Chapter 10. Priority Populations

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 disparities related to "racial factors and socioeconomic factors in priority populations."ⁱ 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.

In 2009, the Institute of Medicine released recommendations on improving race, ethnicity, and language data in a report called Race, Ethnicity, and Language Data: Standardization for Health Care Quality Improvement.¹ The Subcommittee on Standardized Collection of Race/Ethnicity Data for Healthcare Quality Improvement recommends collecting data based on existing Office of Management and Budget race and Hispanic ethnicity categories. They also recommend using more fine-grained categories of ethnicity (referred to as granular ethnicity and based on one's ancestry) and language need (a rating of spoken English language proficiency of "less than very well" and preferred language for health-related encounters).¹ Standardized race, ethnicity, and language data are needed to support comparisons across organizations and regions, create pooled datasets, and track data over time. Standardized race, ethnicity, and language data also support reporting and measuring successes of disparities reduction initiatives.

This chapter of the National Healthcare Disparities Report (NHDR) addresses the congressional directive on priority populations in addition to what is presented throughout the NHDR and in the National Healthcare Quality Report (NHQR) this year.ⁱⁱ Chapters 2 through 9 of this report examine racial, ethnic, socioeconomic, gender, geographic location, and age differences in quality of and access to health care in the general U.S. population. Subpopulation data for Asians and Hispanics are also presented in these chapters where data are available.

This chapter summarizes differences for each of the racial and ethnic and low-income populations for which there is relatively more data from multiple sources. For other relatively smaller populations, such as Native Hawaiians and Other Pacific Islanders (NHOPIs), American Indians and Alaska Natives (AI/ANs), and people with disabilities, this chapter highlights some unique data and findings.

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. The Data Tables appendix 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.ⁱⁱⁱ
• Low-income groups.^iv
• Women.
• Children (under age 18).
• Older adults (age 65 and over).
• Residents of rural areas.^v
• Individuals with special health care needs,^vi 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.
• Residents of rural areas.
• Individuals with disabilities or special health care needs.

Measures related to women, children, and older adults are presented in other chapters of this report and include comparisons by gender and age.

This chapter does not provide a comprehensive assessment of health care differences in each priority population. In general, most of the measures tracked in the NHQR and NHDR were selected to be applicable across many population groups to fulfill the purpose of these reports, which is to track quality and disparities at the national level. 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 NHOPIs and 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.² 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 Americans³ (12.9% of the U.S. population)⁴; more than 45.5 million Hispanics or Latinos (15.1%)³; almost 13.4 million Asians (4.4%); more than half a million NHOPIs (0.2%); and nearly 3 million AI/ANs (1.0%), of whom 57% reside on Federal trust lands.⁵ Racial and ethnic minorities are more likely than non-Hispanic Whites to be poor or near poor.⁶ In addition, Hispanics, Blacks, and some Asian subgroups are less likely than non-Hispanic Whites to have a high school education.⁷

Previous chapters of the NHDR describe health care differences by racial and ethnic categories as defined by the Office of Management and Budget and used by the U.S. Census Bureau.⁸ 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.^vii 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 over time in differences related to race and ethnicity. 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 2006-2008, depending on the 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 (Table 1.3) 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.

Gaps in Information

As in previous NHDRs, this section includes information on programs and issues that may affect racial and ethnic disparities. In interpreting findings for racial and ethnic minorities, readers should note that considerable gaps exist in information for some racial and ethnic minorities. These gaps 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, presents more detailed descriptions of current data limitations and ways data are gradually improving.

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 1.3) of quality of and access to health care are shown below.

Table 10.1. Measures for which Blacks were worse than Whites in most recent year and their trends over time

Figure 10.1. Change in Black-White disparities over time for all core measures

Improving = Black-White difference becoming smaller at an average annual rate greater than 1%.
Same = Black-White difference not changing.
Worsening = Black-White difference becoming larger at an average annual rate greater than 1%.
Note: The time period for this figure is the most recent and oldest years of data used in the NHDR. Only 53 core report measures could be tracked over time for Blacks.

Asians

Previous NHDRs showed that Asians had similar or better quality of care than Whites but worse access to care than Whites for many measures that the report tracks. Findings based on core report measures of quality and access to health care that support estimates for either Asians or Asians and Pacific Islanders in aggregate are shown below.

