2012 National Healthcare Disparities Report

Chapter 4. Timeliness

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 can help reduce mortality and morbidity for chronic conditions such as kidney disease (Kinchen, et al., 2002).
  • Timeliness in 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 can reduce admissions for pediatric asthma, which account for more than $1.25 billion in total hospitalization charges annually (AHRQ, 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.
  • 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, 2002-2009

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Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2009.
Denominator: Civilian noninstitutionalized population age 18 and over.
Note: For this measure, lower rates are better. Data were insufficient for this analysis for multiple race in 2003, 2007, and 2008.

  • In 7 of 8 years from 2002 to 2009, 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 Whites than for Blacks. In 6 of 8 years, the percentage was lower for Whites than for Asians (Figure 4.1). The gap between Whites and Blacks and Whites and Asians remains unchanged.
  • In all years, 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, the percentage who reported not getting care as soon as wanted was significantly lower for people with any college education than for people with less than a high school education (data not shown).

Also, in the NHQR:

  • From 2002 to 2009, the percentage of adults who did not receive care as soon as wanted was significantly higher for adults ages 18-44 compared with all other age groups.

  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 language spoken at home, 2002-2009

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Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2009.
Denominator: Civilian noninstitutionalized population under age 18.
Note: For this measure, lower rates are better. The 2009 data for non-Hispanic Blacks did not meet criteria for statistical reliability, data quality, or confidentiality.

  • From 2002 to 2009, non-Hispanic White children and children who spoke English at home showed improvement in the percentage who received care as soon as wanted (Figure 4.2).
  • During this period, there was no statistically significant difference between non-Hispanic White and non-Hispanic Black children in any year.
  • In 5 of 8 years, the percentage of children who did not receive care as soon as wanted was significantly lower for children from homes where English was the language spoken most often than for children from homes where a language other than English was spoken most often.

Also, in the NHQR:

  • From 2002 to 2009, the percentage of children residing in large central metropolitan areas who needed care right away for an illness, injury, or condition in the last 12 months and sometimes or never got care as soon as wanted decreased.

Emergency Department Visit Waiting Times

  • In 2010, an estimated 130 million visits were made to hospital EDs compared with almost 124 million visits in 2008 (CDC, 2010).
  • The median waiting time for patients to be seen by a physician during an ED visit in the United States was 28 minutes (CDC, 2010).
  • Not all patients seeking care in an ED need urgent care, and use of EDs for nonurgent care could lead to longer waiting 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, 2009-2010

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Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Ambulatory Medical Care Survey (NHAMCS), 2009-2010.
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: For 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 in 2007 NHAMCS Microdata File Documentation, ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/NHAMCS/. Insurance status is 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 2009-2010, among ED visits for immediate/emergent conditions, the percentage of patients who had to wait an hour or more was higher for Blacks than for Whites (Figure 4.3). Also, a higher percentage of uninsured patients had to wait an hour or more compared with patients with private insurance.
  • Among visits for urgent conditions, the percentage of patients who had to wait an hour or more was higher for Blacks than for Whites and for uninsured patients than for privately insured patients.

Also, in the NHQR:

  • In 2009-2010, among ED visits for both immediate/emergent and urgent conditions, the percentage of patients who had to wait an hour or more was significantly higher for those ages 18-44 than for those under age 18 and those age 65 and over.
  • For both immediate/emergent and urgent conditions, the percentage was lower among patients in nonmetropolitan areas compared with patients in metropolitan areas.

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 (Gerczuk & Kloner, 2012). 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, 2005-2010

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Key: AI/AN = American Indian or Alaska Native.
Source: Centers for Medicare & Medicaid Services, Medicare Quality Improvement Organization Program, 2005-2010.
Denominator : Patients hospitalized with a principal diagnosis of acute myocardial infarction who were appropriate candidates for percutaneous coronary intervention.

  • Among heart attack patients, the percentage of patients receiving timely PCI improved for all racial/ethnic groups from 2005 to 2010 (Figure 4.4). In all years, Blacks and Hispanics were less likely than Whites to receive timely PCI.
  • The benchmark for this measure was changed because, overall, the 2008 benchmark had been achieved.
  • The 2010 top 5 State achievable benchmark was 96%.i At the current rates of improvement, the achievable benchmark could be attained overall and among all racial/ethnic groups in less than 1 year.

Also, in the NHQR:

  • In 2005, a significantly higher percentage of patients under age 65 received PCI than patients in all other age groups; however, by 2010 there were no statistically significant differences by age in the percentage of patients who received PCI.

  Figure 4.5. Hospital patients with heart attack who received fibrinolytic medication within 30 minutes, by race/ethnicity, 2005-2010

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Source: Centers for Medicare & Medicaid Services, Medicare Quality Improvement Organization Program, 2005-2010.
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 2010 (Figure 4.5). In all years, Blacks were less likely to receive timely fibrinolytic medication compared with Whites and the disparity between Hispanics and Whites grew.
  • The benchmark for this measure was changed because, overall, the 2008 benchmark had been achieved.
  • In 2010, the top 5 State achievable benchmark was 68%.ii At the current rate of improvement, the achievable benchmark could be attained overall in less than a year (data not shown).
  • At their current rates of improvement, Whites and Asians should reach the achievable benchmark in about 1 year; Blacks should reach the benchmark in about 3 years, and Hispanics should reach the benchmark in about 7 years.

Also, in the NHQR:

  • The percentage of patients who received fibrinolytic medication was significantly higher for patients under age 65 than for patients ages 75-84 in 4 of 6 years and significantly higher than for patients age 85 and over in 5 of 6 years.

References

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

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.

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: 2010 emergency department summary tables. Available at http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2010_ed_web_tables.pdf [Plugin Software Help]. Accessed March 8, 2013.

Gerczuk PZ, Kloner, RA. An update on cardioprotection: a review of the latest adjunctive therapies to limit myocardial infarction size in clinical trials. J Am Coll Cardiol 2012;59:969-78.

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.

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.

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 Maine, Minnesota, North Carolina, Rhode Island, and South Carolina.
ii. The top 5 States that contributed to the achievable benchmark are Arkansas, California, Georgia, Mississippi, and Texas.

Page last reviewed May 2013
Internet Citation: 2012 National Healthcare Disparities Report: Chapter 4. Timeliness. May 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/nhqrdr/nhdr12/chap4.html