Chapter 4. Priority Populations

Contents

Racial and Ethnic Minorities
Low-Income Groups
Women
Children
Older Adults
Residents of Rural Areas
Individuals With Disabilities and Special Health Care Needs

To examine the issue of disparities in health care, Congress directed the Agency for Healthcare Research and Quality (AHRQ) to produce an annual report to track "prevailing disparities in health care delivery as it relates to racial factors and socioeconomic factors in priority populations." Although the emphasis is on disparities related to race, ethnicity, and socioeconomic status, this directive includes a charge to examine disparities in "priority populations"—groups with unique health care needs or issues that require special attention.

This chapter addresses the congressional directive on priority populations.ⁱ Chapters 2 and 3 of this report examine racial, ethnic, and socioeconomic differences in quality of health care and access to health care in the general U.S. population. This chapter focuses on differences within and across priority populations. For example, comparisons are made between Black and White women and between children from low and high income families. This year, the National Healthcare Disparities Report (NHDR) section on low-income groups is focused on examining differences in quality of care and access to care by insurance status.

The approach taken in this chapter may help policymakers to understand the impact of racial, ethnic, and socioeconomic differences on specific populations and target quality improvement programs toward groups in greatest need. Appendix D includes detailed tables that allow examination of racial, ethnic, and socioeconomic disparities both in the general population and across priority populations for most measures.

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ⁱ The congressional mandate for the National Healthcare Disparities Report also identifies populations living in inner-city areas as a priority population. However, currently no data are available to support findings for this population.

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AHRQ's Priority Populations

AHRQ's priority populations, specified by Congress in the Healthcare Research and Quality Act of 1999 (Public Law 106-129), are:

• Minority groups.ⁱⁱ
• Low-income groups.ⁱⁱⁱ
• Women.
• Children (age 0-17).
• Older adults (age 65 and over).
• Residents of rural areas^iv
• Individuals with special health care needs,^v including individuals with disabilities and individuals who need chronic care or end-of-life health care.

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ⁱⁱ Racial categories include White, Black, Asian, Native Hawaiian or Other Pacific Islander, American Indian or Alaska Native, and more than one race. Ethnic categories are Hispanic or Latino, non-Hispanic White, and non-Hispanic Black.
ⁱⁱⁱ In the NHDR, low income refers to poor people. Thresholds for income categories—poor, near poor, middle income, and high income—vary by family size and composition and are updated annually by the U.S. Bureau of the Census. For example, in 2005 the Federal poverty threshold for a family of two adults and two children was $19,806.
^iv Rural areas can be defined differently depending on the data source. The NHDR uses Office of Management and Budget revised definitions of metropolitan and micropolitan statistical areas. Noncore areas are rural areas. Data for metropolitan and micropolitan areas are used for comparisons with noncore areas.
^v Individuals with special health care needs include children with special health care needs, defined as those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.

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How This Chapter Is Organized

This chapter provides the most recent information available on racial, ethnic, and income differences in quality and access for priority populations. It is presented in the following order:

• Racial and ethnic minorities.
• Low-income groups (focus on uninsured people).
• Women.
• Children.
• Older adults.
• Residents of rural areas.
• Individuals with disabilities or special health care needs.

To avoid repetition of findings from previous chapters' findings on race, ethnicity, and socioeconomic status, the first two sections summarize quality of and access to health care for racial and ethnic minorities and low-income groups. Subsequent sections focus on the remaining priority populations and examine disparities in care within each population group and changes in disparities over time. To present this greater detail, these sections highlight a small number of measures that supplement the core measures presented in Chapters 2 and 3. While these measures may not necessarily be the core measures presented each year, they add detail to the picture of disparities that each population may face. Interagency Work Group members and AHRQ experts on particular populations assisted in selecting measures for these priority populations.

For smaller priority populations, measure selection was often driven by available sample sizes. When possible, measures were selected to encompass multiple components of health care need, such as preventive services, treatment of acute illness, management of chronic disease, and access to health care. Results for all measures are found in the detailed appendix tables.

