Chapter 4. Priority Populations

National Healthcare Disparities Report, 2009

Contents

Racial and Ethnic Minorities
Low-Income Groups
Women
Children
Older Adults
Residents of Rural Areas
Individuals With Disabilities or Special Health Care Needs

To examine the issue of disparities in health care, Congress directed the Agency for Healthcare Research and Quality (AHRQ) to produce an annual report to track "prevailing disparities in health care delivery as it relates to racial factors and socioeconomic factors in priority populations." Although the emphasis is on disparities related to race, ethnicity, and socioeconomic status, this directive includes a charge to examine disparities in "priority populations," which are groups with unique health care needs or issues that require special attention.

This chapter of the National Healthcare Disparities Report (NHDR) addresses the congressional directive on priority populations.i Chapters 2 and 3 of this report examine racial, ethnic, and socioeconomic differences in quality of health care and access to health care in the general U.S. population. This chapter focuses on differences within and across priority populations. For example, comparisons are made between Black and White women and between children from low- and high-income families.

The approach taken in this chapter may help policymakers understand the impact of racial, ethnic, and socioeconomic differences on specific populations and target quality improvement programs toward groups in greatest need. Appendix D includes detailed tables that allow examination of racial, ethnic, and socioeconomic disparities both in the general population and across priority populations for most measures.

 

AHRQ's Priority Populations

AHRQ's priority populations, specified by Congress in the Healthcare Research and Quality Act of 1999 (Public Law 106-129), are:

  • Racial and ethnic minority groups.ii
  • Low-income groups.iii
  • Women.
  • Children (under age 18).
  • Older adults (age 65 and over).
  • Residents of rural areas.iv
  • Individuals with special health care needs,v including individuals with disabilities and individuals who need chronic care or end-of-life care.

How This Chapter Is Organized

This chapter provides the most recent information available on racial, ethnic, and income differences in quality and access for priority populations. It is presented in the following order:

  • Racial and ethnic minorities.
  • Low-income groups (focus on uninsured people).
  • Women.
  • Children.
  • Older adults.
  • Residents of rural areas.
  • Individuals with disabilities or special health care needs.

To avoid repeating the previous chapters' findings on race, ethnicity, and socioeconomic status, the first two sections summarize quality of and access to health care for racial and ethnic minorities and low-income groups. Subsequent sections focus on the remaining priority populations and examine disparities in care within each population group and changes in disparities over time. To present this greater detail, some sections highlight a small number of measures that supplement the core measures presented in Chapters 2 and 3. While these measures may not necessarily be the core measures presented each year, they add detail to the picture of disparities that each population may face. Interagency Work Group members and AHRQ experts on particular populations assisted in selecting measures for these priority populations.

For smaller priority populations, measure selection was often driven by available sample sizes. When possible, measures were selected to encompass multiple components of health care need, such as preventive services, treatment of acute illness, management of chronic disease, and access to health care. Results for all measures are found in the detailed appendix tables.

The measures discussed in this chapter are as follows:

SectionMeasure
Blacks or African Americans 
Asians 
Native Hawaiians and Other Pacific IslandersCholesterol screening
Colorectal cancer screening
Pneumonia admissions
Medical costs
American Indians and Alaska Natives 
Hispanics or Latinos 
Recent Immigrants and Limited-English-Proficient PopulationsTuberculosis therapy
Poor communication with health providers
Uninsurance
Language assistance
Low-Income Groups 
WomenAdults with obesity given advice about healthy eating
Heart attack mortality
New AIDS cases
Usual source of care
Birth trauma
ChildrenEarly childhood vaccinations
Counseling to parents about healthy eating
Dental visits in the past year
Accidental puncture or laceration during procedure
Hospital admissions with perforated appendix
Health insurance
Older AdultsInfluenza vaccination
Vision screening
Delayed care due to cost
Residents of Rural AreasHeart attack mortality
Recommended services for diabetes
Care for illness or injury as soon as wanted
Uninsurance
Individuals With Disabilities or Special Health Care NeedsAdults with disabilities
Delayed dental care, dental visits
Underinsurance, financial burden of health care costs

It should be noted that this chapter does not provide a comprehensive assessment of health care differences in each priority population. Most of the measures tracked in the NHDR were selected to be applicable across many population groups. Only a few, such as immunizations among children, were specific to particular groups.

