Chapter 4. Priority Populations (continued, 3)

National Healthcare Disparities Report, 2008


Women

The U.S. Census Bureau estimated 152 million females in the United States in 2006, 51% of the U.S. population26, of whom 47 million are members of racial or ethnic minority groups.27 By 2050, it is projected that just under half of females in the United States will be members of racial or ethnic minority groups.27 The ratio of males to females is highest at birth, when male infants outnumber female infants, and gradually declines with age due to higher male mortality rates. Among Americans 85 and older, women outnumber men by more than 2 to 1.28 Poverty disproportionately affects women; in 2006, 14.1% of women lived in households with incomes below the Federal poverty level compared with 11.1% of men.29

Women in the United States have a life expectancy 5.2 years longer than men30 and lower age-adjusted death rates than men for 12 of the 15 leading causes of death.31 However, women are more likely than men to report having arthritis, asthma,32 and serious mental illness.33 There is significant variation in health status and health-related behaviors for women of different races and ethnicities.34 In general, gender differences in quality of care are small.

Many measures of relevance to women are tracked in the NHDR. Findings presented here highlight four quality measures and one access measure of particular importance to women:

Component of health care needMeasure
PreventionPrenatal care and maternal health, obese adults advised about exercise
TreatmentMortality rate for acute myocardial infarction
ManagementNew AIDS cases
Access to careUsual source of care

Quality of Health Care

Prevention: Prenatal Care and Maternal Health

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, childbirth is the most common reason for hospital admission.35 Given that birth outcomes may have lifetime effects, good prenatal care has the potential to affect the Nation's future health and health care needs.36 Prenatal care is expected to maintain and improve the health of both mother and newborn during pregnancy. It is recommended that women begin receiving prenatal care in the first trimester of pregnancy.

Figure 4.25. Women who completed a pregnancy in the last 12 months who first received prenatal care in the first trimester for selected States, by race, ethnicity, and education, 2005

Bar chart show percent of pregnant women with prenatal care in the first trimester, for selected States, by race, ethnicity, and education, 2005. Total: 83.9%. By Race: White, 85.5%; Black, 76.3%; API, 85.3%; AI/AN, 69.6%. By Ethnicity: Non-Hispanic White, 88.7%; Hispanic, 77.6%. By Education: Less Than High School: 72.8%; High School Graduate: 82.0; and Some College: 91.2%. Target for Healthy People 2010 is 90%.

Key: AI/AN = American Indian or Alaska Native; API = Asian or Pacific Islander.
Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System-Natality, 2005.
Reference population: Women with live births.
Note: Data for 2005 include the 39 reporting areas (37 States, DC, and New York City) that used the 1989 revision of the US Standard Certificate of Live Birth in 2005. Reporting areas that have adopted the 2003 revision are excluded because prenatal data based on the 2003 revision are not comparable with data based on 1989 and earlier revisions of the US Standard Certificate of Live Birth. More information on the measure specification can be found in the Measure Specifications Appendix. Further discussion of this measure can be found in the Residents of Rural Areas section.

  • In 2005, the percentage was significantly lower for Blacks (76.3%) and AI/ANs (69.6%) compared with Whites (85.5%).
  • In 2005, the percentage was significantly lower for Hispanics than for non-Hispanic Whites (77.6% compared with 88.7%).
  • The percentage was significantly lower for women with less than a high school education (72.8%) and high school graduates (82.0%) than for women with any college education (91.2%).
  • Only women with some college education achieved the Healthy People 2010 target of 90% of women receiving prenatal care in the first trimester.

Racial and ethnic minorities are disproportionately of lower socioeconomic status than Whites.20 Since information about income is not typically collected on birth certificates, the source of some health data, education is commonly used as a proxy for socioeconomic status. To distinguish the effects of race, ethnicity, and education on quality of health care, this measure is stratified by level of education.

Figure 4.26. Women who completed a pregnancy in the last 12 months who first received prenatal care in the first trimester for selected States, by race (top) and ethnicity (bottom), stratified by education, 2005

Bar chart shows pregnant women who received prenatal care in the first trimester, by race, stratified by education, 2005. Less than High School: White, 74.0%; Black, 67.8%; API, 73.6%; AI/AN, 60.4%. High School Grad: White, 84.3%; Black, 77.0%; API, 79.4%; AI/AN, 69.9%. Some College: White, 93.2%; Black, 85.0%; API, 90.2%; AI/AN, 81.5%.

Bar chart shows pregnant women who received prenatal care in the first trimester, by ethnicity, stratified by education, 2005. Less than High School: Non-Hispanic White, 73.9%; Hispanic, 74.2%. High School Grad: Non-Hispanic White, 86.0%; Hispanic, 80.5%. Some College: Non-Hispanic White, 93.5%; Hispanic, 87.2%.

Key: AI/AN = American Indian or Alaska Native; API = Asian or Pacific Islander.
Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System-Natality, 2005.
Reference population: Women with live births.
Note: Data for 2005 include the 39 reporting areas (37 States, DC, and New York City) that used the 1989 revision of the US Standard Certificate of Live Birth in 2005. Reporting areas that have adopted the 2003 revision are excluded because prenatal data based on the 2003 revision are not comparable with data based on 1989 and earlier revisions of the US Standard Certificate of Live Birth. More information on the measure specification can be found in the Measure Specifications Appendix. Further discussion of this measure can be found in the Residents of Rural Areas section.

  • Education explains some but not all of the differences in prenatal care among women by race and ethnicity. Overall racial and ethnic differences in early prenatal care tended to persist among women with similar education (Figure 4.26).
  • Only college-educated APIs (90.0%), and non-Hispanic Whites (93.2%) achieved the Healthy People 2010 target of 90% of women receiving prenatal care in the first trimester.

