all years since 2006, Black, Hispanic, AI/AN, and Asian patients were less likely than White patients to receive influenza immunization status assessment or provision.

Prevention: Influenza and Pneumococcal Immunization Among Long-Stay Nursing Home Residents

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

New! Figure 2.34. Long-stay nursing home residents who were assessed and given influenza and pneumococcal immunization, by age and sex, 2011

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

  • In 2011, 89.5% of long-stay nursing home residents were assessed and given influenza immunization and 93.3% were assessed and given pneumococcal immunization (Figure 2.34).
  • Residents ages 0-64, 65-74, and 75-84 were less likely than residents age 85 and over to receive both influenza and pneumococcal immunization.
  • Females were more likely than males to receive pneumococcal immunization.
  • In 2011, the top 5 State achievable benchmark for influenza immunization was 94%xxviii and the benchmark for pneumococcal immunization was 98%.xxix No age group or sex has achieved the benchmark.

Also, in the NHDR:

  • Black, AI/AN, multiple-race, and Hispanic residents were less likely than White residents to receive both influenza and pneumococcal immunization. NHOPI residents were less likely than White residents to receive pneumococcal immunization.

Outcome: Completion of Tuberculosis Therapy

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

Figure 2.35. Patients with tuberculosis who completed a curative course of treatment within 1 year of initiation of treatment, by age and sex, 2000-2009

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Source: Centers for Disease Control and Prevention, National Tuberculosis Surveillance System, 2000-2009.
Denominator: U.S. civilian noninstitutionalized population treated for tuberculosis.

  • The percentage of patients who completed tuberculosis therapy within 1 year increased from 80.2% in 2000 to 86.1% in 2009 (Figure 2.35). Improvements were observed among all age and sex categories.
  • In all years, children ages 0-17 with tuberculosis were more likely than adults ages 18-44 to complete a curative course of treatment within 1 year of initiation of treatment.
  • From 2004 to 2009, males were less likely than females to complete tuberculosis treatment.
  • The 2008 top 4 State achievable benchmark was 94%.xxx At the current annual rate of increase, this benchmark could not be attained overall for about 12 years. Children ages 0-17 could achieve the benchmark in about 4 years while patients age 65 and over would need 20 years. Females could not achieve the benchmark for about 9 years while males would need about 15 years.

Also, in the NHDR:

  • In 8 of 10 years, Hispanics were less likely than non-Hispanic Whites to complete tuberculosis treatment.

Management: Daily Asthma Medication

Improving quality of care for people with asthma can reduce the occurrence of asthma attacks and avoidable hospitalizations. The National Asthma Education and Prevention Program, coordinated by the National Heart, Lung, and Blood Institute, develops and disseminates evidence-based guidelines for asthma diagnosis and management (NHLBI, 2007). These recommendations are built around four essential components of asthma management critical for effective long-term control of asthma: assessment and monitoring, control of factors contributing to symptom exacerbation, pharmacotherapy, and education for partnership in care.

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

Figure 2.36. People with current asthma who reported taking preventive asthma medicine daily or almost daily, by insurance and age, 2003-2010

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Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2003-2010.
Denominator: Civilian noninstitutionalized population with current asthma.
Note: Age adjusted to the 2000 U.S. standard population using four age groups: 0-17, 18-44, 45-64, and 65 and over. People with current asthma report that they still have asthma or had an asthma attack in the last 12 months. Insurance groups presented are for patients under age 65.

  • From 2003 to 2010, the percentage of people with current asthma who reported taking preventive asthma medicine daily or almost daily fell from 29.6% to 26.5% (Figure 2.36). Significant decreases were observed among children ages 0-17 and people with private and public insurance.
  • In all years, uninsured people under age 65 were less likely than people under age 65 with any private health insurance to take daily preventive asthma medicine.
  • In all years, people ages 18-44 were less likely than other age groups to take daily preventive asthma medicine.

Also, in the NHDR:

  • In 5 of 8 years, Blacks were less likely than Whites to take daily preventive asthma medicine.
  • In 5 of 8 years, poor and low-income people were less likely than high-income people to take daily preventive asthma medicine.

Management: Written Asthma Management Plans

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

Figure 2.37. People with current asthma who received written asthma management plans from their health provider, by age and family income, 2008

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Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2008.
Denominator: Civilian noninstitutionalized population with current asthma.

  • In 2008, only one-third of people with current asthma received written asthma management plans from their provider (data not shown).
  • Children ages 0-17 were more likely to receive written asthma management plans than adults ages 18-44 (Figure 2.37). This age effect was most significant in middle- and high-income families.

Also, in the NHDR:

  • Blacks were more likely than Whites to receive written asthma management plans. Black-White differences were most significant in middle- and high-income families.

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


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Page last reviewed May 2014
Page originally created May 2014

 

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