Chapter 2. Effectiveness of Care (continued)

 Chronic Kidney Disease

Importance

Measures

The NHQR and NHDR track several measures of management of chronic kidney disease to assess the quality of care provided to renal dialysis patients. A previous core measure, adequacy of dialysis, was retired because it achieved a rate above 95%. Three measures are highlighted here:

• Nephrology care before kidney failure.
• Use of arteriovenous fistula (AVF) at first outpatient dialysis.
• Registration for transplantation.

Findings

New! Management: Nephrology Care Before Kidney Failure

Early referral to a nephrologist is important for patients with progressive chronic kidney disease approaching kidney failure. Mindful management during the transition to ESRD permits informed selection of renal replacement therapy, placement and maturation of vascular access, and workup for kidney transplantation. Patients who begin nephrology care more than a year before kidney failure are less likely to begin dialysis with a catheter, experience infections related to vascular access, or die during the months after dialysis initiation (USRDS, 2010).

Figure 2.12. Patients beginning nephrology care more than 12 months before start of dialysis, by race and ethnicity, 2006-2008

[D] Select for Text Description.

Key: AI/AN = American Indian or Alaska Native; API = Asian or Pacific Islander.
Source: National Institute of Diabetes and Digestive and Kidney Diseases, U.S. Renal Data System, 2006-2008.
Denominator: New end stage renal disease patients.

• In 2008, only 28% of new ESRD patients began nephrology care more than 12 months before start of dialysis (Figure 2.12).
• In all years, Blacks and APIs were less likely than Whites and Hispanics were less likely than non-Hispanic Whites to begin nephrology care more than 12 months before start of dialysis.

Also, in the NHDR:

• In all years, Blacks and APIs were less likely than Whites and Hispanics were less likely than non-Hispanic Whites to receive timely nephrology care.

Management: Use of Arteriovenous Fistula at First Outpatient Dialysis

For people with ESRD, dialysis can accommodate for lost kidney function by balancing minerals and water in the blood and removing waste. Vascular access is needed to reach blood vessels so dialysis can be performed. An AVF is the preferred type of access for most hemodialysis patients for three reasons: It provides adequate blood flow for dialysis, it lasts a long time, and it has a low complication rate compared with other methods.

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

Figure 2.13. Incident hemodialysis patients who used an arteriovenous fistula at first outpatient dialysis, by race and ethnicity, 2008-2010

[D] Select for Text Description.

Key: API = Asian or Pacific Islander; AI/AN = American Indian or Alaska Native.
Source: Medicare eligibility forms (Centers for Medicare & Medicaid Services [CMS] Form 2728) (2008-2010), Fistula First Incident AVF Dataset, CMS.
Denominator: New end stage renal disease hemodialysis patients, all ages.

• In 2010, only 15% of dialysis patients used an AVF at first dialysis (Figure 2.13).
• In all years, Blacks had lower rates of AVF at first dialysis than Whites, and Hispanics had lower rates than non-Hispanic Whites.
• The 2009 top 5 State achievable benchmark was 27%.^xii No group has attained this benchmark.

Also, in the NHQR:

• In all years, patients ages 65-74 had higher rates of AVF at first dialysis than those younger than age 65. Female patients had significantly lower rates of AVF at first dialysis than males.

Management: Registration for Transplantation

Kidney transplantation is a procedure that replaces a failing kidney with a healthy kidney. Transplantation is not best for all patients. If a patient is deemed a good candidate for transplant, he or she is placed on the transplant program's waiting list. Patients wait for transplant centers to match them with the most suitable donor. Registration for transplantation is an initial step toward kidney transplantation. Early transplantation that decreases or eliminates the need for dialysis can also lessen the occurrence of acute rejection and patient mortality.

Figure 2.14. Dialysis patients who were registered on a waiting list for transplantation, by race and ethnicity, 2000-2007

[D] Select for Text Description.

Key: AI/AN = American Indian or Alaska Native.
Source: National Institute of Diabetes and Digestive and Kidney Diseases, U.S. Renal Data System, 2000-2007.
Denominator: End stage renal disease hemodialysis patients and peritoneal dialysis patients under age 70.

• From 2000 to 2007, the percentage of dialysis patients who were registered on a waiting list for transplantation increased from 15% to 17% (Figure 2.14). Improvements were observed among all racial and ethnic groups.
• In all years, Blacks and AI/ANs were less likely to be registered on a waiting list than Whites. However, Asians were more likely to be registered on a waiting list than Whites.
• From 2000 to 2005, Hispanics were less likely to be registered on a waiting list than non-Hispanic Whites. However, in 2006 and 2007, this difference no longer met our criteria for significance.
• The 2006 top 5 State achievable benchmark was 27%.^xiii At the current rate of improvement, the benchmark could not be attained overall for almost 23 years.
• Although Asians have already surpassed the 2006 achievable benchmark, Blacks could not attain the benchmark for 30 years and AI/ANs could not attain it for 27 years.

