Chapter 2. Quality of Health Care (continued)

National Healthcare Disparities Report, 2009

Effectiveness (continued)

Diabetes

Mortality
Number of deaths (2006)72,4494
Cause of death rank (2006)6th4
Prevalence
Total number of Americans with diabetes (2007)23.6 million14
Number of people with diagnosed diabetes (2007)17.9 million14
Number of people with undiagnosed diabetes (2007)5.7 million14
Incidence
New cases (age 20 and over, 2007)1.6 million14
Cost
Total cost (2007 est.)$174 billion15
Direct medical costs (2007 est.)$116 billion15

Management: Receipt of Three Recommended Diabetes Services

Effective management of diabetes includes hemoglobin A1c (HbA1c)v testing, eye examination, and foot examination, as well as appropriate influenza immunization and lipid management.16-18

 

Figure 2.9. Composite measure: Adults age 40 and over with diagnosed diabetes who received three recommended services for diabetes (HbA1c testing, eye examination, foot examination) in the calendar year, by race, ethnicity, family income, and education, 2002-2006

Trend line chart. percentages; White, 2002, 43.3; 2003, 46.4; 2004, 43.7; 2005, 41.0; 2006, 42.2; Black, 2002, 42.8; 2003, 36.8; 2004, 43.3; 2005, 37.0; 2006, 36.6.

Non-Hispanic white; 2002, 45.1; 2003, 47.8; 2004, 45.4; 2005, 42.4; 2006, 44.6; Hispanic; 2002, 33.7; 2003, 39.3; 2004, 35.7; 2005, 33.8; 2006, 31.6.

Poor; 2002, 38.6; 2003, 31.8; 2004, 33.1; 2005, 30.3; 2006, 33.4; Near Poor; 2002, 35.0; 2003, 30.5; 2004, 35.1; 2005, 28.5; 2006, 31.9; Middle Income; 2002, 41.4; 2003, 46.5; 2004, 37.9; 2005, 38.4; 2006, 42.7; High Income; 2002, 52.1; 2003, 55.1; 2004, 55.3; 2005, 52.6; 2006, 47.8.

Less than High School; 2002, 34.1; 2003, 36.0; 2004, 32.2; 2005, 31.5; 2006, 31.4; High School Grad; 2002, 43.1; 2003, 48.2; 2004, 41.7; 2005, 39.9; 2006, 42.9; At Least Some College; 2002, 51.3; 2003, 48.3; 2004, 52.3; 2005, 47.7; 2006, 46.4.

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

Denominator: Civilian noninstitutionalized population age 40 and over.

Note: Recommended services for diabetes are: (1) HbA1c testing, (2) dilated 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 Asians, Native Hawaiians and Other Pacific Islanders, and American Indians and Alaska Natives.

  • In 2006, there were no statistically significant differences between Blacks and Whites for adults age 40 and over with diagnosed diabetes who received three recommended services for diabetes in the calendar year (36.6% compared with 42.2%; Figure 2.9).
  • In 2006, the percentage was significantly lower for Hispanics than for non-Hispanic Whites (31.6% compared with 44.6%).
  • In 2006, the percentage was also significantly lower for poor (33.4%), near-poor (31.9%), and middle-income people (42.7%) than for high-income people (47.8%).
  • In 2006, 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 (31.4%) and high school graduates (42.9%) than for people with at least some college education (46.4%).

As noted above, multivariate analyses were conducted to identify the independent effects of race and socioeconomic factors on several measures. Adjusted percentages are shown for receipt of diabetes services after controlling for race/ethnicity, family income, education, health insurance status, and location.

 

Figure 2.10. Composite measure: Adjusted percentages of adults ages 40-64 with diagnosed diabetes who received three recommended services for diabetes in the calendar year, by race/ethnicity, family income, education, insurance status, and residence location, 2002-2006

Bar chart. In percentages. Non-Hispanic White; 43. Non-Hispanic Black; 41. Hispanic; 38. Poor; 35. Low Income; 33. Middle Income; 39. High Income; 50. Less than High School; 38. High School Grad; 41. Some College; 45. Private Insurance; 44. Public Insurance Only; 41. Uninsured; 31. Metropolitan; 43. Nonmetropolitan; 39.

