Chapter 2. Effectiveness (continued, 3)

Effectiveness (continued)

Respiratory Diseases

Importance

Measures

The NHDR tracks several quality measures for prevention and treatment of this broad category of illnesses that includes influenza, pneumonia, asthma, upper respiratory infection, and tuberculosis. The four core report measures highlighted in this section are:

• Pneumococcal vaccination.
• Receipt of recommended care for pneumonia.
• Completion of tuberculosis therapy.
• Daily asthma medication.

Findings

Prevention: Pneumococcal Vaccination

Vaccination is an effective strategy for reducing illness, death, and disparities associated with pneumococcal disease and influenza.^72,73

Figure 2.29. Adults age 65 and over who reported ever receiving pneumococcal vaccination, by race, ethnicity, and income, 2000-2008

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2000-2008.
Denominator: Civilian noninstitutionalized population age 65 and over.
Note: Age adjusted to the 2000 U.S. standard population. Benchmark is derived from the Behavioral Risk Factor Surveillance System (BRFSS); go to Introduction and Methods for details.

• From 2000 to 2008, improvements were observed for Whites, Blacks, non-Hispanic Whites, and high-income people who reported ever receiving pneumococcal vaccination (Figure 2.29).
• In 2008, the percentage of adults age 65 and over who reported ever having pneumococcal vaccination was significantly lower for Blacks and Asians than for Whites.
• In 2008, the percentage of Hispanic adults age 65 and over who reported ever having pneumococcal vaccination continued to be significantly lower, almost half that of non-Hispanic Whites.
• In 2008, the percentage was significantly lower for poor older adults than for high-income older adults (46.2% compared with 64.9%).
• The 2008 top 5 State achievable benchmark was 66.4%.^xxv At the current 1.2% annual rate of increase, this benchmark could be attained overall in about 9 years.
• Whites could attain the benchmark in about 6 years, while Blacks and Asians would not attain the benchmark for 14 years and 25 years, respectively. Hispanics would not attain the benchmark for about 54 years.

Also, in the NHQR:

• From 2000 to 2008, the overall percentage of adults age 65 and over who reported ever having pneumococcal vaccination increased.

Treatment: Receipt of Recommended Care for Pneumonia

Older adults are at high risk for pneumonia. The highest rate of hospitalizations for pneumonia occurs in the population age 65 and over—220.4 per 10,000 population for this group in 2004, compared with 45.5 per 10,000 for the overall population.⁷⁴

CMS tracks a set of measures for quality of pneumonia care for hospitalized patients from the CMS Quality Improvement Organization Program. This set of measures has been adopted by the Hospital Quality Alliance. Recommended care for patients with pneumonia includes receipt of: (1) initial antibiotics within 6 hours of hospital arrival, (2) antibiotics consistent with current recommendations, (3) blood culture before antibiotics are administered, (4) influenza vaccination status assessment/vaccine provision, and (5) pneumococcal vaccination status assessment/vaccine provision. The NHDR shows a composite measure of recommended hospital care that includes these five measures.

Figure 2.30. Composite measure: Hospital patients with pneumonia who received recommended hospital care, by race/ethnicity, 2008

Key: AI/AN = American Indian or Alaska Native.
Source: Centers for Medicare & Medicaid Services, Quality Improvement Organization Program, 2008.
Denominator: Patients hospitalized with a principal discharge diagnosis of pneumonia or a principal discharge diagnosis of either septicemia or respiratory failure and secondary diagnosis of pneumonia.
Note: Composite is calculated by averaging the percentage of opportunities for care in which the patient received all five incorporated components of care.

• In 2008, the percentage of patients with pneumonia who received recommended hospital care was significantly lower for Blacks (87.6%; Figure 2.30), Asians (87.6%), AI/ANs (84.8%), and Hispanics (85.2%) compared with Whites (90.7%).
• The percentage of patients with pneumonia who received recommended hospital care was also lower for females than for males (89.8% compared with 90.0%; data not shown).
• In 2008, the top 5 State achievable benchmark was 93.5%.^xxvi The available data were not sufficient to calculate time to benchmark.

Also, in the NHQR:

• Among the five components of the composite measure, patients were most likely to receive antibiotics within 6 hours and least likely to have their influenza vaccination status assessed.

