Chapter 4. Timeliness

National Healthcare Disparities Report, 2011


Timeliness in health care is the system's capacity to provide care quickly after a need is recognized. It is one of the six dimensions of quality the Institute of Medicine established as a priority for improvement in the health care system (Institute of Medicine, 2001). Measures of timeliness include time spent waiting in doctors' offices and emergency departments (EDs), and the interval between identifying a need for specific tests and treatments and actually receiving services.

Importance

Morbidity and Mortality

  • Lack of timeliness can result in emotional distress, physical harm, and higher treatment costs (Boudreau, et al., 2004).
  • Stroke patients' mortality and long-term disability are largely influenced by the timeliness of therapy (Kwan, et al., 2004).
  • Timely delivery of appropriate care also can help reduce mortality and morbidity for chronic conditions such as kidney disease (Kinchen, et al., 2002).
  • Timely delivery of childhood immunizations helps maximize protection from vaccine-preventable diseases while minimizing risks to the child and reducing the chance of disease outbreaks (Luman, et al., 2005).
  • Timely antibiotic treatments are associated with improved clinical outcomes (Houck & Bratzler, 2005).

Cost

  • Early care for comorbid conditions has been shown to reduce hospitalization rates and costs for Medicare beneficiaries (Himelhoch, et al., 2004).
  • Some research suggests that, over the course of 30 years, the costs of treating diabetic complications can approach $50,000 per patient (Caro, et al., 2002). Early care for complications in patients with diabetes can reduce overall costs of the disease (Ramsey, et al., 1999).
  • Timely outpatient care also can reduce admissions for pediatric asthma, which account for $1.25 billion in total hospitalization charges annually (Agency for Healthcare Research and Quality, 2009).

Measures

This report includes three measures related to timeliness of primary, emergency, and hospital care: getting care for illness or injury as soon as wanted, ED wait times, and timeliness of cardiac reperfusion for heart attack patients.

Findings

Getting Care for Illness or Injury As Soon As Wanted

A patient's primary care provider should be the first point of contact for most illnesses and injuries. A patient's ability to receive timely treatment for illness and injury is a key element in a patient-centered health care system.

Figure 4.1. Adults who needed care right away for an illness, injury, or condition in the last 12 months who sometimes or never got care as soon as wanted, by race and income, 2002-2008

Figure 4.1. Adults who needed care right away for an illness, injury, or condition in the last 12 months who sometimes or never got care as soon as wanted, by race and income, 2002-2008. For details, go to [D] Text Description below.     Figure 4.1. Adults who needed care right away for an illness, injury, or condition in the last 12 months who sometimes or never got care as soon as wanted, by race and income, 2002-2008. For details, go to [D] Text Description below.
[D] Select for Text Description.

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2008.
Denominator: Civilian noninstitutionalized population age 18 and over.
Note: For this measure, lower rates are better. Data were insufficient for this analysis for Native Hawaiians and Other Pacific Islanders, for American Indians and Alaska Natives, and for multiple race in 2003, 2007, and 2008.

  • From 2002 to 2008, the percentage of Whites who needed care right away for an illness, injury, or condition in the last 12 months who sometimes or never got care as soon as wanted was significantly lower than the percentage of Blacks in 6 of 7 years. The percentage for Whites was lower than for Asians in 5 of 7 years (Figure 4.1).
  • During the same period, the percentage who reported not getting care as soon as wanted was significantly lower for high-income people than for poor, low-income, and middle-income people in all years. Also, the percentage who reported not getting care as soon as wanted was significantly lower for people with any college education than for high school graduates in all years and people with less than a high school education in 5 of 7 years (data not shown).

Also, in the NHQR:

  • From 2002 to 2008, the percentage of adults who needed care right away for an illness, injury, or condition in the last 12 months who sometimes or never got care as soon as wanted was significantly lower for adults age 65 and over than for adults ages 18-64.

Figure 4.2. Children who needed care right away for an illness, injury, or condition in the last 12 months who sometimes or never got care as soon as wanted, by ethnicity and income, 2002-2008

Figure 4.2. Children who needed care right away for an illness, injury, or condition in the last 12 months who sometimes or never got care as soon as wanted, by ethnicity and income, 2002-2008. For details, go to [D] Text Description below.    Figure 4.2. Children who needed care right away for an illness, injury, or condition in the last 12 months who sometimes or never got care as soon as wanted, by ethnicity and income, 2002-2008. For details, go to [D] Text Description below.
[D] Select for Text Description.

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2008.
Denominator: Civilian noninstitutionalized population under age 18.
Note: For this measure, lower rates are better. The 2007 data for high-income people did not meet criteria for statistical reliability, data quality, or confidentiality.

