Chapter 2. Quality of Health Care

National Healthcare Disparities Report, 2008

Contents

Components of Health Care Quality
How This Chapter Is Organized
Categorization of Effectiveness Measures by Health Care Need
Effectiveness
   Cancer
   Diabetes
   End Stage Renal Disease (ESRD)
   Heart Disease
   HIV and AIDS
   Mental Health and Substance Abuse
   Respiratory Diseases
   Nursing Home, Home Health, and Hospice Care
Patient Safety
Timeliness
Patient Centeredness
Summary Tables
References

As better understanding of health and sickness has led to superior ways of preventing, diagnosing, and treating diseases, the health of most Americans has improved dramatically. However, ample evidence indicates that some Americans do not receive the full benefits of high-quality care. Specifically, a substantial body of public health, social science, and health services research has shown extensive disparities in health care related to race, ethnicity, and socioeconomic status (SES). These disparities have been confirmed in previous releases of the National Healthcare Disparities Report. 

Components of Health Care Quality

Quality health care means doing the right thing, at the right time, in the right way, for the right people—and having the best possible results.1 Quality health care is care that is:2

  • Effective—Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit.
  • Safe—Avoiding injuries to patients from the care that is intended to help them.
  • Timely—Reducing waits and sometimes harmful delays for both those who receive and those who give care.
  • Patient centered—Providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.
  • Equitable—Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and SES.
  • Efficient—Avoiding waste, including waste of equipment, supplies, ideas, and energy.

Health care quality is measured in several ways, including:

  • Clinical performance measures of how well providers deliver specific services needed by specific patients, such as whether children get the immunizations that they need.
  • Assessments by patients of how well providers meet health care needs from the patient's perspective, such as whether providers communicate clearly.
  • Outcome measures, such as death rates from cancers preventable by screening, that may be affected by the quality of health care received.

How This Chapter Is Organized

This chapter presents information about disparities in the quality of health care in America, with a presentation of a subset of core measures. The measures used here are the same as those used in the National Healthcare Quality Report (NHQR). This chapter is constructed to mirror sections in the NHQR—effectiveness, patient safety, timeliness, and patient centeredness. Due to constraints on the length of this report, only a subset of the core measures is presented.

Effectiveness of care is presented in Chapter 2 in eight clinical condition or care setting areas: cancer; diabetes; end stage renal disease (ESRD); heart disease; HIV and AIDS; mental health and substance abuse; respiratory diseases; and nursing home, home health, and hospice care. Maternal and child health is discussed in Chapter 4, Priority Populations.

As in previous NHDRs, this chapter's discussion of quality of care focuses on disparities in quality related to race, ethnicity, and SES in the general U.S. population. Disparities in quality of care within specific priority populations are presented in Chapter 4. This chapter also presents analyses of changes over time by race, ethnicity, and SES, as well as some stratified analyses. 

Categorization of Effectiveness Measures by Health Care Need

In the effectiveness section of this chapter, measures are organized into categories related to the patient's need for preventive care, treatment of acute illness, and chronic disease management. There is sizable overlap among these categories, and some measures may be considered to belong in more than one category. Outcome measures are particularly difficult to categorize when prevention, treatment, and management all play important roles. For the purposes of this report, however, measures are placed into categories that best fit the general descriptions below:

  • Prevention—Caring for healthy people is an important component of health care. Educating people about healthy behaviors can help to postpone and avoid illness and disease. Additionally, detecting health problems at an early stage increases the chances of effectively treating them, often reducing suffering and expenditures.
  • Treatment—Even when preventive care is ideally implemented, it cannot entirely avert the need for acute care. Delivering optimal treatments for acute illness can help reduce the consequences of illness and promote the best recovery possible.
  • Management—Some diseases, such as diabetes and end stage renal disease, are chronic, which means they cannot simply be treated once; they must be managed across a lifetime. Management of chronic disease often involves lifestyle changes and regular contact with a provider to monitor the status of the disease. For patients, effective management of chronic disease can mean the difference between normal, healthy living and frequent medical problems.

Note that findings for women and children, which parallel those presented in the NHQR for maternal and child health, are presented in the sections on women and children in Chapter 4. Effectiveness measures presented in this section are organized within the categories of prevention, treatment, and management. For findings related to all core measures of effectiveness, go to Tables 2.1a and 2.1b.