Outcome: Completion of Tuberculosis Therapy

To be effective for individuals as well as the public, tuberculosis therapy must be taken to its completion. Failure to complete tuberculosis therapy puts patients at increased risk for treatment failure and for spreading the disease to others. Even worse, it may result in the development of drug-resistant strains of the disease.⁷⁵

Figure 2.31. Patients with tuberculosis who completed a curative course of treatment within 1 year of initiation of treatment, people born outside the United States, by race and ethnicity, 1999-2006

Key: API = Asian or Pacific Islander.
Source: Centers for Disease Control and Prevention, National Tuberculosis Surveillance System, 1999-2006.
Denominator: Foreign-born U.S. resident population with verified tuberculosis, all ages.

• In 2006, among the foreign-born population, Blacks and APIs were more likely than foreign-born Whites to complete tuberculosis therapy within 1 year (85.7% and 84.3%, respectively, compared with 81.7%; Figure 2.31).
• The 2006 top 5 State achievable benchmark was 91.5%.^xxvii At the current 0.7% annual rate of increase for the general population and for the foreign-born population, this benchmark could be attained overall in about 14 years and 21 years, respectively.
• Among the foreign-born population, Whites would not attain the benchmark for about 31 years, while Blacks and Asians would not attain the benchmark for 13 years and 19 years, respectively. Hispanics would not achieve the benchmark for 28 years.

Also, in the NHQR:

• In all years, among the general population, children ages 0-17 with tuberculosis were more likely than adults age 18 and over to complete a curative course of treatment within 1 year of initiation of treatment.
• Overall, among the general population, females with tuberculosis were more likely to complete treatment within 1 year than males.

Management: Daily Asthma Medication

Improving quality of care for people with asthma can reduce the occurrence of asthma attacks and avoidable hospitalizations. The National Asthma Education and Prevention Program, coordinated by the National Heart, Lung, and Blood Institute, develops and disseminates science-based guidelines for the diagnosis and management of asthma.⁷⁶ These recommendations are built around four essential components of asthma management critical for effective long-term control of asthma: assessment and monitoring, control of factors contributing to symptom exacerbation, pharmacotherapy, and education for partnership in care.⁷⁷

Daily long-term controller medication is necessary to prevent exacerbations and chronic symptoms for all patients with persistent asthma. Appropriate controller medications for people with mild persistent asthma^78,xxviii include inhaled corticosteroids, cromolyn, nedocromil, theophylline, and leukotriene modifiers.⁷⁹

Figure 2.32. People with current asthma who are now taking preventive medicine daily or almost daily (either oral or inhaler), by race/ethnicity, education, income, and language spoken at home, 2003-2007

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2003-2007.
Denominator: Noninstitutionalized population with asthma, as defined below.
Note: People with current asthma are defined as people who report they still have asthma or had an episode or attack in the last 12 months.

• From 2003 to 2007, there were no statistically significant changes over time for any group in the percentage of people with current asthma who are taking daily preventive medicine, except for people with at least some college (from 34.0% to 27.1%; Figure 2.32).
• In 2007, there were no statistically significant differences by race/ethnicity in the percentage of people with current asthma who are taking daily preventive medicine.
• In 2007, poor people with current asthma were less likely than high-income people to take daily preventive medicine for asthma (23.5% compared with 32.9%).
• In 2007, there were no statistically significant differences in the percentage of people with current asthma who are taking daily preventive medicine between people who spoke English at home and people who spoke another language at home.

Also, in the NHQR:

• Of those with current asthma under age 65 in 2007, 29.1% reported taking preventive medicine daily or almost daily.
• In 2007, people living in large central metropolitan areas were less likely than people living in large fringe metropolitan areas to take daily preventive medication.
• In 2007, there were no statistically significant differences between people with current asthma taking preventive medicine daily who live in metropolitan areas and nonmetropolitan areas.

The data show that disparities for Asians exist not only in comparison with Whites but also between Asian subgroups (Chinese, Filipino, Japanese, Korean, Vietnamese, and South Asian) and across Asian subgroups by income and insurance status. Differences in English proficiency and place of birth are also significant. The following section shows only some of the significant disparities for these groups in California from California Health Interview Survey data.

Figure 2.33. People with current asthma who were taking prescription medication to control asthma during the past 12 months, by Asian and Hispanic subgroups, California, 2007

Source: University of California, Los Angeles, Center for Health Policy Research, California Health Interview Survey, 2007.
Denominator: Civilian noninstitutionalized population in California.

• In California, there were no statistically significant differences by ethnicity in the percentage of people with current asthma who took prescription medication to control asthma during the past 12 months (Figure 2.33). This is due to relatively large standard errors for many of the subpopulations.