The measures discussed in this chapter are the following:

Section	Measure
Blacks or African Americans
Asians
Native Hawaiians and Other Pacific Islanders	Cholesterol screening Influenza and pneumococcal vaccinations for older adults Health insurance
American Indians and Alaska Natives
Hispanics or Latinos
Recent Immigrants and Limited-English-Proficient Populations	Tuberculosis therapy Poor communication with health providers Health insurance Language assistance
Low-income Groups Focus on Uninsurance	Colorectal cancer screening Counseling parents about physical activity in children Dental care
Women	Pregnant women receiving prenatal care in the first trimester Adults with obesity given advice about physical activity Acute myocardial infarction mortality New AIDS cases Usual source of care
Children	Early childhood vaccinations Counseling to parents about physical activity Vision screening Accidental puncture or laceration during procedure Hospital admissions with perforated appendix Health insurance
Older Adults	Influenza vaccination Vision screening Delayed care due to cost Health literacy
Residents of Rural Areas	Pregnant women receiving prenatal care in the first trimester Recommended services for diabetes Recommended care for colorectal cancer Care for illness or injury as soon as wanted Health insurance
Individuals With Disabilities or Special Health Care Needs	Adults with disabilities   Pneumococcal vaccination for adults age 65 and over   Private health insurance for adults ages 18-64   Source of ongoing care   Hospital, emergency room, or clinic as source of ongoing care
	Children with special health care needs   Effective care coordination   Family-centered care   Health insurance   Adequacy of health insurance

It should be noted that this chapter does not provide a comprehensive assessment of health care differences in each priority population. Most of the measures tracked in the NHDR were selected to be applicable across many population groups; only a few, such as immunizations among children, were specific to particular groups.

These general measures overlook some important health care problems specific to particular populations. For example, people with disabilities may face barriers in getting access to care and experience differences in quality of care that are not captured by data because of the limitations in the survey instruments. In addition, national data may not address key health issues for specific population groups, and it is not always possible to generate reliable estimates for many smaller groups such as Native Hawaiians or Other Pacific Islanders (NHOPIs) and American Indians and Alaska Natives (AI/ANs). Instead, this chapter should be seen as a starting point, identifying some problem areas and indicating gaps in current data and understanding.

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Racial and Ethnic Minorities

In 2000, about 33% of the U.S. population identified themselves as members of racial or ethnic minority groups.¹ By 2050, it is projected that these groups will account for almost half of the U.S. population. For 2007, the U.S. Census Bureau estimated that the United States had almost 38.8 million Blacks or African Americans² (12.9% of the U. S. population);³ more than 45.5 million Hispanics or Latinos (15.1%);² almost 13.4 million Asians (4.4%); more than 0.5 million NHOPIs (0.2%); and more than 2.9 million AI/ANs (1.0%), of whom 38% reside on Federal trust lands.⁴ Racial and ethnic minorities are more likely than non-Hispanic Whites to be poor or near poor.⁵ In addition, Hispanics, Blacks, and some Asian subgroups are less likely than non-Hispanic Whites to have a high school education.⁶

Previous chapters of the NHDR described health care differences by racial^vi and ethnic^vii categories as defined by the Office of Management and Budget and used by the U.S. Census Bureau.⁸ In this section, quality of and access to health care for each minority group are summarized to the extent that statistically reliable data are available for each group.^viii Criteria for importance are that the difference is statistically significant at the alpha = 0.05 level, two-tailed test, and that the relative difference from the reference group is at least 10% when framed positively as a favorable outcome or negatively as an adverse outcome. Access measures focus on facilitators and barriers to health care and exclude health care utilization measures.

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^vi Races include Black or African American, Asian, Native Hawaiian or Other Pacific Islander, American Indian or Alaska Native, White, and persons of multiple races.
^vii Ethnicity differentiates Hispanics and non-Hispanics. Among non-Hispanics, this report identifies non-Hispanic Whites and non-Hispanic Blacks.
^viii Data are presented for each minority group except for persons of multiple races due to unreliable estimates for this group.

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Changes Over Time

This section also examines changes in differences related to race and ethnicity over time. For each core report measure, racial, ethnic, and socioeconomic groups are compared with a designated comparison group at different points in time. Consistent with Healthy People 2010, disparities are measured in relative terms as the percent difference between each group and a comparison group. Changes in disparity are measured by subtracting the percent difference from the comparison group at the baseline year from the percent difference from the comparison group at the most recent year. The change in each disparity is then divided by the number of years between the baseline and most recent estimate to calculate change in disparity per year.

Core report measures (Table 1.2) for which the relative differences are changing less than 1% per year are identified as staying the same. Core report measures for which the relative differences are becoming smaller at a rate of more than 1% per year are identified as improving. Core report measures for which the relative differences are becoming larger at a rate of more than 1% per year are identified as worsening. Changes of greater than 5% per year are also differentiated from changes of between 1% and 5% per year in some figures.