Also, in the NHQR:

• In all years, patients ages 20-69 were less likely than patients ages 0-19 and females were less likely than males to be registered on a waiting list. 

Diabetes

Importance

Measures

Routine monitoring of blood glucose levels with hemoglobin A1c (HbA1c^xiv ) tests and foot and dilated eye examinations have been shown to help prevent or mitigate complications of diabetes, such as diabetic neuropathy, retinopathy, and vascular and kidney disease. With more than half a million discharges in 2006, diabetes is one of the leading causes of hospitalization in the United States (CDC, 2009). However, with appropriate and timely ambulatory care, it may be possible to prevent many hospitalizations for diabetes and related complications.

The measures reported in this section examine the extent to which individuals with diabetes receive care needed to prevent complications and the development of kidney failure, a serious complication of diabetes:

• Receipt of four recommended diabetes services.
• Hospitalization for short-term diabetes complications.
• Development of kidney failure due to diabetes.

Findings

New! Management: Receipt of Four Recommended Diabetes Services

A composite measure is used to track the national rate of receipt of four recommended annual diabetes interventions: at least two HbA1c tests, a foot examination, an eye examination, and a flu shot. These are basic process measures that provide an assessment of the quality of diabetes management. This diabetes composite measure differs from the composite presented last year. To be more consistent with current recommendations, the required frequency of HbA1c testing has been increased to two per year and receipt of a flu shot has been added.

Figure 2.15. Adults age 40 and over with diagnosed diabetes who reported receiving four recommended services for diabetes in the calendar year (2+ HbA1c tests, foot exam, dilated eye exam, and flu shot), by race/ethnicity, 2008

[D] Select for Text Description.

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2008.
Denominator: Civilian noninstitutionalized population with diagnosed diabetes, age 40 and over.
Note: Data include people with both type 1 and type 2 diabetes. Rates are age adjusted to the 2000 U.S. standard population. White and Black groups are non-Hispanic; Hispanic includes all races.

• Among adults age 40 and over with diagnosed diabetes, report of receipt of recommended services ranged from 52% to 76%. However, only 21% of adults with diabetes received all four recommended services in 2008 (Figure 2.15).
• Among adults with diabetes, Hispanics were less likely than non-Hispanic Whites to receive at least two HbA1c tests, a foot examination, and an eye examination while non-Hispanic Blacks were less likely than non-Hispanic Whites to receive a flu shot. There were no statistically significant differences between groups in rates of receipt of all four recommended services.

Also, in the NHQR:

• Adults with diabetes ages 40-59 were less likely than those age 60 and over to receive a foot examination, an eye examination, and a flu shot as well as the composite of four recommended services.

Multivariate analyses were conducted to identify the independent effects of race/ethnicity and socioeconomic factors on several measures. Adjusted percentages are shown for receipt of diabetes services after controlling for race/ethnicity, family income, education, health insurance status, and location.

Figure 2.16. Composite measure: Adjusted percentages of adults ages 40-64 with diagnosed diabetes who received four recommended services for diabetes in the calendar year, by race/ethnicity, family income, education, insurance status, and sex, 2002-2008

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Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, pooled 2002-2008.
Note: Adjusted percentages are predicted marginals from a statistical model that includes the covariates race/ethnicity, family income, education, health insurance, sex, and residence location. Chapter 1, Introduction and Methods, provides more information.

• After adjustment, among adults ages 40-64 with diagnosed diabetes, non-Hispanic Blacks and Hispanics were less likely than non-Hispanic Whites to receive the four recommended services for diabetes (Figure 2.16).
• In addition, poor, low-income, and middle-income adults with diabetes were less likely than high-income adults to receive all four services.
• Adults with less than a high school education were less likely than adults with any college education to receive all four services.
• Uninsured adults were less likely than adults with private insurance to receive all four services.
• Males were less likely than females to receive all four services.

Outcome: Hospitalization for Short-Term Diabetes Complications

Individuals who do not achieve good control of their diabetes are more prone to short-term complications that can reduce quality of life, increase chances of death, and increase health care costs both directly and indirectly. The acute metabolic complications of diabetes typically require hospitalization for treatment and include diabetic ketoacidosis and hyperosmolar nonketotic coma.