Figure 2.34. People with current asthma who were taking prescription medication to control asthma during the past 12 months, by ethnic subgroups and English proficiency, California, 2007

Source: University of California, Los Angeles, Center for Health Policy Research, California Health Interview Survey, 2007.
Denominator: Civilian noninstitutionalized population in California.
Note: Data were not statistically reliable for Whites who did not speak English well or did not speak English at all and for Filipinos who spoke English only and Filipinos who did not speak English well or did not speak English at all.

• Overall, there were no statistically significant differences in the percentage of people with current asthma who were taking prescription medication to control asthma during the past 12 months in California between people who spoke English only and those who spoke English well or very well and those who did not speak English well or did not speak English at all (data not shown).
• Among people who spoke English only at home in California, Asians were less likely than non-Hispanic Whites to take prescription medication to control asthma during the past 12 months (31.2% compared with 47.2%; Figure 2.34).
• Also, among people who spoke English only at home in California, Hispanics and Mexicans were less likely than non-Hispanic Whites to take prescription medication to control asthma during the past 12 months (37.7% and 35.2%, respectively, compared with 47.2%).

Lifestyle Modification

Importance

Measures

Unhealthy behaviors place many Americans at risk for a variety of diseases. Lifestyle practices account for more than 40% of the differences in health among individuals.⁸⁴ A recent study examined the effects on incidence of coronary heart disease, stroke, diabetes, and cancer of four healthy lifestyles: never smoking, not being obese, engaging in at least 3.5 hours of physical activity per week, and eating a healthy diet (higher consumption of fruits, vegetables, and whole grain bread and lower consumption of red meat). Engaging in one healthy lifestyle compared with none cut the risk of developing these diseases in half while engaging in all four cut risk by 78%.⁸⁵ Unfortunately, healthy lifestyle practices have declined over the past two decades.⁸⁵

Helping patients choose and maintain healthy lifestyles is a critical role of health care professionals. The NHDR tracks several quality measures for modifying unhealthy lifestyles, including the following three core report measures:

• Counseling smokers to quit smoking.
• Counseling obese adults about exercise.
• Counseling obese adults about healthy eating.

In addition, one supporting measure is presented:

• Counseling obese adults about overweight.

Findings

Prevention: Counseling Smokers To Quit Smoking

Smoking harms nearly every organ of the body and causes or exacerbates many diseases. Smoking causes more than 80% of deaths from lung cancer and more than 90% of deaths from chronic obstructive pulmonary disease.⁸⁶ Heart disease is the leading cause of death in the United States for both men and women,⁸⁷ with approximately 135,000 deaths due to smoking.⁸⁸ Cigarette smoking increases the risk of dying from coronary heart disease (CHD) two- to threefold.⁸⁸

Quitting smoking has immediate and long-term health benefits. The risk of developing CHD attributed to smoking can be decreased by 50% after one year of cessation.⁸⁹ Smoking is a modifiable risk factor, and health care providers can help encourage patients to change their behavior and quit smoking.

Figure 2.35. Adult current smokers under age 65 with a checkup in the last 12 months who received advice from a doctor to quit smoking, by race, ethnicity, income, and language spoken at home, 2002-2007

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2007.
Denominator: Civilian noninstitutionalized adult current smokers under age 65 who had a checkup in the last 12 months.

• In 2007, only 66.2% of current adult smokers who had a checkup in the last 12 months were advised to quit smoking (data not shown).
• There were no statistically significant differences by race and ethnicity in the percentage of current adult smokers who received advice to quit smoking (Figure 2.35).
• From 2002 to 2007, there were no statistically significant changes overall and for all groups in the percentage of current adult smokers with a checkup in the last 12 months who received advice to quit smoking, except for poor patients (from 57.9% to 67.9%).
• In 2007, near-poor current adult smokers were significantly less likely than high-income current adult smokers to receive advice to quit smoking (58.8% compared with 67.8%).
• There were no statistically significant differences in the percentage of current adult smokers with a checkup in the last 12 months who received advice to quit smoking by language spoken at home.

Also, in the NHQR:

• There were no statistically significant differences between adult current smokers living in metropolitan areas and those living in nonmetropolitan areas with a checkup in the last 12 months who received advice to quit smoking. Among metropolitan areas, residents of small metropolitan areas who were current smokers were least likely to receive advice to quit smoking.
• From 2002 to 2007, female current adult smokers continued to be more likely than males to receive advice to quit smoking.

Each year, multivariate analyses are conducted in support of the NHDR to identify the independent effects of race and socioeconomic status on quality of health care. Past reports have listed some of these findings as odds ratios. This year, the NHDR presents the results of a multivariate model as adjusted percentages for this measure: Adult smokers ages 18-64 with advice to quit smoking. Adjusted percentages show the expected percentage for a given subpopulation after controlling for a number of factors, which include race/ethnicity, family income, education, health insurance status, and geographic location.

