Chapter 2. Quality of Health Care (continued)

National Healthcare Disparities Report, 2008

Effectiveness (continued)

Heart Disease

Type of statisticNumber
Number of deaths (2005)652,0914
Cause of death rank (2005)1st4
Number of cases of coronary heart disease (2005)16.0 million23
Number of cases of heart failure (2005)5.3 million23
Number of cases of high blood pressure (2005)73.0 million23
Number of heart attacks (2005)8.1 million24
Number of new cases of congestive heart failure (2005)366,81523
Total cost of cardiovascular disease (2008 est.)$448.5 billion6
Total cost of congestive heart failure (2008 est.)$34.8 billion23
Direct medical costs of cardiovascular disease (2008 est.)$296.4 billion6
Cost effectiveness of hypertension screening$14,000-$35,000/QALY7
Cost effectiveness of aspirin chemoprophylaxiscost savings7,vii

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

Prevention: Counseling Obese Adults About Overweight

As in the 2005 report, measures related to overweight and obesity are presented in the NHDR. In this section, measures for counseling obese adults about overweight and exercise are presented. In Chapter 4, Priority Populations, a measure for counseling children about overweight is presented in the section on children.

Over 32% of adults age 20 and over in the United States are obese (defined as having a body mass index of 30 or higher),25,viii putting them at increased risk for many chronic, often deadly conditions, such as hypertension, cancer, diabetes, and coronary heart disease.26 Reducing obesity is a major objective in preventing heart disease and stroke.27 Although physician guidelines recommend that health care providers screen all adult patients for obesity,28 obesity remains underdiagnosed in U.S. adults.29 The health care system has a central role to play in helping people become aware of the risks of obesity when they are overweight and suggesting strategies for reducing these risks.


vii Unlike other interventions which often involve greater costs for health benefits, this intervention actually results in net cost savings to society.
viii Obesity is defined as having a body mass index (BMI) of 30 or higher. It is noteworthy that BMI incorporates both a person's weight and height in determining if he or she is overweight or obese.


Figure 2.13. Adults with obesity age 20 and over who were told by a doctor they were overweight, by race/ethnicity, income, and education, 1999-2002 and 2003-2006

bar chart. percent. From 1999 through 2002, Total, 67.8, White, 70.5, Black, 63.0, Mexican American, 56.5, Family income, Poor, 66.3, Near poor, 66.5, Middle income, 66.3, High income, 71.3, Education, Less than high school, 63.6, High school grad., 70.1, At least some college, 72.8. From 2003 through 2006, Total, 64.8, White, 66.4, Black, 60.5, Mexican American, 57.1, Family income, Poor, 61.5, Near poor, 62.5, Middle income, 62.4, High income, 70.6, Education, Less than high school, 59.2, High school grad., 64.2, At least some college, 70.3.

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

Reference population: Civilian noninstitutionalized population age 20 and over.

Note: Obesity is defined as a body mass index of 30 or higher. "Mexican American" is used in place of "Hispanic" because the NHANES is designed to provide estimates for this group rather than all Hispanics. Education groups are for adults age 25 and over only. Rates other than the total are age adjusted to the 2000 standard population. Data were not available for Asians, Native Hawaiians and Other Pacific Islanders, and American Indians and Alaska Natives.

  • There were no statistically significant changes from 1999-2002 to 2003-2006 in the percentage of obese adults told that they were overweight.
  • During this period, trends were different for men and women. The percentage of obese women who were told they were overweight increased (from 63.1% to 69.8%; data not shown), while the percentage decreased for men (from 71.9% to 59.6%; data not shown).
  • The percentage of obese adults told that they were overweight was significantly lower for Blacks (60.5%) and Mexican Americans (57.1%) compared with Whites (66.4%); for poor (61.5%), near-poor (62.5%), and middle-income (62.4%) people compared with high-income people (70.6%); and for adults with less than a high school education (59.2%) and high school graduates (64.2%) compared with adults with any college education (70.3%) (Figure 2.13).

Prevention: Counseling Obese Adults About Exercise

Exercise counseling within the clinical setting is an important component of effective weight loss interventions.28 Regular exercise aids in weight loss and blood pressure control efforts, reducing the risk of heart disease, stroke, diabetes, and other diseases.