  • From 2002 to 2008, the percentage of children from high-income families who did not receive care as soon as wanted was significantly lower than the percentage of children from poor families in 5 of 7 years (Figure 4.2). The percentage for high-income children was lower than for low-income children in 4 of 7 years.
  • During this period, there was no statistically significant change in the gap between non-Hispanic White children and Hispanic children who did not receive care as soon as wanted. The gap between non-Hispanic White children and non-Hispanic Black children also did not change.

Also, in the NHQR:

  • From 2002 to 2008, there was no statistically significant change in the gap between children living in large central metropolitan areas who did not receive care as soon as wanted and children in all other geographic areas.

Emergency Department Visit Waiting Times

  • In 2008, an estimated 123.8 million visits were made to hospital EDs compared with 116.8 million visits in 2007 (NHAMCS: 2008 Emergency Department Tables; Niska, et al., 2010).
  • The median waiting time for patients to be seen by a physician during an ED visit in the United States was 35 minutes (NHAMCS: 2008 Emergency Department Tables).
  • Not all patients seeking care in an ED need urgent care, and use of EDs for nonurgent care could lead to longer wait times.

The National Hospital Ambulatory Medical Care Survey defines five levels of urgency of ED visits:

  • Immediate, requiring immediate care.
  • Emergent, requiring care in less than 15 minutes.
  • Urgent, requiring care within 1 hour.
  • Semiurgent, requiring care within 2 hours.
  • Nonurgent, not requiring care within 2 hours.

Figure 4.3. Emergency department visits in which patient had to wait an hour or more by urgency, race, and insurance status, 2008-2009

Figure 4.3. Emergency department visits in which patient had to wait an hour or more by urgency, race, and insurance status, 2008-2009 . For details, go to [D] Text Description below.     Figure 4.3. Emergency department visits in which patient had to wait an hour or more by urgency, race, and insurance status, 2008-2009 . For details, go to [D] Text Description below.
[D] Select for Text Description.

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Ambulatory Medical Care Survey (NHAMCS), 2008-2009.
Denominator (Immediate or Emergent): Visits to U.S. emergency departments with triage assessments of immediate or emergent.
Denominator (Urgent): Visits to U.S. emergency departments with triage assessments of urgent.
Note: or this measure, lower rates are better. Race data were missing for 13.3% of total visits included in this chart. Missing race data were imputed. Standard errors were inflated as described at 2007 NHAMCS Microdata File Documentation, ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/NHAMCS/. Insurance status shown for patients under age 65 and classified based on all expected payment sources. Public insurance includes Medicare, Medicaid, and State Children's Health Insurance Program. Uninsured is defined as having "only self-pay" or "no charge/charity" as payment sources.

  • In 2008-2009, among ED visits for immediate/emergent conditions, there was no statistically significant difference between Whites and Blacks in the percentage who had to wait an hour or more. There were also no statistically significant differences between uninsured patients and patients with private insurance (Figure 4.3).
  • Among visits for urgent conditions, the percentage of patients who had to wait an hour or more was higher for Blacks compared with Whites and for uninsured patients under age 65 compared with privately insured patients under age 65.

Also, in the NHQR:

  • In 2008-2009, among ED visits for immediate/emergent conditions, there was no statistically significant difference between patients living in metropolitan and nonmetropolitan areas in the percentage who had to wait an hour or more. Among visits for urgent conditions, the percentage who had to wait an hour or more was lower among nonmetropolitan patients compared with metropolitan patients.

Timeliness of Cardiac Reperfusion for Heart Attack Patients

The capacity to treat hospital patients in a timely manner is especially important for emergency situations such as heart attacks. Some heart attacks are caused by blood clots. Early actions, such as percutaneous coronary intervention (PCI) or fibrinolytic medication, may open blockages caused by blood clots, reduce heart muscle damage, and save lives (Kloner & Rezkalla, 2004). To be effective, these actions need to be performed quickly after the start of a heart attack.

In this report, we present two measures of timeliness of cardiac reperfusion:

  • PCI within 90 minutes among appropriate patients.
  • Fibrinolytic medication within 30 minutes among appropriate patients.

Figure 4.4. Hospital patients with heart attack who received percutaneous coronary intervention within 90 minutes, by race/ethnicity, 2005-2009

Figure 4.4. Hospital patients with heart attack who received percutaneous coronary intervention within 90 minutes, by race/ethnicity, 2005-2009. For details, go to [D] Text Description below.

[D] Select for Text Description.

Key: AI/AN = American Indian or Alaska Native.
Source: Centers for Medicare & Medicaid Services, Medicare Quality Improvement Organization Program, 2005-2009.
Denominator: Patients hospitalized with a principal diagnosis of acute myocardial infarction who were appropriate candidates for percutaneous coronary intervention.
Note: Data were insufficient for this analysis for Native Hawaiians and Other Pacific Islanders.