These general measures overlook some important health care problems specific to particular populations. For example, people with disabilities may face barriers in getting access to care and experience differences in quality of care that are not captured by data because of the limitations in the survey instruments. In addition, national data may not address key health issues for specific population groups. It is not always possible to generate reliable estimates for many smaller groups, such as Native Hawaiians and Other Pacific Islanders (NHOPIs) and American Indians and Alaska Natives (AI/ANs). Instead, this chapter should be seen as a starting point, identifying some problem areas and indicating gaps in current data and understanding.

 

 

Racial and Ethnic Minorities

In 2000, about 33% of the U.S. population identified themselves as members of racial or ethnic minority groups.1 By 2050, it is projected that these groups will account for almost half of the U.S. population. For 2007, the U.S. Census Bureau estimated that the United States had almost 38.8 million Blacks or African Americans2 (12.9% of the U.S. population)3; more than 45.5 million Hispanics or Latinos (15.1%)2; almost 13.4 million Asians (4.4%); more than 0.5 million NHOPIs (0.2%); and more than 2.9 million AI/ANs (1.0%), of whom 57% reside on Federal trust lands.4 Racial and ethnic minorities are more likely than non-Hispanic Whites to be poor or near poor.5 In addition, Hispanics, Blacks, and some Asian subgroups are less likely than non-Hispanic Whites to have a high school education.6

Previous chapters of the NHDR described health care differences by racialvi and ethnicvii categories as defined by the Office of Management and Budget and used by the U.S. Census Bureau.7 In this section, quality of and access to health care for each minority group are summarized to the extent that statistically reliable data are available for each group.viii Criteria for importance are that the difference is statistically significant at the alpha = 0.05 level (two-tailed test) and that the relative difference from the reference group is at least 10% when framed positively as a favorable outcome or negatively as an adverse outcome. Access measures focus on facilitators and barriers to health care and exclude health care utilization measures.

Changes Over Time

This section also examines changes in differences related to race and ethnicity over time. For each core report measure, racial, ethnic, and socioeconomic groups are compared with a designated comparison group. The time periods range from 2000-2002 to 2005-2007, depending on data source. Consistent with Healthy People 2010, disparities are measured in relative terms as the percentage difference between each group and a comparison group. Changes in disparity are measured by subtracting the percentage difference from the comparison group at the baseline year from the percentage difference from the comparison group at the most recent year. The change in each disparity is then divided by the number of years between the baseline and most recent estimate to calculate change in disparity per year.

Core report measures (refer to Table 1.2) for which the relative differences are changing less than 1% per year are identified as staying the same. Core report measures for which the relative differences are becoming smaller at a rate of 1% or more per year are identified as improving. Core report measures for which the relative differences are becoming larger at a rate of 1% or more per year are identified as worsening. Changes of greater than 5% per year are also differentiated from changes of between 1% and 5% per year in some figures.

Gaps in Information

As in previous NHDRs, this section includes information on programs and issues that may affect racial and ethnic disparities. The assessment of disparities AI/ANs face includes information on the approximately 1.5 million individuals who obtain care from Indian Health Service (IHS) facilities and Tribal facilities that receive IHS funding.

In interpreting findings for racial and ethnic minorities, readers should note that considerable gaps exist in information for some racial and ethnic minorities and limit the NHDR's ability to identify the current state of disparities for some groups. Gaps can relate to insufficient data to produce reliable estimates or, when estimates are possible, to inadequate power to detect large differences. For example, of core report measures of quality, it is rarely possible to provide estimates for NHOPIs and people of more than one race. For Asians, only about two-thirds of core report measures of quality support analyses. For AI/ANs, only about half of these same measures support analyses.

In addition, many data sources changed racial classifications for Asians and NHOPIs in 2003 to adhere to new Federal standards. This change has further constrained the ability to perform trend analyses for these groups. Chapter 1, Introduction and Methods, and the summary section at the end of this report present more detailed descriptions of current data limitations and ways data are gradually improving.

For all groups, opportunities exist to improve health care quality and access. A summary of the measures that identify opportunities for improvement is presented below.