Figure 2.14. Adults with obesity who ever received advice from a health provider to exercise more, by race (top left), ethnicity (top right), income (bottom left), and education (bottom right), 2002-2005.

trend line charts, percent. Race. 2002, White, 57.0, Black, 55.3, 2003, White, 58.5, Black, 56.3, 2004, White, 57.0, Black, 55.3, 2005, White, 58.7, Black, 56.0. Ethnicity; 2002, Non-Hispanic White, 59.7, Hispanic, 43.2; 2003, Non-Hispanic White, 60.8, Hispanic, 47.2; 2004, Non-Hispanic White, 62.6, Hispanic, 44.7; 2005, Non-Hispanic White, 61.9, Hispanic, 44.1; 2002.

Poor, 48.8, Near Poor, 51.4, Middle income, 55.0, High income, 63.5, 2003, Poor, 52.2, Near Poor, 51.5, Middle income, 57.4, High income, 64.5; 2004, Poor, 52.0, Near Poor, 53.5, Middle income, 58.1, High income, 65.0; 2005, Poor, 49.5, Near Poor, 51.9, Middle income, 58.7, High income, 64.2; 2002 less than high school, 50.9, high school grad, 55.1, some college, 61.6, 2003, less than high school, 52.1, high school grad, 56.7, some college, 62.7, 2004, less than high school, 52.0, high school grad, 57.7, some college, 63.4, 2005, less than high school, 50.5, high school grad, 57.0, some college, 63.2.

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

Reference population: Civilian noninstitutionalized population age 18 and over.

Note: Obesity is defined as a body mass index of 30 or higher. Data were insufficient for this analysis for Asians, Native Hawaiians and Other Pacific Islanders, and American Indians and Alaska Natives.

  • From 2002 to 2005, there were no significant changes in the proportion of obese adults who were given advice about exercise (Figure 2.14).
  • During the same time period, there was no significant gap between Blacks and Whites on this measure.
  • From 2002 to 2005, the gap between Hispanics and non-Hispanic Whites increased. In 2005, this proportion was significantly lower for Hispanics than for non-Hispanic Whites (49.5% compared with 64.2%).
  • The gap between poor people and high income people remained the same. In 2004, this proportion was significantly lower for poor people compared with high income people (52.0% compared with 65.0%).
  • The gap between people with less than a high school education and people with at least some college education remained the same. In 2005, the proportion of obese adults who were given advice about exercise was significantly lower for people with less than a high school education than for people with at least some college education (50.5% compared with 63.2%).

Each year, multivariate analyses are conducted in support of the NHDR to identify the independent effects of race, ethnicity, and socioeconomic status on quality of health care. Past reports have listed some of these findings. This year, the NHDR presents the results of a multivariate model for one measure: obese adults who were given advice about exercise. Adjusted odds ratios are shown to quantify the relative magnitude of disparities after controlling for a number of confounding factors.

To identify the independent effects of socioeconomic factors on obese (BMI of 30 or higher) adults ages 18-64 given advice by a doctor or health professional about exercise, logistic regressions were run using pooled 2002-2005 MEPS data. The predictive variables included race, ethnicity, income, education, age, gender, insurance, and residence location. White, non-Hispanic White, high income, some college, private insurance, ages 45-64, male, and metropolitan were used as reference groups (odds ratio = 1). The odds ratios estimate the ratios of probability of received advice by each covariate group over the reference group and are reported in Figure 2.15. A lower odds ratio indicates that the group is less likely to receive advice.

Figure 2.15. Adults with obesity who ever received advice from a health provider to exercise more: Adjusted odds ratios, 2002-2005.

bar chart. Odds ratios. No Insurance, .56 ; Private Insurance. 1; Nonmetropolitan, .81 Metropolitan, 1; < High School, .81; High School Grad, .84; Some college, 1 ; Poor, .78 ; Near Poor, .81; Middle Income, .92; High Income, 1; Female, 1.51; Male, 1; Hispanic, .66; Non-Hispanic White, 1; Non-Hispanic Black, .92; Non-Hispanic White, 1.

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

Reference population: Obese civilian noninstitutionalized population ages 18-64.

Note: Obesity is defined as a body mass index of 30 or higher. Adjusted odds ratios are calculated from logistic regression models controlling for race, ethnicity, income, education, age, gender, insurance, and residence location. White, non-Hispanic White, male, high income, some college, metropolitan, and private insurance are reference groups with odds ratio = 1; odds ratios < 1 indicate that a group is less likely to receive a service than the reference group. For example, compared with obese adults with private insurance, obese adults with no insurance had 0.6 times the odds of receiving advice about exercise after controlling for other factors. Data were insufficient for this analysis for Asians, Native Hawaiians and Other Pacific Islanders, and American Indians and Alaska Natives.