SectionMeasure
Prevention:
CancerColorectal cancer screening
CancerAdvanced stage colorectal cancer patients*
Heart diseaseCounseling obese adults about overweight*
Heart diseaseCounseling obese adults about exercise
Respiratory diseasesPneumococcal vaccination
Maternal and child health (women)Prenatal care/maternal care
Maternal and child health (women)Obese adults advised about exercise
Maternal and child health (children)Early childhood vaccinations
Maternal and child health (children)Counseling about physical activity*
Maternal and child health (children)Vision screening
Treatment:
CancerRecommended care for breast and colorectal cancer*
Heart diseaseReceipt of recommended hospital care for heart failure
Mental health and substance abuseReceipt of needed treatment for illicit drug use
Mental health and substance abuseReceipt of treatment for depression
Mental health and substance abuseReceipt of minimally adequate treatment for mental disorders
Respiratory diseasesReceipt of recommended care for pneumonia
Maternal and child health (women)Mortality rate for acute myocardial infarction
Maternal and child health (women)Recommended hospital care for heart attack
Management:
DiabetesReceipt of three recommended diabetes services
DiabetesLower extremity amputations
DiabetesControlled hemoglobin, cholesterol, and blood pressure
End stage renal diseasePatients with adequate hemodialysis
End stage renal diseaseRegistration for transplantation
HIV and AIDSNew AIDS cases
HIV and AIDSPCP and MAC prophylaxis*
Respiratory diseasesDaily asthma medication
Nursing home, home health, and hospice careUse of physical restraints on nursing home residents
Nursing home, home health, and hospice carePresence of pressure sores in nursing home residents
Nursing home, home health, and hospice careImprovement by home health care patients in walking
or moving around
Nursing home, home health, and hospice careAcute care hospitalization of home health care patients
Nursing home, home health, and hospice careHospice care*,i
Maternal and child health (women)New AIDS cases

* Noncore measure


i Two noncore measures of hospice care are from the National Hospice and Palliative Care Organization Family Evaluation of Hospice Care: hospice patients who did not receive the right amount of medicine for pain and hospice patients who did not receive end-of-life care consistent with their stated wishes.


 

Effectiveness

Cancer

Type of statisticNumber
Number of deaths (2008 est.)565,6503
Cause of death rank (2005)2nd4
Number of living Americans who have been diagnosed with cancer (2005 est.)11,098,4505
New cases of cancer (2008 est.)1,437,1803
New cases of colorectal cancer (2008 est.)148,8103
Total costii (2007)$219.2 billion6
Direct costsiii (2007)$89.0 billion6
Cost effectivenessiv of colorectal cancer screening$0-$14,000QALY7
Cost effectiveness of breast cancer screening$35,000-$165,000QALY7
Cost effectiveness of cervical cancer screening$14,000-$35,000/QALY7

Note: Statistics may vary from previous years due to revised and updated source statistics or addition of new data sources.

Prevention: Colorectal Cancer Screening

Ensuring that all populations have access to appropriate cancer screening services is a core element of reducing cancer health disparities.8 This year the NHDR focuses on colorectal cancer; findings for breast cancer are found in the 2007 NHDR. Screening for colorectal cancer—including fecal occult blood test (FOBT), sigmoidoscopy, colonoscopy, and proctoscopy—is an effective way of reducing new cases of late-stage disease and mortality caused by this cancer.


ii Total cost is composed of the cost of medical care itself (direct cost) and the economic costs of morbidity and mortality (indirect cost).
iii Direct costs are defined as "personal health care expenditures for hospital and nursing home care, drugs, home care, and physician and other professional services."6
iv Cost effectiveness is measured here by the average net cost of each quality-adjusted life year (QALY) that is saved by the provision of a particular health intervention. QALYs are a measure of survival adjusted for its value: 1 year in perfect health is equal to 1.0 QALY, while a year in poor health would be something less than 1.0. A lower cost per QALY saved indicates a greater degree of cost effectiveness. For example, the net cost for colorectal cancer screening ranges from $0 to $14,000 for each QALY saved.


Figure 2.1. Composite measure: Adults age 50 and over who received colorectal cancer screening (colonoscopy, sigmoidoscopy, proctoscopy, or fecal occult blood test [FOBT]), by race (left), ethnicity (top right), and income (bottom left), 2000-2005.

trend line charts, percent, race, Total, 2000, 49.8%, 2003, 51.7%, 2005, 55.5%, White, 2000, 50.8%, 2003, 52.6%, 2005, 56.8%, Black, 2000, 43.8%, 2003, 47.3%, 2005, 48.6%, Asian, 2000, 42.1%, 2003, 37.6%, 2005, 42.4%, AI/AN, 2000, 48.7%, 2003, 41.6%, 2005, 38.1%, >1 Race, 2000, 53.7%, 2003, 47%, 2005, 55.8%. trend line charts, percent, ethnicity, 2005, Non-Hispanic White, 2000, 51.7%, 2003, 54%, 2005, 58.5%, Hispanic, 2000, 34.8%, 2003, 37.1%, 2005, 37.3%.

trend line charts, percent, income, Poor, 2000, 38.6%, 2003, 39.1%, 2005, 40.5%, Near Poor, 2000, 43.7%, 2003, 42.4%, 2005, 48%, Middle Income, 2000, 48.5%, 2003, 51.6%, 2005, 54.3%, High Income, 2000, 57.1%, 2003, 59.6%, 2005, 63.7%

Key: AI/AN = American Indian/Alaska Native.

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2000, 2003, 2005.

Reference population: Civilian noninstitutionalized population age 50 and over.

Note: Data were insufficient for this analysis for Native Hawaiians and Other Pacific Islanders.

