Chapter 2. Effectiveness (continued)

Effectiveness (continued)

End Stage Renal Disease (ESRD)

Importance

Measures

The NHDR tracks several measures of ESRD management to assess the quality of care provided to renal dialysis patients. The two core report measures and one noncore measure highlighted here are:

• Adequacy of hemodialysis (core).
• Registration for transplantation (core).
• Use of arteriovenous fistula (AVF) at first outpatient dialysis (supporting).

Findings

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 2.11. Adult hemodialysis patients with adequate dialysis (urea reduction ratio 65% or greater), by race, 2008

Key: AI/AN = American Indian or Alaska Native.
Source:University of Michigan Kidney Epidemiology and Cost Center, 2009 Dialysis Facility Report.
Denominator: End stage renal disease hemodialysis patients age 20 and over.

• In 2008, the overall percentage of adult hemodialysis patients receiving adequate dialysis was 95.8% (data not shown).
• The percentage of Asian and AI/AN adult hemodialysis patients receiving adequate dialysis was higher than for Whites (97.8% and 96.7%, respectively, compared with 95.9%; Figure 2.11).
• In 2008, the top 5 State achievable benchmark was 98.1%.^xi The available data were not sufficient to calculate time to benchmark.

Also, in the NHQR:

• In 2008, the percentage of male adult hemodialysis patients receiving adequate dialysis was lower than that of females.
• The percentage of adult hemodialysis patients receiving adequate dialysis was lower for those age 65 years and over than for those ages 20 to 64 years.

Management: Registration for Transplantation

Kidney transplantation is a procedure that replaces a failing kidney with a healthy kidney. If a patient is deemed a good candidate for transplant, he or she is placed on the transplant program's waiting list. Dialysis patients wait for transplant centers to match them with the most suitable donor. Registration for transplantation is an initial step toward patients receiving the option of kidney transplantation. Patients who receive transplants from living donors, about 36% of kidney transplants, do not need to register on a waiting list.

Early transplantation that decreases or eliminates the need for dialysis can also lessen the occurrence of acute rejection and patient mortality. In 2006, 70,778 patients were on the Organ Procurement and Transplantation Network's deceased donor kidney transplant waiting list in the United States, but only 10,212 deceased donor kidney transplants were performed.¹⁵ In 2007, the number of kidney transplants from deceased donors decreased by 1.3%, and kidney transplants from living donors dropped by 6.1%.¹⁶

Figure 2.12. Dialysis patients who were registered on a waiting list for transplantation, by race and ethnicity, 2000-2006

Key: AI/AN = American Indian or Alaska Native.
Source: National Institute of Diabetes and Digestive and Kidney Diseases, U.S. Renal Data System, 2000-2006.
Denominator: End stage renal disease hemodialysis patients and peritoneal dialysis patients under age 70.

• From 2000 to 2006, the percentage of dialysis patients who were registered on a waiting list for transplantation increased from 14.5% to 17.1% (data not shown). Improvements were observed among all racial and ethnic groups (Figure 2.12).
• In 2006, Blacks and AI/ANs were less likely to be registered on a waiting list than Whites (13.1% and 11.9%, respectively, compared with 18.6%). However, Asians (30.6%) were more likely to be registered on a waiting list than Whites.
• The 2006 top 5 State achievable benchmark was 27.3%.^xii At the current rate of improvement, the benchmark could not be attained overall for almost 24 years.
• Although Asians have already surpassed the 2006 achievable benchmark (in 2006, 30.6% of Asians were registered on a waiting list), Blacks could not attain the benchmark for almost 34 years and AI/ANs could not attain it for almost 37 years.

Also, in the NHQR:

• In all years, patients ages 20-69 were less likely to be registered on a waiting list than patients ages 0-19.
• In 2006, females were less likely than males to be registered on a waiting list.
• At their current rates of improvement, male patients could attain the achievable benchmark in about 20 years, whereas female patients could not attain the benchmark for more than 29 years.

Use of Arteriovenous Fistula for Vascular Access

For people with ESRD, vascular access is a way to reach the blood vessels so that harmful urea can be removed from the blood. An arteriovenous fistula (AVF) is the preferred type of access for most hemodialysis patients for three reasons: (1) it provides adequate blood flow for dialysis, (2) it lasts a long time, and (3) it has a low complication rate compared with other methods.

Although there is consensus that AVF should be the primary method of vascular access, incidence rates of AVF have historically been very low. Therefore, the Centers for Medicare & Medicaid Services (CMS) has sought to increase rates of AVF for primary access across the country by forming a nationwide initiative and collaborative effort to increase overall use of AVF. In 2005, this effort, called the Fistula First Breakthrough Initiative, set the goal for national prevalence at 66%.