  • In multivariate models controlling for race, ethnicity, income, education, insurance, age, gender, and residence location, obese Hispanics had 0.7 times the odds of receiving advice about exercise compared with non-Hispanic Whites (Figure 2.15).
  • In this multivariate model, poor individuals had 0.8 times the odds compared with high-income individuals. Individuals with less than a high school education had 0.8 times the odds compared with individuals with some college education.
  • Obese individuals with no health insurance had 0.6 times the odds compared with individuals with private insurance to receive advice about exercise.
  • In this multivariate model, obese individuals within nonmetropolitan areas had 0.8 times the odds of being given advice about exercise compared with individuals within metropolitan areas.
  • In this multivariate model, obese females had 1.5 times the odds of being given advice about exercise compared with obese males.

 

Treatment: Receipt of Recommended Hospital Care for Heart Failure

Recommended hospital care for heart failure includes evaluation of the left ventricular ejection fraction and receipt of an angiotensin-converting enzyme (ACE) inhibitor for left ventricular systolic dysfunction. In 2005, the ACE inhibitor measure was modified to include receipt of angiotensin receptor blockers (ARBs) as an alternative to ACE inhibitor receipt.

Figure 2.16. Composite measure: Hospital patients with heart failure who received recommended hospital care, Medicare only by race/ethnicity, 2002-2004 (left) and All payer, 2005-2006 (right).

Trend line chart 2002-2004. 2002, Total, 73.4, White, 73.4, Black, 74.9, Asian, 76.3, AI/AN, 68.9, Hispanic, 68.6; 2003, Total, 74.6, White, 74.3, Black, 76.3, Asian, 77.3, AI/AN, 74.3, Hispanic, 71.3. 2004, Total, 77.7, White, 77.9, Black, 78.1, Asian, 78.6, AI/AN, 72.3, Hispanic, 73.5. Trend line chart 2005-2006. 2005, Total, 86.9, White, 87.4, Black, 89.1, Asian, 86.6, AI/AN, 85.9, Hispanic, 86.7; 2006, Total, 89.2, White, 90, Black, 91.4, Asian, 90.1, AI/AN, 86.3, Hispanic, 89.3.

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

Source: Centers for Medicare & Medicaid Services, Medicare Quality Improvement Organization program, 2002-2006.

Denominator: Patients hospitalized for heart failure, all ages.

Note: Whites, Blacks, AI/ANs, and Asians are non-Hispanic groups. Composite incorporates the following measures: (1) receipt of evaluation of left ventricular ejection fraction and (2) receipt of ACE inhibitor for left ventricular systolic dysfunction. Composite is calculated by averaging the percentage of the population that received each of the two incorporated components of care. For further details on composite measures, go to Chapter 1, Introduction and Methods. Data for 2002-2004 and 2005-2006 differ due to modification of the ACE inhibitor measure in 2005 to include receipt of ARBs as an acceptable alternative to ACE inhibitors and the data collection method change made in 2005 from the abstraction of randomly selected medical records for Medicare beneficiaries to the receipt of hospital self-reported data for all payer types. Data were not available for Native Hawaiians and Other Pacific Islanders.

  • In 2006, the percentage of patients with heart failure who received recommended hospital care was higher for Blacks than for Whites (91.4% compared with 90.0%; Figure 2.16).
  • In 2006, the percentage of patients with heart failure who received recommended hospital care was lower for AI/ANs than Whites (86.3% compared with 90.0%).
  • From 2002 to 2004, the overall percentage of Medicare patients with heart failure who received recommended hospital care improved from 73.4% to 77.7% (Figure 2.16; 2005-2006 data not comparable to this time period).
  • During the same period, this percentage was significantly lower for Hispanics compared with Whites. In 2004, the percentage was also significantly lower for AI/ANs compared with Whites (72.3% compared with 77.9%).
  • From 2002 to 2004, the percentage of Medicare patients with heart failure who received recommended hospital care improved significantly for the total population and for Whites, Blacks, and Hispanics.