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

Note: Adjusted percentages are predicted marginals from a statistical model that includes the covariates race/ethnicity, family income, education, health insurance, and residence location. Chapter 1, Introduction and Methods, provides more information.

  • In the multivariate model used, after adjustment, among adults ages 40-64 with diagnosed diabetes, 35% of poor adults, 33% of low-income adults, and 39% of middle-income adults would have received the three recommended services for diabetes in the calendar year compared with 50% of high-income adults.
  • After adjustment, only 38% of adults with diabetes with less than a high school education would have received the three recommended services for diabetes compared with 45% of those with some college education.
  • After adjustment, only 31% of adults with diabetes who were uninsured all year would have received all three recommended services for diabetes compared with 44% of those who had any private insurance.
  • After adjustment, 39% of adults with diabetes who were living in nonmetropolitan areas would have received all three recommended services for diabetes compared with 43% of those who were living in metropolitan areas.

Outcome: Short-Term Complications

Short-term complications can occur for patients with diabetes when their condition is not managed properly. Very high or very low blood sugar levels or too little insulin can be fatal if untreated and requires emergency care.

 

Figure 2.11. Hospital admissions for diabetes with short-term complications per 100,000 population, age 18 and over, by race/ethnicity and income, 2001-2006

Trend line charts. percentages. Race/ethnicity. Total; 2001, 55.3, 2002, 57.0, 2003, 55.9, 2004, 57.4, 2005, 57.7, 2006, 57.8. White; 2001, 43.0, 2002, 44.2, 2003, 44.6, 2004, 46.0, 2005, 47.1, 2006, 46.8. Black; 2001, 159.0, 2002, 163.5, 2003, 148.9, 2004, 154.3, 2005, 145.4, 2006, 151.2. API; 2001, 19.3, 2002, 17.6, 2003, 17.9, 2004, 19.3, 2005, 16.4, 2006, 15.5. Hispanic; 2001, 51.3, 2002, 56.7, 2003, 58.1, 2004, 55.7, 2005, 56.8, 2006, 53.6. Income level.

Less than $25,000; 2001, 84.9, 2002, 114.5, 2003, 130.4, 2004, 90.1, 2005, 92.2, 2006, 90.1. $25,000-34,999; 2001, 58.3, 2002, 78.0, 2003, 78.3, 2004, 61.2, 2005, 59.6, 2006, 61.2. $35,000-44,999; 2001, 46.3, 2002, 63.4, 2003, 62.0; 2004, 49.2, 2005, 48.6, 2006, 49.2. $45,000+; 2001, 33.7, 2002, 42.8, 2003, 40.8, 2004, 33.3, 2005, 33.7, 2006, 33.3.

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, 2001-2006.

Note: Short-term complications include ketoacidosis, hyperosmolarity, or coma and exclude obstetric admissions and transfers from other institutions. White, Black, and API are non-Hispanic. Data were not available for American Indians and Alaska Natives. Data are adjusted for age, gender, and diagnosis-related group clusters. The HCUP SID disparities analysis file is designed to provide national estimates using weighted records from a sample of hospitals from 25 States that have 66% of the U.S. resident population.

  • In 2006, the rate of hospital admissions for short-term complications was more than three times as high for Blacks as for Whites (151.2 per 100,000 population compared with 46.8 per 100,000 population).
  • The rate of hospital admissions for short-term complications was higher for Hispanics than for Whites (53.6 per 100,000 population compared with 46.8 per 100,000 population).
  • The rate of hospital admissions for short-term complications was almost three times as high for people living in communities with median household incomes of less than $25,000 as it was for people living in communities with median household incomes of $45,000 or more (90.1 per 100,000 population compared with 33.3 per 100,000 population).

