End Stage Renal Disease (ESRD)

Importance

Mortality
Total end stage renal disease (ESRD) deaths (2006)	87,65410
Prevalence
Total cases (2006).	506,25610
Incidence
Number of new cases (2006)	110,85410
Cost
Total ESRD Medicare program expenditures (2006 est.)	$20.0 billion11

Measures

The NHQR includes six measures of ESRD management to assess the quality of care provided to renal dialysis patients. The two core report measures highlighted here are:

• Adequacy of hemodialysis.
• Registration for transplantation.

Findings

Outcome: Adequate Hemodialysis

Dialysis removes harmful waste and excess fluid buildup in the blood that occurs when kidneys fail to function. Hemodialysis is the most common method used to treat advanced and permanent kidney failure. The adequacy of dialysis is measured by the percentage of hemodialysis patients with a urea reduction ratio equal to or greater than 65%; this measure indicates how well urea, a waste product, is eliminated by the dialysis machine.

Figure 2.10. Adult hemodialysis patients with adequate dialysis (urea reduction ratio 65% or greater), by age, 2002-2007

Source: Centers for Medicare & Medicaid Services, ESRD Clinical Performance Measures Project, 2002-2007.

Denominator: ESRD hemodialysis patients age 18 and over.

• From 2002 to 2007, the percentage of adult hemodialysis patients receiving adequate dialysis improved from 86.4% to 89.2% (Figure 2.10). Improvements were observed among all age groups.
• In all years, adults ages 18-44 and 45-64 were less likely than adults age 65 and over to receive adequate dialysis.

Management: Registration for Transplantation

Kidney transplantation is a procedure that replaces a failing kidney with a healthy kidney. If a patient is deemed a good candidate for transplant, he or she is placed on the transplant program's waiting list. Dialysis patients wait for transplant centers to match them with the most suitable donor. Registration for transplantation is an initial step toward patients receiving the option of kidney transplantation. Patients who receive transplants from living donors, about 36% of kidney transplants, do not need to register on a waiting list.

Early transplantation that decreases or eliminates the need for dialysis can also lessen the occurrence of acute rejection and patient mortality. In 2006, 70,778 patients were on the Organ Procurement and Transplantation Network's deceased donor kidney transplant waiting list in the United States. Only 10,212 deceased donor kidney transplants were performed.¹²

Figure 2.11. Dialysis patients who were registered on a waiting list for transplantation, by age, 2000-2005

Source: National Institute of Diabetes and Digestive and Kidney Diseases, U.S. Renal Data System, 2000-2005.

Denominator: ESRD hemodialysis patients and peritoneal dialysis patients under age 70.

• From 2000 to 2005, the percentage of dialysis patients who were registered on a waiting list for transplantation improved from 14.5% to 16.0% (Figure 2.11). Improvements were observed among all age groups except patients ages 20-39.
• In all years, patients ages 20-69 were less likely to be registered on a waiting list compared with patients ages 0-19.
• Registration rates among patients ages 0-39 exceeded the Healthy People 2010 target of 25.0%, while rates among other age groups were not on track to meet this target.

Figure 2.12. State variation: Dialysis patients who were registered on a waiting list for transplantation, 2005

Key: Best quartile indicates States with highest rates of registration on a waiting list; worst quartile indicates States with lowest rates.

Source: National Institute of Diabetes and Digestive and Kidney Diseases, U.S. Renal Data System, 2005.

• The 13 States^xi in the best quartile (highest rates of registration on a waiting list) in 2005 (Figure 2.12) had rates of registration that ranged from 19.9% to 28.7%. These States are primarily located in the Northeast and Midwest.
• Eleven States,^xii the District of Columbia, and Puerto Rico were in the worst quartile (lowest rates) in 2005 and had rates of registration that ranged from 5.9% to 11.1%. These States are primarily located in the South.