Prevention: Obese Adults Advised About Exercise

In 2005-2006, more than 35% of adult women age 20 and over in the United States were obese, compared with 33% of men,37, xiii putting them at increased risk for many chronic, deadly conditions, such as hypertension, cancer, diabetes, and coronary heart disease.38 Reducing obesity is a major objective in preventing heart disease and stroke.39 Research shows large racial and ethnic differences among women. The prevalence of obesity is higher for Black and Mexican-American women compared with White women.40 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.

Figure 4.27. Adults with obesity who ever received advice from a health provider to exercise more, by race (top) and ethnicity (bottom), stratified by gender, 2005

Bar chart shows percent of adults with obesity who ever received advice from a health provider to exercise more, by race, stratified by gender, 2005. Total: Male, 53.5%; Female, 62.6%. White: Male, 53.6%; Female: 62.7%. Black: Male: 47.2%; Female: 61.9%.

Bar charts graphs shows percent adults with obesity who ever received advice from a health provider to exercise more, by ethnicity, stratified by gender, 2005. Non-Hispanic White: Male, 58.6%; Female, 65.4%. Hispanic: Male, 35%; Female, 52.5%.

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2005.
Reference population: Civilian noninstitutionalized population age 18 and over.
Note: Data were insufficient for this analysis for Asians, Native Hawaiians and Other Pacific Islanders, and American Indians and Alaska Natives.

  • Obese women were more likely than men to receive advice about exercise (62.6% compared with 53.5%; Figure 4.27). Among obese women, Hispanics were less likely than non-Hispanic Whites to receive advice about exercise (52.5% compared with 65.4%). There were no significant differences between Black women and White women.

xiii 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.


Treatment: Mortality Rate for Acute Myocardial Infarction

Cardiovascular disease is the number one killer among women.41 While significant progress has been made in reducing mortality from heart disease over the past three decades, one woman in four still dies from this group of conditions. Women are generally older than men when diagnosed with heart disease (e.g., 73 versus 65 years on average, according to one study42). Therefore, treatment and outcomes may be compromised by the fact that women are more likely to have other chronic conditions when initially diagnosed. Acute myocardial infarction (AMI) is one type of cardiovascular disease discussed in this report. Measuring processes of AMI 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 an AMI patient needs. Measuring outcomes of AMI 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.

Figure 4.28. Deaths per 1,000 adult hospital admissions with acute myocardial infarction (AMI), by gender and race, 2005

Bar chart shows rate of deaths per 1,000 adult hospital admissions with acute myocardial infarction (AMI), by gender and race, 2005. Total: 79.8. Male: 67.9. Female, 94.8. White Female: 100.6. Black Female: 66.5. API Female: 82.5. Hispanic Female: 83.7.

Key: API = Asian or Pacific Islander.
Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project (HCUP), State Inpatient Databases (SID) disparities analysis file, 2005.
Note: Rates are adjusted by age, gender, age-gender interactions, and All Patient Refined-Diagnosis-Related Group risk of mortality score. The HCUP SID disparities analysis file is designed to provide national estimates using weighted records from a sample of hospitals from 23 States that have 63% of the U.S. resident population.

  • The mortality rate for hospital admissions with AMI was higher for females compared with males (94.8 per 1,000 compared with 67.9 per 1,000; Figure 4.28). Among females, rates were lower both for Black (66.5 per 1,000) and Hispanic (83.7 per 1,000) females than for White females (100.6 per 1,000).

Management: New AIDS Cases

Although differences in the progression of HIV to AIDS do not necessarily result from differences in quality of care, early and appropriate treatment of HIV infection can delay progression to AIDS. Improved management of HIV infections has likely contributed to reduced transmission and therefore decline in new AIDS cases.

Figure 4.29. New AIDS cases per 100,000 population age 13 and over, by race/ethnicity, stratified by gender, 2006

Bar chart shows number of new AIDS cases per 100,000 population age 13 and over, by race/ethnicity, stratified by gender. Total: Male, 22.4; Female, 7.8. White: Male, 11.2; Female, 1.9. Black: Male, 82.9; Female, 40.4. API: Male, 7.5; Female, 1.6. AI/AN: Male, 12.2; Female, 3.6. Hispanic: Male, 31.3; Female, 9.5.

Key: API = Asian or Pacific Islander; AI/AN = American Indian or Alaska Native.
Source: Centers for Disease Control and Prevention, HIV/AIDS Surveillance System, 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.

  • For the overall U.S. population, the rate of new AIDS cases for males was nearly triple that for females (22.4 compared with 7.8 per 100,000 population; Figure 4.29).
  • The rate was significantly higher for males than for females in all groups: Blacks (82.9 per 100,000 for males and 40.4 per 100,000 for females), APIs (7.5 per 100,000 for males and 1.6 per 100,000 for females), AI/ANs (12.2 per 100,000 for males and 3.6 per 100,000 for females), Hispanics (31.3 per 100,000 for males and 9.5 per 100,000 for females), and Whites (11.2 per 100,000 for males and 1.9 per 100,000 for females).
  • Among females, Blacks and Hispanics had significantly higher rates of new AIDS cases than Whites (40.4 and 9.5 per 100,000, respectively, compared with 1.9 per 100,000). API women had lower rates than White women (1.6 per 100,000 compared with 1.9 per 100,000).
  • No group has yet achieved the Healthy People 2010 target of 1.0 new AIDS case per 100,000 population.

Access to Care

Usual Source of Care

Higher costs, poorer outcomes, and greater disparities are observed among individuals without a usual source of care.43

Figure 4.30. People with a specific source of ongoing care, by race, ethnicity, and income, stratified by gender, 2006

Bar chart shows percentage of people with a specific source of ongoing care, by race, ethnicity, and income, stratified by gender, 2006. Total: Female, 88.2; Male, 81.2. White: Female, 88.2; Male, 80.8. Black: Female, 88.2; Male, 83.5. Asian: Female, 97.3; Male, 82.2. Non-Hispanic White: Female, 90.9; Male, 83.6. Hispanic: Female, 78.5; Male, 72.8. Poor: Female, 84.9; Male, 77.1. Near Poor: Female, 86.6; Male, 78.5. Middle Income: Female, 90.2; Male, 83.6. High Income: Female, 97.0; Male, 89.7.