 

End Stage Renal Disease (ESRD)

Mortality
Total ESRD deaths (2006)87,65419
Prevalence
Total cases (2006)506,25620
Incidence
New cases (2006)110,85420
Cost
Total Medicare program expenditure for ESRD (2006 est.)$20.0 billion21

Outcome: Adequate Hemodialysis

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

 

Figure 2.12. Adult hemodialysis patients with adequate dialysis (urea reduction ratio 65% or greater), by race and ethnicity, 2002-2007

Percentages. By race; White, 2002, 87.0; 2003, 88.0; 2004, 89.0; 2005, 88.0; 2006, 88.0; 2007, 89.3; Black, 2002, 83.0; 2003, 85.0; 2004, 85.0; 2005, 87.0; 2006, 85.0; 2007, 87.9; Asian, 2002, 93.0; 2003, 95.0; 2004, 95.0; 2005, 95.0; 2006, 94.0; 2007, 96.3; AI/AN, 2002, 89.0; 2003, 88.0; 2004, 92.0; 2005, 91.0; 2006, 91.0; 2007, 93.4; More than 1 Race, 2002, 85.0; 2003, 85.0; 2004, 91.0; 2005, 83.0; 2006, no data; 2007, no data.

Ethnicity, Non-Hispanic White, 2002, 87.0; 2003, 87.0; 2004, 88.0; 2005, 87.0; 2006, 87.0; 2007, 88.6; Hispanic, 2002, 89.0; 2003, 90.0; 2004, 91.0; 2005, 90.0; 2006, 90.0; 2007, 92.1.

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

Source: Centers for Medicare & Medicaid Services, End Stage Renal Disease (ESRD) Clinical Performance Measures Project, 2002-2007.

Denominator: ESRD hemodialysis patients age 18 and over.

Note: Data were not available for Native Hawaiians and Other Pacific Islanders for any data years. Data were not available for multiple race for 2006 and 2007.

  • In 2007, Blacks were less likely than Whites to have adequate dialysis (87.9% compared with 89.3%; Figure 2.12).
  • In 2007, the percentage with adequate dialysis continued to be higher for Asians than for Whites (96.3% compared with 89.3%). Furthermore, the percentage of Asians with adequate dialysis remained significantly higher than the percentage of Whites from 2002 through 2007.
  • From 2002 to 2007, the percentage of Hispanics with adequate dialysis increased (from 89% to 92.1%). Hispanics continued to have a higher percentage with adequate dialysis than non-Hispanic Whites (92.1% for Hispanics compared with 88.6% for non-Hispanic Whites).
  • In 2007, women were more likely than men to have adequate dialysis (93.4% compared with 85.5%; 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.22 It is important for people with ESRD to 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.23 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.19

 

Figure 2.13. Dialysis patients under age 70 who were registered on a waiting list for transplantation, by race and ethnicity, 2000-2005

Trend line chart. percentage. Healthy People 2010 target: 25%,  White, 2000, 16.3; 2001, 15.9; 2002, 16.1; 2003, 16.4; 2004, 16.7; 2005, 17.7; Black; 2000, 10.8; 2001, 10.3; 2002, 10.7; 2003, 10.6; 2004, 11.7; 2005, 12.3; Asian; 2000, 28.0; 2001, 27.7; 2002, 26.8; 2003, 27.5; 2004, 29.5; 2005, 26.7; AI/AN; 2000, 9.7; 2001, 8.5; 2002, 11.1; 2003, 9.2; 2004, 10.8; 2005, 11.6.

Trend line chart. percentage. Healthy People 2010 target: 25%,  Non-Hispanic White; 2000, 17.3; 2001, 16.7; 2002, 16.8; 2003, 17.0; 2004, 17.5; 2005, 18.5; Hispanic; 2000, 12.1; 2001, 12.8; 2002, 13.5; 2003, 13.9; 2004, 13.7; 2005, 15.3.

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

Source: U.S. Renal Data System, 2000-2005.

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

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

  • In 2005, Black dialysis patients continued to be less likely to be registered for transplantation than Whites (12.3% compared with 17.7%; Figure 2.13).
  • In 2005, AI/ANs continued to be less likely to be registered for transplantation than Whites (11.6% compared with 17.7%).
  • In 2005, this percentage was higher for Asians than for Whites (26.7% compared with 17.7%).
  • The gap between Hispanics and non-Hispanic Whites decreased. However, in 2005, the percentage was still lower for Hispanics than for non-Hispanic Whites (15.3% compared with 18.5%).
  • From 2000 to 2005, only Asians achieved the Healthy People 2010 target of 25%.

