Chapter 2. Quality of Health Care (continued, 3)

Patient Safety

* For more information, refer to Gurwitz JH, Field TS, Harrold LR, et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA 2003 Mar 5;289:1107-16.

In 1999, the IOM published To Err Is Human, which called for a national effort to reduce medical errors and increase patient safety.⁸⁶ The IOM defines patient safety as freedom from accidental injury due to medical care or medical errors.⁸⁶ In response to the IOM's report on patient safety, President Bush signed the Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act). The act was designed to spur the development of voluntary, provider-driven initiatives to improve the quality, safety, and outcomes of patient care. The Patient Safety Act addresses many of the current barriers to improving patient care.

Several factors limit our current ability to aggregate data in sufficient numbers to rapidly identify the most prevalent risks and hazards in the delivery of patient care, their underlying causes, and the practices that are most effective in mitigating them. These include the reluctance of providers to participate in improvement initiatives, based on fear of increased liability; and difficulty in aggregating and sharing data confidentially across facilities or State lines.

To Err Is Human does not mention race or ethnicity when discussing the problem of patient safety. A 2006 review of the literature found that only 9 of 323 articles on pediatric patient safety (2.8%) included race or ethnicity in the analysis. Five of the nine studies from this review used data from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project (HCUP).⁹⁴

This section highlights five measures of patient safety in three areas:

• Health care-associated infections (HAIs).
• Other complications of hospital care.
• Complications of medications.

For findings related to all core measures of patient safety, refer to Table 2.2a. 

Health Care-Associated Infections

Postoperative Wound Infections

Infections acquired during hospital stays (health care-associated or nosocomial infections) are among the most serious safety concerns. A common HAI is a wound infection following surgery. Hospitals can reduce the risk of wound infection after surgery by making sure patients get the right antibiotics at the right time on the day of their surgery. However, taking these antibiotics for more than 24 hours after routine surgery is usually not necessary and can increase the risk of side effects, such as stomachaches, serious types of diarrhea, and antibiotic resistance.

Among adult hospital patients having surgery, the NHDR tracks an opportunities model composite of two measures: receipt of antibiotics within 1 hour prior to surgical incision and discontinuation of antibiotics within 24 hours after the end of surgery.

Figure 2.34. Composite measure: Adult surgery patients who received appropriate timing of antibiotics, by race/ethnicity, 2005-2007

Key: AI/AN = American Indian or Alaska Native.
Source: Centers for Medicare & Medicaid Services, Medicare Quality Improvement Organization Program, 2005-2007.
Denominator: Medicare patients age 18 and over having surgery.
Note: Whites, Blacks, Asians, and AI/ANs are non-Hispanic groups. Data were insufficient for this analysis for Native Hawaiians and Other Pacific Islanders. Appropriate timing of antibiotics received by adult surgical patients for all payers included in this composite are: (1) antibiotics started within 1 hour of surgery, and (2) antibiotics stopped within 24 hours after surgery.

• From 2005 to 2007, the percentage of appropriately timed antibiotics provided to surgery patients improved substantially for the overall population as well as for each racial and ethnic group.
• In 2007, the percentage of appropriately timed antibiotics provided to surgery patients was significantly lower for Blacks (85.8%), Asians (84.6%), AI/ANs (85.2%), and Hispanics (80.9%) than for Whites (86.8%; Figure 2.34).

Other Complications of Hospital Care

Various types of care delivered in hospitals in addition to surgery can place patients at risk for injury or death.

Adverse Events Associated With Central Venous Catheters

Patients who require a central venous catheter (CVC) to be inserted into the great vessels of their heart tend to be severely ill. However, the procedure itself can result in a number of infectious and noninfectious complications.

Figure 2.35. Composite measure: Bloodstream infections or mechanical adverse events associated with central venous catheter placements, Medicare hospital patients, by race, 2004-2007

Source: Centers for Medicare & Medicaid Services, Medicare Patient Safety Monitoring System (MPSMS), 2004-2007.
Denominator: Medicare fee-for-service (FFS) discharges from the MPSMS sample with central venous catheter placement, all ages.
Note: Central venous catheter complications included in this composite are bloodstream infections and mechanical adverse events. Data were not available for Asians, Native Hawaiians and Other Pacific Islanders, and American Indians and Alaska Natives.

• No statistically significant disparities were observed between Blacks and Whites in the percentage of CVC complications among hospital patients (Figure 2.35).
• From 2004 to 2007, there was no statistically significant change in the percentage of CVC complications.