  • Among heart attack patients, the percentage of patients receiving timely PCI improved for all racial/ethnic groups from 2005 to 2009 (Figure 4.4). In all years, Blacks and Hispanics were less likely than Whites to receive timely PCI.
  • The 2008 top 5 State achievable benchmark was 91%.i At the current rate of improvement, the achievable benchmark could be attained overall in less than 1 year.
  • All racial/ethnic groups should reach the achievable benchmark in less than a year.

Also, in the NHQR:

  • From 2005 to 2009, among heart attack patients, a significantly higher percentage of patients under age 65 received PCI within 90 minutes than patients of all other age groups.

Figure 4.5. Hospital patients with heart attack who received fibrinolytic medication within 30 minutes, by race/ethnicity, 2005-2009

Figure 4.5. Hospital patients with heart attack who received fibrinolytic medication within 30 minutes, by race/ethnicity, 2005-2009. For details, go to [D] Text Description below.

[D] Select for Text Description.

Source: Centers for Medicare & Medicaid Services, Medicare Quality Improvement Organization Program, 2005-2009.
Denominator: Patients hospitalized with a principal diagnosis of acute myocardial infarction who were appropriate candidates for fibrinolytic medication.

  • Among heart attack patients, the percentage of patients receiving timely fibrinolytic medication improved for all racial/ethnic groups from 2005 to 2009 (Figure 4.5). In all years, Blacks were less likely to receive timely fibrinolytic medication compared with Whites.
  • In 2008, the top 5 State achievable benchmark was 61%.ii At the current rate of improvement, the achievable benchmark could be attained in about 1.5 years.
  • At their current rates of improvement, Whites should reach the achievable benchmark in a little over 1 year; Hispanics should reach the benchmark in about 2 years, and Blacks should reach the benchmark in about 3 years.

Also, in the NHQR:

  • From 2005 to 2009, in 4 of 5 years, a significantly higher percentage of heart attack patients under age 65 received fibrinolytic medication within 30 minutes than patients age 75 and over.

References

Boudreau RM, McNally C, Rensing EM, et al. Improving the timeliness of written patient notification of mammography results by mammography centers. Breast J 2004 Jan-Feb;10(1):10-19.

Calculated from Web site: Agency for Healthcare Research and Quality. Healthcare Cost and Utilization Project. Kids' Inpatient Database. Rockville, MD. Available at: http://hcupnet.ahrq.gov/. Accessed April 24, 2009.

Caro JJ, Ward AJ, O'Brien JA. Lifetime costs of complications resulting from type 2 diabetes in the U.S. Diabetes Care 2002 Mar;25(3):476-81.

Centers for Disease Control and Prevention. National Hospital Ambulatory Medical Care Survey: 2008 emergency department summary tables. Available at http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/nhamcsed2008.pdf [Plugin Software Help]. Accessed May 9, 2011.

Himelhoch S, Weller WE, Wu AW, et al. Chronic medical illness, depression, and use of acute medical services among Medicare beneficiaries. Med Care 2004 Jun;42(6):512-21.

Houck PM, Bratzler DW. Administration of first hospital antibiotics for community-acquired pneumonia: does timeliness affect outcomes? Curr Opin Infect Dis 2005 Apr;18(2):151-6.

Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academies Press; 2001.

Kinchen KS, Sadler J, Fink N, et al. The timing of specialist evaluation in chronic kidney disease and mortality. Ann Intern Med 2002 Sep 17;137(6):479-86.

Kloner RA, Rezkalla SH. Cardiac protection during acute myocardial infarction: where do we stand in 2004? J Am Coll Cardiol 2004 Jul 21;44(2):276-86.

Kwan J, Hand P, Sandercock P. Improving the efficiency of delivery of thrombolysis for acute stroke: a systematic review. QJM 2004 May;97(5):273-9.

Luman ET, Barker LE, Shaw KM, et al. Timeliness of childhood vaccinations in the United States: days undervaccinated and number of vaccines delayed. JAMA 2005 Mar 9;293(10):1204-11.

Niska R, Bhuiya F, Xu J, et al. National Hospital Ambulatory Medical Care Survey: 2007 emergency department summary. Natl Health Stat Report 2010 Aug 6(26). Available at: http://www.cdc.gov/nchs/data/nhsr/nhsr026.pdf [Plugin Software Help]. Accessed February 1, 2012.

Ramsey SD, Newton K, Blough D, et al. Patient-level estimates of the cost of complications in diabetes in a managed-care population. Pharmacoecon 1999 Sep;16(3):285-95.


i. The top 5 States that contributed to the achievable benchmark are Massachusetts, Minnesota, North Carolina, Rhode Island, and South Carolina.
ii. The top 5 States that contributed to the achievable benchmark are Arkansas, California, Georgia, Kentucky, and Tennessee.



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Current as of April 2012
Internet Citation: Chapter 4. Timeliness: National Healthcare Disparities Report, 2011. April 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/nhqrdr/nhdr11/chap4.html