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2006.
Reference population: Civilian noninstitutionalized population, all ages.
Notes: Measure is age adjusted to the 2000 standard population.

  • Overall, the percentage of people with a specific source of ongoing care was significantly higher for females than for males (88.2% compared with 81.2%; Figure 4.30).
  • This percentage was also significantly higher for females than males for all racial and ethnic groups: Whites (88.2% for females compared with 80.8% for males), Asians (97.3% for females compared with 82.2% for males), non-Hispanic Whites (90.9% for females compared with 83.6% for males), and Hispanics (78.5% for females compared with 72.8% for males).
  • Among women, this percentage was significantly lower for poor (84.9%), near-poor (86.6%) and middle-income (90.2%) individuals than for high-income individuals (97.0%).

Figure 4.31. People without a usual source of care who indicate a financial or insurance reason for not having a source of care, by race (top) and ethnicity (bottom), stratified by gender, 2005

Bar chart showing percentage of people without a usual source of care who indicate a financial or insurance reason for not having a source of care, by race, stratified by gender, 2005. Total: Male, 14.0; Female, 19.0. White: Male, 13.9; Female, 20.2. Black: Male, 13.3; Female, 13.9. Asian: Male, No data; Female, 17.2.

Bar chart showing percentage of people without a usual source of care who indicate a financial or insurance reason for not having a source of care, by ethnicity, stratified by gender, 2005. Non-Hispanic White: Male, 10.0; Female, 17.0. Hispanic: Male, 21.0; Female, 27.5.

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2005.
Note: Data for Native Hawaiians and Other Pacific Islanders women, American Indians and Alaska Natives, and Asian males did not meet the criteria for statistical reliability, data quality, or confidentiality.

  • Women were more likely than men to not have a usual source of care due to financial or insurance reasons (19.0% compared with 14.0%; Figure 4.31). This was also true among Blacks, non-Hispanic Whites, and Hispanics.
  • There were no statistically significant racial or ethnic differences among women.

Children

Children (individuals less than 18 years old) made up 24.8% of the U.S. population, or 73.5 million people, in 2006.26 Almost 40% of all children were members of racial and ethnic minority groups,1 and 17.6% of children lived infamilies with incomes below the Federal poverty level.19

In 2003, Black children and AI/AN children had death rates about one and one-half to two times higher than White children. In 2005, Black infants were more than twice as likely as White infants to die during their first year.30 Life expectancy at birth was 78.3 years for White children30 and 73.2 years for Black children, a difference of about 5 years.30

Many measures relevant to children are tracked in the NHDR. Findings presented here highlight four quality measures and two access measures of particular importance to children (for ages 2 months to 19 years, depending on the measure):

Component of health care needMeasure
PreventionEarly childhood vaccinations, counseling about physical activity, vision screening
Patient safetyAccidental puncture or laceration
TimelinessAdmissions with perforated appendix
Access to careHealth insurance

In addition, the final section of this chapter, which discusses individuals with special health care needs, includes findings related to children with special health care needs.

Quality of Health Care

Prevention: Early Childhood Vaccinations

Childhood vaccinations protect recipients from illness and disability and protect others in the community. Vaccinations are important for reducing mortality and morbidity in populations.

Figure 4.32. Composite measure: Children ages 19-35 months who received all recommended vaccines, by race (top), ethnicity (middle), and income (bottom), 2000-2006

Line graph showing children ages 19-35 months who received all recommended vaccines, by race, 2000-2006: White: 2000, 74.2%; 2001, 75.1%; 2002, 76.6%; 2003, 81.7%; 2004, 83.1%; 2005, 81.3%; 2006: 81.6%. Black: 2000, 67.9%; 2001, 67.5%; 2002, 68.8%; 2003, 72.4%; 2004, 74.9%; 2005, 78.7%; 2006, 77.0%. Asian: 2000, 69.0%; 2001, 73.6%; 2002, 79.2%; 2003, 78.9%; 2004, 82.7%; 2005, 79.1%; 2006, 80.0%. AI/AN: 2000, 71.7%; 2001, 72.2%; 2002, 61.7%; 2003, 77.3%; 2004, 75.8%; 2005, 78.6%; 2006, 81.4%. More than 1 Race: 2000, 73.5%; 2001, 72.5%; 2002, 68.0%; 2003, 77.1%; 2004, 75.6%; 2005, 81.6%; 2006, 77.0%.

Line graphs show children ages 19-35 months who received all recommended vaccines, by ethnicity, 200-2006: Non-Hispanic White: 2000, 76.1%; 2001, 75.4%; 2002, 77.7%; 2003, 82.5%; 2004, 83.3%; 2005, 82.1%; 2006, 82.2%. Hispanic: 2000, 68.5%; 2001, 74.1%; 2002, 72.7%; 2003, 77.0%; 2004, 79.7%; 2005, 78.8%; 2006, 80.0%.

Line graphs show children ages 19-35 months who received all recommended vaccines, by income, 2006-2006. By Income: High Income: 2000, 78.8%; 2001, 79.3%; 2002, 81.6%; 2003, 86.7%; 2004 87.6%; 2005, 86.5%; 2006, 86.3%. Middle Income: 2000, 76.1%; 2001, 75.4%; 2002, 77.1%; 2003, 80.9%; 2004, 82.5%; 2005, 82.3%, 2006, 80.6%. Near Poor: 2000, 70.2%; 2001, 71.0%; 2002, 69.9%; 2003, 77.5%; 2004, 79.1%; 2005, 78.2%; 2006, 79.5%. Poor: 2000, 67.2%; 2001, 68.0%; 2002, 69.3%; 2003, 75.0%; 2004, 76.8%; 2005, 76.5%; 2006, 76.5%.