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Heart Disease

Importance

Mortality
Number of deaths (2006)	631,6322
Cause of death rank (2006)	1st2
Prevalence
Number of cases of coronary heart disease (2006)	16.8 million13
Number of cases of heart failure (2006)	5.7 million13
Number of cases of high blood pressure (2006)	73.6 million13
Number of heart attacks (2006)	7.9 million13
Incidence
Number of new cases of heart failure (2004)	550,00014
Cost
Total cost of cardiovascular disease (2009 est.)	$474.8 billion4
Total cost of heart failure (2009 est.)	$37.2 billion13
Direct costs of cardiovascular disease (2009 est.)	$313.3 billion4
Cost effectiveness of hypertension screening	$14,000-$35,000/QALY5

Measures

The NHQR tracks several quality measures for preventing and treating heart disease, including the following three core report measures:

• Receipt of angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) for heart attack.
• Inpatient deaths following heart attack.
• Receipt of recommended care for 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 4, Timeliness, and receipt of complete written discharge instructions by patients with heart failure is tracked in Chapter 5, Patient Centeredness.

Findings

Treatment: Receipt of Angiotensin-Converting Enzyme Inhibitor or Angiotensin Receptor Blocker for 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 a number of measures of quality of care for heart attack have occurred in recent years. Four measures that have been tracked in past NHQRs (administration of aspirin within 24 hours and at discharge, administration of beta blocker at discharge, and counseling to quit smoking) have attained overall performance levels exceeding 95%. These measures were included in the composite measure of care for heart attack in past NHQRs. However, the success of these measures creates a ceiling effect that limits the report's ability to track improvement over time. In addition, administration of beta blocker within 24 hours has been discontinued. Hence, this NHQR focuses on one measure of heart attack care, ACE inhibitor or ARB treatment among patients with left ventricular systolic dysfunction.

Figure 2.13. Hospital patients with heart attack and left ventricular systolic dysfunction who received ACE inhibitor or ARB, by age, 2005-2007

Key: ACE = angiotensin-converting enzyme; ARB = angiotensin receptor blocker.

Source: Centers for Medicare & Medicaid Services, Medicare Quality Improvement Organization Program, 2005-2007.

Denominator: Patients hospitalized with a principal diagnosis of acute myocardial infarction and left ventricular systolic dysfunction.

• From 2005 to 2007, the percentage of heart attack patients with left ventricular systolic dysfunction who received an ACE inhibitor or ARB improved from 83.4% to 91.3% (Figure 2.13). Improvements over time were observed among all age groups.
• In all years, patients ages 65-74, 75-84, and 85 and over were less likely than patients under age 65 to receive ACE inhibitor or ARB treatment.

Outcome: Inpatient Deaths Following Heart Attack

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 in order to receive services. It also may partly reflect receipt of appropriate health services.

Figure 2.14. Deaths per 1,000 adult hospital admissions with heart attack, by insurance status, 2004-2006

Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 2004-2006.

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: Rates are adjusted by age, gender, age-gender interactions, and all payer refined-diagnosis related group scoring of risk of mortality.

• Between 2004 and 2006, the overall inpatient mortality rate decreased significantly for those with private insurance, Medicare, Medicaid, and no insurance (Figure 2.14).
• In all 3 years, death rates among uninsured/self-pay/no charge patients were higher than among patients with private insurance.

Treatment and Outcome: Receipt of Angiotensin-Converting Enzyme Inhibitor or Angiotensin Receptor Blocker and Deaths per 1,000 Admissions With Heart Attack

Figure 2.15 shows States that perform poorly on both a process measure and an outcome measure related to heart attack. As noted earlier, these maps are intended to help identify those States that may have the greatest opportunity to improve performance in this area. For heart attacks, receipt of ACE inhibitor or ARB when indicated may be a marker of better cardiac care overall. Greater compliance with recommended care for heart attack may be associated with better outcomes.

Figure 2.15. State variation: Heart attack patients with left ventricular systolic dysfunction who received ACE inhibitor or ARB (2007) and deaths per 1,000 admissions with heart attack (2006)

Key: ACE = angiotensin-converting enzyme; ARB = angiotensin receptor blocker. Process measure in worst quartile indicates States with the lowest rates of ACE inhibitor or ARB treatment; outcome measure in worst quartile indicates States with the highest inpatient death rates for acute myocardial infarction.

Source: Centers for Medicare & Medicaid Services, Medicare Quality Improvement Organization Program, 2007 (ACE inhibitor or ARB); Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, 2006 (heart attack deaths).