 

Table 4.1. Percentage of core quality and access measures that are not improving for various racial and ethnic groups

GroupReference groupPercentage of core measures not improving (n = number of measures that could be tracked)
Quality of careAccess to care
Black
Asian
AI/AN
Hispanic
White
White
White
Non-Hispanic White
  • 71 (n = 38)
  • 85 (n = 27)
  • 57 (n = 19)
  • 68 (n = 37)
  • 50 (n = 10)
  • 60 (n = 10)
  • 71 (n = 7)
  • 50 (n = 10)

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

Note: "Not improving" is defined for quality measures as a population that received about the same or worse quality of care as Whites or non-Hispanic Whites and for access measures, as a population that had about the same or worse access to care as Whites or non-Hispanic Whites. Percentages are based on a subset of core measures that have data for these groups. Some data sources do not collect data for these groups or do not have statistically reliable data to report for these groups. Some measures include data for all ages and some are age-group specific. Refer to the Measure Specifications and Data Tables appendixes for more information. Baseline year and most recent year are not the same for all measures, depending on the data source.

For each racial or ethnic group, Table 4.2 highlights the core measures with gaps that are increasing (i.e., getting worse) for the group compared with its reference group.

 

Table 4.2. Core measures that are getting worse for group compared with reference group

TopicMeasure NameBlacksAsiansAmerican Indians/
Alaska Natives
HispanicsPoor
Preventive servicesAdults age 50 and over who received a colorectal cancer screening*****
Adults age 65 and over who ever received pneumococcal vaccination * * 
Adults with obesity who received advice about exercise   **
Children ages 2-17 who received advice about exercise   * 
Children ages 2-17 who received advice about healthy eating**   
Children ages 19-35 months who received all recommended vaccines *  *
Acute illness treatmentHospital patients with heart failure who received recommended care *** 
Hospital patients with heart attack who received recommended care  *  
Hospital patients with pneumonia who received recommended care *** 
Chronic disease managementAdults with diabetes who had three major exams in the past year*  **
Adults with past year major depressive episode who received treatment for the depression in the past year*    
People age 12 and over who needed treatment for any illicit drug use or alcohol problem who received such treatment*  **
Tuberculosis patients who complete a curative course of treatment  *  
Long-stay nursing home residents who were physically restrained  *  
Home health care patients who get better at walking or moving around*    
Home health care patients who were admitted to the hospital  *  
Adults age 65 and over who received potentially inappropriate prescription medications*    
OutcomeBreast cancer diagnosed at advanced stage*    
Colorectal cancer diagnosed at advanced stage *   
Colorectal cancer mortality*  * 
Breast cancer mortality*    
Adult hemodialysis patients with adequate dialysis *** 
Deaths per 1,000 adults hospitalized with heart attack**   
Patient safetyAppropriate timing of antibiotics received by adult Medicare patients having surgery*    
Adults age 65 and over who received potentially inappropriate prescription medications   * 
TimelinessAdults who can sometimes or never get care for illness or injury as soon as wanted    *
Patient centerednessPatient-provider communication—adults    *
Patient-provider communication—children    *
AccessPeople who were unable to get or delayed in getting needed medical care, dental care, or prescription medications  ***
People who have a specific source of ongoing care  *  
People under age 65 with health insurance  *  
People who have a usual primary care provider *   
People without a usual source of care due to a financial or insurance reason**   

Note: "Asian" includes "Asian or Pacific Islander" when information is not collected separately for each group. The time period for this table is the most recent and oldest years of data used in the NHDR. Measures with the highest annual percentage change in the direction of "getting worse" are shown here. Measures with no change are not included here. A blank cell indicates that no disparity in quality of care was getting worse for the group, which could reflect lack of data or small sample sizes for some populations.

 

Blacks or African Americans

Previous NHDRs showed that Blacks had poorer quality of care and worse access to care than Whites for many measures tracked in the reports. Findings based on core report measures (Table 1.2) of quality and access to health care are shown below.

 

Figure 4.1. Blacks compared with Whites on core measures of quality and access

Stacked column chart. percentage. Quality (40 C R M), Worse, 16 (40%), Same, 20 50%), Better, 4 (10%), Access (6 C R M), Worse, 1 (17%), Same, 4 (66%), Better, 1 (17%).