  • Overall, the percentage of adults age 50 and over who received colorectal cancer screening increased from 2000 to 2005 (49.8% to 55.5%; Figure 2.1).
  • From 2000 to 2005, the gap between Blacks and Whites in the percentage of adults age 50 and over who received colorectal cancer screening increased. In 2005, Blacks were less likely than Whites to receive a colonoscopy, sigmoidoscopy, or proctoscopy or an FOBT (48.6% compared with 56.8%).
  • The gap between Asians and Whites increased. In 2005, Asians were less likely than Whites to receive colorectal cancer screening (42.4% compared with 56.8%).
  • The gap between American Indian/Alaska Natives (AI/ANs) and Whites remained the same. In 2005, AI/ANs were less likely than Whites to receive a colorectal cancer screening (38.1% compared with 56.8%).
  • The gap between Hispanics and non-Hispanic Whites increased. In 2005, Hispanics were less likely than non-Hispanic Whites to receive colorectal cancer screening (37.3% compared with 58.5%).

Racial and ethnic minorities are disproportionately of lower SES. To distinguish the effects of race, ethnicity, income, and education on cancer screening, this measure is stratified by income (Figure 2.2) and education level (Figure 2.3).

Figure 2.2. Composite measure: Adults age 50 and over who received colorectal cancer screening (colonoscopy, sigmoidoscopy, proctoscopy, or fecal occult blood test [FOBT]), by race (left) and ethnicity (right), stratified by income, 2005.

bar charts, Percentages; race, Poor, White, 40.6, Black, 39.3, Near Poor, White, 48.7, Black, 45.6, Middle Income, White, 55.6, Black, 49.2, High Income, White, 64, Black, 63.8. bar charts, ethnicity, Poor, Non-Hispanic White, 43.1, Hispanic, 30.7, Near Poor, Non-Hispanic White, 51.4, Hispanic, 34.5, Middle Income, Non-Hispanic White, 57.3, Hispanic, 36.5, High Income, Non-Hispanic White, 64.7, Hispanic, 46.6.

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2005.

Reference population: Civilian noninstitutionalized population age 50 and over.

Note: Data were insufficient for this analysis for Asians, Native Hawaiians and Other Pacific Islanders, and American Indians and Alaska Natives.

Figure 2.3. Adults age 50 and over who received a colonoscopy, sigmoidoscopy, or proctoscopy or a fecal occult blood test (FOBT), by race (left) and ethnicity (right), stratified by education, 2005.

education, 2005, <High School, White, 43.1, Black, 39.9, High School Grad, White, 53.6, Black, 49.1, At Least Some College, White, 63.8, Black, 57.8. ethnicity, <High School, non-Hispanic White, 48.7, Hispanic, 29.6, High School Grad, non-Hispanic White, 54.3, Hispanic, 39.7, At Least Some College, non-Hispanic White, 64.4, Hispanic, 50.6.

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2005.

Reference population: Civilian noninstitutionalized population age 50 and over.

Note: Data were insufficient for this analysis for Asians, Native Hawaiians and Other Pacific Islanders, and American Indians and Alaska Natives.

  • After controlling for income, there were no statistically significant differences between Blacks and Whites in the percentage of adults age 50 and over who received colorectal cancer screening (Figure 2.2).
  • There were no statistically significant differences between Blacks and Whites of the same education level except among college-educated adults. Blacks with at least some college education were less likely than Whites to receive colorectal cancer screening (57.8% compared with 63.8%; Figure 2.3).
  • Both before and after controlling for income and education, Hispanics were less likely than non-Hispanic Whites to receive colorectal cancer screening at all income and education levels.

 

Prevention: Advanced Stage Colorectal Cancer

Cancers can be diagnosed at different stages. The rate of cancers that are diagnosed at advanced stages is a measure of the effectiveness of cancer screening efforts. Differences in rates may vary across racial and ethnic groups due to differences in prevalence.

Figure 2.4. Colorectal cancer diagnosed at advanced stage (tumors diagnosed at regional or distant stage) per 100,000 population age 50 and over, by race (left) and ethnicity (right), 2000-2005.

Colorectal cancer diagnosed at advanced stage (tumors diagnosed at regional or distant stage) per 100,000 population age 50 and over, by race, 2000-2005. Trend line charts. Race: White: 2000, 94.4; 2001, 93.1.; 2002, 90.5; 2003, 87.6; 2004, 83.2; 2005, 80. Black, 2000, 117.7, 2001, 117.8, 2002, 114, 2003, 114.8, 2004, 110, 2005, 103.8; API, 2000, 79.8, 2001, 84, 2002, 79.2, 2003, 70.9, 2004, 68, 2005, 66.7, AI/AN, 2000, 53.5, 2001, 59.5, 2002, 57.2, 2003, 54, 2004, 56.9, 2005, 42.3. Colorectal cancer diagnosed at advanced stage (tumors diagnosed at regional or distant stage) per 100,000 population age 50 and over, by ethnicity, 2000-2005. Trend line charts. Non-Hispanic White, 2000, 96.5, 2001, 94.9, 2002, 92.5, 2003, 89.2, 2004, 84.9, 2005, 81.5, Hispanic, 2000, 73.8, 2001, 73.9, 2002, 70.4, 2003, 71.2, 2004, 67.6, 2005, 65.6.

