Chapter 2. Effectiveness (continued, 2)

Effectiveness (continued)

Maternal and Child Health

Importance

Measures

The NHQR and NHDR track several prevention and treatment measures related to maternal and child health care. The core report measures highlighted in this section are:

• Receipt of recommended immunizations by young children.
• Vision checks for children.
• Counseling of children or parents about physical activity.
• Counseling of children or parents about healthy eating.

In addition, two supporting measures are presented:

• Obstetric trauma.
• Weight monitoring of overweight children.

Findings

Outcome: Obstetric Trauma

Childbirth and reproductive care are the most common reasons for women of childbearing age to use health care services. With nearly 12,000 births each day in the United States,³² childbirth is the most common reason for hospital admission.

Obstetric trauma involving a severe tear to the vagina or surrounding tissues during delivery is a common complication of childbirth. The higher risk of severe perineal laceration may be related to the degree of fetal-maternal size disproportion. Asian and Pacific Islander (API) women, with the smallest body size, are most likely to experience obstetric trauma.³⁴ In addition, although any delivery can result in trauma, existing evidence shows that severe perineal trauma can be reduced by restricted use of episiotomy and forceps.³⁵

Figure 2.19. Obstetric trauma with 3rd or 4th degree laceration per 1,000 vaginal deliveries without instrument assistance, by race/ethnicity, 2001-2007, and area income, 2004-2007

Key: API = Asian or Pacific Islander; Q = Quartile; Q1 indicates the lowest area income quartile while Q4 indicates the highest area income quartile.
Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, State Inpatient Databases disparities analysis file, 2001-2007, and Nationwide Inpatient Sample, 2004-2007.
Denominator: All patients hospitalized for vaginal delivery without indication of instrument assistance.
Note: Rates are adjusted by age and comorbidities.

• Declines were observed among all racial/ethnic and area income groups (Figure 2.19).
• In all years, Blacks and Hispanics had lower rates than Whites and residents of the lower two area income quartiles had lower rates than residents of the highest area income quartile.
• In all years, APIs had higher rates than Whites.
• The 2007 top 3 State achievable benchmark was 25 per 1,000 deliveries.^xix At the current 8% annual rate of decrease, this benchmark could be attained overall and by most racial/ethnic and income groups in about 3 years. Whites and residents of the highest area income quartile would need 4 years, while APIs would need more than 23 years.

Also, in the NHQR:

• From 2004 to 2007, rates of obstetric trauma with 3rd or 4th degree laceration decreased from 40 to 32 per 1,000 vaginal deliveries without instrument assistance.
• In most years, residents of small metropolitan, micropolitan, and noncore areas had lower rates of obstetric trauma compared with residents of large fringe metropolitan areas.
• The achievable benchmark could be attained in most urban-rural locations in about 3 years. Residents of large fringe metropolitan areas would need about 4 years to attain the benchmark.

Prevention: Receipt of Recommended Immunizations by Young Children

Immunizations are important for reducing mortality and morbidity. They protect recipients from illness and disability and protect others in the community who cannot be vaccinated. In 2008, recommended vaccines for children that should have been completed by ages 19-35 months included four doses of diphtheria-tetanus-pertussis vaccine, three doses of polio vaccine, one dose of measles-mumps-rubella vaccine, three doses of Haemophilus influenzae type B vaccine, and three doses of hepatitis B vaccine. These vaccines constitute the 4:3:1:3:3 vaccine series tracked in Healthy People 2010. This series does not include varicella vaccine or vaccines added to the recommended schedule after 1998.

Figure 2.20. Children ages 19-35 months who received the 4:3:1:3:3 vaccine series, by race, ethnicity, and household income, 2000-2008

Key: AI/AN = American Indian or Alaska Native.
Source: Centers for Disease Control and Prevention, National Center for Health Statistics and National Center for Immunization and Respiratory Diseases, National Immunization Survey, 2000-2008.
Denominator: U.S. civilian noninstitutionalized population ages 19-35 months.
Note: The vaccines included in this measure are based on the corresponding Healthy People 2010 objective, which does not include varicella vaccine or vaccines added to the recommended schedule after 1998.