Figure 2.17. Hospital admissions for diabetes with short-term complications per 100,000 population, age 18 and over, by race/ethnicity and area income, 2001-2008

[D] Select for Text Description.

Key: API = Asian or Pacific Islander. Q1 represents the lowest income quartile and Q4 represents the highest income quartile based on the median income of a patient's ZIP Code of residence.
Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, State Inpatient Databases disparities analysis file and Nationwide Inpatient Sample, 2001-2008, and AHRQ Quality Indicators, version 4.1.
Denominator: U.S. resident population age 18 and over.
Note: For this measure, lower rates are better. Short-term complications include ketoacidosis, hyperosmolarity, or coma and exclude obstetric admissions and transfers from other institutions. White, Black, and API groups are non-Hispanic; Hispanic includes all races. Data are adjusted for age and gender.

• Between 2001 and 2008, the rate of hospital admissions for adults with short-term complications of diabetes increased overall and among Whites and all income groups (Figure 2.17). The rate decreased among APIs.
• In all years, the rate of hospital admissions for short-term complications was significantly higher for Blacks and lower for APIs compared with Whites. Hispanics also had higher rates than Whites between 2001 and 2006, but this difference was not statistically significant in 2007 and 2008.
• In all years, the rate of hospital admissions for short-term complications was significantly higher for adults living in communities with median household incomes in the first, second, and third quartiles than for people living in communities with median household incomes in the fourth quartile.
• The 2008 top 4 State achievable benchmark was 38 per 100,000 population.^xv While APIs and residents of high-income neighborhoods achieved the benchmark, most other groups were far from the benchmark or moving away from it.

Also, in the NHQR:

• In all years, adults ages 45-64 and age 65 and over had lower rates of short-term complications of diabetes than adults ages 18-44. Residents of micropolitan areas had higher rates than residents of suburbs.

Focus on Indian Health Service Facilities

AI/ANs who are members of federally recognized Tribes are eligible for services provided by the Indian Health Service (IHS). About 2 million of the 3.4 million AI/ANs in the United States receive care directly from IHS, through tribally contracted and operated health programs or through services purchased by IHS from other providers (IHS, 2011). Due to low numbers and lack of data, information about AI/AN hospitalizations is difficult to obtain in most Federal and State hospital utilization data sources. The NHQR and NHDR address this gap by examining utilization data from IHS, Tribal, and contract hospitals.

Diabetes is one of the leading causes of morbidity and mortality among AI/AN populations. Its prevention and control are a major focus of the IHS Director's Chronic Disease Initiative and the IHS Health Promotion/Disease Prevention Initiative. Addressing barriers to health care is a large part of the overall IHS goal of ensuring that comprehensive, culturally acceptable personal and public health services are available and accessible to AI/ANs.

Figure 2.18. Hospital admissions for diabetes with short-term complications per 100,000 population in IHS, Tribal, and contract hospitals, age 6 and over, by age group, 2001-2009

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Source: Indian Health Service, Office of Information Technology/National Patient Information Reporting System, National Data Warehouse, Workload and Population Data Mart, 2001-2009.
Note: For this measure, lower rates are better. Data for ages 6-12 and 13-17 only available for 2005, 2006, 2008, and 2009.

• From 2001 to 2009, the age-adjusted rate of total hospitalizations for short-term complications of diabetes did not change for AI/AN patients in IHS, Tribal, and contract hospitals (data not shown). Rates among patients ages 45-64 and 65 and over decreased while rates among patients ages 18-44 increased (Figure 2.18).
• In all years, patients ages 18-44 and 45-64 had higher rates than patients age 65 and over. In 2005, 2006, 2008, and 2009, patients ages 6-12 and 13-17 had lower rates than patients of older ages.
• The 2008 top 4 State achievable benchmark based on Healthcare Cost and Utilization Project State Inpatient Databases data was 38. Patients ages 6-12, 13-17, and 65 and over are below the achievable benchmark. Patients ages 45-64 are approaching the benchmark while patients ages 18-44 are moving away from the benchmark.

New! Outcome: Kidney Failure Due to Diabetes

Diabetes is the most common cause of kidney failure. Keeping blood sugar levels under control can prevent or slow the progression of kidney disease due to diabetes. In addition, when kidney disease is detected early, medication can slow the disease's progress. If it is detected late, progression to ESRD requiring dialysis is common. While some cases of kidney failure due to diabetes cannot be avoided, other cases reflect inadequate control of blood sugar or delayed detection and treatment of early kidney disease due to diabetes.

Figure 2.19. End stage renal disease due to diabetes per million population, by race and ethnicity, 2000-2008

[D] Select for Text Description.