Figure 2.36. Adjusted percentages of adults ages 18-64 with advice to quit smoking, 2007

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2007.
Denominator: Civilian noninstitutionalized adult current smokers under age 65 who had a checkup in the last 12 months.
Note: Adjusted percentages are predicted marginals from a statistical model that includes the covariates race/ethnicity, family income, education, health insurance, and residence location.

• In the multivariate model used, after adjustment, 54.7% of Hispanic adult smokers ages 18-64 received advice to quit smoking compared with 64.8% of White adults (Figure 2.36).
• After adjustment, male adult smokers ages 18-64 were less likely than females to receive advice to quit smoking (60.7% compared with 66.5%).
• After adjustment, compared with adult smokers ages 18-64 with any private insurance (65.2%), adults with public insurance were more likely (70.7%) and adults with no insurance were less likely (52.3%) to receive advice to quit smoking.
• After adjustment, adult smokers ages 18-64 who lived in metropolitan areas (64.6%) were more likely than adults in nonmetropolitan areas (60.5%) to receive advice to quit smoking.

Prevention: Counseling Obese Adults About Overweight

More than 34% of adults age 20 and over in the United States are obese (defined as having a BMI of 30 or higher),⁸² putting them at increased risk for many chronic, often deadly conditions, such as hypertension, cancer, diabetes, and CHD.⁹⁰ Although physician guidelines recommend that health care providers screen all adult patients for obesity,⁹¹ obesity remains underdiagnosed among U.S. adults.⁹²

Figure 2.37. Adults with obesity who reported being told by a doctor they were overweight, by race/ethnicity, income, and education, 2005-2008

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health and Nutrition Examination Survey, 2005-2008.
Denominator: Civilian noninstitutionalized obese adults age 20 and over.
Note: Estimates are age adjusted to the 2000 standard population using three age groups: 20-44, 45-64, and 65 and over for total, race, ethnicity, and family income and 25-44, 45-64, and 65 and over for education.

• Overall, in 2005-2008, 65.9% of obese adults age 20 and over reported being told by a doctor or health professional that they were overweight (data not shown).
• Non-Hispanic Black and Mexican-American obese adults were less likely than non-Hispanic White obese adults to report being told by a doctor that they were overweight (61.4% and 59.9%, respectively, compared with 67.2%; Figure 2.37).
• Poor (60.8%), near-poor (61.6%), and middle-income (65.1%) obese adults were less likely than high-income (72.8%) obese adults to report being been told by a doctor that they were overweight.
• Obese adults with less than a high school education (59.7%) and those with a high school education (65.4%) were less likely than obese adults with at least some college (71.5%) to report being told by a doctor that they were overweight.

Also, in the NHQR:

• Obese adults ages 45-64 and age 65 and over were more likely than obese adults ages 20-44 to report being told by a doctor that they were overweight.
• Female obese adults age 20 and over were more likely than males to report being told by a doctor or health professional that they were overweight.

Prevention: Counseling Obese Adults About Exercise

Physician-based exercise and diet counseling is an important component of effective weight loss interventions,⁹¹ and it has been shown to produce increased levels of physical activity among sedentary patients.⁹³ Although every obese person may not need counseling about exercise and diet, many would likely benefit from improvements in these activities. Regular exercise and a healthy diet aid in maintaining normal blood cholesterol levels, weight, and blood pressure, reducing the risk of heart disease, stroke, diabetes, and other comorbidities of obesity.

Figure 2.38. Adults with obesity who ever received advice from a health provider to exercise more, by race/ethnicity, income, education, and language at home, 2002-2007

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2007.
Denominator: Civilian noninstitutionalized population age 18 and over.
Note:Obesity is defined as a body mass index of 30 or higher.

• Overall, in 2007, 59.2% of adults with obesity had ever received advice from a health provider to exercise more (data not shown).
• There was no statistically significant difference between non-Hispanic Black adults with obesity and non-Hispanic White adults with obesity in the percentage who received advice from a health provider to exercise more (Figure 2.38).
• From 2002 to 2007, the percentage of Hispanic adults with obesity who ever received advice to exercise more improved (from 43.2% to 50.2%). However, Hispanics were less likely than non-Hispanic Whites to ever receive advice to exercise more (50.2% compared with 61.1%).
• In 2007, the percentage of obese adults who had ever received advice to exercise more was lower for poor people (52.7%), near-poor people (53.2%), and middle-income people (56.6%) compared with high-income people (66.6%).
• In 2007, the percentage of obese adults who had ever received advice to exercise more was lower for people with less than a high school education (50.6%) and people with a high school education (57.4%) compared with people with at least some college (64.7%).
• In 2007, adults with obesity who spoke a language other than English at home were less likely to ever receive advice from a health provider about exercise than adults with obesity who spoke English at home (49.5% compared with 60.3%).