HIV and AIDS

Type of statisticNumber
Number of persons living with HIV (2006)>226,47730
Number of persons living with AIDS (2006)436,69330
Number of deaths among people with AIDS (2006)14,62730
Number of new HIV/AIDS cases (2006)56,30031
Number of new AIDS cases (2006)37,85232
Federal spending on domestic HIV/AIDS care, cash and housing assistance, and prevention and research(fiscal year 2008 est.)$18.2 billion32

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

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 and by the availability of appropriate treatments for HIV-infected individuals. Improved treatments that extend life for those with the disease are reflected in the fact that the number of deaths due to AIDS fell from about 18,000 to 14,600 between 2002 and 2006, after showing no change for the previous 3 years.33

The impact of human immunodeficiency virus (HIV) infection and its late-stage manifestation, acquired immune deficiency syndrome (AIDS), is disproportionately higher for racial and ethnic minorities and persons of lower socioeconomic position. While access to care has improved, research shows that Blacks, Latinos, women, and uninsured people with HIV remain less likely to have access to care and less likely to have optimal patterns of care.34

According to the Centers for Disease Control and Prevention, HIV and AIDS disproportionately affect African Americans in the United States. The spread of HIV is related to factors faced by many African Americans, including poverty, high-risk behaviors related to sexually transmitted diseases, and stigma (negative attitudes, beliefs, and actions directed at people living with HIV/AIDS or directed at people who do things that might put them at risk for HIV).35

The HIV/AIDS epidemic is also a serious threat to the Hispanic/Latino community. According to current surveillance data, 39% of Latinos who are newly diagnosed with HIV infection progress to an AIDS diagnosis within 1 year.35 In addition to being a population seriously affected by HIV, Hispanics/Latinos continue to face challenges in accessing health care, prevention services, and HIV treatment. In 2005, HIV/AIDS was the fourth leading cause of death among Hispanic/Latino men and women ages 35-44.36 While having Medicaid insurance and a usual source of care decreased the likelihood of delaying care for HIV, research shows that delay in care is still greater for Latinos and African Americans.37

Although the number of cases of HIV and AIDS from 2001 through 2005 decreased (by 1% for men and 19% for women),38 HIV and AIDS are having an increasing impact on women of color, particularly on African-American women (68.7% of estimated AIDS cases among adult women were Black).39 Women with HIV and AIDS face particular challenges to accessing care. Women are often the primary caregivers in their families, thus making their own health a lesser priority. Risk behaviors such as drug use and sex trading also put HIV-infected women at higher risk for depression, violence, family problems, and inadequate social support.40

Management: New AIDS Cases

Currently, comprehensive data on HIV infection rates across the Nation are lacking; however, early and appropriate treatment of HIV disease can delay progression to AIDS. Improved management of chronic HIV disease has likely contributed to declines in new AIDS cases. For example, as the use of highly active antiretroviral therapy (HAART) to treat HIV infection became widespread in the mid-1990s, rates of new AIDS cases declined.41,42

Figure 2.17. New AIDS cases per 100,000 population age 13 and over, by race/ethnicity, 1998-2006.

Trend line chart. Percent: Total, 1998: 18, 1999: 17.3, 2000: 17.3, 2001: 17, 2002: 17.2, 2003: 17.7, 2004: 17.1, 2005: 18.1, 2006: 14.9. White, 1998: 8.2, 1999: 7.7, 2000: 7.2, 2001: 7, 2002: 7.1, 2003: 7.2, 2004: 7.1, 2005: 7.5, 2006: 6.4. Black: 1998: 80.7, 1999: 77.1, 2000: 75, 2001: 74.5, 2002: 75.4, 2003: 75.3, 2004: 72.1, 2005: 75, 2006: 60.3. API: 1998: 4.4, 1999: 4.6, 2000: 4.2, 2001: 4.3, 2002: 4.6, 2003: 4.7, 2004: 4.4, 2005: 4.9, 2006: 4.4. AI/AN: 1998: 10.1, 1999: 10.4, 2000: 11.5, 2001: 10.3, 2002: 11, 2003: 10.3, 2004: 9.9, 2005: 10, 2006: 7.8. Hispanic: 1998: 31.3; 1999: 29.6, 2000: 26.2, 2001: 25.2, 2002: 24.2, 2003: 26.8, 2004: 25, 2005: 26.4, 2006: 20.8.

Prevention: HIV Testing

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

Source: Centers for Disease Control and Prevention, National Center for HIV, STD, and TB Prevention, HIV/AIDS Surveillance System, 1998-2006.

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

Note: The source categorizes race/ethnicity as a single item. White = non-Hispanic White; Black = non-Hispanic Black. Data are based on hospital self-reports.