• A pattern of rising and then falling rates was observed among all racial, ethnic, and income groups, although the peak year and statistical significance varied (Figure 2.20). The rise between 2000 and 2004 was significant for Whites, Blacks, Asians, Hispanics, and all income groups. The fall between 2004 and 2008 was only significant for Whites and the two higher income groups.
• In almost all years, Black children were less likely than White children and poor, low-income, and middle-income children were less likely than high-income children to receive the 4:3:1:3:3 vaccine series.
• From 2002 to 2006, Hispanic children were less likely than non-Hispanic White children to receive these vaccines. In 2007, rates were comparable, and in 2008, Hispanic children had achieved the higher rate.
• The 2008 top 5 State achievable benchmark was 84%.^xx All racial, ethnic, and income groups are moving away from the benchmark.

Also, in the NHQR:

• From 2000 to 2004, the percentage of children ages 19-35 months who received the 4:3:1:3:3 vaccine series increased. From 2004 to 2008, the percentage of children with these vaccines fell.
• Since 2004, the overall rate and rates for boys nd girls have been moving away from the achievable benchmark.

Prevention: Children's Vision Care

Vision checks for children may detect problems of which children and their parents were previously unaware. Early detection also improves the chances that corrective treatments will be successful.

Figure 2.21. Children ages 3-6 who ever had their vision checked by a health provider, by race/ethnicity and income, 2002-2007

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2007.
Denominator: U.S. civilian noninstitutionalized population ages 3-6.

• From 2002 to 2007, significant improvements were observed among non-Hispanic Whites and Blacks and among residents of poor and middle-income neighborhoods (Figure 2.21).
• Hispanic children tended to be less likely to receive vision checks than non-Hispanic White children, but this was statistically significant in only 3 of 6 years.
• Poor, low-income, and middle-income children tended to be less likely to receive vision checks than high-income children, but again this was statistically significant in only about half of the years.

Also, in the NHQR:

• From 2002 to 2007, the percentage of children ages 3-6 who ever had their vision checked by a health provider increased.
• Children in large central metropolitan areas tended to be less likely to receive vision checks.
• Children with special health care needs tended to be more likely to receive vision checks.

Prevention: Weight Monitoring of Overweight Children

American children are getting heavier. Overweight children are identified using growth charts that show body mass index (BMI) for age. These growth charts are based on national data collected between 1963 and 1994. Children with BMI values at or above the 95th percentile are considered overweight. From 1976-1980 to 2003-2006, the proportion of children classified as overweight increased from 6.5% to 17% among children ages 6 to 11 and from 5% to 17.6% among adolescents ages 12 to 19.^36,37

Pediatricians are advised to monitor BMI and excessive weight gain in children to recognize and address cases of overweight and obesity.³⁸ When providers alert young patients and their parents about their overweight status, a new opportunity is created to encourage the development of healthy diet and exercise habits that may be carried into adulthood.³⁹

Figure 2.22. People ages 2-19 who were overweight and who reported^xxi having been told by a health provider they were overweight, by race and income, 2001-2004 and 2005-2008

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health and Nutrition Examination Survey, 2001-2004 and 2005-2008.
Denominator: U.S. civilian noninstitutionalized population ages 2-19 who were overweight.
Note: Overweight children are identified using age- and sex-specific reference data from the 2000 Centers for Disease Control and Prevention body mass index (BMI) for age growth charts. Children with BMI values at or above the 95th percentile of the sex-specific BMI growth charts are categorized as overweight.

• Between the two time periods, only non-Hispanic Blacks ages 2-19 who were overweight experienced an increase in being told by a health provider they were overweight (Figure 2.22).
• In 2005-2008, overweight non-Hispanic Blacks were more likely than overweight non-Hispanic Whites to report being told by a health provider that they were overweight.
  

Also, in the NHQR:

• The percentage of people ages 2-19 who were overweight based on height and weight measurement and who reported having been told by a health provider they were overweight did not change significantly between 2001-2004 and 2005-2008 overall.
• In both time periods, overweight children ages 2-5 and 6-11 were less likely than overweight youths ages 12-19 to report being told by a health provider that they were overweight.

Prevention: Counseling for Children About Physical Activity

Childhood represents a period when healthy lifelong habits are often formed. Physicians can play an important role in encouraging healthy behaviors, such as regular exercise, in children.