Figure 2.13. Incident hemodialysis patients who used an arteriovenous fistula at first outpatient dialysis, by race and ethnicity, 2008-2009

Key: AI/AN = American Indian or Alaska Native; NHOPI = Native Hawaiian or Other Pacific Islander.
Source: Medicare eligibility forms (Centers for Medicare & Medicaid Services [CMS] Form 2728) (2008-2009), Fistula First Incident AVF Dataset, CMS.
Denominator: New end stage renal disease hemodialysis patients.

• From 2008 to 2009, the percentage of dialysis patients who used an AVF at first dialysis improved from 13.7% to 14.3% (data not shown).
• In 2009, a higher percentage of Asians than Whites used AVF at first dialysis, but a lower percentage of Blacks than Whites used AVF at first dialysis (17.6%, 14.7%, and 13.1%, respectively; Figure 2.13).
• Also in 2009, Hispanics had lower rates of AVF at first dialysis than non-Hispanic Whites (11.6% compared with 14.8%).
• The 2009 top 5 State achievable benchmark was 26.7%.^xiii

Also, in the NHQR:

• In 2009, female dialysis patients had substantially lower rates of AVF at first dialysis than males.

Heart Disease

Importance

Measures

The NHDR tracks several quality measures for preventing and treating heart disease, including the following three core report measures:

• Receipt of angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) for heart attack.
• Inpatient deaths following heart attack.
• Receipt of recommended care for heart failure.

Several measures related to heart disease are also presented in other chapters of this report. Timeliness of cardiac reperfusion for heart attack patients is tracked in Chapter 4, Timeliness, and receipt of complete written discharge instructions by patients with heart failure is tracked in Chapter 6, Care Coordination.

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

Heart attack, or acute myocardial infarction, is a common life-threatening condition that requires rapid recognition and efficient treatment in a hospital to reduce the risk of serious heart damage and death. Measuring processes of heart attack care can provide information about whether a patient received specific needed services, but these processes make up a very small proportion of all the care that a heart attack patient needs. Measuring outcomes of heart attack care, such as mortality, can provide a more global assessment of all the care a patient receives and usually is the aspect of quality that matters most to patients.

Significant improvements in a number of measures of quality of care for heart attack have occurred in recent years. Four measures that have been tracked in past NHDRs (administration of aspirin within 24 hours and at discharge, administration of beta blocker at discharge, and counseling to quit smoking) have attained overall performance levels exceeding 95%. These measures were included in the composite measure of care for heart attack in past NHDRs. However, the success of these measures creates a ceiling effect that limits the report's ability to track improvement over time. Moreover, administration of beta blocker within 24 hours as recommended care has been discontinued. Hence, this NHDR focuses on one measure of heart attack care: ACE inhibitor or ARB treatment among patients with left ventricular systolic dysfunction.

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, 2005-2008

Key: AI/AN = American Indian or Alaska Native.
Source: Centers for Medicare & Medicaid Services, Medicare Quality Improvement Organization Program, 2005-2008.
Denominator: Patients hospitalized with a principal diagnosis of acute myocardial infarction and left ventricular systolic dysfunction.

• From 2005 to 2008, the percentage of heart attack patients with left ventricular systolic dysfunction who received an ACE inhibitor or ARB improved from 83.4% to 93.7% (data not shown). Improvements were observed among all racial and ethnic groups during the same period (Figure 2.14).
• The 2008 top 5 State achievable benchmark was 97.2%.^xiv At the current rate of increase, the 2008 achievable benchmark could be achieved in 1 year. With the exception of AI/ANs (who would attain the benchmark in about 1.7 years), the other racial and ethnic groups would attain the benchmark in about 1 year.

Also, in the NHQR:

• At their current rates of improvement, the achievable benchmark could be reached by each age group in about 1 year.

Outcome: Inpatient Deaths Following Heart Attack

Survival following admission for heart attack reflects multiple patient factors, such as a patient's comorbidities, as well as health care system factors, such as the possible need to transfer patients to other hospitals to receive services. It also may partly reflect receipt of appropriate health services.

Figure 2.15. Deaths per 1,000 adult hospital admissions with heart attack, by race/ethnicity and insurance status, 2004-2007

Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 2004-2007.
Denominator: Adults age 18 and over admitted to a non-Federal community hospital in the United States with acute myocardial infarction as principal discharge diagnosis.
Note: White, Black, and Asian groups are non-Hispanic. Rates are adjusted by age, gender, age-gender interactions, and all payer refined-diagnosis related group scoring of risk of mortality.