• Twelve States^xiii and Puerto Rico were in the worst quartile (lowest rates) for heart attack patients with left ventricular systolic dysfunction who received ACE inhibitor or ARB in 2007 (Figure 2.15). Among these areas, receipt of an ACE inhibitor or ARB ranged from 80.1% to 90.2%.
• Nine States^xiv were in the worst quartile (highest rates) for deaths per 1,000 admissions with heart attack in 2006. Among these States, inpatient mortality ranged from 82.9 to 96.2 deaths per 1,000 admissions.
• Two States^xv were in the worst quartile for both measures with both low rates of receipt of ACE inhibitor or ARB and high rates of deaths per 1,000 admissions for heart attack.

Treatment: Receipt of Recommended Care for Heart Failure

The NHQR tracks the national rates of receipt of the following services:

• Recommended test for heart functioning (heart failure patients having evaluation of left ventricular ejection fraction).
• Recommended medication treatment (patients with left ventricular systolic dysfunction prescribed ACE inhibitor or ARB at discharge).

In addition, an overall composite measure describes the percentage of all episodes in which heart failure patients receive recommended care.

Figure 2.16. Hospital patients with heart failure who received recommended hospital care: Overall composite, by age, 2005-2007

Source: Centers for Medicare & Medicaid Services, Medicare Quality Improvement Organization Program, 2005-2007.

Denominator: Patients hospitalized with a principal diagnosis of acute heart failure.

• In 2007, 93.1% of recommended hospital care was received by patients hospitalized for heart failure (Figure 2.16).
• From 2005 to 2007, the percentage of recommended hospital care received improved overall and for all age groups.

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HIV and AIDS

Importance

Mortality
Number of deaths of people with AIDS (2007)	14,56115
Prevalence
Number of people living with HIV infection (not including those with AIDS) (2007)	263,93615
Number of people living with AIDS (2007)	468,57815
Incidence
Number of new HIV infections (2007)	56,30015
Number of new AIDS cases (2007)	37,04115
Cost
Federal spending on HIV/AIDSxvi (fiscal year 2009 est.)	$19.4 billion16

Measures

This section highlights one core report measure focusing on quality of preventive care for HIV-infected individuals:

• New AIDS cases.

In addition, three noncore measures are presented on the prevention of opportunistic infections in AIDS patients and on HIV infection deaths:

• Eligible AIDS patients receiving prophylaxis for Pneumocystis pneumonia (PCP).
• Eligible AIDS patients receiving prophylaxis for Mycobacterium avium complex (MAC).
• HIV infection deaths.

Findings

Outcome: New AIDS Cases

Changes in HIV infection rates reflect changes in behavior by at-risk individuals that may only partly be influenced by the health care system. However, individual and community programs have shown progress in influencing behavior change. Changes in the incidence of new AIDS cases are affected by changes in HIV infection rates, screening and early detection of HIV disease, and availability of appropriate treatments for HIV-infected individuals. Improved treatments that extend life for those with the disease are reflected in the decrease in deaths due to AIDS from about 18,000 to 14,600 between 2003 and 2007, after showing no change for the previous 3 years.¹⁷

Figure 2.17. New AIDS cases per 100,000 population age 13 and over, by age, 2000-2007

Source: Centers for Disease Control and Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, HIV/AIDS Reporting System, 2000-2007.

Denominator: U.S. population age 13 and over.

Note: Rates are age adjusted to the 2000 U.S. standard population.

• The overall rate of new AIDS cases per 100,000 population decreased between 2000 and 2007 (16.8 to 14.4) (Figure 2.17).
• From 2000 to 2007, the rate of new AIDS cases also decreased for people ages 18-44 (24.5 to 19.9).
• The 2007 national rate of 14.4 new AIDS cases per 100,000 population is well above the Healthy People 2010 target of 1.0 new case per 100,000 population. If current trends continue, this target will not be met.

