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National Healthcare Quality 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 distribution.
  • 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, rural 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).

Electronic Health Records in Hospitals

The 2012 Commonwealth Fund report Using Electronic Health 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 NHQR 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.

Figure 9.1. Electronic health record use in hospitals, by bed size and geographic region, 2011

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Key: CPOE = computerized provider order entry.
Source: American Hospital Association Annual Survey, 2011 Information Technology Supplement.
Note: Data were obtained from an average of 3,360 hospitals.

Fully Implemented EHR

  • In 2011, 29.6% of hospitals had a fully implemented EHR system (data not shown). The percentage of hospitals with a fully implemented EHR system was higher for hospitals with 400 or more beds (44.0%) compared with hospitals with 100-399 beds (30.5%) and hospitals with fewer than 100 beds (25.8%; Figure 9.1).
  • In 2011, hospitals in 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 (data not shown).

Medication Lists

  • In 2011, 43.5% of hospitals had an EHR system that supports medication lists. The percentage of hospitals with an EHR system that supports medication lists was higher for hospitals with 400 beds or more (57.5%) compared with hospitals with 100-399 beds (48.7%) and hospitals with fewer than 100 beds (36.3%).
  • Hospitals in the Midwest had the highest percentage of hospitals with an EHR system that supports medication lists (47.5%). In the Northeast and the West, 45.0% and 44.8% of hospitals, respectively, had an EHR system that supports medication lists. In the South, 38.8% of hospitals had an EHR system that supports medication lists.
  • More than 46% of urban hospitals and 40.0% of rural hospitals had an EHR system that supports medication lists (data not shown).

Drug Decision Support

  • In 2011, 62.0% of hospitals had an EHR system that had a component for drug decision support. The percentage of hospitals with an EHR system that had a component for drug decision support was higher for hospitals with 400 beds or more (84.0%) compared with hospitals with 100-399 beds (72.3%) and hospitals with fewer than 100 beds (49.2%; Figure 9.1).
  • The Northeast had the highest percentage of hospitals with an EHR system that had a component for drug decision support (64.9%). In the Midwest and the South, 64.6% and 60.8% of hospitals, respectively, had an EHR system that had a component for drug decision support. In the West, 57.4% of hospitals had an EHR system that had a component for drug decision support.
  • Nearly 68% of urban hospitals and 55.3% of rural hospitals had an EHR system that had a component for drug decision support (data not shown).

Computerized Provider Order Entry of Medications

  • In 2011, 48.3% of hospitals had an EHR system that supports CPOE of medications. The percentage of hospitals with an EHR system that supports CPOE of medications was higher for hospitals with 400 beds or more (72.0%) compared with hospitals with 100-399 beds (51.8%) and hospitals with fewer than 100 beds (40.6%).
  • The Northeast had the highest percentage of hospitals with an EHR system that supports CPOE of medications (55.1%). In the Midwest and the West, 50.7% and 47.7% of hospitals, respectively, had an EHR system that supports CPOE of medications. In the South, 43.8% of hospitals had an EHR system that supports CPOE of medications.
  • Nearly 53% of urban hospitals and 43.0% of rural hospitals had an EHR system that supports CPOE of medications (data not shown).

Pharmaceutical Bar Coding

  • In 2011, 45.9% of hospitals had an EHR system that supports pharmaceutical bar coding. The percentage of hospitals with an EHR system that supports pharmaceutical bar coding was higher for hospitals with 400 beds or more (61.0%) compared with hospitals with 100-399 beds (56.3%) and hospitals with fewer than 100 beds (34.8%; Figure 9.1).
  • The Midwest and the South had the highest percentages of hospitals with an EHR system that supports pharmaceutical bar coding (47.9%). In the West and the Northeast, 41.5% and 41.1% of hospitals, respectively, had an EHR system that supports pharmaceutical bar coding.
  • More than 50% of urban hospitals and 40.6% of rural hospitals had an EHR system that supports pharmaceutical bar coding (data not shown).