 

Heart Disease

Mortality
Number of deaths (2006)631,6364
Cause of death rank (2006)1st4
Prevalence
Number of cases of coronary heart disease (2006)16.8 million24
Number of cases of heart failure (2006)5.7 million24
Number of cases of high blood pressure (2006)73.6 million24
Incidence
Number of new cases of heart failure (2004)550,00025
Cost
Total cost of cardiovascular disease (2009)$474.8 billion6
Total cost of heart failure (2009 est.)$37.2 billion24
Direct costs of cardiovascular disease (2009)$313.3 billion6
Cost-effectiveness of hypertension screening$14,000-$35,000/QALY7
Cost-effectiveness of aspirin prophylaxisNet cost savings7,vi

Treatment: Receipt of Angiotensin-Converting Enzyme Inhibitor or Angiotensin Receptor Blocker for Heart Attack

One aspect of recommended hospital care for heart attack includes 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 inhibitors.

 

Figure 2.14. Hospital patients with heart attack and left ventricular systolic dysfunction who received angiotensin-converting enzyme inhibitor or angiotensin receptor blocker treatment (all payers), by race/ethnicity, 2005-2007

Trend line charts, percentage. Race/ethnicity. Total; 2005, 83.4; 2006, 86.4; 2007, 91.3; White; 2005, 83.2; 2006, 86.5; 2007, 91.4; Black; 2005, 84.0; 2006, 86.9; 2007, 91.9; Asian; 2005, 82.0; 2006, 86.4; 2007, 91.7; AI/AN; 2005, 85.2; 2006, 88.3; 2007, 90.8; Hispanic; 2005, 80.9; 2006, 84.5; 2007, 89.2.

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

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

Denominator: Patients hospitalized for heart attack with left ventricular systolic dysfunction.

Note: Whites, Blacks, AI/ANs, and Asians are non-Hispanic groups.

  • In 2007, there were no statistically significant differences between racial groups in the percentage of hospital patients with heart attack and left ventricular systolic dysfunction who received ACE inhibitor or ARB treatment (Figure 2.14).
  • During the same period, the difference between Hispanics and non-Hispanic Whites remained statistically significant. In 2007, the percentage was significantly lower for Hispanics compared with non-Hispanic Whites (89.2% compared with 91.4%).

 

 

HIV and AIDS

Mortality
Number of deaths of people with AIDS (2007)14,56126
Prevalence
Number of people living with HIV infection (not including AIDS; 2007)263,93626
Number of people living with AIDS (2007)468,57826
Incidence
Number of new HIV infections (2007)56,30027
Number of new AIDS cases (2007)37,04126
Cost
Federal spending on domestic HIV/AIDS care, cash and housing assistance, and prevention and research (fiscal year 2009 est.)$19.4 billion28

The impact of HIV infection and its late-stage manifestation, AIDS, is disproportionately higher for racial and ethnic minorities and people of lower income and education levels. Although access to care has improved, research shows that Blacks, Hispanics, women, and uninsured people with HIV remain less likely to have access to care and less likely to have optimal patterns of care.29

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 linked to complex social and economic factors, including poverty, concentration of the virus in specific geographic areas and smaller sexual networks, sexually transmitted disease comorbidities, stigma (negative attitudes, beliefs, and actions directed at people living with HIV/AIDS or directed at people who engage in behaviors that might put them at risk for HIV), and injection and noninjection drug use and associated behaviors.30

The HIV/AIDS epidemic is also a serious threat to the Hispanic community. Hispanics accounted for 15% of the population but had an estimated 17% of the new HIV infections in 2006, which was 2½ times the rate of Whites.31 In addition to being seriously affected by HIV, Hispanics continue to face challenges in accessing health care, preventive services, and HIV treatment. Undocumented Hispanics face an even greater challenge in accessing care and information regarding HIV and AIDS, but data are limited on HIV infection rates of undocumented immigrants.32 In 2006, HIV/AIDS was the fourth leading cause of death among Hispanic men and women ages 35-44.33 Having Medicaid and a usual source of care decreased the likelihood of delaying care for HIV, but research shows that delay in care is still greater for Hispanics and African Americans.34

Outcome: New AIDS Cases

Early and appropriate treatment of HIV infection can delay progression to AIDS, so improved management of chronic HIV infection 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.26,35

 

Figure 2.15. New AIDS cases per 100,000 population age 13 and over, by race/ethnicity, 2000-2007