Key: AI/AN = American Indian or Alaska Native.
Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Immunization Survey, 2000-2006.
Reference population: Civilian noninstitutionalized population ages 19-35 months.
Note: Recommended vaccines for children 19-35 months are based on the Healthy People 2010 objective and do not include varicella vaccine or vaccines added to the recommended schedule after 1998 for children up to 35 months of age. Racial categories changed in 2000 and may not be comparable with those used for previous years. More information can be found in the Measure Specifications Appendix.

  • From 2000 to 2006, the gap between Blacks and Whites and between Asians and Whites who received all recommended vaccines decreased (Figure 4.32). However, in 2006, Black children were less likely than White children to receive all recommended vaccines (77.0% compared with 81.6%).
  • The gap between Hispanics and non-Hispanic Whites in the percentage of children who received all recommended vaccines decreased during this time period. In 2006, there were no statistically significant differences between Hispanics and non-Hispanic Whites.
  • The gap between children from poor families and children from high-income families decreased. However, in 2006, the percentage of children who received all recommended vaccines was lower for children from poor (76.5%), near-poor (79.5%), and middle-income families (80.6%) than for children from high-income families (86.3%).
  • Nationally, vaccination coverage levels among White (81.6%), AI/AN (81.4%), non-Hispanic White (82.2%), middle-income (80.6%), and high-income (86.3%) children achieved the Healthy People 2010 objective of 80% of children receiving all recommended vaccines.

Prevention: Counseling About Physical Activity

Lack of physical activity contributes to overweight in children. Routine promotion of physical activity among children is widely recommended and may help them develop habits that will last into adulthood, thereby influencing better long-term health.

Figure 4.33. Children ages 2-17 for whom a health provider ever gave advice about the amount and kind of exercise, sports, or physically activity hobbies they should have, by race (top), ethnicity (middle), and income (bottom), 2002-2005

Line graph shows percent of children ages 2-17 for whom a health provider ever gave advice about the amount and kind of exercise, sports, or physically activity hobbies they should have, by race, 2002-2005. Total, 2002: 31.9%, 2005: 34.8%; Black, 2002: 32%, 2005: 32%. Asian: 2002: 30%; 2005: 26.3%. White: 2002: 32%; 2005: 35.9%. More than one race: 2002: 28%; 2006: 28%.

Line graph shows percent of children ages 2-17 for whom a health provider ever gave advice about the amount and kind of exercise, sports, or physically activity hobbies they should have, by ethnicity, 2002-2005. Non-Hispanic White: 2002: 31%; 2003: 30.5%; 2004: 31%; 2005: 35%. Hispanic: 2002: 31%; 2003: 33%; 2004: 35%; 2005: 35.5%.

Line graph shows percent of children ages 2-17 for whom a health provider ever gave advice about the amount and kind of exercise, sports, or physically activity hobbies they should have, by income, 2002-2005. Poor: 2002: 30.9%; 2003: 31%; 2004: 30.9%; 2005: 33.7%. Low Income: 2002: 29%; 2003: 26%; 2004: 30%; 2005: 35%. Middle Income: 2002: 30%; 2003: 30%; 2004: 30.5%; 2005: 33.7%. High Income: 2002: 38.5%; 2003: 38%; 2004: 38%; 2005: 38.5%.

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2005.
Reference population: Civilian noninstitutionalized population ages 2-17.
Note: More data by insurance status can be found in the Low-Income Groups section.

  • From 2002 to 2005, the overall percentage of children whose parents or guardians reported ever receiving advice from a health provider about physical activity improved (from 31.9% to 34.8%; Figure 4.33). However, there were no significant changes for racial or ethnic groups.
  • In 2005, Asian children (26.3%) and children of multiple race (28.0%) were less likely than Whites (35.9%) to have received advice about physical activity.
  • From 2002 to 2005, the gap between poor and high-income families in the percentage of children whose parents or guardians reported advice from a health care provider about physical activity remained the same. In 2005, poor children (30.9%) and middle-income children (33.7%) were less likely than high-income children (38.7%) to have received advice about physical activity.
  • In 2005, uninsured children were less likely than privately insured children to have received advice about physical activity (28.5% compared with 36.1%; data not shown in this figure. (Go to Figure 4.23).

Prevention: Vision Screening

Vision checks for children can help to detect eye problems early and, in some cases, improve the chances that corrective treatments will be prescribed and successful.

Figure 4.34. Children ages 3-6 who ever had their vision checked by a health provider, by race (top), ethnicity (middle), and income (bottom), 2001-2005

Line graphs show children ages 3-6 who ever had their vision checked by a health provider, by race, 2001-2005: Black: 2001: 67%; 2002: 65.6%; 2003: 61.8%; 2004: 62.1%; 2005: 65%. White: 2001: 58%; 2002: 59%; 2003: 61%; 2004: 56.5%; 2005: 60%.

Line graphs show children ages 3-6 who ever had their vision checked by a health provider, by ethnicity, 2001-2005: Non-Hispanic White: 2001: 60%; 2002: 60.5%; 2003: 63%; 2004: 57%; 2005: 60.5%. Hispanic: 2001: 52%; 2002: 54%; 2003: 58%; 2004: 57%; 2005: 59%.

Line graphs show children ages 3-6 who ever had their vision checked by a health provider, by income, 2001-2005: Poor: 2001: 53.5%; 2002: 55%; 2003: 58%; 2004: 56%; 2005: 58%. Near Poor, 2001: 57.6%; 2002: 57.5%; 2003: 57.5%; 2004: 58%; 2005: 59.8%. Middle Income, 2001: 56%; 2002: 59.5%; 2003: 60%; 2004: 51.5%; 2005: 57.5%. High Income: 2001: 69.5%; 2002: 67.5%; 2003: 66%; 2004: 67.5%; 2005: 65%.

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2001-2005.
Reference population: Civilian noninstitutionalized population ages 3-6.