Figure 2.23. Children ages 2-17 for whom a health provider ever gave advice about the amount and kind of exercise, sports, or physically active hobbies they should have, by race, ethnicity, household income, and insurance status, 2002-2007

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2007.
Denominator: U.S. civilian noninstitutionalized population ages 2-17.

• Significant improvements were observed among Whites, Hispanics, all income groups, and all insurance groups (Figure 2.23).
• In all years, poor, low-income, and middle-income children were less likely than high- income children and uninsured children were less likely than privately insured children to receive advice about exercise.

Also, in the NHQR:

• From 2002 to 2007, the percentage of children for whom a health provider ever gave advice about the amount and kind of exercise, sports, or physically active hobbies they should have improved.
• In all years, children in micropolitan and noncore areas were less likely than children in large fringe metropolitan areas and children with special health care needs were more likely than children without such needs to receive advice about exercise

Prevention: Counseling for Children About Healthy Eating

Physicians play an important role in encouraging children's healthy eating. Overweight and obesity during childhood often persist into adulthood, with consequences that are numerous and costly. Unfortunately, overweight and obesity among children under age 18 have risen dramatically in the past two decades.³⁸ The American Academy of Pediatrics recommends that pediatricians discuss and promote healthy diets with all children and their parents or guardians, both those who are overweight and those who are not.³⁸

Figure 2.24. Children ages 2-17 for whom a health provider ever gave advice about healthy eating, by race, ethnicity, household income, and insurance status, 2002-2007

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2007.
Denominator: U.S. civilian noninstitutionalized population ages 2-17.

• Significant improvements were observed among Whites, Hispanics, all income groups, and all insurance groups (Figure 2.24).
• In all years, poor, low-income, and middle-income children were less likely than high-income children and uninsured children were less likely than privately insured children to receive advice about healthy eating.

Also, in the NHQR:

• From 2002 to 2007, the percentage of children for whom a health provider ever gave advice about healthy eating improved from 51.0% to 57.6%, about 3% per year.
• In almost all years, children in small metropolitan, micropolitan, and noncore areas were less likely than children in large fringe metropolitan areas and children with special health care needs were more likely than children without such needs to receive advice about healthy eating.

Mental Health and Substance Abuse

Importance

Measures

The NHDR and NHQR track measures of the quality of treatment for major depression and substance abuse. Mental health treatment includes counseling, inpatient care, outpatient care, and prescription medications. This section highlights three core measures of mental health and substance abuse treatment:

• Receipt of treatment for depression.
• Suicide deaths.
• Receipt of needed treatment for illicit drug use or alcohol problem.

In addition, one supporting measure is discussed:

• Completion of substance abuse treatment.

According to data from the Healthcare Cost and Utilization Project, in 2007, 12.5% of emergency department visits (12 million visits) were related to mental health and substance abuse.⁴⁴ About 40% of these emergency department visits resulted in hospital admission (4.8 million visits). In 2006, approximately 1.4 million hospitalizations were specifically for mental health conditions⁴⁵ and 1 in 5 hospital stays included some mention of a mental health condition as either a principal or secondary diagnosis. Mood disorders were the most common principal diagnosis for all nonelderly people. For individuals age 65 and over, dementia and associated cognitive disorders were the most common cause of mental health hospitalizations.

Social and cultural factors may dramatically affect mental health. Culturally and linguistically appropriate services can decrease the prevalence, incidence, severity, and duration of certain mental disorders. However, many factors adversely affect the mental health of racial and ethnic groups, such as discrimination^xxii and racism. Some factors also present significant barriers to treatment. These include cost of care, lack of sufficient insurance for mental health services, social stigma, fragmented organization of services,⁴⁶ and mistrust.

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

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

For racial and ethnic populations in rural areas, these problems are compounded by the lack of culturally and linguistically competent providers. And as of September 2009, the number of federally designated mental health professional shortage areas reached 3,291.⁴⁷

Treatment: Receipt of Treatment for Depression

It has been estimated that about 1 out of 7 individuals in the United States will have a major depressive episode in their lifetime.⁴² Treatment can be very effective in reducing symptoms and associated illnesses and returning individuals to a productive lifestyle.