Management: PCP and MAC Prophylaxis

Management of chronic HIV disease includes outpatient and inpatient services. Without adequate treatment, as HIV disease progresses, CD4 cell counts fall and patients become increasingly susceptible to opportunistic infections. When CD4 cell counts fall below 200, medicine to prevent development of PCP is routinely recommended. When CD4 cell counts fall below 50, medicine to prevent development of disseminated MAC infection is routinely recommended.¹⁸

Because national data on HIV care are not routinely collected, HIV measures tracked in the NHQR come from the HIV Research Network, which consists of 18 medical practices across the United States that treat large numbers of patients living with HIV. Data from the voluntary HIV Research Network are not nationally representative of the level of care received by all Americans living with HIV. Network data represent only patients who are actually receiving care (about 14,000 HIV patients per year) and do not represent patients who do not receive care. Furthermore, data shown below are not representative of the HIV Research Network as a whole because they represent only a subset of network sites that have the best data.

The Ryan White HIV/AIDS Program is the largest Federal program dedicated to providing HIV-related services to individuals who otherwise could not afford these services. These include individuals who are uninsured or have inadequate insurance and cannot cover the costs of care on their own. This safety net program may help mitigate the effects of uninsurance on receipt of HIV care.

Figure 2.18. Eligible adult AIDS patients receiving PCP and MAC prophylaxis in the calendar year, by insurance, 2004-2006

     

Key: PCP = Pneumocystis pneumonia; MAC = Mycobacterium avium complex.

Source: Agency for Healthcare Research and Quality, HIV Research Network, 2004-2006.

Denominator: Adult patients with HIV receiving care from an HIV Research Network medical practice who have CD4 cell counts below 200 (PCP) or below 50 (MAC).

• Of eligible patients (2,052 AIDS patients with at least two CD4 cell counts below 200), 93.2% received PCP prophylaxis in 2006 (Figure 2.18). From 2004 to 2006, receipt of PCP prophylaxis improved overall and for all insurance groups.
• In 2004, eligible patients with private insurance, Medicare, or Medicaid were less likely to receive PCP prophylaxis than those who were uninsured or receiving services funded by the Ryan White Program. In 2006, only patients with Medicare were significantly less likely to receive PCP prophylaxis than patients who were uninsured or received assistance through the Ryan White HIV/AIDS Program.
• Of eligible patients (594 AIDS patients with at least two CD4 cell counts below 50), 88.2% received MAC prophylaxis in 2006. From 2004 to 2006, receipt of MAC prophylaxis improved among patients with Medicaid.
• For all years, there were no statistically significant differences between insurance groups in receipt of MAC prophylaxis.

Outcome: HIV Infection Deaths

HIV infection deaths reflect a number of factors, including underlying rates of HIV risk behaviors, prevention of HIV transmission, early detection and treatment of HIV disease, and management of AIDS and its complications.

Figure 2.19. State variation: HIV infection deaths per 100,000 population, 2006

Key: Best quartile indicates States with lowest rates of HIV deaths; worst quartile indicates States with highest rates.

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System—Mortality, 2006.

Denominator: U.S. population.

Note: Rates are age adjusted to the 2000 U.S. standard population.

• The 10 States^xvii in the best quartile (lowest rates of HIV deaths) in 2006 had a combined average rate of 1.3 deaths per 100,00 population (Figure 2.19).
• Nine States^xviii and the District of Columbia were in the worst quartile (highest rates) in 2006 and had a combined average rate of 10.2 deaths per 100,00 population. These States are primarily located in the mid-Atlantic and the South.

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Maternal and Child Health

Importance

Mortality
Number of maternal deaths (2006)	5692
Number of infant deaths (2006)	28,5272
Demographics
Number of childrenxix (2007)	73,590,24319
Number of babies born in United States (2006)	4,265,55520
Cost
Total cost of health care for children (2002 est.)	$79 billion21
Cost-effectiveness of vision screening for children	$0-$14,000/QALY5
Cost-effectiveness of childhood immunization seriesxx	Cost saving5

Measures

Throughout the report, the NHQR tracks several prevention and treatment measures related to maternal and child health care. The core report measures highlighted in this section are:

• Receipt of all recommended immunizations by young children.
• Dental visits for children.
• Counseling children or parents about physical activity.
• Counseling children or parents about healthy eating.

In addition, two noncore measures are presented:

• Obstetric trauma.
• Weight monitoring of overweight children.

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Findings

Outcome: Obstetric Trauma

Childbirth and reproductive care are the most common reasons for women of childbearing age to use health care services. With more than 11,000 births each day in the United States,²⁰ childbirth is the most common reason for hospital admission. Obstetric trauma involving a severe tear to the vagina or surrounding tissues during delivery is a common complication of childbirth.