Trend line chart. Healthy People 2010 target: 1.0.  Total; 2000, 16.8; 2001, 16.2; 2002, 16.2; 2003, 16.3; 2004, 15.6; 2005, 14.8; 2006, 14.5; 2007, 14.4; White, 2000, 7.0; 2001, 6.6; 2002, 6.8; 2003, 6.6; 2004, 6.6; 2005, 6.3; 2006, 6.2; 2007, 6.1; Black; 2000, 73.0; 2001, 70.5; 2002, 70.0; 2003, 70.2; 2004, 66.1; 2005, 61.5; 2006, 59.1; 2007, 59.2; Asian/Pacific Islander; 2000, 3.3; 2001, 3.6; 2002, 4.0; 2003, 4.1; 2004, 3.9; 2005, 3.7; 2006, 4.0; 2007, 4.3; AI/AN; 2000, 10.6; 2001, 9.9; 2002, 10.6; 2003,

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, 2000-2007.

Denominator: 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 2007, the overall rate of new AIDS cases decreased to 14.4 cases per 100,000 population (Figure 2.15).
  • From 2000 to 2007, the rate of new AIDS cases decreased for Blacks (from 73.0 to 59.2 per 100,000), Hispanics (from 26.4 to 20.4 per 100,000), and Whites (from 7.0 to 6.1 per 100,000).
  • During this period, the gap between Blacks and Whites decreased. However, in 2007, the rate of new AIDS cases was still almost 10 times as high for Blacks as for Whites (59.2 per 100,000 compared with 6.1 per 100,000).
  • From 2000 to 2007, the gap between Hispanics and non-Hispanic Whites also decreased. However, in 2007, the rate of new AIDS cases was still more than three times as high for Hispanics as for Whites (20.4 per 100,000 compared with 6.1 per 100,000).
  • In 2007, the rate of new AIDS cases was almost three times as high for men as for women (21.6 per 100,000 compared with 7.5 per 100,000; data not shown).
  • No group has reached the Healthy People 2010 target of 1 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,vii HIV measures tracked in the NHDR come from the HIV Research Network. Data from the HIV Research Network are not nationally representative of the level of care received by all Americans living with HIV. Participation in this network is voluntary. Network data represent only patients who are actually receiving care, about 14,000 HIV patients per year. Network data do not include patients who do not receive care. Furthermore, data shown below are not representative of the HIV Research Network as a whole because they represent only a subset of network sites that have the best data. 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, oral 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.36

 

Figure 2.16. Adult patients with HIV and CD4 count <200 who received PCP prophylaxis in the calendar year, by race/ethnicity, 2004-2006

 

Trend line chart; in percentages; Total; 2004, 85.2; 2005, 90.3; 2006, 93.2; White, 2004, 86.8; 2005, 91.2; 2006, 92.1; Black, 2004, 83.9; 2005, 89.9; 2006, 93.2; Hispanic, 2004, 86.1; 2005, 90.6; 2006, 94.7. Source: Agency for Healthcare Research and Quality, HIV Research Network, 2004-2006.

Denominator: Adult patients with HIV and CD4 cell counts below 200 receiving care from an HIV Research Network medical practice.

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 2004 to 2006, the overall percentage of HIV patients with CD4 cell count <200 who received PCP prophylaxis increased. There were no statistically significant differences between any racial or ethnic group and non-Hispanic Whites (Figure 2.16).
  • During this period, the difference between men and women stopped being statistically significant for HIV patients with CD4 cell count <200 who received PCP prophylaxis. In 2006, women were as likely to receive PCP prophylaxis treatment as men (data not shown).

 

Figure 2.17. Adult patients with HIV and CD4 count <50 who received MAC prophylaxis in the past year, by race/ethnicity, 2004-2006

Trend line chart; in percentages; Total, 2004, 82.2; 2005, 86.0; 2006, 88.2; White, 2004, 83.0; 2005, 82.5; 2006, 82.8; Black, 2004, 80.8; 2005, 86.4; 2006, 88.5; Hispanic, 2004, 85.6; 2005, 89.6; 2006, 91.5.

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

Denominator: Adult patients with HIV and CD4 cell counts below 50 receiving care from an HIV Research Network medical practice.