Table 10.2. Measures for which Asians were worse than Whites for most recent year and their trends over time

Figure 10.2. Change in Asian-White disparities over time

Improving = Asian-White difference becoming smaller at an average annual rate greater than 1%.
Same = Asian-White difference not changing.
Worsening = Asian-White difference becoming larger at an average annual rate greater than 1%.
Note: The time period for this figure is the most recent and oldest years of data used in the NHDR. Only 24 core report measures could be tracked over time for Asians.

Native Hawaiians and Other Pacific Islanders

The ability to assess disparities among NHOPIs for the NHDR has been a challenge for two main reasons. First, the NHOPI racial category is relatively new to Federal data collection. Before 1997, NHOPIs were classified as part of the Asian and Pacific Islander racial category and could not be identified separately in most Federal data. In 1997, the Office of Management and Budget promulgated new standards for Federal data on race and ethnicity and mandated that information about NHOPIs be collected separately from information about Asians.⁸ However, these standards have not yet been incorporated into all databases. Second, when information about this population was collected, databases often included insufficient numbers of NHOPIs to allow reliable estimates to be made.

Due to these challenges, in previous NHDRs estimates for the NHOPI population could be generated for only a handful of measures. A lack of quality data on this population prevents the NHDR from detailing disparities for this group. This year, the NHDR features data from the Behavioral Risk Factor Surveillance System (BRFSS) to supplement the NHDR information for the NHOPI population. Preventive care and access to care measures were selected to highlight quality of care for people who identified themselves as NHOPI (including people of mixed race who identified primarily as NHOPI). This year, the measures include cholesterol screening, pneumonia admissions, and cost as a barrier to medical care.

BRFSS data do not replace the need for continued efforts to improve data collection and statistical methods to provide more information on health and health care of the NHOPI population. BRFSS may have larger samples of NHOPIs due to State efforts to improve sample sizes, but it is not necessarily a comprehensive survey of health and health care. Other surveys and data collection efforts, such as vital statistics and hospital administrative data, include more topics but do not identify NHOPIs or have large enough sample sizes to provide data for these populations.

For all national data sources, the relatively small population sizes of many Pacific Islander groups can cause these populations to be overlooked when categorized as NHOPIs. In addition, identifying individuals with chronic conditions or other health conditions within such small populations further reduces the sample sizes. However, as data become available, this information will be included in future reports.

Preventive Care: Cholesterol Screening

In the State of Hawaii, where 54% of Native Hawaiians reside, cardiovascular disease is the leading cause of death.⁹ Screening for risk factors for cardiovascular disease, such as high blood pressure and high cholesterol, is important in preventing disease. Cholesterol screening is shown below to highlight one aspect of cardiovascular disease prevention for Native Hawaiians.

Figure 10.3. Adults who did NOT receive a cholesterol check in the last 5 years, Hawaii, 2005, 2007, and 2009

Key: NHOPI = Native Hawaiian or Other Pacific Islander.
Source: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System, 2005, 2007, and 2009.
Denominator: Adults age 18 and over in Hawaii.
Note: These data are self-reported from a survey of adults in a household.

• From 2005 to 2009, the percentage of adults who did not receive a cholesterol check in Hawaii improved overall for the general population (from 26.6% to 22.5%) and for NHOPIs (from 34.8% to 30.2%; Figure 10.3).
• In 2009, the percentage of adults who did not receive a cholesterol check in the last 5 years in Hawaii was significantly higher for NHOPIs than for Whites (30.2% compared with 21.2%).

Treatment: Pneumonia

High rates of hospitalizations for pneumonia may indicate poor outpatient care and low vaccination rates. NHOPIs have more hospital admissions for bacterial pneumonia than Whites. The problem appears to be worse for Pacific Islanders other than Native Hawaiians.

Figure 10.4. Bacterial pneumonia admissions per 100,000 population, age 18 and over, Hawaii only, by race, 2005-2007

Key: NHOPI = Native Hawaiian or Other Pacific Islander.
Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Hawaii State Inpatient Databases, 2005-2007, and AHRQ Quality Indicators, version 3.1.
Denominator: Adults age 18 and over in Hawaii based on the Hawaii Health Survey.
Note: Excludes sickle cell or hemoglobin-S conditions, transfers from other institutions, and obstetric admissions. Rates are adjusted by age and gender using the total U.S. population for 2000 as the standard population.