Key: AI/AN = American Indian or Alaska Native; API=Asian or Pacific Islander.

Source: National Cancer Institute, Surveillance, Epidemiology, and End Results program, 2000-2005.

Reference population: Men and women age 50 and over.

  • From 2000 to 2005, the total rate of diagnosis for advanced stage colorectal cancer decreased (from 95.2 per 100,000 to 80.8 per 100,000; data not shown). The rate decreased for all groups except AI/ANs, for whom the change was not statistically significant.
  • From 2000 to 2005, the gap between Blacks and Whites remained the same. In 2005, Blacks were more likely to be diagnosed at advanced stage with colorectal cancer than Whites (103.8 per 100,000 compared with 80.0 per 100,000).
  • APIs were less likely than Whites to be diagnosed at advanced stage with colorectal cancer (66.7 per 100,000 compared with 80.0 per 100,000).
  • From 2000 to 2005, there was no statistically significant change in the rate for AI/ANs, who were less likely than Whites to be diagnosed at advanced stage with colorectal cancer (42.3 per 100,000 compared with 80.0 per 100,000).
  • Hispanics were less likely than non-Hispanic Whites to be diagnosed at advanced stage with colorectal cancer (65.6 per 100,000 compared with 81.5 per 100,000).

 

Treatment: Recommended Care for Breast and Colorectal Cancer Patients

Different diagnostic and treatment options exist for various types of cancer. Some aspects of cancer care are well established as beneficial and are commonly recommended. The appropriateness of recommended care depends on different factors, such as the stage or the extent of the cancer within the body (especially whether the disease has spread from the original site to other parts of the body). Other types of care are important for accurate diagnosis, such as ensuring the adequate examination of lymph nodes when surgery is performed (e.g., to remove colon cancer).

Among women diagnosed with breast cancer who receive surgical therapy, approximately 63% undergo breast-conserving surgery.9 Randomized controlled trials have shown that women who undergo breast-conserving surgery and postoperative radiation therapy significantly reduce local recurrence rates.10-12

Figure 2.5. Women under age 70 treated for breast cancer* with breast-conserving surgery who received radiation therapy to the breast within 1 year of diagnosis, by race (left) and ethnicity (right), 1999-2005.

trend line charts. Percent, race, Total, 1999, 73.7%, 2000, 73%, 2001, 72.8%, 2002, 71.5%, 2003, 74.6%, 2004, 73.7%, 2005, 74%, White, 1999, 74.6%, 2000, 73.9%, 2001, 73.9%, 2002, 72.7%, 2003, 75.7%, 2004, 75%, 2005, 75.3%, Black, 1999, 68.8%, 2000, 67.2%, 2001, 66.5%, 2002, 64.8%, 2003, 68.9%, 2004, 66.8%, 2005, 68.1%, Asian, 1999, 73.2%, 2000, 75.4%, 2001, 71.4%, 2002, 71.2%, 2003, 73%, 2004, 70.8%, 2005, 71%. ethnicity, Non-Hispanic White, 1999, 75.1%, 2000, 74.1%, 2001, 73.9%, 2002, 72.9%, 2003, 76.2%, 2004, 75.6%, 2005, 76%; Hispanic, 1999, 65.4%, 2000, 64.9%, 2001, 63.2%, 2002, 62.5%, 2003, 62.1%, 2004, 60.4%, 2005, 61.5%.

* American Joint Committee on Cancer Stage I, II, or III, primary invasive epithelial breast cancer.

Source: Commission on Cancer, American College of Surgeons and American Cancer Society, National Cancer Data Base, 1999-2005.

Reference population: U.S. population, women.

  • From 1999 to 2005, the gap between Blacks and Whites remained the same. In 2005, Black patients with breast cancer were less likely than Whites to receive radiation therapy to the breast within 1 year of diagnosis (68.1% compared with 75.3%; Figure 2.5).
  • From 1999 to 2005, the gap between Hispanics and non-Hispanic Whites increased. In 2005, Hispanic patients with breast cancer were less likely than non-Hispanic Whites to receive radiation therapy to the breast within 1 year of diagnosis (61.5% compared with 76.0%).