Deaths Following Complications of Care

Many complications that arise during hospital stays cannot be prevented. However, rapid identification and aggressive treatment of complications may prevent these complications from leading to death. This indicator, also called "failure to rescue," tracks deaths among patients whose hospitalizations are complicated by pneumonia, thromboembolic event, sepsis, acute renal failure, shock, cardiac arrest, gastrointestinal bleeding, or acute ulcer.

Figure 2.36. Deaths per 1,000 discharges with complications potentially resulting from care (failure to rescue), adults ages 18-74, by race/ethnicity, 2001-2006

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.
Denominator: Patients ages 18-74 from U.S. community hospitals whose hospitalizations were complicated by pneumonia, thromboembolic event, sepsis, acute renal failure, shock, cardiac arrest, gastrointestinal bleeding, or acute ulcer.
Note: White, Black, and API are non-Hispanic. Data were not available for American Indians and Alaska Natives. Data are adjusted for age, gender, and all patient refined-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.

• From 2001 to 2006, there was significant improvement overall in the rates of in-hospital deaths following complications of care (from 152.2 per 1,000 in 2001 to 116.8 per 1,000 in 2006; Figure 2.36).
• During this period, initially the rates of in-hospital deaths following complications of care in Blacks were higher than in non-Hispanic Whites, but eventually they became lower. In 2006, the rate among Blacks was 111.0 per 1,000 discharges compared with 117.1 per 1,000 for non-Hispanic Whites.
• In 2006, Hispanics had a higher rate of in-hospital deaths following complications of care than non-Hispanic Whites (122.1 per 1,000 compared with 117.1 per 1,000).

Figure 2.37. Deaths per 1,000 discharges with complications potentially resulting from care (failure to rescue), adults ages 18-74, by income, 2006

Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project (HCUP), State Inpatient Databases (SID) disparities analysis file, 2006.
Denominator: Patients ages 18-74 from U.S. community hospitals whose hospitalization is complicated by pneumonia, thromboembolic event, sepsis, acute renal failure, shock, cardiac arrest, gastrointestinal bleeding, or acute ulcer.
Note: Data are adjusted for age, gender, and diagnosis-related group clusters. Quartile income categories are used instead of the NHDR's usual descriptive categories because that is how data are collected for this measure. Quartile 1 corresponds to the lowest income quartile, and Quartile 4 corresponds to the highest income quartile. Income categories are based on the median household income of the ZIP Code of the patient's residence. 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, people living in communities in Quartile 1 (lowest income) had a higher rate of in-hospital deaths following complications of care than people living in communities in Quartile 4 (highest income) (118.8 per 1,000 compared with 114.4 per 1,000; Figure 2.37).

Complications of Medications

Complications of medications are common safety problems. Some adverse drug events may be related to misuse of medication, but others are not. However, prescribing medications that are inappropriate for a specific population may increase the risk of adverse drug events.

Adverse Drug Events in the Hospital

Some medications used in hospitals can cause serious complications. The Medicare Patient Safety Monitoring System tracks a number of "high-risk" drugs and the adverse events associated with them. Adverse drug events can include serious bleeding associated with intravenous heparin, subcutaneously administered low-molecular-weight heparin, and oral warfarin, as well as hypoglycemia associated with insulin or oral hypoglycemics.

Figure 2.38. Medicare hospital patients with medication-related adverse drug events, by race, 2004-2007

Intravenous heparin

Low-molecular-weight heparin

Warfarin

Insulin

Source: Centers for Medicare & Medicaid Services, Medicare Patient Safety Monitoring System (MPSMS), 2004-2007.
Denominator: Medicare fee-for-service (FFS) discharges from the MPSMS sample that received the drug, all ages.
Note: Data were not collected for Asians, Native Hawaiians and Other Pacific Islanders, American Indians and Alaska Natives, and Hispanics. In 2007, data for adverse drug events for intravenous heparin among Blacks were not statistically reliable.

• In 2007, between 3.4% and 8.9% of hospitalized Medicare patients overall experienced an adverse drug event in the hospital, depending on the type of drug (Figure 2.38).
• From 2004 to 2006, the percentage of patients taking intravenous heparin who experienced an adverse drug event significantly decreased overall (from 14.6% to 8.9%). In 2006, there was no statistically significant difference between Blacks and Whites (no statistically reliable data available for Blacks in 2007).
• From 2004 to 2007, the percentage of patients taking low-molecular-weight heparin who experienced an adverse drug event decreased overall (from 9.7% to 3.4%). There was no statistically significant difference between Blacks and Whites.
• From 2004 to 2007, the percentage of patients taking warfarin who experienced an adverse drug event decreased overall (from 8.8% to 4.2%).
• From 2004 to 2007, the percentage of patients taking insulin or hypoglycemics who experienced an adverse drug event decreased overall (from 10.7% to 7.8%). In 2007, Blacks were more likely than Whites to experience an adverse event with insulin (10.2% compared with 7.4%).