Better = Blacks receive better quality of care or have better access to care than Whites.

Same = Blacks and Whites receive about the same quality of care or access to care.

Worse = Blacks receive poorer quality of care or have worse access to care than Whites.

Key: CRM = core report measures (Table 1.2).

Note: Data presented are the most recent available.

Table 4.3. Blacks compared with Whites on measures of quality and access for most current data year: Specific measures

TopicBetter than WhitesWorse than WhitesSame as Whites
Cancer Colorectal cancer diagnosed at advanced stageWomen age 40 and over who reported they had a mammogram within the past 2 years
 Adults age 50 and over who report they ever received a colonoscopy, sigmoidoscopy, proctoscopy, or fecal occult blood test 
 Colorectal cancer deaths per 100,000 population 
 Breast cancer diagnosed at advanced stage 
 Cancer deaths per 100,000 female population due to breast cancer 
Diabetes  Adults with diabetes who had three major exams in the past year
End stage renal disease  Hemodialysis patients with urea reduction ratio 65% or higher
  Dialysis patients registered on the waiting list for transplantation
Heart diseaseDeaths per 1,000 admissions with acute myocardial infarction as principal diagnosis, age 18 and over  
Hospital patients who received recommended care for heart failure Hospital patients who received recommended care for heart attack
HIV and AIDS New AIDS cases per 100,000 population age 13 and over 
Maternal and child health  Children ages 2-17 given advice about exercise
 Children ages 2-17 who had a dental visitChildren ages 2-17 given advice about healthy eating
 Children ages 19-35 months who received all recommended vaccinesChildren ages 3-6 with a vision check
Mental health and substance abuseSuicide deaths per 100,000 populationAdults age 18 and over with past year major depressive episode who received treatment for the depression in the past yearPeople age 12 and over who needed treatment for any illicit drug use or alcohol problem and who received such treatment in the past year
Respiratory diseases Adults age 65 and over who ever received pneumococcal vaccinationTuberculosis patients who completed a curative course of treatment within 1 year of initiation of treatment
 Hospital patients with pneumonia who received recommended care 
Lifestyle modification  Current smokers age 18 and over given advice to quit smoking
  Adults with obesity given advice about exercise
Functional status preservation and rehabilitation Female Medicare beneficiaries age 65 and over who reported ever being screened for osteoporosisHome health care patients whose ability to walk or move around improved
Supportive and palliative careLong-stay nursing home residents who were physically restrainedHigh-risk long-stay nursing home residents with pressure sores 
 Short-stay nursing home residents with pressure sores 
 Home health care patients who were admitted to the hospital 
Patient safety  Appropriate timing of antibiotics received by adult Medicare patients having surgery
  Postoperative complications
  Failure to rescue
  Central venous catheter-associated adverse events
  Adults age 65 and over who received potentially inappropriate prescription medications
Timeliness Emergency department visits in which patients left without being seenAdults who can sometimes or never get care for illness or injury as soon as wanted
Patient centeredness  Poor provider-patient communication—children
  Poor provider-patient communication—adults
AccessPeople without a usual source of care due to a financial or insurance reasonPeople who have a usual primary care providerPeople under age 65 with health insurance
  People under age 65 uninsured all year
  People who have a specific source of ongoing care
  People who were unable to get or delayed in getting needed medical care, dental care, or prescription medications

 

Figure 4.2. Change in Black-White disparities over time

Stacked

Improving >5% = Black-White difference becoming smaller at an average annual rate greater than 5%.

Improving 1-5% = Black-White difference becoming smaller at an average annual rate between 1% and 5%.

Same = Black-White difference not changing.

Worsening 1-5% = Black-White difference becoming larger at an average annual rate between 1% and 5% per year.

Worsening >5% = Black-White difference becoming larger at an average annual rate greater than 5%.

Key: CRM = core report measures (Table 1.2).

Note: The time period for this figure is the most recent and oldest years of data used in the NHDR. Only 46 core report measures could be tracked over time for Blacks.