Figure 2.6. Women with Stage I-IIb breast cancer who received axillary node dissection or sentinel lymph node biopsy (SLNB) at the time of surgery (lumpectomy or mastectomy), by race (left) and ethnicity (right), 1999-2005.

trend line charts, race, ethnicity, Total, 1999, 75.3, 2000, 78.1, 2001, 80.2, 2002, 81.5, 2003, 84.3, 2004, 85.2, 2005, 86.5; White, 1999, 75, 2000, 78, 2001, 80, 2002, 81.4, 2003, 84.3, 2004, 85.2, 2005, 86.3; Black, 1999, 77, 2000, 78.1, 2001, 81, 2002, 80.7, 2003, 83.8, 2004, 84.4, 2005, 87, Asian, 1999, 83.2, 2000, 85.8, 2001, 84.3, 2002, 87.5, 2003, 87.6, 2004, 87.8, 2005, 88.5. Non-Hispanic 1999, 74.7, 2000, 78, 2001, 79.9, 2002, 81.4, 2003, 84.1, 2004, 85.1, 2005, 86.3; Hispanic, 1999, 81.4, 2000, 81.3, 2001, 84.8, 2002, 84.2, 2003, 85.8, 2004, 85.7, 2005, 87.9.

Source: Commission on Cancer, American College of Surgeons and American Cancer Society, National Cancer Data Base, 1999-2005.

Reference population: U.S. population, women.

  • From 1999 to 2005, overall there was improvement in the percentage of women with Stage I-IIb breast cancer who received an axillary node dissection or sentinel lymph node biopsy at the time of surgery (from 75.3% to 86.5%; Figure 2.6).
  • There were no statistically significant differences by race or ethnicity (Figure 2.6) or income (data not shown).

Lymph nodes must be examined to accurately stage colon cancers and guide adjuvant therapy treatment decisions.13-14 The quality measure of the percentage of colon cancer patients who have had at least 12 lymph nodes examined is endorsed by the National Quality Forum and is intended to be a benchmark for hospital quality improvement initiatives.

Figure 2.7. Patients with colon cancer who received surgical resection of colon cancer that included at least 12 lymph nodes pathologically examined, by race (top left), ethnicity (top right), and income (bottom left), 2003-2005.

Trend line charts. Total, 2003, 51.5%, 2004, 54.8%, 2005, 59.9%; White, 2003, 51.2%, 2004, 54.7%, 2005, 59.9%. Black, 2003, 52.1%, 2004, 53.6%, 2005, 58.2%; Asian, 2003, 56.6%, 2004, 59.7%, 2005, 64.9%. Trend line charts. Non-Hispanic White, 2003, 51.1%, 2004, 54.7%, 2005, 60.1%; Hispanic, 2003, 52.4%, 2004, 55.7%, 2005, 60.7%.

Trend line charts. Poor, 2003, 58.5%, 2004, 55.4%, 2005, 57.1%; Low income, 2003, 50.3%, 2004, 53.2%, 2005, 58.4%; Middle Income, 2003, 54.7%, 2004, 59%, 2005, 63.8%; High Income, 2003, 56.2%, 2004, 61.7%, 2005, 66.7%.

Source: Commission on Cancer, American College of Surgeons and American Cancer Society, National Cancer Data Base, 2003-2005.

Reference population: U.S. population.

  • From 2003 to 2005, there was improvement among racial and ethnic groups in the percentage of patients with colon cancer who received recommended care (Figure 2.7).
  • During this period, the gap between Asians and Whites remained the same. In 2005, Asians with colon cancer were more likely than Whites to receive recommended care for colon cancer (64.9% compared with 59.9%).
  • During this period, the gap between poor people and high-income people increased. In 2005, poor people with colon cancer were much less likely than high-income people to receive recommended care for colon cancer (57.1% compared with 66.7%).

 

Diabetes

Type of statisticNumber
Number of deaths (2005)75,1194
Cause of death rank (2005)6th4
Total number of Americans with diabetes (2007)23.6 million15
Number of people with diagnosed diabetes (2007)17.9 million15
Number of people with undiagnosed diabetes (2007)5.7 million15
New cases (age 20 and over, 2007)1.6 million15
Total cost (2007)$174 billion16
Direct medical costs (2007)$116 billion16

Note: Statistics may vary from previous years due to revised and updated source statistics or addition of new data sources.

Management: Receipt of Three Recommended Diabetes Services

Effective management of diabetes includes hemoglobin A1c (HbA1c)v testing, eye examination, and foot examination in the past year, as well as appropriate influenza immunization and lipid management.17-19


v HbA1c is glycosylated hemoglobin and its level provides information about control of blood sugar levels.


Figure 2.8. Composite measure: Adults age 40 and over with diagnosed diabetes who received all three recommended services for diabetes in the calendar year, by race (top left), ethnicity (top right), family income (bottom left), and education (bottom right), 2002-2005.

trend line charts. percent. race, White, 2002, 52.4%, 2003, 49.4%, 2004, 47.4%, 2005, 41.0%, Black, 2002, 54.1%, 2003, 41.5%, 2004, 46.7%, 2005, 37.0%. Ethnicity;Non-Hispanic White, 2002, 55.1%, 2003, 51.0%, 2004, 49.2%, 2005, 42.4%, Hispanic, 2002, 37.9%, 2003, 41.6%, 2004, 38.8%, 2005, 33.8%.