Potentially Inappropriate Medication Prescriptions for Older Patients

Some drugs that are appropriate for some patients are considered potentially harmful for older patients but are still prescribed to them.^95,xvii Inappropriate medication use by older patients includes the use of drugs that should often or always be avoided for these patients. 

Figure 2.39. Adults age 65 and over who received potentially inappropriate prescription medications in the calendar year, by race, ethnicity, income, education, insurance status, and gender, 2006

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2006.
Denominator: Civilian noninstitutionalized population age 65 and over.
Note: Data were insufficient for this analysis for Asians and Other Pacific Islanders and for American Indians and Alaska Natives. This measure includes 33 inappropriate prescription medications. Prescription medications received include all prescribed medications initially purchased or otherwise obtained, as well as any refills.

• In 2006, there were no statistically significant differences by race, ethnicity, income, or education in the percentage of older adults receiving potentially inappropriate prescription medications (Figure 2.39). 

Timeliness

Timeliness is the health care system's capacity to provide care quickly after a need is recognized. For patients, lack of timeliness can result in emotional distress, physical harm, and financial consequences.^96,97 For example, stroke patients' mortality and long-term disability are largely influenced by the timeliness of therapy.^98,99 Timely delivery of appropriate care can also help reduce mortality and morbidity for chronic conditions such as chronic kidney disease,¹⁰⁰ and timely antibiotic treatments are associated with improved clinical outcomes.¹⁰¹ Timely delivery of childhood immunizations helps maximize protection from vaccine-preventable diseases while minimizing risks to the child and reducing the chance of disease outbreaks.¹⁰²

Early care for comorbid conditions has been shown to reduce hospitalization rates and costs for Medicare beneficiaries.¹⁰³ Some research suggests that, over the course of 30 years, the costs of treating diabetic complications can approach $50,000 per patient.¹⁰⁴ Timely outpatient care also can reduce admissions for pediatric asthma, which account for $1.25 billion in total hospitalization charges annually.¹⁰⁵

The measures of timeliness highlighted in this section are getting care for illness or injury as soon as wanted and timeliness of cardiac reperfusion for heart attack patients. (For findings related to all core measures of timeliness, refer to Tables 2.3a and 2.3b.)

Getting Care for Illness or Injury As Soon As Wanted

The ability of patients to receive illness and injury care in a timely fashion is a key element in a patient-centered health care system.

Figure 2.40. Adults who needed care right away for an illness, injury, or condition in the last 12 months who sometimes or never got care as soon as wanted, by race, ethnicity, and income, 2002-2006

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2006.
Denominator: Civilian noninstitutionalized population age 18 and over.
Note: Data were insufficient for this analysis for Native Hawaiians and Other Pacific Islanders and for American Indians and Alaska Natives.

• In 2006, Blacks fared worse than Whites on this measure of timeliness (16.5% compared with 14.7%; Figure 2.40).
• In 2006, Asians also were more likely than Whites to report problems getting care as soon as wanted (21.3% compared with 14.7%).
• During this period, the gap between Hispanics and non-Hispanic Whites in the percentage of adults who reported delayed care remained the same. In 2006, Hispanics remained more likely than non-Hispanic Whites to report problems getting care as soon as wanted (20.6% compared with 13.8%).
• In 2006, poor adults were more than twice as likely as high-income adults to report problems getting care as soon as wanted (23.0% compared with 10.5%).

Socioeconomic factors may explain at least some of the racial and ethnic differences in timeliness. To distinguish the effects of race, ethnicity, income, and education on timeliness of primary care, this measure is stratified by income and education. 