• In 2007, the overall rate of inpatient mortality was 64 per 1,000 admissions for heart attack (data not shown). Asians had higher rates of inpatient heart attack mortality than Whites, but Blacks had a lower rate (74.5, 67.5, and 57.4 per 1,000 admissions, respectively; Figure 2.15).
• Also in 2007, the inpatient heart attack mortality for the Medicaid group was significantly higher than for people with private insurance (75.3 per 1,000 admissions compared with 66.9).
• The 2007 top 4 State achievable benchmark for inpatient heart attack mortality was 54.6 per 1,000 admissions.^xv At the current rate, the achievable benchmark could be attained in about 2.5 years.
• At their current rates of improvement, Blacks could attain the benchmark in less than 1 year, but Asians could not attain the benchmark for more than 6 years.

Also, in the NHQR:

• From 2004 to 2007, the overall inpatient mortality rate decreased significantly overall and for each geographic location and gender group.
• At their current rates of improvement, males could attain the achievable benchmark in less than 1 year; however, females could not attain the benchmark for almost 3 years.
• Although most geographic areas could attain the benchmark in 1 to 2 years, small metropolitan, micropolitan, and noncore areas could not attain the benchmark until later (about 5 years, about 3.6 years, and about 3 years, respectively).

Treatment: Receipt of Recommended Care for Heart Failure

The NHDR tracks the national percentages of receipt of the following services (found in the Data Tables Appendix):

• Recommended test for heart functioning (heart failure patients having evaluation of left ventricular ejection fraction).
• Recommended medication treatment (patients with left ventricular systolic dysfunction prescribed ACE inhibitor or ARB at discharge).

In addition, an overall composite measure describes the percentage of all episodes in which heart failure patients receive recommended care.

Figure 2.16. Hospital patients with heart failure who received recommended hospital care: Overall composite, by race and ethnicity, 2005-2008

Key: AI/AN = American Indian or Alaska Native.
Source: Centers for Medicare & Medicaid Services, Medicare Quality Improvement Organization Program, 2005-2008.
Denominator: Patients hospitalized with a principal diagnosis of acute heart failure.

• From 2005 to 2008, the overall percentage of patients with heart failure who received recommended care improved from 87.7% to 95% (Figure 2.16). In addition, the percentage of Asian patients who received recommended care for heart failure improved (from 86.6% to 96.6%).
• The 2008 top 5 State achievable benchmark for patients with heart failure who received recommended hospital care was 97.2%.^xvi At the current rate of improvement, Whites, Blacks, Asians, and non-Hispanic Whites could attain the achievable benchmark in less than a year.
• Although the other racial and ethnic groups could attain the benchmark in less than 1 year, AI/ANs and Hispanics could not attain the benchmark until later (about 3 years and about 1.5 years, respectively).

Also, in the NHQR:

• The percentage of patients with heart failure who received recommended care improved for those age 85 years and over.
• At their current rates of improvement, all age and gender groups could attain the achievable benchmark in about 1 year.

HIV and AIDS

Importance

HIV is a virus that kills or damages cells of the body's immune system. AIDS is the most advanced stage of HIV infection. HIV is spread through unprotected sex with an infected person and by sharing drug needles or through contact with the blood of an infected person. In addition, women with HIV can give it to their babies during pregnancy, childbirth, or breastfeeding.

The impact of HIV infection and 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.²¹

According to the Centers for Disease Control and Prevention, HIV and AIDS disproportionately affect African Americans in the United States. In 2008, African Americans accounted for 52% of all diagnoses of HIV infection and had a rate of 73.7 per 100,000 population compared with 8.2 per 100,000 for Whites.²² 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 co-infections, 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.²³

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 2.5 times the rate of Whites.²⁴ 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.²⁵ In 2006, HIV/AIDS was the fourth leading cause of death among Hispanic men and women ages 35-44.²⁶ 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.²⁷

The White House Office of National AIDS Policy launched the National HIV/AIDS Strategy (NHAS) in July 2010. The NHAS is a comprehensive plan focused on: (1) reducing the number of people who become infected with HIV, (2) increasing access to care and optimizing health outcomes for people living with HIV, and (3) reducing HIV-related health disparities. The plan will serve as a roadmap for policymakers, partners in prevention, and the public on steps the United States must take to lower HIV incidence, get people living with HIV into care, and reduce HIV-related health disparities.

Measures

This year, five supporting measures are presented on the prevention of opportunistic infections in HIV and AIDS patients and one on HIV infection deaths:

• Eligible patients receiving prophylaxis for Pneumocystis pneumonia (PCP).
• Eligible patients receiving prophylaxis for Mycobacterium avium complex (MAC).
• Adult HIV patients who had at least two outpatient visits during the year.
• Adult HIV patients who received two or more CD4 tests during the year.
• Adult HIV patients who received highly active antiretroviral therapy (HAART).