Key: AI/AN = American Indian or Alaska Native; API = Asian or Pacific Islander.
Source: National Institute of Diabetes and Digestive and Kidney Diseases, U.S. Renal Data System, 2000-2008.
Denominator: U.S. resident population.
Note: For this measure, lower rates are better. Rates are age adjusted. Hispanic and non-Hispanic include all races.

• Between 2000 and 2008, the overall incidence of ESRD due to diabetes did not change (Figure 2.19). The rate fell among Hispanics and AI/ANs.
• In all years, AI/ANs, APIs, and Blacks had higher rates than Whites and Hispanics had higher rates than non-Hispanic Whites.

Also, in the NHQR:

• In all years, people ages 45-64, 65-74, and 75 and over had higher rates of ESRD due to diabetes than people ages 20-44. Males had higher rates than females. 

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 can be spread through unprotected sex with an infected person, sharing of drug needles, or 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 (Shapiro, et al., 1999).

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 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 (CDC, 2010).

According to the Centers for Disease Control and Prevention (CDC), HIV and AIDS disproportionately affect Blacks in the United States. In 2009, Blacks represented 14% of the U.S. population but accounted for 44% of all diagnoses of new HIV infections (CDC, 2011c). The HIV/AIDS epidemic is also a serious threat to the Hispanic community. An estimated 20% of new HIV infections occurred among Hispanics in 2009, which is three times the rate of Whites (CDC, 2011b). In addition to being seriously affected by HIV, Hispanics continue to face challenges in accessing health care, especially preventive services and HIV treatment.

Undocumented immigrants 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 (Carrillo & DeCarlo, 2003). In 2007, HIV/AIDS was the fourth leading cause of death among Hispanic men and women ages 35-44 (CDC, 2011b). 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 Blacks (Turner, et al., 2000).

Another group that is severely affected by HIV includes gay, bisexual, and other men who have sex with men (MSM). MSM represent 2% of the U.S. population and is the only risk group in which new HIV infections have been gradually increasing since the 1990s. MSM have constantly represented the largest percentage of people diagnosed with AIDS and persons with an AIDS diagnosis who have died. In 2009, MSM accounted for more than half (61%) of all new HIV infections in the United States (CDC, 2011d).

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, a measure is presented on HIV testing, and five supporting measures are presented on the prevention of opportunistic infections in HIV patients:

• 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).
• Eligible patients receiving prophylaxis for Pneumocystis pneumonia (PCP).
• Eligible patients receiving prophylaxis for Mycobacterium avium complex (MAC).

In addition, a measure is included on HIV infection deaths.

Findings

New! Prevention: HIV Testing

According to CDC, approximately 20% of the 1.2 million people living with HIV are unaware of their infection (CDC, 2011d). CDC recommends routine voluntary HIV testing as part of normal medical practice in all health care settings (Branson, et al., 2006). HIV infection is a serious health disorder that can be diagnosed before symptoms develop. HIV can be detected by reliable, inexpensive, and noninvasive screening tests. Although blood donations are routinely tested for HIV, it is important to track HIV testing in a health care setting to determine the impact of preventive care for the population. HIV-infected patients have years to gain if treatment is initiated early, before symptoms develop.

To normalize HIV testing as a routine part of medical care, in September 2006, CDC published revised recommendations that all patients ages 13-64 be tested on a voluntary basis. The revised recommendations also expanded the existing recommendations for screening pregnant women (Branson, et al., 2006).

Figure 2.20. Population ages 15-44 years who ever had an HIV test outside of blood donation, by race/ethnicity and education, 2006-2010

[D] Select for Text Description.

Source: Special tabulations based on National Survey of Family Growth, 2006-2010, conducted by the National Center for Health Statistics, Centers for Disease Control and Prevention.
Note: White and Black groups are non-Hispanic; Hispanic includes all races.

• Overall, in the period between 2006 and 2010, 50% of people ages 15-44 had ever been tested for HIV outside of blood donation (Figure 2.20).
• In the period between 2006 and 2010, the percentage of people ages 15-44 who had ever been tested for HIV outside of blood donation was higher for non-Hispanic Blacks (68%) than for non-Hispanic Whites (48%).
• In the period between 2006 and 2010, there were no statistically significant differences by educational attainment in the percentage of people ages 15-44 who were tested for HIV outside of blood donation.

Also, in the NHQR:

• In the period between 2006 and 2010, HIV testing outside of blood donation was reported most often among people ages 35-39 (65%) and least often among those ages 15-19 (16%).
• In the period between 2006 and 2010, females (59%) reported more HIV testing outside of blood donation than males (42%).