Figure 2.41. Adults who needed care right away for an illness, injury, or condition in the last 12 months who sometimes or never got care as soon as wanted, by race and ethnicity, stratified by income, 2006

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

Figure 2.42. Adults who needed care right away for an illness, injury, or condition in the last 12 months who sometimes or never got care as soon as wanted, by race and ethnicity, stratified by education, 2006

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

• Socioeconomic factors may explain at least some of the racial and ethnic differences in timeliness of primary care (Figures 2.41 and 2.42).
• High-income and middle-income Hispanics were about 1½ times as likely as high-income and middle-income non-Hispanic Whites to report problems getting care as soon as wanted.
• Among people with a high school education and people with some college education, Blacks were more likely than Whites to report problems getting care as soon as wanted (18.3% compared with 13% for high school graduates, and 14.8% compared with 13.5% for people with some college education).
• Among people with some college education, Hispanics were more likely than non-Hispanic Whites to report problems getting care as soon as wanted (18% compared with 13.2%).

Figure 2.43. Children who needed care right away for an illness, injury, or condition in the last 12 months who sometimes or never got care as soon as wanted, by race, ethnicity, and income, 2002-2006

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2006.
Denominator: Civilian noninstitutionalized population under age 18.

• From 2002 to 2006, the percentage whose parents reported problems getting care as soon as wanted decreased for Hispanic children (from 10.6% to 6.7%) and poor children (from 12.2% to 7.6%) (Figure 2.43).
• In 2006, there were no statistically significant differences observed by race or ethnicity.
• In 2006, children from poor and near-poor families were more likely than children from high-income families to sometimes or never get care as soon as wanted (7.6% and 10.1%, respectively, compared with 4.7%).

Emergency Department Visits in Which Patients Left Without Being Seen

In 2006, almost a quarter (24.8%) of patients who had an emergency department (ED) visit in the United States spent 4 hours or more in the ED, with the same percentage of patients waiting 1 hour or more to be seen by a physician.¹⁰⁶ This finding may reflect the population-based 18% per person increase in ED visit volumes from 1996 to 2006.^106,107 Although there are many reasons that a patient seeking care in an ED may leave without being seen, long waits tend to explain many departures.

Figure 2.44. Emergency department visits in which patients left without being seen, by race and payment source, 2000-2007

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Ambulatory Medical Care Survey, 2000-2001, 2001-2002, 2003-2004, 2005-2006, and 2006-2007.

Denominator: Visits by patients (of all ages) to the EDs of non-Federal, short-stay, and general hospitals.

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

• Between 2000-2001 and 2006-2007, the overall percentage of ED visits in which patients left without being seen remained the same (Figure 2.44).
• In 2006-2007, there was no statistically significant difference between Blacks and Whites in the percentage of ED visits in which patients left without being seen.
• In 2006-2007, the percentage of ED visits in which Medicaid patients left without being seen remained the same and was higher than the rate among patients with private insurance (1.8% compared with 1.3%).
• In 2006-2007, the gap between uninsured patients and patients with private insurance remained the same. Uninsured patients were more than twice as likely to leave without being seen as patients with private insurance (2.9% compared with 1.3%).
• Medicare patients were the least likely to leave the ED without being seen, with a rate of 0.6% in 2006-2007.

Timeliness of Cardiac Reperfusion for Heart Attack Patients

The capacity to treat hospital patients in a timely manner is especially important for emergency situations such as heart attacks. Some heart attacks are caused by blood clots. Early actions, such as percutaneous coronary intervention (PCI) or fibrinolytic medication, may open blockages caused by blood clots by restoring blood flow to the heart, thus reducing heart muscle damage and saving lives.¹⁰⁸ To be effective, these actions need to be performed quickly after the start of a heart attack. In the NHDR, we examine a new measure of timeliness of cardiac reperfusion: receipt of PCI within 90 minutes among appropriate patients.

Figure 2.45. Hospital patients with heart attack who received percutaneous coronary intervention within 90 minutes, by race/ethnicity, 2005-2007

Key: AI/AN = American Indian or Alaska Native.
Source: Centers for Medicare & Medicaid Services, Medicare Quality Improvement Organization Program, 2005-2007.
Denominator: Patients hospitalized with a principal diagnosis of acute myocardial infarction who were appropriate candidates for percutaneous coronary intervention.

• Among heart attack patients, the percentage of patients receiving timely PCI improved for all race/ethnicity groups from 2005 to 2007 (Figure 2.45).
• In all years, Blacks and Hispanics were less likely to receive timely PCI compared with Whites. In 2006 and 2007, Asians were also less likely to receive timely PCI compared with Whites. 