Findings

Management: HIV Patients Receiving Care

Management of chronic HIV disease includes outpatient and inpatient services. Without adequate treatment, as HIV disease progresses, CD4 cell counts fall and patients become increasingly susceptible to opportunistic infections.

HIV/AIDS core clinical performance measures are indicators for use in monitoring the quality of care provided to adults and adolescents living with HIV. Based on the set of quality measures developed by the HIV/AIDS Bureau of the Health Resources and Services Administration (HRSA), performance can be measured for various HIV prevention and treatment services. Services indicated for patients with HIV include:

1. Two or more CD4 cell counts performed in the measurement year.
2. HAART for patients with AIDS.
3. Two or more medical visits in an HIV care setting in the measurement year.²⁸
4. PCP prophylaxis for patients with CD4 cell count below 200.

Currently, national data on HIV care are not routinely collected. HIV measures tracked in the NHDR come from the HIV Research Network, which consists of 18 medical practices across the United States that treat large numbers of patients living with HIV. Data from the voluntary HIV Research Network are not nationally representative of the level of care received by all Americans living with HIV. Network data represent only patients who are actually receiving care (about 14,000 HIV patients per year) and do not represent 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.

Below are data from the HIV Research Network that capture four of the recommended HRSA measures. In addition, when CD4 cell counts fall below 50, medicine to prevent development of disseminated MAC infection is routinely recommended.²⁹

Figure 2.17. Adult patients with HIV who received care, by race/ethnicity and gender, 2007

Key: HAART = highly active antiretroviral therapy; PCP = Pneumocystis pneumonia; MAC = Mycobacterium avium complex.
Source: Agency for Healthcare Research and Quality, HIV Research Network, 2007.
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.

• Overall in 2007, Black patients with HIV were less likely than White patients to receive the minimum care for HIV, except in the receipt of MAC and PCP prophylaxis (Figure 2.17).
• In 2007, female patients with HIV were more likely to have had two or more outpatient visits than male patients but were less likely to receive HAART and MAC prophylaxis.
• There were no statistically significant differences in other recommended care.

Also, in the NHQR:

• Adult HIV patients age 45 and over were more likely to receive recommended care than HIV patients ages 18-44.

Outcome: Deaths of People With HIV Infection

Improved management of HIV infection has contributed to declines in the number of new AIDS cases in the United States since the 1990s.³⁰ HIV infection deaths reflect a number of factors, including underlying rates of HIV risk behaviors, prevention of HIV transmission, early detection and treatment of HIV disease, and management of AIDS and its complications.

Figure 2.18. HIV infection deaths per 100,000 population, by race, ethnicity, and gender,1999-2007

Key: API = Asian or Pacific Islander; AI/AN = American Indian or Alaska Native.
Source:Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System – Mortality, 1999-2007
Note: Rates are age adjusted to the 2000 standard population.

• Overall, from 1999 to 2007, the rate of HIV infection deaths decreased from 5.3 per 100,000 population to 3.7 per 100,000 population (data not shown).
• From 1999 to 2007, HIV infection death rates improved for all groups. The HIV infection death rate decreased for Blacks (from 23.6 per 100,000 population to 17.3 per 100,000 population) but remains significantly higher than the rate for Whites (which decreased from 2.9 per 100,000 population to 1.9; Figure 2.18).
• From 1999 to 2007, the HIV infection death rate decreased for Hispanics (from 6.9 per 100,000 to 4.1 per 100,000) but remains more than twice as high as the rate for non-Hispanic Whites (which decreased from 2.3 per 100,000 population to 1.5).
• In 2007, the HIV infection death rate for males was more than twice that of females (5.4 per 100,000 population compared with 2.1).

Also, in the NHQR:

• From 1999 to 2007, the rate of HIV infection deaths decreased for adults ages 45-64 but was still highest among all age groups.
• In 2007, the rates of HIV infection deaths were highest for residents in large central metropolitan areas and lowest in noncore areas.

^xi The top 5 States contributing to the achievable benchmark are Colorado, Connecticut, Hawaii, Rhode Island, and Texas.
^xii The top 5 States contributing to the achievable benchmark are California, Minnesota, New Hampshire, Pennsylvania, and South Dakota.
^xiii The top 5 States contributing to the achievable benchmark are Hawaii, Maine, Montana, New Hampshire, and Oregon.
^xiv The top 5 States contributing to the achievable benchmark are Alaska, Minnesota, New Hampshire, North Dakota, and Oregon.
^xv The top 4 States contributing to the achievable benchmark are Arizona, Florida, Maryland, and Michigan.
^xvi The top 5 States contributing to the achievable benchmark are Connecticut, Maine, New Hampshire, New Jersey, and South Carolina.

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