  • There were no statistically significant racial or ethnic differences in the percentage of children who received vision screening (Figure 4.34).
  • Uninsured children were less likely than privately insured children to receive vision screening (41.6% compared with 61.4%; data not shown).

Patient Safety: Accidental Puncture or Laceration

Adverse events occurring during surgical procedures include unintended cuts, punctures, perforations, and lacerations. Such events may be more likely in children, whose smaller anatomy may make avoiding such events more technically challenging. Prior analyses of Healthcare Cost and Utilization Project (HCUP) data from 2000 using earlier versions of the present indicator identified a cumulative incidence of 1 accidental puncture or laceration per 1,000 pediatric discharges, with significant associated increases in length of stay, billed charges, and inpatient mortality.44 To the degree that such adverse events can be avoided by proper surgical technique, variations in their occurrence may be a marker of differences in the quality of pediatric surgical care. However, such rates are best interpreted in light of the risks associated with medical or surgical discharges of varying complexity.

Figure 4.35. Accidental puncture or laceration during procedure per 1,000 discharges, children under age 18, by race/ethnicity (top) and income (bottom), 2005

Bar chart showing rates of accidental puncture or laceration during procedure per 1,000 discharges, children under age 18, by race/ethnicity, 2005. White: 0.96; Black: 0.79; API: 0.82; Hispanic: 0.77.

Bar chart showing rates of accidental puncture or laceration during procedure per 1,000 discharges, children under age 18, by income, 2005. Poor: 0.9; Low Income: 0.96; Middle Income: 0.79; High Income: 0.84.

Key: API = Asian or Pacific Islander.
Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID) disparities analysis file, 2005.
Note: White, Black, and API are non-Hispanic. The HCUP SID disparities analysis file is designed to provide national estimates on disparities using weighted records from a sample of hospitals from 23 States that have 63% of the U.S. resident population. Income categories are based on the median income of the ZIP Code of the patient's residence. These data are not risk adjusted. Rates include medical or surgical discharges only.

  • Black children (0.79 per 1,000 discharges) and Hispanic children (0.77 per 1,000 discharges) had lower rates of accidental puncture or laceration than White children (0.96 per 1,000 discharges) (Figure 4.35).
  • Children living in low-income communities had a higher rate of accidental puncture or laceration than children living in high-income communities (0.96 per 1,000 discharges compared with 0.84 per 1,000 discharges).

Timeliness: Admissions With Perforated Appendix

Appendiceal perforation or rupture may increase risks of internal organ damage, female infertility, and even death.45 Research suggests that there is little lag in the United States between correct diagnosis of appendicitis and surgical intervention.46 Therefore, perforated appendicitis in children may better reflect delayed symptom recognition by parents or providers, combined with logistical, financial, racial, sociocultural, and other barriers to timely access to acute care for what is a time-dependent acute illness.47 Prior studies based on data from the HCUP and other sources have identified minority status, lower income, lack of private insurance, and admission from a non-emergency department source as risk factors for discharge with appendiceal rupture.48

Figure 4.36. Perforated appendixes per 1,000 admissions with appendicitis, ages 1-17, by race/ethnicity (top) and income (bottom), 2005

Bar chart shows perforated appendixes per 1,000 admissions with appendicitis, ages 1-17, by race/ethnicity, 2005. White: 272.9; Black: 367.0; API: 299.0; Hispanic: 328.0.

Bar charts shows Perforated appendixes per 1,000 admissions with appendicitis, ages 1-17, by income, 2005. Poor: 324.1; Low Income: 298.6; Middle Income: 296.7; High Income: 271.3.

Key: API = Asian or Pacific Islander.
Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID) disparities analysis file, 2005.
Note: White, Black, and API are non-Hispanic. Rates are adjusted for age and gender. The HCUP SID disparities analysis file is designed to provide national estimates on disparities using weighted records from a sample of hospitals from 23 States that have 63% of the U.S. resident population. Income categories are based on the median income of the ZIP Code of the patient's residence.

  • Among children with appendicitis, discharges with perforations were higher for Blacks (367.0 per 1,000 admissions) and Hispanics (328.0 per 1,000 admissions) than Whites (272.9 per 1,000 admissions) (Figure 4.36).
  • Among children with appendicitis, discharges with perforations were higher for people living in poor communities (324.1 per 1,000 admissions), low-income communities (298.6 per 1,000 admissions), and middle-income communities (296.7 per 1,000 admissions) than for people living in high-income communities (271.3 per 1,000 admissions).

To distinguish between the effects of race and ethnicity and those of income on pediatric discharges with perforated appendix, this measure is stratified by income level.

Figure 4.37. Perforated appendixes per 1,000 admissions with appendicitis, ages 1-17, by race/ethnicity, stratified by income, 2005

Bar chart shows perforated appendixes per 1,000 admissions with appendicitis, ages 1-17, by race/ethnicity, stratified by income, 2005. Refer to notes below for summary information.

Key: API = Asian or Pacific Islander.
Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID) disparities analysis file, 2005.
Note: White, Black, and API are non-Hispanic. Rates are adjusted for age and gender. The HCUP SID disparities analysis file is designed to provide national estimates on disparities using weighted records from a sample of hospitals from 23 States that have 63% of the U.S. resident population. Income categories are based on the median income of the ZIP Code of the patient's residence.

  • Hispanic children living in communities of every income level except high-income communities had higher rates of hospital discharges with perforated appendix than Whites (Figure 4.37).
  • Black children living in communities of every income level except middle-income communities had higher rates of hospital discharges with perforated appendix than Whites.
  • There were no statistically significant differences between APIs and Whites at any income level.