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Gaps in Information

As in previous NHDRs, this section includes information on programs and issues that may affect racial and ethnic disparities. The assessment of disparities AI/ANs face includes information on the approximately 1.5 million individuals who obtain care from Indian Health Service (IHS) facilities and tribal facilities that receive IHS funding.

In interpreting findings for racial and ethnic minorities, readers should note that considerable gaps in information for some racial and ethnic minorities exist, which limit the NHDR's ability to identify the current state of disparities for some groups. Gaps can relate to insufficient data to produce reliable estimates or, when estimates are possible, to inadequate power to detect large differences. For example, of core report measures of quality, it is rarely possible to provide estimates for NHOPIs and people of more than one race. For Asians, only about two-thirds of core report measures of quality support analyses. For AI/ANs, only about half of these same measures support analyses. In addition, many data sources changed racial classifications for Asians and NHOPIs in 2003 to adhere to new Federal standards. This change has further constrained the ability to perform trend analyses for these groups. Chapter 1, Introduction and Methods, and the summary section at the end of this report present more detailed descriptions of current data limitations and ways in which data are gradually improving.

Below is a summary of the percentage of measures that need improvement. For all groups, opportunities to improve health care quality and access exist.

Table 4.1. Percentage of core quality and access measures that are not improving for various racial and ethnic groups

Group	Reference group	Percentage of core measures not improving (n = number of measures that could be tracked)
		Quality of care	Access to care
Black Asian AI/AN Hispanic	White White White Non-Hispanic White	77 (n = 35) 82 (n = 22) 67 (n = 15) 65 (n = 31)	50 (n =4) 60 (n = 5) 33 (n = 3) 50 (n = 4)

Key: AI/AN = American Indian or Alaska Native.
Note: "Not improving" is defined for quality measures as population received about the same or worse quality of care as Whites or non-Hispanic Whites; and for access measures as population had about the same or worse access to care as Whites or non-Hispanic Whites. Percentages are based on a subset of core measures that have data for these groups. Some measures include data for all ages and some are age-group specific. Refer to Measure Specifications and Data Tables appendixes for more information. Baseline year and most recent year are not the same for all measures, depending on the data source.

For each racial or ethnic group, Table 4.2 highlights the core measures with gaps that are increasing (i.e., getting worse) for the group compared with its reference group.

Table 4.2. Core measures that are getting worse for group compared with reference group

Group	Preventive services	Acute illness treatment	Chronic disease management	Patient safety	Timeliness	Patient centeredness	Access
Black vs. White	Adults age 50 and over who received colorectal cancer screening	Patients with tuberculosis who completed treatment within 1 year of initiation of treatment.	Colorectal cancer diagnosed at advanced stage	Adults age 65 and over who received potentially inappropriate prescription medicines	Adults who can sometimes or never get care for illnesses or injury as soon as wanted.	Adults with poor provider-patient communication	People with a usual primary care provider
	Children ages 2-17 for whom a health provider ever gave advice about physical activity		Adults age 40 and over with diagnosed diabetes who received all three recommended services
	Adults age 65 and over who ever received pneumo- coccal vaccination		Hospital admissions for lower extremity amputations per 1,000 population age 18 and over with diabetes
	Adult current smokers who received advice to quit smoking		Adults with a major depressive episode who received treatment for depression
			Adult home health care patients whose ability to walk or move around improved
Asian vs. White	Adults age 50 and over who received colorectal cancer screening		Colorectal cancer diagnosed at advanced stage	Adult surgery patients who received appropriate timing of antibiotics	Adults who can sometimes or never get care for illnesses or injury as soon as wanted.	Adults with poor provider-patient communication	People with a specific source of ongoing care
	Adults age 65 and over who ever received pneumococcal vaccination.		Adult hemodialysis patients with adequate dialysis (urea reduction 65% or higher)
			Dialysis patients who were registered on a waiting list for transplantation
			Short-stay nursing home residents with pressure sores
American Indian/Alaska Native vs. White	Adults age 50 and over who received colorectal cancer screening		Adult hemodialysis patients with adequate dialysis (urea reduction 65% or higher)				People under age 65 who were uninsured all year
			Long-stay nursing home residents with physical restraints
			Adult home health care patients who were admitted to the hospital
Hispanic vs. non-Hispanic White	Adults age 50 and over who received colorectal cancer screening	Patients with tuberculosis who complete treatment within 12 months of initiation of treatment	Adult hemodialysis patients with adequate dialysis (urea reduction 65% or higher)	Adults age 65 and over who received potentially inappropriate prescription medicines
	Adults age 65 and over who ever received pneumo- coccal vaccination		Adults with obesity who received advice to exercise more	Adult surgery patients who received appropriate timing of antibiotics
			Adults age 18 and over with a major depressive episode who received treatment for depression
Poor vs. high income	Adults age 50 and over who received colorectal cancer screening		Adults age 40 and over with diagnosed diabetes who received all three recommended services		Adults who can sometimes or never get care for illnesses or injury as soon as wanted	Adults with poor provider-patient communication
	Children ages 19-35 months who received all recommended vaccines		People age 12 and over who needed treatment for illicit drug use and who received such treatment at a specialty facility in the last 12 months			Children with poor provider-patient communication	People without a usual source of care who indicated a financial or insurance reason