 

Table 4.4. Change in Black-White disparities over time: Specific measures

TopicImprovingWorseningSame
Cancer Adults age 50 and over who report they ever received a colonoscopy, sigmoidoscopy, proctoscopy, or fecal occult blood testWomen age 40 and over who reported they had a mammogram within the past 2 years
 Colorectal cancer deaths per 100,000 population per yearColorectal cancer diagnosed at advanced stage
 Breast cancer diagnosed at advanced stage 
 Breast cancer deaths per 100,000 female population 
Diabetes Adults with diabetes who had three major exams in the past year 
End stage renal diseaseHemodialysis patients with urea reduction ratio 65% or higher Dialysis patients registered on the waiting list for transplantation
Heart diseaseHospital patients who received recommended care for heart attackDeaths per 1,000 admissions with acute myocardial infarction as principal diagnosis, age 18 and overHospital patients who received recommended care for heart failure
HIV and AIDSNew AIDS cases per 100,000 population age 13 and over  
Maternal and child healthChildren ages 19-35 months who received all recommended vaccines Children ages 2-17 given advice about exercise
Children ages 3-6 with a vision check Children ages 2-17 given advice about healthy eating
 Children ages 2-17 who had a dental visit
Mental health and substance abuse Adults age 18 and over with past year major depressive episode who received treatment for the depression in the past yearSuicide deaths per 100,000 population
 People age 12 and over who needed treatment for any illicit drug use or alcohol problem who received such treatment in the past year 
Respiratory diseasesAdults age 65 and over who ever received pneumococcal vaccinationHospital patients with pneumonia who received recommended careTuberculosis patients who completed a curative course of treatment within 1 year of initiation of treatment
Lifestyle modification  Current smokers age 18 and over given advice to quit smoking
  Adults with obesity given advice about exercise
Functional status preservation and rehabilitation Home health care patients whose ability to walk or move around improved 
Supportive and palliative careShort-stay nursing home residents with pressure sores Long-stay nursing home residents who were physically restrained
  High-risk long-stay nursing home residents with pressure sores
  Home health care patients who were admitted to the hospital
Patient safetyPostoperative complicationsAdults age 65 and over who received potentially inappropriate prescription medicationsFailure to rescue
Central venous catheter-associated adverse eventsAppropriate timing of antibiotics received by adult Medicare patients having surgery 
TimelinessEmergency department visits in which patients left without being seen  
Adults who can sometimes or never get care for illness or injury as soon as wanted  
Patient centeredness  Poor provider-patient communication—children
  Poor provider-patient communication—adults
AccessPeople under age 65 with health insurancePeople without a usual source of care due to a financial or insurance reasonPeople under age 65 uninsured all year
People who have a specific source of ongoing care
People who have a usual primary care provider
People who were unable to get or delayed in getting needed medical care, dental care, or prescription medications

Note: Measures in bold indicate improvement or worsening at a rate of greater than 5% per year.


i The congressional mandate for the NHDR also identifies populations living in inner-city areas as a priority population. However, no data are available to support findings for this population.
ii Racial categories include White, Black, Asian, Native Hawaiian or Other Pacific Islander, American Indian or Alaska Native, and more than one race. Ethnic categories are Hispanic or Latino, non-Hispanic White, and non-Hispanic Black.
iii In the NHDR, "low income" refers to poor people. Thresholds for income categories—poor, near poor, middle income, and high income—vary by family size and composition and are updated annually by the U.S. Bureau of the Census. For example, in 2008 the Federal poverty threshold for a family of two adults and two children was $21,834.
iv Rural areas can be defined differently depending on the data source. The NHDR uses Office of Management and Budget revised definitions of metropolitan and micropolitan statistical areas. Noncore areas are rural areas. Data for metropolitan and micropolitan areas are used for comparisons with noncore areas.
v Individuals with special health care needs include children who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.
vi Races include Black or African American, Asian, Native Hawaiian or Other Pacific Islander, American Indian or Alaska Native, White, and people of multiple races.
vii Ethnicity differentiates Hispanics and non-Hispanics. Among non-Hispanics, this report identifies non-Hispanic Whites and non-Hispanic Blacks.
viii Data are presented for each minority group except for people of multiple races due to unreliable estimates for this group.



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Current as of March 2010
Internet Citation: Chapter 4. Priority Populations: National Healthcare Disparities Report, 2009. March 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/nhqrdr/nhdr09/Chap4.html