Family income, Poor, 2002, 45.6%, 2003, 37.2%, 2004, 38.4%, 2005, 30.3%, Near Poor, 2002, 46.6%, 2003, 33.0%, 2004, 37.6%, 2005, 28.5%, Middle Income, 2002, 50.3%, 2003, 47.6%, 2004, 41.9%, 2005, 38.4%, High Income, 2002, 61.1%, 2003, 59.2%, 2004, 58.4%, 2005, 52.6%. Education, less than high school, 2002, 46.6%, 2003, 38.5%, 2004, 35.2%, 2005, 31.5%, high school, 2002, 53.9%, 2003, 50.0%, 2004, 45.7%, 2005, 39.9%, some college, 2002, 57.4%, 2003, 52.5%, 2004, 55.9%, 2005, 47.7%.

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2005.

Reference population: Civilian noninstitutionalized population age 40 and over.

Note: Recommended services for diabetes are: (1) HbA1c testing, (2) retinal eye examination, and (3) foot examination. Data include people with both type 1 and type 2 diabetes. Rate is age adjusted to the 2000 U.S. standard population. Data were insufficient for this analysis for Native Hawaiians and Other Pacific Islanders and for American Indians and Alaska Natives.

  • From 2002 to 2005, the gap remained the same between Blacks and Whites in the percentage of adults age 40 and over with diabetes who received three recommended services (Figure 2.8). In 2005, there were no statistically significant differences between Blacks and Whites for this measure (37% compared with 41%).
  • The gap increased between Hispanics and non-Hispanic Whites in the percentage of adults age 40 and over with diabetes who received three recommended services. In 2005, this percentage was significantly lower for Hispanics than for non-Hispanic Whites (33.8% compared with 42.4%).
  • From 2002 to 2005, the gap between poor people and high-income people remained the same. In 2005, this percentage was significantly lower for poor (30.3%), near-poor (28.5%), and middle-income people (38.4%) than for high-income people (52.6%).
  • The gap remained the same between people with less than a high school education and people with at least some college education. In 2005, the percentage of adults age 40 and over with diabetes who received three recommended services was lower for people with less than a high school education (31.5%) and high school graduates (39.9%) than for people with at least some college (47.7%).

 

Management: Lower Extremity Amputations

Although diabetes is the leading cause of lower extremity amputations, amputations can be avoided through proper care on the part of patients and providers. Hospital admissions for lower extremity amputations for patients with diagnosed diabetes reflect poorly controlled diabetes. Better management of diabetes would prevent the need for lower extremity amputations.

Figure 2.9. Hospital admissions for lower extremity amputations per 1,000 population age 18 and over with diabetes, by race, 2001-2003 and 2004-2006.

Bar chart: HP 2010 target: 2.9. Race. Rate per 1,000 population. from 2001 through 2003, Total, 4.8, White, 3.7, Black, 5.3; Rate per 1,000 population. from 2004 through 2006, Total, 3.8, White, 2.5, Black, 5.7.

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Discharge Survey and National Health Interview Survey, 2001-2003 and 2004-2006.

Note: Data years were combined to create sufficient sample sizes for this analysis.

  • While the rate of hospitalizations for lower extremity amputations improved overall from 2001-2003 to 2004-2006, the gap between Blacks and Whites increased. The percentage of hospitalizations for lower extremity amputations among diabetes patients remained higher for Blacks than Whites (5.7 admissions per 1,000 population with diagnosed diabetes compared with 2.5 admissions per 1,000 population with diagnosed diabetes; Figure 2.9).
  • Women with diabetes were less likely than men with diabetes to be hospitalized for lower extremity amputation (2.3 per 1,000 compared with 5.4 per 1,000; data not shown).
  • The Healthy People 2010 target rate of 2.9 lower extremity amputations in adults with diagnosed diabetes per 1,000 population has not been met by any group except Whites.

 

Management: Controlled Hemoglobin, Cholesterol, and Blood Pressure

People with diagnosed diabetes often have other cardiovascular risk factors, such as high blood pressure and high cholesterol. The combination of these conditions with diabetes increases the likelihood of complications from diabetes, such as heart disease and stroke. Therefore, in addition to controlling blood sugar levels, diabetes management often includes treating high blood pressure and high cholesterol. HbA1c testing determines the average blood sugar level over 2 to 3 months and provides information about control of blood sugar levels. Checking blood pressure and cholesterol levels is also needed to assess control of these risk factors.vi


vi Blood pressure control guidelines were updated in 2005. Previously, having a blood pressure reading of <140/90 mm Hg was considered under control. For this measure, the new threshold of <140/80 mm Hg has been applied to historic data for the sake of consistency and comparability.