Figure 2.21. Percentage of women ages 15-44 years with a completed pregnancy within the past 12 months who were tested for HIV as part of prenatal care, by race/ethnicity and education, 2006-2010

[D] Select for Text Description.

Source: Special tabulations based on National Survey of Family Growth, 2006-2010, conducted by the National Center for Health Statistics.

• Overall, between 2006 and 2010, 67% of women with a recently completed pregnancy had an HIV test as part of their prenatal care (Figure 2.21).
• In the period between 2006 and 2010, roughly 75% of recently pregnant Hispanic and non-Hispanic Black women had prenatal HIV testing, compared with 64% of recently pregnant non-Hispanic White women.
• In the period between 2006 and 2010, 75% of recently pregnant women with less than a high school education had prenatal HIV testing, compared with 63% of those with any college.

Also, in the NHQR:

• In the period between 2006 and 2010, there were no statistically significant differences between age groups in the percentage of women with a recently completed pregnancy who had an HIV test as part of prenatal care.

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:

• Two or more CD4 cell counts performed in the measurement year.
• HAART for patients with AIDS.
• Two or more medical visits in an HIV care setting in the measurement year.
• 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 everyone in the United States living with HIV.

HIV Network data represent only patients with HIV who are actually receiving care (about 14,000 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 (Yeargin, et al., 2003).

Figure 2.22. Adults with HIV who received recommended care, by race/ethnicity and gender, 2008

[D] Select for Text Description.

Key: HAART = highly active antiretroviral therapy; PCP = Pneumocystis pneumonia; MAC = Mycobacterium avium complex.
Source: Agency for Healthcare Research and Quality, HIV Research Network, 2008.
Note: For HAART measure, adult HIV patients had to be enrolled in an HIV Network clinic, receive at least one CD4 test, and have at least one outpatient visit in addition to having at least one CD4 test result of 350 or less.

• Overall, in 2008, nearly 90% of people with HIV had two or more outpatient visits during the year, and 83% of people with HIV had two or more CD4 tests during the year (Figure 2.22). In addition, 89% of people with HIV in care received HAART, 95% of people with HIV and CD4 count less than 200 received PCP prophylaxis, and 90% of people with HIV and CD4 count less than 50 received MAC prophylaxis.
• In 2008, there were no statistically significant differences by race/ethnicity in the percentage of people with HIV receiving recommended services.
• In 2008, the rate for people with HIV who had two or more CD4 tests during the year was lower than the rates for all other recommended services for HIV care, at approximately 83% for both males and females.
• In 2008, there were no statistically significant gender differences in the percentage of people with HIV receiving recommended services.

Also, in the NHQR:

• In 2008, there were no statistically significant differences by age in the percentage of people with HIV receiving recommended services.

Outcome: Deaths of People With HIV

Improved management of HIV infection has contributed to declines in the number of new AIDS cases in the United States since the 1990s (CDC, 2005). 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 2.23. HIV infection deaths per 100,000 population, by ethnicity/gender and ethnicity/age, 2007

[D] Select for Text Description.

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System—Mortality, 2007.
Note: For this measure, lower rates are better. Rates are age adjusted to the 2000 standard population.

• Overall, in 2007, the HIV infection death rate for males was more than twice that of females (5 deaths per 100,000 population compared with 2 deaths per 100,000 population) (data not shown).
• In 2007, the rate of HIV infection deaths was higher for non-Hispanic Black males (25 deaths per 100,000 population) and Hispanic males (6 deaths per 100,000 population) compared with non-Hispanic White males (3 deaths per 100,000 population) (Figure 2.23).
• In 2007, non-Hispanic Black females (12 deaths per 100,000 population) and Hispanic females (2 deaths per 100,000 population) had higher HIV infection death rates than non-Hispanic White females (1 death per 100,000 population).
• In 2007, non-Hispanic Blacks had higher HIV death rates than non-Hispanic Whites for all age groups.

Also, in the NHQR:

• From 2004 to 2007, the rate of HIV infection deaths decreased for people ages 18-44 (from 6 to 4 deaths per 100,000 population) and 45-64 (from 9 to 8 deaths per 100,000 population). Males were more likely than females to have higher HIV death rates.

^xii. The top 5 States contributing to the achievable benchmark are Hawaii, Maine, Montana, New Hampshire, and Oregon.
^xiii. The top 5 States contributing to the achievable benchmark are California, Minnesota, New Hampshire, Pennsylvania, and South Dakota.
^xiv. HbA1c, or glycosylated hemoglobin, is a measure of average levels of glucose in the blood.
^xv. The top 4 States contributing to the benchmark are Hawaii, Minnesota, Nebraska, and Utah.

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