Note: "Asian" includes "Asian or Pacific Islander" when information is not collected separately for each group. The time period for this table is the most recent and oldest years of data used in the NHDR. Measures with the highest annual percentage change in the direction of "getting worse" are shown here. Measures with no change are not included here. A blank cell indicates that no disparity in quality of care was getting worse for the group, which could reflect lack of data or small sample sizes for some populations.

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Blacks or African Americans

Previous NHDRs showed that Blacks had poorer quality of care and worse access to care than Whites for many measures tracked in the reports. Findings based on core report measures (Table 1.2) of quality and access to health care are shown below.

Figure 4.1. Blacks compared with Whites on core measures of quality and access

Better = Blacks receive better quality of care or have better access to care than Whites.
Same = Blacks and Whites receive about the same quality of care or access to care.
Worse = Blacks receive poorer quality of care or have worse access to care than Whites.
CRM = core report measures (Table 1.2)
Note: Data presented are the most recent available.

Table 4.3. Blacks compared with Whites on measures of quality and access: Specific measures

Topic	Better than Whites	Worse than Whites	Same as Whites
Cancer		Colorectal cancer diagnosed at advanced stage
		Adults age 50 and over who report they ever received a colonoscopy, sigmoidoscopy, proctoscopy, or fecal occult blood test
		Colorectal cancer deaths per 100,000 population per year
Diabetes		Hospital admissions for lower extremity amputations per 1,000 population age 18 and over with diabetes	Adults age 40 and over with diagnosed diabetes who received all three recommended services
End stage renal disease		Adult hemodialysis patients with adequate dialysis (urea renal reduction ratio 65% or greater)
		Dialysis patients who were registered on a waiting list for transplantation
Heart disease	Deaths per 1,000 adult hospital admissions with acute myocardial infarction (AMI)		Adult current smokers who received advice to quit smoking
	Recommended hospital care for heart failure		Recommended hospital care for heart attack
			Adults with obesity who ever received advice to exercise more
HIV and AIDS		New AIDS cases per 100,000 population age 13 and over
Maternal and child health		Pregnant women who first received prenatal care in the first trimester	Children ages 2-17 for whom a health provider ever gave advice about physical activity
		Children ages 19-35 months who received all recommended vaccines	Children ages 3-6 who ever had their vision checked
Mental health and substance abuse	Suicide deaths per 100,000 population	Adults with a major depressive episode who received treatment for depression	People age 12 and over who needed treatment for illicit drug use and who received such treatment at a specialty facility in the last 12 months
		People age 12 and over treated for substance abuse who completed treatment course
Respiratory diseases		Adults age 65 and over who ever received pneumococcal vaccination.	Patients with tuberculosis who completed a curative course treatment within 12 months of initiation of treatment.
		Recommended hospital care for pneumonia
Nursing home, home health, and hospice care	Long-stay nursing home residents with physical restraints	High-risk, long-stay nursing home residents with pressure sores	Adult home health care patients whose ability to walk or move around improved
		Short-stay nursing home residents with pressure sores
		Adult home health care patients who were admitted to the hospital
Patient safety			Adult surgery patients who received appropriate timing of antibiotics
			Adult surgery patients with postoperative complications
			Failure to rescue Central venous catheter-associated adverse events
			Adults age 65 and over who received potentially inappropriate prescription medicines
Timeliness		Emergency department visits in which patients left without being seen
		Adults who can sometimes or never get care for illness or injury as soon as wanted
Patient centeredness		Adults with poor provider-patient communication	Children with poor provider-patient communication
Access	People without a usual source of care who indicated a financial or insurance reason	People under age 65 who were uninsured all year	People under age 65 with health insurance
		People with a usual primary care provider	People with a specific source of ongoing care
		People unable to get or delayed in getting needed medical care, dental care, or prescription medicines