  • In 2006, the overall rate of new AIDS cases decreased to about 15 cases per 100,000 population (Figure 2.17).
  • From 1998 to 2006, the rate of new AIDS cases decreased for Blacks (from 80.7 to 60.3 per 100,000), Hispanics (from 31.3 to 20.8 per 100,000), and Whites (from 8.2 to 6.4 per 100,000).
  • During this period, the gap between Blacks and Whites decreased. However, in 2006, the rate of new AIDS cases was still almost 10 times higher (60.3 per 100,000 compared with 6.4 per 100,000) for Blacks than for Whites.
  • From 1998 to 2006, the gap between Hispanics and non-Hispanic Whites decreased. However, in 2006, the rate of new AIDS cases was still more than three times higher for Hispanics than for Whites (20.8 per 100,000 compared with 6.4 per 100,000).
  • In 2006, the rate of new AIDS cases was almost three times higher for men compared with women (22.4 per 100,000 compared with 7.8 per 100,000; data not shown)
  • No group has reached the Healthy People 2010 target of 1.0 new AIDS case per 100,000 population.

 

Management: PCP and MAC Prophylaxis

Management of chronic HIV disease includes outpatient and inpatient services. Because national data on HIV care are not routinely collected,ix HIV measures tracked in the NHDR come from the HIV Research Network. This network consists of 18 medical practices across the United States that treat large numbers of HIV patients.

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 Pneumocystis pneumonia (PCP) is routinely recommended; when CD4 cell counts fall below 50, medicine to prevent development of disseminated Mycobacterium avium complex (MAC) infection is routinely recommended.43

Figure 2.18. Adult patients with HIV and CD4 count < 200 who received PCP prophylaxis in the calendar year, by race/ethnicity, 2003-2005.

Trend line chart. 2003, Total, 83.9, White, 83.5, Black, 83.1, Hispanic, 86.4; 2004, Total, 86.6, White, 86.9, Black, 85.7, Hispanic, 88.3; 2005, Total, 90.6, White, 91.1, Black, 90.6, Hispanic, 90.3.

Source: Agency for Healthcare Research and Quality, Center for Delivery, Organization, and Markets, HIV Research Network, 2003-2005.

Reference population: HIV patients age 18 and over receiving care from HIV Research Network providers.

Note: Whites and Blacks are non-Hispanic populations. Data were not available for Asians, Native Hawaiians and Other Pacific Islanders, and American Indians and Alaska Natives.


ix Although program data are collected from all Ryan White CARE Act grantees, the aggregate nature of the data make it difficult to assess the quality of care provided by the Ryan White HIV/AIDS Program.


  • From 2003 to 2005, the overall percentage of HIV patients with CD4 cell count <200 who received PCP prophylaxis increased. The percentage was not significantly different for any racial or ethnic group compared with Whites (Figure 2.18).
  • During this period, the gap between men and women increased for HIV patients with CD4 cell count <200 who received PCP prophylaxis. In 2005, women were less likely than men to receive PCP prophylaxis treatment (86.5% compared with 91.9%; data not shown).

Figure 2.19. Adult patients with HIV and CD4 count <50 who received MAC prophylaxis in the past year, by race/ethnicity, 2003-2005.

trend line chart. percent. 2003, Total, 84.3, White, 81.2, Black, 85.5, Hispanic, 84.2; 2004, Total, 81.8, White, 79.1, Black, 80.9, Hispanic, 86.7; 2005, Total, 87.1, White, 83.4, Black, 87.2, Hispanic, 90.4.

Source: Agency for Healthcare Research and Quality, Center for Delivery, Organization, and Markets, HIV Research Network, 2003-2005.

Reference population: HIV patients age 18 and over receiving care from HIV Research Network providers.

Note: Whites and Blacks are non-Hispanic populations. Data were not available for Asians, Native Hawaiians and Other Pacific Islanders, and American Indians and Alaska Natives.

  • From 2003 to 2005, the overall percentage of HIV patients with CD4 cell count <50 who received MAC prophylaxis remained the same.
  • During this period, the gap between Hispanics and non-Hispanic Whites remained the same. In 2005, the percentage of HIV patients with CD4 cell count <50 who received MAC prophylaxis was higher for Hispanics than for Whites (90.4% compared with 83.4%; Figure 2.19).
  • From 2003 to 2005, the gap between men and women in the percentage of HIV patients with CD4 cell count <50 who received MAC prophylaxis remained the same. However, in 2005, women were still less likely than men to receive MAC prophylaxis treatment (85.3% compared with 87.7%; data not shown).
Current as of March 2009
Internet Citation: Chapter 2. Quality of Health Care (continued): National Healthcare Disparities Report, 2008. March 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/nhqrdr/nhdr08/Chap2a.html