Access to Health Care

Health Insurance

Insurance coverage is among the most important factors in access to health care. Special efforts have been made to provide insurance coverage to children.49

Figure 4.38. Children with health insurance, by race (top), ethnicity (middle), and family income (bottom), 1999-2006

Line graphs show children with health insurance, 1999-2006. By Race: White: 1999, 89.2%; 2000, 88.4%; 2001, 89.7%; 2002, 89.8%; 2003, 90.4%; 2004, 90.4%; 2005, 90.8%; 2006, 90.5%. Black: 1999, 88.0%; 2000, 87.9%; 2001, 89.3%; 2002, 89.9%; 2003, 90.9%; 2004, 92.9%; 2005, 91.2%; 2006, 90.5%. Asian: 1999, 89.7%; 2000, 87.4%; 2001, 87.1%; 2002, 86.4%; 2003, 88.0%; 2004, 89.7%; 2005, 88.9%; 2006, 90.6%. AI/AN, 1999, 63.8%; 2000, 64.4%; 2001, 72.6%; 2002, 72.6%; 2003, 65.7%; 2004, 72.8%; 2005, 79.5%; 2006, 76.0%. More than 1 Race: 1999, 92.0%; 2000, 87.9%; 2001, 90.2%; 2002, 88.3%; 2003, 90.9%; 2004, 95.9%; 2005, 93.0%; 2006: 88%.

Line graphs show children with health insurance, 1999-2006. By Ethnicity: Non-Hispanic White: 1999, 91.9%; 2000, 91.3%; 2001, 92.8%; 2002, 92.5%; 2003, 93.6%; 2004, 93.6%; 2005, 93.5%; 2006: 93.8%. Hispanic: 1999, 73.3%; 2000, 74.1%; 2001, 75.4%; 2002, 78.1%; 2003, 79.8%; 2004, 80.5%; 2005, 82.5%; 2006: 80.7%.

Line graphs show children with health insurance, 1999-2006. By family income. Poor: 1999, 78.7%; 2000, 79.3%; 2001, 81.0%; 2002, 83.8%; 2003, 84.2%; 2004, 85.0%; 2005, 85.7%; 2006: 86.1%. Near Poor: 1999, 78.3%; 2000, 78.5%; 2001, 82.5%; 2002, 83.6%; 2003, 84.5%; 2004, 84.9%; 2005, 85.0%; 2006: 84.0%. Middle Income: 1999, 93.7%; 2000, 92.0%; 2001, 93.2%; 2002, 91.7%; 2003, 92.8%; 2004, 92.4%; 2005, 92.2%; 2006: 93%. High Income: 1999, 97.9%; 2000, 97.5%; 2001, 98.1%; 2002, 97.6%; 2003, 97.5%; 2004, 97.4%; 2005, 96.8%; 2006: 97.9%

Key: AI/AN = American Indian or Alaska Native.
Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 1999-2006.
Reference population: Civilian noninstitutionalized population under age 18.
Note: Insurance status is determined at the time of interview. Children are considered uninsured if they lack private health insurance, public assistance (including the State Children's Health Insurance Program), Medicare, Medicaid, a State-sponsored health plan, other government-sponsored programs, or a military health plan, or if their only coverage is through the Indian Health Service. This measure reflects the percentage of children who were covered by health insurance at the time of the interview.

  • From 1999 to 2006, the gap between AI/ANs and Whites, between Hispanics and non-Hispanic Whites in the percentage of children with health insurance decreased (Figure 4.38).
  • In 2006, the percentage of children with health insurance was significantly lower for AI/AN children than for White children (76.0% compared with 90.5%).
  • In 2006, the percentage of children with health insurance was significantly lower for Hispanic children than for non-Hispanic White children (80.7% compared with 93.8%).
  • In 2006, the percentage of children with health insurance was significantly lower for poor (86.1%) and near-poor children (84.0%) than for high-income children (96.9%).

Older Adults

In 2005, 37.3 million persons age 65 and over lived in the United States.50 Further, the percentage of the population over age 65 is swiftly increasing. People age 65 and over represented 12.4% of the population in 2006 but are expected to grow to about 20% of the population by 2030.51 The past century has seen significant increases in life expectancy, and 65-year-olds could expect to live an additional 18.7 years.50 Nonetheless, older adults face greater health care concerns than younger populations. In 2006, 38.9% of noninstitutionalized older adults assessed their health as excellent or very good, compared with 65.1% of persons ages 18-64,52 and the majority of older persons have at least one chronic condition.

Older women outnumber older men by more one-third.50 In addition, members of minority groups are projected to represent more than 25% of the older population in 2030, up from about 16% in 200053. About 3.4 million older people lived below the poverty level in 2006, corresponding to a poverty rate of 9.4%.50 Another 2.2 million, or 6.2% of older people, were classified as near poor, with incomes between 100% and 125% of the Federal poverty level.50

The Medicare program provides core health insurance to nearly all older Americans and reduces many financial barriers to acute and post-acute care. The Medicare Prescription Drug Improvement and Modernization Act of 2003 has added prescription drug and preventive benefits to Medicare and provides extra financial help to persons with low incomes. Therefore, differences in access to and quality of health care tend to be smaller among Medicare beneficiaries than among younger populations.

Surveys of the general population often do not include enough older people to examine racial, ethnic, or socioeconomic differences in health care. Consequently, the NHDR relies on data from the Medicare Current Beneficiary Survey to examine disparities in access to and quality of care. Findings presented here highlight three quality measures and one access measure of particular importance to the older population:

Component of health care needMeasure
PreventionInfluenza vaccination, vision screening
Access to careDelayed care due to cost
Patient centerednessHealth literacy

Quality of Health Care

Prevention: Influenza Vaccination

Influenza is responsible for significant morbidity and decreased productivity during outbreaks. Older adults are at increased risk for complications from influenza infections. Vaccination is an effective strategy to reduce illness and deaths due to influenza. The U.S. Preventive Services Task Force and the Centers for Disease Control and Prevention recommend annual influenza vaccination of all older individuals.