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 2004 to 2006, the overall percentage of HIV patients with CD4 cell count <50 who received MAC prophylaxis increased (Figure 2.17).
  • In 2006, there was no statistically significant difference between Blacks and non-Hispanic Whites in the percentage of HIV patients with CD4 cell count <50 who received MAC prophylaxis.
  • During this period, the percentage of Hispanic HIV patients with CD4 cell count <50 who received MAC prophylaxis surpassed that of non-Hispanic Whites. In 2006, the percentage of HIV patients with CD4 cell count <50 who received MAC prophylaxis was higher for Hispanics than for non-Hispanic Whites (91.5% compared with 82.8%). Hispanics had the highest rate of MAC prophylaxis treatment during this period. 

 

Mental Health and Substance Abuse

Mortality
Rank among causes of death in the United States - suicide (2006)11th4
Alcohol-impaired driving fatalities (2007)12,99837
Prevalence
People age 12 and over with alcohol and/or illicit drug dependence or abuse in the past year (2007)22.3 million (9.0%)38
Adults age 18 and over with serious psychological distress in the past year (2007)24.3 million (10.9%)38
Youths ages 12-17 with a major depressive episode during the past year (2007)2.0 million (8.2%)38
Adults age 18 and over with a major depressive episode during the past year (2007)16.5 million (7.5%)38
Adults with at least one major depressive episode in their lifetime (2006)30.4 million (13.9%)39
Cost
Total medical expenditures for substance abuse and mental disorders (2003 est.)$121 billion40
Cost-effectiveness of screening and brief counseling for problem drinking$0-$14,000/QALY7

In 2004, almost one-fourth of all stays in U.S. community hospitals for patients age 18 and over—7.6 million of nearly 32 million stays—involved mental disorders such as depression, bipolar disorder, schizophrenia, and substance use-related disorders.41 The 12-month prevalence of anxiety disorders in the United States in 2001-2003 was 19.1%; mood disorders, 9.7%; impulse control disorder, 10.5%; and any substance disorder (including drug abuse, alcohol abuse, and nicotine dependenceviii), 13.4%.42

Social and cultural factors may dramatically affect mental health. Culturally and linguistically appropriate services can decrease the prevalence, incidence, severity, and duration of certain mental disorders. However, many factors adversely affect the mental health of racial and ethnic groups, such as discriminationix and racism. Some factors also present significant barriers to treatment. These include cost of care, lack of sufficient insurance for mental health services, social stigma, fragmented organization of services,43 and mistrust.

In addition, economic factors can have a significant effect on mental health. For example, poverty can be a risk factor for poor mental health and a result of poor mental health. But low-income individuals may be more likely to receive needed substance abuse treatment due to linkages in service delivery between substance abuse and public assistance services in many States.

In rural and remote areas, many people with mental illnesses have less adequate access to care, more limited availability of skilled care providers, lower family incomes, and greater societal stigma for seeking mental health treatment than their urban counterparts. In addition, rural Americans are less likely to have private health insurance benefits for mental health care. Lack of coverage often occurs because small employers and individual purchasers dominate the rural health insurance marketplace. Therefore, insurance policies are more likely to have limited or no mental health coverage.

For racial and ethnic populations in rural areas, these problems are compounded by the lack of culturally and linguistically competent providers. Finally, of the 1,669 federally designated mental health professional shortage areas, more than 85% are rural areas.44 As of September 2009, the number of federally designated mental health professional shortage areas had increased to an estimated 3,291.45

Treatment: Receipt of Treatment for Depression

Treatment for depression is an effective way to reduce the chances of future major depressive episodes.

 

Figure 2.18. Adults with a major depressive episode in the last 12 months who received treatment for depression in the last 12 months, by race, ethnicity, income, education, and gender, 2007

Bar chart; in percentages; Total, 64.5; white, 66.8; black, 52.6; non-Hispanic white, 68.5; Hispanic, 53.9; Poor, 66.3; Low income, 67.8; Middle income, 69.9; High income, 71.3;  less than high school, 65.2; high school grad, 65.3; at least some college, 63.9; Male, 57.8; female, 68.0.

 

Source: Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2007.

Denominator: U.S. population age 18 and over who had a major depressive episode in the last 12 months.