Figure 2.10. Adults age 40 and over with diagnosed diabetes with HbA1c (top left), total cholesterol (top right), and blood pressure (bottom left) under control, by race/ethnicity and income, 1988-1994, 1999-2002, and 2003-2006

Bar chart. HbA1C <7%. From 1988 through 1994, Total, 41.2%, White, 41.6%, Black, 39.9%, Mexican American, 34.5%, Poor, 45.9%, Near Poor, 38.9%, Middle Income, 39.7%, High Income, 42.2%, From 1999 through 2002, Total, 45.5%, White, 51.8%, Black, 35.2%, Mexican American, 34.3%, Poor, 35.6%, Near Poor, 45.0%, Middle Income, 47.1%, High Income, 48.5%. From 2003 through 2006, Total, 54.6%, White, 60.5%, Black, 43.0%, Mexican American, 37.6%, Poor, 42.7%, Near Poor, 54.3%, Middle Income, 58.9%, High Income, 56.4%. Total Cholesterol <200 mg/dL (bar chart). From 1998 through 2004. Total: 35.1%; White: 27%; Black: 31%; Mexican American: 32%; Poor: 40%; Near Poor: 35%; Middle Income: 30%; High Income: 29%. From 1999 through 2002, Total, 48.1%, White, 47.0%, Black, 51.3%, Mexican American, 49.0%, Poor, 40.6%, Near Poor, 48.9%, Middle Income, 48.3%, High Income, 53.5%. From 2003 through 2006, Total, 54.9%, White, 55.2%, Black, 60.9%, Mexican American, 52.4%, Poor, 51.1%, Near Poor, 41.3%, Middle Income, 61.0%, High Income, 61.5%.

Blood Pressure <140/80 mm Hg (bar chart). From 1988 through 1994, Total, 54.5%, White, 57.5%, Black, 39.4%, Mexican American, 48.5%, Poor, 48.8%, Near Poor, 59.0%, Middle Income, 54.4%, High Income, 59.2%. From 1999 through 2002, Total, 53.4%, White, 61.9%, Black, 38.7%, Mexican American, 48.9%, Poor, 46.6%, Near Poor, 53.4%, Middle Income, 43.6%, High Income, 66.7%, From 2003 through 2006, Total, 58.5%, White, 58.9%, Black, 57.9%, Mexican American, 66.8%, Poor, 59.8%, Near Poor, 43.9%, Middle Income, 65.0%, High Income, 63.3%

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health and Nutrition Examination Survey (NHANES), 1988-1994, 1999-2002, and 2003-2006.

Reference population: Civilian noninstitutionalized population with diagnosed diabetes, age 40 and over.

Note: Whites and Blacks are non-Hispanic groups; "Mexican American" is used in place of "Hispanic" because the NHANES is designed to provide estimates for this group rather than all Hispanics. Age adjusted to the 2000 U.S. standard population. Data were insufficient for this analysis for Native Hawaiians and Other Pacific Islanders and for American Indians and Alaska Natives.

HbA1c under control

  • From the 1988-1994 to 2003-2006 periods, the percentage of adults with diagnosed diabetes who had their HbA1c under optimal control improved (Figure 2.10). However, in 2003-2006, only 54.6% of adults with diagnosed diabetes had their HbA1c under optimal control.
  • The gap between Blacks and Whites increased. In 2003-2006, the rate was significantly lower for Blacks than Whites (43.0% compared with 60.5%).
  • The gap between Mexican Americans and Whites increased. In 2003-2006, the rate was significantly lower for Mexican Americans than Whites (37.6% compared with 60.5%).
  • In 2003-2006, there were no statistically significant differences among income groups.

Total cholesterol under control

  • From the 1988-1994 to 2003-2006 periods, the percentage of adults with diagnosed diabetes who had their total cholesterol under control increased significantly. However, in 2003-2006, only 54.9% of adults with diagnosed diabetes had their total cholesterol under control.
  • In 2006, there were no statistically significant differences across racial groups and income groups.

Blood pressure under control

  • From the 1988-1994 to 2003-2006 periods, the percentage of adults with diagnosed diabetes who had their blood pressure under control did not change. In 2003-2006, only 58.5% of adults with diagnosed diabetes had their blood pressure under control.
  • The gap between Blacks and Whites decreased. In 2003-2006, there was no significant difference between Blacks, Mexican Americans, and Whites for this measure.
  • The gap between poor people and high-income people remained the same. In 2003-2006, the rate was significantly lower for poor than for high-income people (59.8% compared with 63.3%).

 

 

End Stage Renal Disease (ESRD)

Type of statisticNumber
Total ESRD deaths (2005)85,79020
Total cases (2005)485,01221
New cases (2005)106,91221
Total Medicare program expenditure for ESRD (2005)$19.3 billion21

Note: Statistics may vary from previous years due to revised and updated source statistics or addition of new data sources.

Management: Patients With 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 (URR) equal to or greater than 65%; this measure indicates how well urea, a waste product, is eliminated by the dialysis machine.

Figure 2.11. Adult hemodialysis patients with adequate dialysis (urea reduction ratio 65% or greater), by race (left) and ethnicity (right), 2001-2006.