Prevention: Counseling Obese Adults About Healthy Eating

Figure 2.39. Adults with obesity who ever received advice from a health provider about eating fewer high-fat or high-cholesterol foods, by race/ethnicity, income, education, and language spoken at home, 2002-2007

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2007.
Denominator: Civilian noninstitutionalized population age 18 and over.
Note: Obesity is defined as a body mass index of 30 or higher.

• Overall, in 2007, about 51.6% of adults with obesity received advice from a health provider about healthy eating. This percentage improved from 2002, when 48.9% said they received this advice (data not shown).
• From 2002 to 2007, the percentage of non-Hispanic Black adults with obesity who received advice from a health provider about healthy eating increased (from 45.8% to 51.2%; Figure 2.39). There was no statistically significant difference for non-Hispanic Whites.
• From 2002 to 2007, the percentage of Hispanic adults with obesity who received advice from a health provider about healthy eating increased (from 35.6% to 44.6%). In 2007, Hispanics were also less likely to receive this advice than non-Hispanic Whites (44.6% compared with 53.4%).
• In 2007, the percentage of obese adults who received advice about eating fewer high-fat or high-cholesterol foods was significantly lower for poor, near-poor, and middle-income adults compared with high-income adults (45.9%, 46.9%, and 48.3%, respectively, compared with 58.7%).
• In 2007, the percentage of obese adults who were given advice about eating fewer high-fat or high-cholesterol foods was significantly lower for people with less than a high school education and people with a high school education compared with people with at least some college (47.3% and 48.8%, respectively, compared with 56.1%).
• In 2007, the percentage of adults with obesity who spoke another language at home who received advice about healthy eating was lower than it was for adults with obesity who spoke English at home (43.4% compared with 52.4%).

Also, in the NHQR:

• Adults with obesity ages 18-44 were least likely to receive advice about healthy eating.
• The percentage of adults with obesity who received advice from a health provider about healthy eating was lower for people who lived in nonmetropolitan areas than for people who lived in metropolitan areas.
• From 2002 to 2007, the percentage of adults with obesity who received advice about healthy eating improved for females. In 2007, there was no statistically significant difference between males and females.

Outcome: Obese Adults Who Exercise

Figure 2.40. Adults with obesity who spend half an hour or more in moderate or vigorous physical activity at least 3 times a week, by race/ethnicity, income, and education, 2002-2007

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2007.
Denominator: Civilian noninstitutionalized population age 18 and over.
Note: Obesity is defined as a body mass index of 30 or higher.

• Overall, about 46.3% of adults with obesity spent half an hour or more in moderate or vigorous activity at least 3 times a week (data not shown).
• From 2002 to 2007, the percentage of adults with obesity who exercised at least 3 times a week increased for non-Hispanic Blacks and Hispanics (Figure 2.40). In 2007, Hispanics were less likely than non-Hispanic Whites to exercise at least 3 times a week.
• In 2007, poor and low-income adults with obesity were less likely than high-income adults to exercise as least 3 times a week. Obese adults who had less than a high school education were less likely than adults with at least some college to exercise at least 3 times a week.
• Obese adults who spoke a language other than English at home were less likely than adults who spoke English at home to exercise at least 3 times a week (data not shown).

Also, in the NHQR:

• Adults age 65 and over with obesity were least likely of all age groups to exercise at least 3 times a week.
• Female adults with obesity were less likely than males to exercise at least 3 times a week.
• Among those living in metropolitan areas, adults with obesity in large central metropolitan and small metropolitan areas were less likely to exercise at least 3 times a week compared with adults with obesity in large fringe metropolitan areas.

^xxiv Chronic lower respiratory diseases include emphysema and chronic bronchitis.
^xxv The top 5 States contributing to the achievable benchmark are Colorado, Delaware, Maine, New Hampshire, and Oklahoma.
^xxvi The top 5 States contributing to the achievable benchmark are Iowa, Maine, New Hampshire, New Jersey, and Vermont.
^xxvii The top 5 States contributing to the achievable benchmark are Alaska (tie), Indiana (tie), Kansas, Maryland, and Oregon.
^xxviii "Mild persistent asthma" refers to cases in which people experience asthma symptoms more than 2 days per week and more than 2 nights per month, as well as other clinical indicators.

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