Patient Centeredness

The IOM identifies patient centeredness as a core component of quality health care.² Patient centeredness is defined as:

[H]ealth care that establishes a partnership among practitioners, patients, and their families (when appropriate) to ensure that decisions respect patients' wants, needs, and preferences and that patients have the education and support they need to make decisions and participate in their own care. ¹⁰⁹

Patient centeredness "encompasses qualities of compassion, empathy, and responsiveness to the needs, values, and expressed preferences of the individual patient."² In addition, effective communication between the provider and the patient is often a legal requirement.*

Patient-centered care is supported by good provider-patient communication so that patients' needs and wants are understood and addressed, and patients understand and participate in their own care.^109-112 This style of care has been shown to improve patients' health and health care.^{110,111,113-115} Unfortunately, many barriers exist to good communication.

About one-third of Americans are not "health literate,"^116,117 which means they lack the "capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions."¹¹⁸ They experience many difficulties, including:

• Less preventive care.¹¹⁹
• Poorer understanding of their conditions and care.^116,120,121
• Higher use of emergency and inpatient services and higher rates of rehospitalization.^122,123
• Lower adherence to medication schedules.¹²²
• Lower participation in medical decisionmaking.¹²⁴

Individuals with inadequate health literacy incur higher medical costs and are more likely to have an inefficient mix of service use compared with those with adequate health literacy.¹²⁵

Providers also differ in communication proficiency, including varied listening skills and different views from their patients' of symptoms and treatment effectiveness.¹²⁶ Additional factors influencing patient centeredness and provider-patient communication include:

• Language barriers.
• Racial and ethnic concordance between the patient and provider.
• Effects of disabilities on patients' health care experiences.
• Providers' cultural competency.

When health care is patient centered, both underuse and overuse of medical services are reduced.¹²⁷ Fewer diagnostic tests and referrals reduce strains on system resources and costs.¹¹³

Efforts to remove these possible impediments to patient centeredness are underway within the Department of Health and Human Services (HHS). For example, the Office of Minority Health has developed a set of Cultural Competency Curriculum Modules that aim to equip providers with cultural and linguistic competencies to help promote patient-centered care.^128,xviii These modules are based on the National Standards on Culturally and Linguistically Appropriate Services. The standards are directed at health care organizations and aim to improve the patient centeredness of care for people with limited English proficiency (LEP). Another example, which is being administered by the Health Resources and Services Administration, is Unified Health Communication, a new Web-based course for providers that integrates concepts related to health literacy with cultural competency and LEP.^xix

In addition, the HHS Office for Civil Rights has issued Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons. This guidance explains that recipients of Federal financial assistance must take reasonable steps to provide LEP people with a meaningful opportunity to participate in HHS-funded programs. Failure to do so may violate the prohibition under Title VI of the Civil Rights Act of 1964, 42 U.S.C. 2000d, against national origin discrimination.¹²⁹

The NHDR includes one core measure of patient centeredness—a composite measure on the patient experience of care. In addition, this year's report includes a new supplemental measure of workforce diversity—race/ethnicity of the Nation's dental workforce. Having a diverse workforce of health care providers may be an important component of patient-centered health care for many patients.

* For example, Title VI of the Civil Rights Act of 1964, 42 U.S.C. 2000d, may require the practitioner or hospital to provide language interpreters and translate vital documents for limited-English-proficient persons. Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. 794, may require the practitioner or hospital to provide sign language interpreters, materials in Braille, and/or accessible electronic formats for individuals with disabilities.

^xvii Eleven drugs that should always be avoided for older patients include barbiturates, flurazepam, meprobamate, chlorpropamide, meperidine, pentazocine, trimethobenzamide, belladonna alkaloids, dicyclomine, hyoscyamine, and propantheline. Twenty-two drugs that should often be avoided for older patients include carisoprodol, chlorzoxazone, cyclobenzaprine, metaxalone, methocarbamol, amitriptyline, chlordiazepoxide, diazepam, doxepin, indomethacin, dipyridamole, ticlopidine, methyldopa, reserpine, disopyramide, oxybutynin, chlorpheniramine, cyproheptadine, diphenhydramine, hydroxyzine, promethazine, and propoxyphene.
^xviii This online program (available at http://www.thinkculturalhealth.org ) is accredited for 9 Continuing Medical Education credits for physicians and 10.8 and 0.9 Continuing Education Units for nurses and pharmacists, respectively.
^xixThis online program (available at http://www.hrsa.gov/healthliteracy/training.htm) is accredited for 5 Continuing Medical Education credits for physicians and 5 Continuing Education Units for nurses, physician assistants, pharmacists, and Certified Health Education Specialists.

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