Trend line charts. percent. race, White, 2001, 86%, 2002, 87%, 2003, 88%, 2004, 89%, 2005, 88%, 2006, 88%, Black, 2001, 82%, 2002, 83%, 2003, 85%, 2004, 85%, 2005, 87%, 2006, 85%. Asian, 2001, 92%, 2002, 93%, 2003, 95%, 2004, 95%, 2005, 95%, 2006, 94%, AI/AN, 2001, 87%, 2002, 89%, 2003, 88%, 2004, 92%, 2005, 91%, 2006, 91%. More than 1 Race, 2001, 86%, 2002, 85%, 2003, 85%, 2004, 91%, 2005, 83%, 2006.  Ethnicity, Non-Hispanic White, 2001, 85%, 2002, 86%, 2003, 87%, 2004, 88%, 2005, 87%, 2006, 87%. Hispanic, 2001, 87%, 2002, 88%, 2003, 90%, 2004, 91%, 2005, 90%, 2006, 90%.

Key: AI/AN=American Indian or Alaska Native.

Source: Centers for Medicare & Medicaid Services, End Stage Renal Disease (ESRD) Clinical Performance Measures Project, 2001-2006.

Reference population: ESRD hemodialysis patients age 18 and over.

Note: Data were not available for Native Hawaiians or Other Pacific Islanders, and in 2006 for people of multiple race.

  • From 2001 to 2006, the gap decreased between Blacks and Whites in hemodialysis patients with adequate dialysis. However, in 2006 Blacks were less likely than Whites to have adequate dialysis (85% compared with 88%; Figure 2.11).
  • From 2001 to 2006, the gap between Asians and Whites remained the same. In 2006, the percentage with adequate dialysis continued to be higher for Asians than for Whites (94% compared with 88%).
  • The percentage with adequate dialysis improved for Hispanics (from 87% to 90%) and for non-Hispanic Whites (from 85% to 87%).
  • In 2006, women were more likely than men to have adequate dialysis (92% compared with 83%; data not shown).

Management: Registration for Transplantation

Kidney transplantation often allows people with ESRD to continue a lifestyle similar to what they had before their kidney failure.21 It is important that persons with ESRD be registered on the waiting list for kidney transplantation to increase the likelihood of transplantation. However, the number of people on the waiting list greatly exceeds the number who receive transplants. Thus, being on the waiting list does not ensure a transplant.22 In 2006, 70,778 patients were on the Organ Procurement and Transplantation Network (OPTN) deceased donor kidney transplant waiting list in the United States. Only 10,212 deceased donor kidney transplants were performed.20

Figure 2.12. Dialysis patients under age 70 who were registered on a waiting list for transplantation, by race (left) and ethnicity (right), 1998-2004.

Trend line charts: HP2010 target: 25%. White, 1998, 17.5%, 1999, 17.3%, 2000, 16.3%, 2001, 16.1%, 2002, 16.7%, 2003, 16.9%, 2004, 16.8%, Black, 1998, 10.0%, 1999, 10.6%, 2000, 10.8%, 2001, 10.5%, 2002, 11.1%, 2003, 11.0%, 2004, 11.8%. Asian, 1998, 24.0%, 1999, 26.6%, 2000, 28.0%, 2001, 28.1%, 2002, 27.7%, 2003, 27.9%,2004, 30.0%, AI/AN, 1998, 10.5%, 1999, 9.5%, 2000, 9.7%, 2001, 8.7%, 2002, 11.2%, 2003, 9.6%, 2004, 10.6%. Ethnicity, Non-Hispanic White, 1998, 18.4%, 1999, 18.4%, 2000, 17.3%, 2001, 16.9%, 2002, 17.3%, 2003, 17.5%, 2004, 17.6%. Hispanic, 1998, 10.0%, 1999, 12.4%, 2000, 12.1%, 2001, 12.9%, 2002, 14.2%, 2003, 14.4%, 2004, 13.9%.

Key: AI/AN=American Indian or Alaska Native.

Source: U.S. Renal Data System, 1998-2004.

Reference population: End Stage Renal Disease hemodialysis patients and peritoneal dialysis patients under age 70.

Note: Data were not available for Native Hawaiians and Other Pacific Islanders.

  • From 1998 to 2004, the gap between Blacks and Whites in the percentage of dialysis patients registered for transplantation remained the same. In 2004, Blacks were still less likely to be registered for transplantation than Whites (11.8% compared with 16.8%; Figure 2.12).
  • The gap between AI/ANs and Whites decreased. However, in 2004, AI/ANs were still less likely to be registered for transplantation than Whites (10.6% compared with 16.8%).
  • The gap between Asians and Whites registered for transplantation increased. In 2004, this percentage was higher for Asians than for Whites (30.0% compared with 16.8%).
  • The gap between Hispanics and non-Hispanic Whites decreased. However, in 2004, this percentage was still lower for Hispanics than for non-Hispanic Whites (13.9% compared with 17.6%).
  • From 1998 to 2004, only Asians achieved the Healthy People 2010 target of 25%.
Current as of March 2009
Internet Citation: Chapter 2. Quality of Health Care: National Healthcare Disparities Report, 2008. March 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/nhqrdr/nhdr08/Chap2.html