Figure 2.20. Obstetric trauma with 3^rd or 4^th degree laceration per 1,000 vaginal deliveries without instrument assistance, by age, 2004-2006

Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 2004-2006.

Denominator: All patients hospitalized for vaginal delivery without indication of instrument assistance.

Note: Rates are not adjusted.

• From 2004 to 2006, rates of obstetric trauma with 3^rd or 4^th degree laceration decreased among all age groups (Figure 2.20).
• In all years, females younger than age 35 had higher rates of obstetric trauma compared with women ages 35-54. This may in part reflect lower rates of vaginal delivery and higher rates of cesarean delivery among women ages 35-54.

Prevention: Receipt of All Recommended Immunizations by Young Children

Immunizations are important for reducing mortality and morbidity. They protect recipients from illness and disability and protect others in the community who cannot be vaccinated. In 2006, recommended vaccines for children that should have been completed by ages 19-35 months included four doses of diphtheria-tetanus-pertussis vaccine, three doses of polio vaccine, one dose of measles-mumps-rubella vaccine, three doses of Haemophilus influenzae type B vaccine, and three doses of hepatitis B vaccine.

Figure 2.21. Composite measure: Children ages 19-35 months who received all recommended vaccines, 2000-2007

Source: Centers for Disease Control and Prevention, National Center for Health Statistics and National Center for Immunization and Respiratory Diseases, National Immunization Survey, 2000-2007.

Denominator: U.S. civilian noninstitutionalized population ages 19-35 months.

Note: The vaccines included in this measure are based on the corresponding Healthy People 2010 objective, which does not include varicella vaccine or vaccines added to the recommended schedule after 1998 for children up to 35 months of age. More information can be found in the Measure Specifications appendix.

• From 2000 to 2007, the percentage of children ages 19-35 months who received all recommended vaccines increased from 72.8% to 80.1% (Figure 2.21).
• Since 2004, the rate has exceeded the Healthy People 2010 target of 80.0%.

Prevention: Children's Dental Care

According to the National Institute of Dental and Craniofacial Research, presence of dental caries is the single most common chronic disease of childhood, occurring five to eight times as frequently as asthma,²² the second most common chronic disease in children. Regular dental visits help to improve overall oral health and prevent dental caries.

Figure 2.22. Children ages 2-17 with a dental visit in the calendar year, by insurance status, 2002-2006

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2006.

Denominator: U.S. civilian noninstitutionalized population ages 2-17.

• The percentage of children ages 2-17 with public insurance only who visited a dentist in the calendar year improved from 35.8% in 2002 to 41.4% in 2006 (Figure 2.22). This may, in part, reflect dental services covered by the Children's Health Insurance Program. Rates did not improve significantly overall or for other insurance groups.
• In all data years, uninsured children and children with public insurance only were less likely to visit a dentist in the calendar year than those with any private insurance.

Prevention: Weight Monitoring of Overweight Children

American children are getting heavier. Overweight children are identified using body mass index (BMI) for age growth charts. These growth charts are based on national data collected between 1963 and 1994, and children with BMI values at or above the 95th percentile are considered overweight. From 1976-1980 to 2003-2006, the proportion of children classified as overweight increased from 6.5% to 17% among children ages 6 to 11 and from 5% to 17.6% among adolescents ages 12 to 19.²³ Pediatricians are advised to monitor BMI and excessive weight gain in children in order to recognize and address cases of overweight and obesity.²⁴ When health care providers alert young patients and their parents about their overweight status, a new opportunity is created to encourage the development of healthy diet and exercise habits that may be carried into adulthood.²⁴

Figure 2.23. People ages 2-19 who were overweight and who were told by a health provider they were overweight, by age, 1999-2002 and 2003-2006

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health and Nutrition Examination Survey, 1999-2002 and 2003-2006.

Denominator: U.S. civilian noninstitutionalized population ages 2-19 who were overweight.

Note: Overweight children are identified using age- and sex-specific reference data from the 2000 Centers for Disease Control and Prevention body mass index (BMI) for age growth charts. Children and youth can be categorized as acceptable, underweight, at risk of overweight, or overweight. Children with BMI values at or above the 95th percentile of the sex-specific BMI growth charts are categorized as overweight. Data for ages 2-5 in 1999-2002 did not meet criteria for statistical reliability.