Note: Major depressive episode is defined as a period of at least 2 weeks when a person experienced a depressed mood or loss of interest or pleasure in daily activities and had a majority of the symptoms of depression described in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Treatment for depression is defined as seeing or talking to a medical doctor or other professional or using prescription medication in the past year for depression. Data were insufficient for this analysis for Asians, Native Hawaiians and Other Pacific Islanders, and American Indians and Alaska Natives.

  • The percentage of adults with a major depressive episode in the last 12 months who received any treatment for depression in the last 12 months was significantly lower for Blacks than for Whites (52.6% compared with 66.8%) and lower for Hispanics than for non-Hispanic Whites (53.9% compared with 68.5%; Figure 2.18).
  • In 2007, adult females with a major depressive episode were more likely than their male counterparts to have any treatment for depression in the last 12 months (68.0% compared with 57.8%).
  • There were no statistically significant differences by income level or education level for this measure.

Treatment: Receipt of Needed Treatment for Illicit Drug Use or Alcohol Problem

Illicit drugx use is a medical problem that can have a direct toxic effect on a number of bodily organs. Illicit drug use also can exacerbate numerous health and mental health conditions. Alcohol problems can lead to serious health risks. Heavy drinking can increase the risk of certain cancers and cause damage to the liver, brain, and other organs.46 It also can cause birth defects. Alcoholism increases the risk of death from car crashes and other injuries.47 Treatment for illicit drug use or an alcohol problem at a specialty facility is an effective way to reduce the chances of future illicit drug use or alcohol problems.

 

Figure 2.19. People age 12 and over who needed treatment for illicit drug use or an alcohol problem and who received such treatment at a specialty facility in the last 12 months, by race and ethnicity, 2003-2007

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

Source: Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2007.

Denominator: U.S. population age 12 and over who needed treatment for illicit drug use or an alcohol problem in the last 12 months.

Note: "Received illicit drug treatment at a specialty facility" refers to treatment received at a hospital (inpatient), rehabilitation facility (inpatient or outpatient), or mental health center to reduce or stop the nonmedical use of prescription-type psychotherapeutic drugs or for medical problems associated with drug use. Respondents were classified as needing treatment for an illicit drug problem if they met at least one of these three criteria during the last 12 months: (1) dependence on any illicit drug; (2) abuse of any illicit drug; or (3) treatment for an illicit drug problem at a specialty facility (drug and alcohol rehabilitation facilities [inpatient or outpatient], hospitals [inpatient only], and mental health centers). The 2004 and 2007 data for Asians and Pacific Islanders and American Indians and Alaska Natives were insufficient for this analysis.

  • In 2007, the percentage of people age 12 and over who needed treatment for illicit drug use or an alcohol problem and received it at a specialty facility in the last 12 months continued to be significantly higher for Blacks than for Whites (18.1% compared with 9.3%; Figure 2.19).
  • In 2007, the percentage of people age 12 and over who needed treatment for illicit drug use or an alcohol problem and received it at a specialty facility in the last 12 months was lower for Hispanics than for non-Hispanic Whites (6.0% compared with 9.9%).

v HbA1c is glycosylated hemoglobin and its level provides information about control of blood sugar levels.
vi Unlike other interventions that often involve greater costs for health benefits, this intervention actually results in net cost savings to society.
vii Although program data are collected from all Ryan White CARE Act HIV/AIDS Program grantees, the aggregate nature of the data makes it difficult to assess the quality of care provided by the Ryan White HIV/AIDS Program.
viii Nicotine dependence is a physical addiction to nicotine when delivered by various tobacco products.
ix The Office for Civil Rights (OCR) (http://www.hhs.gov/ocr) is the sole HHS agency with the authority to enforce Title VI of the Civil Rights Act of 1964, 42 U.S.C. 2000d, which prohibits discrimination based on race, color, or national origin in programs and activities that receive Federal financial assistance, including most health care providers and human service agencies. Individuals and advocacy groups may file complaints with OCR to remedy such discrimination.
x Illicit drugs included in this measure are marijuana/hashish, cocaine (including crack), inhalants (e.g., inhalation of various substances other than for intended use - like toluene), hallucinogens, heroin, and prescription-type psychotherapeutic drugs (nonmedical use).



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Current as of March 2010
Internet Citation: Chapter 2. Quality of Health Care (continued): National Healthcare Disparities Report, 2009. March 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/nhqrdr/nhdr09/Chap2a.html