Figure 4.39. Medicare beneficiaries age 65 and over who had an influenza vaccination in the last winter, by race (top), ethnicity (middle), and income (bottom), 1998, 2000, 2002, and 2004

Line graph shows percent Medicare beneficiaries age 65 and over who had an influenza vaccination in the last winter, 1998, 2000, 2002, and 2004. By Race: Total: 1998: 68.7%; 2000: 68.7%; 2002: 68.7%; 2004: 71.7%. White: 1998, 70.8%; 2000, 70.8%; 2002, 70.7%; 2004, 73.7%. Black: 1998, 50.3%; 2000, 53.1%; 2002, 55.8%; 2004, 55.9%. API: 1998, 60%; 2000, 73.6%; 2002, 64.7%; 2004, 66%. AI/AN: 1998, 59.9%; 2000, 62.2%; 2002, 68.1%; 2004, 62%.

Line graph shows percent Medicare beneficiaries age 65 and over who had an influenza vaccination in the last winter, 1998, 2000, 2002, and 2004. By Ethnicity: Non-Hispanic White: 1998, 71.6%; 2000, 71.6%; 2002, 71.5%; 2004, 74.6.% Hispanic: 1998, 57.8%; 2000, 56.9%; 2002, 56.1%; 2004, 58.6.

Line graph shows percent Medicare beneficiaries age 65 and over who had an influenza vaccination in the last winter, 1998, 2000, 2002, and 2004. By Income: Poor: 1998, 57.4%; 2000, 59.6%; 2002, 58.9%; 2004, 61.3%. Near Poor: 1998, 65.9%; 2000, 67.4%; 2002, 67.5%; 2004, 68.6%. Middle Income: 1998, 71.8%; 2000, 71.3%; 2002, 70.7%; 2004, 74.4%. High Income: 1998, 75.1%; 2000, 74.5%; 2002, 74.5%; 2004, 77.6%.

Key: AI/AN = American Indian or Alaska Native; API = Asian or Pacific Islander.
Source: Centers for Medicare & Medicaid Services, Medicare Current Beneficiary Survey, 1998, 2000, 2002, and 2004.
Reference population: Medicare beneficiaries age 65 and over living in the community.

  • From 1998 to 2004, the percentage of Medicare beneficiaries age 65 and over with an influenza vaccination in the last winter increased overall from 68.7% to 71.7% (Figure 4.39).
  • From 1998 to 2004, the gap between Blacks and Whites decreased. However, in 2004, the percentage was still significantly lower for Blacks than for Whites (55.9% compared with 73.7%).
  • During this period, the gap between Hispanics and non-Hispanic Whites increased. In 2004, the percentage was also significantly lower for Hispanics than for non-Hispanic Whites (58.6% compared with 74.6%).
  • In 2004, the percentage was significantly lower for poor (61.3%), near-poor (68.6%), and middle-income (74.4%) beneficiaries than for high-income beneficiaries (77.6%).
  • In 2004, the Healthy People 2010 target of 90% of older Americans with influenza vaccination was not yet achieved by any population group.

Prevention: Vision Screening

Visual impairment is a common and potentially serious problem among older people. Personal safety may be compromised as risks of falls and car accidents increase. Because eye problems are often not recognized by older people, the U.S. Preventive Services Task Force recommends routine vision screening.54

Figure 4.40. Medicare beneficiaries age 65 and over who had an eye examination in the last 12 months, by race (top), ethnicity (middle), and income (bottom), 1998, 2000, 2002, and 2004

Line graph shows Medicare beneficiaries age 65 and over who had an eye examination in the last 12 months, by race, 1998, 2000, 2002, and 2004. White: 1998, 60%; 2000, 60%; 2002, 61%; 2004, 61%. Black: 1998, 54%; 2000, 54%; 2002, 55%; 2004, 56%. AI/AN: 1998, 52%; 2000, 56%; 2002, 56%; 2004, 54%. API: 1998, 56%; 2000, 55%; 2002, 59%; 2004, 55%.

Line graph shows Medicare beneficiaries age 65 and over who had an eye examination in the last 12 months, by ethnicity, 1998, 2000, 2002, and 2004. Non-Hispanic White: 1998, 60%; 2000, 60.5%; 2002, 63%; 2004, 64%. Hispanic: 1998, 55%; 2000, 50%; 2002, 55%; 2004, 58%.

Line graph shows Medicare beneficiaries age 65 and over who had an eye examination in the last 12 months, by income, 1998, 2000, 2002, and 2004. Poor: 1998, 47%; 2000, 50%; 2002, 53%; 2004, 52.8%. Near Poor: 1998, 56%; 2000, 55.5%; 2002, 58.2%; 2004, 58.0%. Middle Income: 1998, 63%; 2000, 63%; 2002, 64%; 2004, 64.2%. High Income: 1998, 66.3.0%; 2000, 65.7%; 2002, 66.6%; 2004, 67.2%.

Key: AI/AN = American Indian or Alaska Native; API = Asian or Pacific Islander.
Source: Centers for Medicare & Medicaid Services, Medicare Current Beneficiary Survey, 1998, 2000, 2002, and 2004.
Reference population: Medicare beneficiaries age 65 and over living in the community.

  • From 1998 to 2004, the gap between Blacks and Whites in the percentage of Medicare beneficiaries age 65 and over with an eye exam in the past year decreased. In 2004, there was no statistically significant difference between Blacks and Whites; Figure 4.40).
  • During this period, there were no statistically significant changes or differences between Hispanics and non-Hispanic Whites.
  • During this period, the gap between poor individuals and high-income individuals remained the same. In 2004, poor (52.8%) and near-poor (58.0%) individuals were less likely than high-income individuals (67.2%) to have had an eye exam in the past year.