• For 19 of the 38 core report measures of quality, Blacks had significantly poorer quality of care than Whites (Figure 4.1). For 4 of the core report measures, Blacks had better quality of care. For example, Black nursing home residents were less likely to be physically restrained, and Blacks were more likely to receive recommended care for heart failure than Whites.
• For 3 of the 6 core report measures of access, Blacks had significantly worse access to care than Whites. For example, Blacks were more likely than Whites to delay or not get medical care. For one measure (people without a usual source of care due to financial or insurance reasons), Blacks had better access to care than Whites.

Figure 4.2. Change in Black-White disparities over time

Improving > 5% = Black-White difference becoming smaller at an average annual rate greater than 5%.
Improving 1-5% = Black-White difference becoming smaller at an average annual rate between 1% and 5%.
Same = Black-White difference not changing.
Worsening 1-5% = Black-White difference becoming larger at an average annual ate between 1% and 5% per year.
Worsening > 5% = Black-White difference becoming larger at an average annual rate greater than 5%.
CRM = core report measures (Table 1.2)
Note: The time period for this figure is the most recent and oldest years of data used in the NHDR. Only 38 core report measures could be tracked over time for Blacks.

Table 4.4. Change in Black-White disparities over time: Specific measures

Topic	Improving	Worsening	Same
Cancer		Colorectal cancer diagnosed at advanced stage
		Adults age 50 and over who report they ever received a colonoscopy, sigmoidoscopy, proctoscopy, or fecal occult blood test
		Colorectal cancer deaths per 100,000 population per year
Diabetes		Adults age 40 and over with diagnosed diabetes who received all three recommended services
		Hospital admissions for lower extremity amputations per 1,000 population age 18 and over with diabetes
End stage renal disease			Adult hemodialysis patients with adequate dialysis (urea renal reduction ratio 65% or greater)
			Dialysis patients who were registered on a waiting list for transplantation
Heart disease		Deaths per 1,000 adult hospital admissions with acute myocardial infarction (AMI)	Adults with obesity who ever received advice to exercise more
			Adult current smokers who received advice to quit smoking
HIV and AIDS	New AIDS cases per 100,000 population age 13 and over
Maternal and child health	Pregnant women who first received prenatal care in the first trimester	Children ages 2-17 for whom a health provider ever gave advice about physical activity	Children ages 19-35 months who received all recommended vaccines
	Children ages 3-6 who ever had their vision checked
Mental health and substance abuse	People age 12 and over treated for substance abuse who completed treatment	Adults age 18 and over with a major depressive episode who received treatment for depression	People age 12 and over who needed treatment for illicit drug use and who received such treatment at a specialty facility in the last 12 months
			Suicide deaths per 100,000 population
Respiratory diseases		Adults age 65 and over who ever received pneumococcal vaccination.
		Patients with tuberculosis who completed a curative course treatment within 12 months of initiation of treatment.
Nursing home, home health, and hospice care	Short-stay nursing home residents with pressure sores		Long-stay nursing home residents with physical restraints
			High-risk, long-stay nursing home residents with pressure sores
			Adult home health care patients who were admitted to the hospital
			Adult home health care patients whose ability to walk or move around improved
Patient safety	Failure to rescue	Adults age 65 and over who received potentially inappropriate prescription medicines	Adult surgery patients who received appropriate timing of antibiotics
	Central venous catheter-associated adverse events
Timeliness	Emergency department visits in which patients left without being seen	Adults who can sometimes or never get care for illness or injury as soon as wanted
Patient centeredness		Adults with poor provider-patient communication	Children with poor provider-patient communication
Access	People under age 65 with health insurance	People with a usual primary care provider	People with a specific source of ongoing care
	People under age 65 who were uninsured all year

• Of core report measures of quality that could be tracked over time for Blacks and Whites, Black-White differences became smaller for 8 measures and larger for 13 measures (Figure 4.2). For example, Black-White differences in central venous catheter-associated adverse events and new AIDS cases have decreased, but the difference in lower extremity amputations for patients with diabetes has increased. For 13 measures, Black-White differences did not change over time.
• Of core report measures of access that could be tracked over time for Blacks and Whites, Black-White differences became smaller for 2 measures and larger for 1 measure. For 1 measure, Black-White differences did not change over time.

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