• From 2005 to 2007, there was significant improvement among all groups in the rate of hospital admissions with bacterial pneumonia in Hawaii.
• In 2007, NHOPIs overall had a higher rate of hospital admission with bacterial pneumonia than Whites in Hawaii (294.4 per 100,000 population compared with 229.1 per 100,000 population; Figure 10.4).
• Native Hawaiians had a higher rate of hospital admissions with bacterial pneumonia than Whites in Hawaii (231.6 per 100,000 population compared with 229.1 per 100,000 population).
• Other Pacific Islanders had a significantly higher rate of hospital admission with bacterial pneumonia than Whites in Hawaii (793.3 per 100,000 population compared with 229.1 per 100,000 population).

Access to Care: Medical Costs

High premiums and out-of-pocket payments can be significant barriers to accessing needed medical treatment and preventive care. Studies show that racial and ethnic minorities are more likely to face barriers due to cost of care than other groups.^{10, 11}

Figure 10.5. Adults who needed to see a doctor in the past year but could not because of cost, Hawaii, 2007-2009

Key: NHOPI = Native Hawaiian or Other Pacific Islander.
Source: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System, 2007-2009.
Denominator: Adults age 18 and over in Hawaii.
Note: These data are self-reported from a survey of adults in a household.

• From 2007 to 2009, the percentage of adults who needed to see a doctor in the past year but could not because of cost in Hawaii worsened overall and for Whites, but improved for NHOPIs (from 16.7% to 15.7%; Figure 10.5).
• In 2007, the percentage of adults who needed to see a doctor in the past year but could not because of cost in Hawaii was higher for NHOPIs than for Whites (15.7% compared with 13.1%).

American Indians and Alaska Natives

Previous NHDRs showed that AI/ANs 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 of quality and access that support estimates for AI/ANs are shown below.

Table 10.3. Measures for which American Indians and Alaska Natives were worse than Whites for most recent year and their trends over time

Figure 10.6. Change in American Indian or Alaska Native-White disparities over time for all core measures

Improving = AI/AN-White difference becoming smaller at an average annual rate greater than 1%.
Same = AI/AN-White difference not changing.
Worsening = AI/AN-White difference becoming larger at an average annual rate greater than1%.
Key: AI/AN = American Indian or Alaska Native.
Note: The time period for this figure is the most recent and oldest years of data used in the NHDR. Only 27 core report measures could be tracked over time for AI/ANs.

Hispanics or Latinos

Previous NHDRs showed that Hispanics had poorer quality of care and worse access to care than non-Hispanic Whites for many measures that the report tracks. Findings based on core report measures of quality of and access to health care that support estimates for Hispanics are shown below. Figure 10.7 shows changes over time.

Table 10.4. Measures for which Hispanics were worse than non-Hispanic Whites for most recent year and their trends over time

Figure 10.7. Change in Hispanic-non-Hispanic White disparities over time for all core measures

Improving = Hispanic-non-Hispanic White difference becoming smaller at an average annual rate greater than 1%.
Same = Hispanic-non-Hispanic White difference not changing.
Worsening = Hispanic-non-Hispanic White difference becoming larger at an average annual rate greater than 1%.
Note: The time period for this figure is the most recent and oldest years of data used in the NHDR. Only 47 core report measures could be tracked over time for Hispanics.

ⁱ Available at: http://origin.www.gpo.gov/fdsys/pkg/USCODE-2000-title42/html/USCODE-2000-title42-chap6A-subchapVII-partA-sec299a-1.htm.
ⁱⁱ Populations of inner-city areas are also identified as one of AHRQ's priority populations pursuant to 42 U.S.C. 299(c)(l)(A). However, no data are available to support findings for this population.
ⁱⁱⁱ Racial groups are White, Black, Asian, Native Hawaiian or Other Pacific Islander, American Indian and Alaska Native, and more than one race. Ethnic groups are Hispanic or Latino, non-Hispanic White, and non-Hispanic Black.
^iv 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 2009 the Federal poverty threshold for a family of two adults and two children was $22,050.
^v 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.
^vi 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.
^vii Data are presented for each minority group except for people of multiple races due to unreliable estimates for this group.
 

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