Access to Care

Delayed Care Due to Cost

Timely delivery of appropriate care has been shown to improve health care outcomes and reduce health care costs. Timely receipt of care is especially important for the older population due to their often increased medical needs. Delayed health care can lead to diagnosis at a more advanced disease stage and reduce opportunities for optimal treatment.xiv

Figure 4.41. Medicare beneficiaries age 65 and over with delayed health care due to cost by race (top), ethnicity (middle), and income (bottom), 1998, 2000, 2002, and 2003, and 2005

Line graph shows percent Medicare beneficiaries age 65 and over with delayed care due to cost, by race, 1998, 2000, 2002, 2003, and 2005. By Race: White: 1998, 4; 2000, 4.5; 2002, 4.7; 2003, 4.2; 2005, 4.7. Black: 1998, 6.1; 2000, 6.9; 2002, 5.4; 2003, 5.9; 2005, 7.

Line graph shows percent Medicare beneficiaries age 65 and over with delayed care due to cost, by ethnicity, 1998, 2000, 2002, 2003, and 2005. By Ethnicity: Non-Hispanic White: 1998, 4; 2000, 4.4; 2002, 4.7; 2003, 4.3; 2005: 4.4. Hispanic: 1998, 4.7; 2000, 6.5; 2002, 5.8; 2003, 3.9; 2005: 7.8.

Line graph shows percent Medicare beneficiaries age 65 and over with delayed care due to cost, by income, 1998, 2000, 2002, 2003, and 2005. By Income: Poor: 1998, 8.5; 2000, 8.7; 2002, 7; 2003, 6.7; 2005, 9.5. Near Poor: 1998, 6.1; 2000, 7.1; 2002, 7; 2003, 6.8; 2005, 6.9. Middle Income: 1998, 2.9; 2000, 3; 2002, 4.3; 2003, 3; 2005, 3.6. High Income: 1998, 1.3; 2000, 1.9; 2002, 2; 2003, 2; 2005, 2.0.

Source: Centers for Medicare & Medicaid Services, Medicare Current Beneficiary Survey, 1998, 2000, 2002, 2003, and 2005.
Reference population: Medicare beneficiaries age 65 and over living in the community.

  • The percentage of Medicare beneficiaries age 65 and over who delayed care due to cost was higher for Hispanics compared with non-Hispanic Whites (7.8% compared with 4.4%; (Figure 4.41).
  • From 1998 to 2005, there were no significant changes in the gap between poor and high-income people in the percentage of Medicare beneficiaries age 65 and over who delayed care due to cost. In 2005, the percentage delaying care was significantly higher for poor (9.5%), near-poor (6.9%), and middle-income (3.6%) beneficiaries than for high-income beneficiaries (2.0%).

xiv In this measure, delayed care due to cost is self-reported by patients.


Focus on Health Literacy

Healthy People 2010's Objective 11-2 is to improve Americans' health literacy, defined as the capacity to obtain, process, and understand basic health information and services needed to make appropriate health care decisions.55 In 2003, the first-ever national assessment of health literacy was conducted—the Health Literacy Component (HLC) of the National Assessment of Adult Literacy (NAAL). The HLC assesses responses to health-related tasks presented in written form. These tasks fall into three categories:

  • Clinical
  • Prevention
  • Health system navigation

The HLC tasks require familiarity with health-related words; experience with written materials, such as drug labels and health insurance forms; or knowledge of how the health care system works. The HLC did not measure the ability to obtain or understand information from nonprint sources.

There are racial and ethnic differences in health literacy, with minority adults having lower health literacy than White adults, with the exception of Asians and Pacific Islanders.56 There is evidence that inadequate health literacy is linked to all-cause mortality and cardiovascular mortality among older adults.57

The HLC measures the English health literacy of adults in the United States. Four million adults had language barriers or cognitive or mental disabilities that prevented them from taking the NAAL; therefore, they are not included in the results presented below. The NAAL captures no information on these adults' literacy in another language.

The NAAL groups adults without language barriers into four performance levels:

  • Below basic: This performance level indicates that a person can understand no more than the most simple and concrete skills (e.g., circle the date of a medical appointment on a hospital appointment slip). Thirty million adults were found to have below basic health literacy; 7 million of these were unable to answer the simplest of questions and were determined to be nonliterate in English.
  • Basic: This performance level indicates that a person can perform the skills needed for simple and everyday activities (e.g., give two reasons a person with no symptoms of a specific disease should be tested for the disease, based on information in a clearly written pamphlet). Forty-seven million adults were found to have basic health literacy.
  • Intermediate: This performance level indicates that a person can perform the skills needed for moderately challenging activities (e.g., identify three substances that may interact with an over-the-counter drug to cause a side effect, using the information on the over-the-counter drug label). One hundred and fourteen million adults were found to have intermediate health literacy.
  • Proficient: This performance level indicates that a person can perform the skills needed for more complex and challenging activities (e.g., find the information required to define a medical term by searching through a complex document) needed to manage health and prevent disease. Twenty-six million adults were found to have proficient health literacy.

Racial and ethnic disparities in health literacy were discussed in the 2007 NHDR.58 Findings on health literacy continue to be a topic of interest in the area of health disparities. This year, differences by age are discussed here.

Figure 4.42. Adults at each health literacy level, by age, 2003

Bar graph showing adults at each health literacy level, by age, 2003. A summary of the information is provided below.

Source: National Assessment of Adult Literacy, Health Literacy Component, 2003.
Note: Adults are defined as people age 16 years and over living in households or prisons. Adults who could not be interviewed because of language spoken or cognitive or mental disabilities (3% in 2003) are excluded from this figure.

  • Adults age 65 and over were more likely to have below basic or basic health literacy skills than those under age 65 (Figure 4.42).
  • The health literacy of adults over age 75 was significantly worse than adults ages 65 to 75. More than two-thirds of adults over age 75 had below basic or basic health literacy.
  • Age had relatively little relationship to health literacy among adults who were under age 65.
Current as of March 2009
Internet Citation: Chapter 4. Priority Populations (continued, 3): National Healthcare Disparities Report, 2008. March 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/nhqrdr/nhdr08/Chap4c.html