For example, the Sequenced Treatment Alternatives to Relieve Depression study, funded by the National Institute on Mental Health, was the largest clinical trial ever conducted to help determine the most effective treatment strategies for major depressive disorder. It involved both primary care and specialty care settings. Participants included people with complex health conditions, such as multiple concurrent medical and psychiatric conditions.⁴⁸ This study found that between 28% and 33% of participants achieved a symptom-free state after the first round of medication, and most of those that continued in the trial had to try multiple different treatment options, including psychotherapy, to receive symptom relief. Nearly 70% of those who remained did achieve remission after 12 months.^49,50

Strategies for treating depression in primary care settings such as the collaborative care model have been shown to generate positive net social benefits in cost-benefit analyses compared with usual care. This is true under a wide range of assumptions regarding the monetary value of a QALY.^51-53 Recent demonstration efforts are also showing promising results for the effectiveness of implementing the collaborative care model in everyday practices.⁵⁴

Figure 2.25. Adults with a major depressive episode in the last 12 months who received treatment for depression in the last 12 months, by race, ethnicity, and gender, 2008

Source: Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2008.
Denominator: U.S. population age 18 and over who had a major depressive episode in the last 12 months.
Note: Major depressive episode is defined as a period of at least 2 weeks when a person experienced a depressed mood or loss of interest or pleasure in daily activities and had a majority of the symptoms of depression described in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Treatment for depression is defined as seeing or talking to a medical doctor or other professional or using prescription medication in the past year for depression.

• In 2008, the percentage of adults in the last 12 months was significantly lower for Blacks than for Whites (56.0% compared with 70.4%; Figure 2.25) and lower for Hispanics than for non-Hispanic Whites (57.4% compared with 71.8%).
• In 2008, adult females with a major depressive episode were more likely than their male counterparts to receive any treatment for depression in the last 12 months (68% compared with 57.8%).

Also, in the NHQR:

• In all years, adults ages 18-44 were less likely to receive treatment for depression than those ages 45-64.
• In 2008, there were no statistically significant differences overall between metropolitan areas and nonmetropolitan areas. However, among metropolitan areas, residents of medium metropolitan areas with depression were more likely than residents of large central and large fringe metropolitan areas to receive treatment for depression in the past year.

Outcome: Suicide Deaths

More than 90% of patients who die by suicide have mental illnesses, such as depression, schizophrenia, or substance abuse.⁵⁵ Suicide may be prevented when its warning signs are detected and treated. A previous suicide attempt is among the strongest predictors of subsequent suicide. Cognitive-behavioral therapy can significantly help those who have attempted suicide consider alternative actions when thoughts of self-harm arise.⁵⁶ Cognitive therapy has been shown to reduce suicide attempts by half during a year of followup.⁵⁷

Figure 2.26. Suicide deaths per 100,000 population, by race and ethnicity, 1999-2007

Placeholder for image.

Key: API = Asian and 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.
Denominator: Civilian noninstitutionalized population.
Note: Estimates are age adjusted to the 2000 standard population.

• Overall, from 1999 to 2007, the rate of suicide deaths increased from 10.5 to 11.3 per 100,000 population (Figure 2.26).
• In 2007, Blacks and APIs had lower suicide rates than Whites (5.0 per 100,000 population and 6.1 per 100,000 population, respectively, compared with 12.5 per 100,000 population).
• There were no statistically significant differences between AI/ANs and Whites. Both had higher suicide rates than other racial groups.
• The Hispanic suicide rate was less than half of the rate for non-Hispanic Whites (6.0 per 100,000 population compared with 13.5 per 100,000 population).

Also, in the NHQR:

• Large central metropolitan areas had lower suicide rates compared with large fringe metropolitan areas.
• From 1999 to 2007, males consistently had suicide rates almost four times as high as females.

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

Illicit drug^xxiii use is a medical problem that can have a direct toxic effect on a number of bodily organs. Illicit drug use also can exacerbate numerous health and mental health conditions. Alcohol problems can lead to serious health risks. Heavy drinking can increase the risk of certain cancers and cause damage to the liver, brain, and other organs.⁵⁸ It also can cause birth defects, including fetal alcohol syndrome.^59,60 Alcoholism increases the risk of death from car crashes and other injuries.⁶¹ Treatment for illicit drug use or an alcohol problem at a specialty facility is an effective way to reduce the chances of future illicit drug use or alcohol problems.