Also, in the NHDR:

  • 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.
  • 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.

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 reason cited for not adopting health IT is 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 physician age and practice size, 2012

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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, 71.8% of physicians had an EHR system (Figure 9.2).
  • In 2012, 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.
  • In 2012, the percentage of physicians working in practices of 11 or more who had an EHR system was significantly higher than the percentage of physicians in practices with 1 or 2 physicians who had an EHR system (89.5% compared with 58.3%). Nearly 81% of practices with 6 to10 physicians and 71.9% of practices with 3 to 5 physicians had an EHR system.

Also, in the NHDR:

  • In 2012, 72% 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.

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 physician age and practice size, 2009-2012

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Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Ambulatory Medical Care Survey, 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 overall adoption of computerized systems for ordering prescriptions showed significant improvement from 42.7% to 79.5%. All physician age groups and practice sizes showed improvement (Figure 9.3).
  • In all years, the percentage of practices with an e-prescribing system for ordering prescriptions was significantly higher for physicians under age 35 than for physicians age 55 and over.
  • 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.

Also, in the NHDR:

  • From 2009 to 2012, 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%.

Figure 9.4. Office-based physicians with a computerized system for sending prescriptions electronically to pharmacies, by physician age and practice size, 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, 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 unavailable.

  • 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 9.4).
  • In all years, the percentage of practices with an e-prescribing system for sending prescriptions to pharmacies was significantly higher for physicians under age 35 than for physicians age 55 and over.
  • In 2012, 88.0% of practices with 11 or more physicians used an e-prescribing system to send prescriptions to pharmacies. This was significantly higher than the percentage of physicians in practices with 1 or 2 physicians (62.4%) and practices with 3 to 5 physicians (72.7%).

Also, in the NHDR:

  • 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 9.5. Office-based physicians with an e-prescribing system with a component for providing warnings of drug interactions or contraindications, by physician age and practice size, 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, 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 overall adoption of e-prescribing systems with a component for providing warnings of drug interactions or contraindications showed significant improvement from 37.3% to 66.5%. All physician age groups and practice sizes showed improvement (Figure 9.5).
  • 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.
  • In 2012, 80.6% of practices with an e-prescribing system and 11 or more physicians had a component for providing warnings of drug interactions or contraindications. This was significantly higher than the percentage for physicians in practices with 1 or 2 physicians (56.5%) and practices with 3 to 5 physicians (66.0%).

Also, in the NHDR:

  • 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.

Workforce Distribution

The IOM defines primary care as the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. 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. Rates of active non-Federal nurse practitioners per 100,000 population, by State quartiles, 2011

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Key: DSU = data statistically unreliable.
Source: U.S. Census Bureau, American Community Survey, 2011.

  • In 2011, there were 31.2 nurse practitioners per 100,000 population (data not shown).
  • The Northeast (38.4 per 100,000) tended to have higher rates of nurse practitioners while the West (26.5 per 100,000) tended to have lower rates (Figure 9.6).
  • There was considerable variation by State, ranging from 11.4 (New Jersey) to 82.8 per 100,000 (Massachusetts).
  • Interquartile ranges were:
    • Lowest quartile: 11.4 to 24.9 per 100,000.
    • 2nd quartile: 26.4 to 29.1 per 100,000.
    • 3rd quartile: 33.2 to 35.9 per 100,000.
    • Highest quartile: 42.7 to 82.8 per 100,000.

Also, in the NHDR:

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

In the mid-1960s, the need for greater patient access to primary care was a principal motivator for establishing the physician assistant program (Coplan, et al., 2013). According to the American Academy of Physician Assistants, the duties of physician assistants include performing physical examinations, diagnosing and treating illnesses, ordering and interpreting lab tests, performing procedures, assisting in surgery, providing patient education and counseling, and making rounds in hospitals and nursing homes. All 50 States and the District of Columbia allow physician assistants to practice and prescribe medication to varying degrees depending on education, experience, State law, facility policy, and physician delegation.