• The percentage of people ages 2-19 who were overweight based on height and weight measurement and who were told by a health provider they were overweight did not change significantly between 1999-2002 and 2003-2006 overall or for any age group (Figure 2.23).
• In 2003-2006, overweight children ages 2-5 (22.3%) and 6-11 (35.7%) were less likely than overweight children and teens ages 12-19 (47.5%) to be told by a health provider that they were overweight.

Prevention: Counseling for Children About Physical Activity

Childhood represents a period when healthy, lifelong habits are often formed. Physicians can play an important role in encouraging healthy behaviors, such as regular exercise, in children.

Figure 2.24. Children ages 2-17 for whom a health provider ever gave advice about the amount and kind of exercise, sports, or physically active hobbies they should have, by insurance status, 2002-2006

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2006.

Denominator: U.S. civilian noninstitutionalized population ages 2-17.

• From 2002 to 2006, the percentage of children for whom a health provider ever gave advice about the amount and kind of exercise, sports, or physically active hobbies they should have improved from 31.9% to 36.9% (Figure 2.24).
• Between 2002 and 2006, the percentage of children for whom a health provider ever gave advice about physical activity improved for both those with any private insurance and those with only public insurance.
• In all years, uninsured children were less likely than those with any private insurance to have received advice about the amount and kind of exercise, sports, or physically active hobbies they should have.

Prevention: Counseling for Children About Healthy Eating

Physicians play an important role in encouraging children's healthy eating. Overweight and obesity during childhood often persist into adulthood, with consequences that are numerous and costly. Unfortunately, overweight and obesity among children under age 18 have risen dramatically in the past two decades.²⁴ The American Academy of Pediatrics recommends that pediatricians discuss and promote healthy diets with all children, both those who are overweight and those who are not.²⁴

Figure 2.25. Children ages 2-17 for whom a health provider ever gave advice about healthy eating, by insurance status, 2002-2006

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2006.

Denominator: U.S. civilian noninstitutionalized population ages 2-17.

• From 2002 to 2006, the percentage of children for whom a health provider ever gave advice about healthy eating improved from 51.0% to 56.4% (Figure 2.25).
• From 2002 to 2006, the percentage of children for whom a health provider ever gave advice about healthy eating improved for both those with any private insurance and those with only public insurance.
• In all years, uninsured children were less likely to receive advice about healthy eating than those with any private insurance.

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^xi The States are California, Colorado, Massachusetts, Michigan, Minnesota, New Hampshire, New Jersey, North Dakota, Pennsylvania, South Dakota, Vermont, Wisconsin, and Wyoming.
^xii The States are Connecticut, Florida, Georgia, Kentucky, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Oregon, and South Carolina.
^xiii The States are Florida, Georgia, Kansas, Kentucky, Louisiana, Maine, Massachusetts, Mississippi, New Mexico, Pennsylvania, Tennessee, and Utah.
^xiv The States are Arkansas, Hawaii, Iowa, Kansas, Nebraska, Nevada, Oklahoma, Utah, and Vermont. Data on this measure were not available for Alabama, Alaska, Delaware, District of Columbia, Idaho, Indiana, Louisiana, Mississippi, Montana, New Mexico, North Dakota, Ohio, Pennsylvania, South Dakota, and Wyoming.
^xv The States are Kansas and Utah.
^xvi Includes costs of domestic care, housing and other financial assistance, prevention, and research.
^xvii The States are Colorado, Kansas, Michigan, Minnesota, Nebraska, Oregon, Utah, Washington, West Virginia, and Wisconsin.
^xviii The States are Delaware, Florida, Georgia, Louisiana, Maryland, Mississippi, New Jersey, New York, and South Carolina.
^xix In this report, children are defined as individuals under age 18.
^xx The childhood immunization series includes vaccinations for diphtheria-tetanus-pertussis, measles-mumps-rubella, inactivated polio virus, Haemophilus influenzae type B, hepatitis B, and varicella. "Cost saving" indicates that childhood immunizations are one of very few services that save more money than they cost.

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