Figure 2.27. People age 12 and over who needed treatment for illicit drug use or an alcohol problem and who received such treatment at a specialty facility in the last 12 months, by race and ethnicity, 2003-2008, and income and education, 2008

Key: AI/AN = American Indian or Alaska Native; API = Asian or Pacific Islander.
Source: Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2003-2008.
Denominator: Civilian noninstitutionalized population age 12 and over who needed treatment for illicit drug use or an alcohol problem in the last 12 months.
Note: Treatment refers to treatment at a specialty facility, such as a drug and alcohol inpatient and/or outpatient rehabilitation facility, inpatient hospital setting, or a mental health center. Data not statistically reliable for all races in all years

• Overall, there were no significant changes from 2003 to 2008 in the percentage of people age 12 and over who needed treatment for illicit drug use or an alcohol problem and received it at a specialty facility in the last 12 months (Figure 2.27), except for high-income and middle-income groups (data not shown).
• In 2008, there were no statistically significant differences between racial or ethnic groups in the percentage of people age 12 and over who needed treatment for illicit drug use or an alcohol problem and received it at a specialty facility in the last 12 months.
• From 2003 to 2008, there were no statistically significant differences between males and females in the percentage of people age 12 and over who needed treatment for illicit drug use or an alcohol problem and received it at a specialty facility in the last 12 months (data not shown).
• In 2008, poor and near-poor people who needed treatment were more likely than high-income people who needed treatment to have received treatment for illicit drug use or an alcohol problem (17.4% and 13.1%, respectively, compared with 6.7%).
• Adults with less than a high school education who needed treatment were more likely than adults with at least some college who needed treatment to have received treatment for illicit drug use or an alcohol problem (17.0% compared with 7.2%).

Also, in the NHQR:

• There were no significant differences by county type in the percentage of people age 12 and over who needed treatment for illicit drug use or an alcohol problem and received it at a specialty facility in the last 12 months.

Treatment: Completion of Substance Abuse Treatment

Figure 2.28. People age 12 and over treated for substance abuse who completed treatment course, by race/ethnicity and education, 2005-2007

Source: Substance Abuse and Mental Health Services Administration, Treatment Episode Data Set, Discharge Data Set, 2005-2007.
Denominator: Discharges age 12 and over from publicly funded substance abuse treatment facilities.

• From 2005 to 2007, there were no statistically significant changes in the percentage of people age 12 and over treated for substance abuse who completed the treatment course (data not shown).
• In 2007, non-Hispanic Blacks who were treated for substance abuse were significantly less likely than non-Hispanic Whites to have completed treatment (41.0% compared with 46.6%; Figure 2.28).
• In 2007, Hispanics who were treated for substance abuse were significantly less likely than non-Hispanic Whites to have completed treatment (45.8% compared with 46.6%).
• People with less than a high school education and people with a high school education who were treated for substance abuse were significantly less likely than people with at least some college to complete treatment (40.6% and 46.1%, respectively, compared with 50.7%).

Also, in the NHQR:

• In 2007, people ages 12-19 were less likely than those age 20 and over and females were significantly less likely than males to complete treatment.

^xvii In this report, children are defined as individuals under age 18.
^xviii The childhood immunization series includes vaccinations for diphtheria-tetanus-pertussis, measles-mumps-rubella, inactivated polio virus, Haemophilus influenzae type B, hepatitis B, and varicella. "Cost saving" indicates that childhood immunizations are one of very few services that save more money than they cost.
^xix The top 3 States contributing to the achievable benchmark are Massachusetts, Utah, and Wyoming.
^xx The top 5 States contributing to the achievable benchmark are Louisiana, Massachusetts, New Hampshire, Tennessee, and Wisconsin.
^xxi For children ages 2-15, a parent or guardian reported this information.
^xxii The Office for Civil Rights (OCR) (http://www.hhs.gov/ocr/) is the sole HHS agency with the authority to enforce Title VI of the Civil Rights Act of 1964, 42 U.S.C. 2000d, which prohibits discrimination based on race, color, or national origin in programs and activities that receive Federal financial assistance, including most health care providers and human service agencies. Individuals and advocacy groups may file complaints with OCR to remedy such discrimination.
^xxiii Illicit drugs included in this measure are marijuana/hashish, cocaine (including crack), inhalants (e.g., inhalation of various substances other than for intended use, such as toluene), hallucinogens, heroin, and prescription-type psychotherapeutic drugs (nonmedical use).

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