A report from the National Center for Health Statistics found that in 2009, 49% of physicians worked in practices that employed nurse practitioners, certified nurse midwives, or physician assistants. Physician assistants were likely to provide care in facilities associated with non-teaching hospitals that had a high percentage of Medicaid, Children's Health Insurance Program (CHIP), and uninsured patients. Physician assistants are used more extensively in smaller facilities in nonurban areas and serve populations who might otherwise be medically underserved (Cawley, 2012).

Figure 9.7. Rates of active non-Federal physician assistants, by State quartiles, 2011

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Key: DSU = data statistically unreliable.
Source: U.S. Census Bureau, American Community Survey, 2011.

  • In 2011, there were 42.7 physician assistants per 100,000 population (data not shown).
  • The Northeast (53.0 per 100,000 population) tended to have higher rates of physician assistants while the Midwest (36.2 per 100,000 population) tended to have lower rates (Figure 9.7).
  • There was considerable variation by State, ranging from 23.6 (Illinois) to 64.1 per 100,000 population (Colorado).
  • Interquartile ranges per 100,000 population were:
    • Lowest quartile: 23.6 to 33.6.
    • 2nd quartile: 35.4 to 41.8.
    • 3rd quartile: 42.2 to 53.4.
    • Highest quartile: 55.7 to 64.1.

Also, in the NHDR:

  • From 2006 to 2011, Whites had significantly higher rates of physician assistants than Blacks.
  • 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.

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 a measure 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. This section also 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 costs (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 age and geographic location, 2010

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Key: MSA = metropolitan statistical area.
Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Emergency Department Sample, 2010.

  • 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 (Figure 9.8).
  • 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.

Also, in the NHDR:

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

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, 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. Characteristics of HSHC patients, by age, sex, and insurance status, 2012

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Key: CHIP = Children's Health Insurance Program.
Source: Health Resources and Services Administration, Bureau of Primary Health Care, Uniform Data System, 2012.
Note: Data were obtained from 1,128 Section 330 grantees.

  • In 2012, the largest group of HSHC patients comprised adults ages 25-64 (51.1%; Figure 9.9), whereas adults age 65 and over made up only a small proportion of HSHC patients (7.2%).
  • In 2012, a substantially larger percentage of females (58.7%) than males (41.3%) received treatment at an HSHC.
  • In 2012, 36.0% of patients seen at an HSHC were uninsured and 40.8% had Medicaid/CHIP

Also, in the NHDR:

  • In 2012, approximately two-thirds of patients seen at an HSHC were White (Hispanic and non-Hispanic), and about one-quarter were Black.
  • 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.

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Coplan B, Cawley J, Stoehr J. Physician assistants in primary care: trends and characteristics. Ann Fam Med 2013;11(1):75-9.

Donabedian A. The definition of quality and approaches to its assessment. Chicago: Health Administration Press; 1980.

E-prescribing shown to improve outcomes, save billions. Health Manag Technol 2012 Apr;33(4):22-3.

Helping primary care clinicians practice in the communities where they are needed most: National Health Service Corps loan repayment and scholarships. Rockville, MD: Health Resources and Services Administration; November 2013. Available at: http://nhsc.hrsa.gov/currentmembers/fieldstrength.pdf (PDF File, 360 KB). Accessed January 23, 2014.

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Institute of Medicine, Board of Health Care Services. Future directions for the National Healthcare Quality and Disparities Reports. Washington, DC: National Academies Press; 2010.

Jariwala KS, Holmes ER, Banaha BF, et al. Factors that physicians find encouraging and discouraging about electronic prescribing: a quantitative study. J Am Med Inform Assoc 2013 Jun;20(e1):e39-43.

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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/nhqr13/chap9.html

 

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