2012 National Healthcare Disparities Report

Chapter 5. Patient Centeredness

The Institute of Medicine identifies patient centeredness as a core component of quality health care (IOM, 2001a). Patient centeredness is defined as:

[H]ealth care that establishes a partnership among practitioners, patients, and their families (when appropriate) to ensure that decisions respect patients' wants, needs, and preferences and that patients have the education and support they need to make decisions and participate in their own care (IOM, 2001b).

Patient centeredness "encompasses qualities of compassion, empathy, and responsiveness to the needs, values, and expressed preferences of the individual patient" (IOM, 2001a). In addition, translation and interpretation services facilitate communication between the provider and the patient and are often a legal requirement.i The patient-centered approach includes viewing the patient as a unique person, rather than focusing strictly on the illness, building a therapeutic alliance based on the patient's and the provider's perspectives.

Patient-centered care is supported by good provider-patient communication so that patients' needs and wants are understood and addressed and patients understand and participate in their own care (IOM, 2001b). This approach to care has been shown to improve patients' health and health care (DiMatteo, 1998; Stewart, et al., 2000; Little, et al., 2001; Anderson, 2002; Beck, et al., 2002). Unfortunately, many barriers exist to good communication.

Providers also differ in communication proficiency, including varied listening skills and different views from their patients of symptoms and treatment effectiveness (Rhoades, et al., 2001). Additional factors influencing patient centeredness and provider-patient communication include:

  • Language barriers.
  • Racial and ethnic concordance between the patient and provider.
  • Effects of disabilities on patients' health care experiences.
  • Providers' cultural competency.

Efforts to remove these possible impediments to patient centeredness are underway within the Department of Health and Human Services (HHS). For example, the Office of Minority Health has developed a set of Cultural Competency Curriculum Modules that aim to equip providers with cultural and linguistic competencies to help promote patient-centered care (HHS, 2011).ii These modules are based on the National Standards on Culturally and Linguistically Appropriate Services. The standards are directed at health care organizations and aim to improve patient centeredness of care for people with limited English proficiency (LEP). Another example, which is administered by the Health Resources and Services Administration, is Effective Communication Tools for Healthcare Professionals, a Web-based course for providers that integrates concepts related to health literacy with cultural competency and LEP.iii

Similarly, the HHS Office for Civil Rights (OCR), in partnership with 18 medical schools in the National Consortium for Multicultural Education, funded by the National Institutes of Health, provides a course on cultural competency in medicine. The course, Stopping Discrimination Before It Starts: The Impact of Civil Rights Laws on Health Care Disparities,,iv focuses on Title VI compliance. This course discusses, in part, the HHS OCR's Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons. This guidance explains that recipients of Federal financial assistance must take reasonable steps to give individuals with LEP a meaningful opportunity to participate in HHS-funded programs. Failure to do so may violate the prohibition under Title VI of the Civil Rights Act of 1964, 42 U.S.C. 2000d et seq., against national origin discrimination (HHS, 2003).

In addition, the HHS OCR is responsible for the enforcement of Section 1557 of the Affordable Care Act, 42 U.S.C. 18116. This section provides that an individual shall not be excluded from participation in, be denied the benefits of, or be subjected to discrimination on the grounds prohibited under Title VI of the Civil Rights Act of 1964, 42 U.S.C. 2000d et seq. (race, color, national origin); Title IX of the Education Amendments of 1972, 20 U.S.C. 1681 et seq. (sex); the Age Discrimination Act of 1975, 42 U.S.C. 6101 et seq. (age); or Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. 794 (disability), under any health program or activity, any part of which is receiving Federal financial assistance, or under any program or activity that is administered by an executive agency or any entity established under Title I of the Affordable Care Act or its amendments.

On February, 26, 2013, the Department published its 2013 Language Access Plan (2013 HHS LAP; HHS, 2013), ensuring access to HHS programs and activities for people with LEP. The covered programs and activities include, but are not limited to, Medicare, Medicaid, and the Children's Health Insurance Program. The 2013 HHS LAP was developed by the HHS Language Access Steering Committee, which is led by the Director of the OCR on behalf of the Secretary.

In accordance with Executive Order 13166, Improving Access to Services for Persons With Limited English Proficiency (White House, 2000), the 2013 HHS LAP establishes the Department's policy and strategy for serving individuals with LEP and reaffirms the Department's commitment to language access principles. The 2013 HHS LAP serves as a blueprint for HHS staff and operating divisions charged with developing their own agency-specific language access plans. Additional information regarding language access requirements is available from the Department of Justice (DOJ, 2011).

The 2013 HHS LAP is organized into 10 cross-cutting elements:

  1. Assessment—Needs and Capacity.
  2. Oral Language Assistance Services.
  3. Written Translations.
  4. Policies and Procedures.
  5. Notification of the Availability of Language Assistance at No Cost.
  6. Staff Training.
  7. Assessment—Access and Quality.
  8. Stakeholder Consultation.
  9. Digital Information.
  10. Grant Assurance and Compliance.

Importance

Morbidity and Mortality

  • Patient-centered approaches to care have been shown to improve patients' health status. These approaches rely on building a provider-patient relationship, improving communication, fostering a positive atmosphere, and encouraging patients to actively participate in provider-patient interactions (Stewart, et al., 2000; Anderson, 2002).
  • A patient-centered approach has been shown to lessen patients' symptom burden (Little, et al., 2001).
  • Patient-centered care encourages patients to comply with treatment regimens (Beck, et al., 2002).
  • Patient-centered care can reduce the chance of misdiagnosis due to poor communication (DiMatteo, 1998).

Cost

  • Patient centeredness has been shown to reduce underuse and overuse of medical care (Berry, et al., 2003).
  • Patient centeredness can reduce the strain on system resources and save money by reducing the number of diagnostic tests and referrals (Little, et al., 2001).
  • Although some studies have shown that being patient centered reduces medical costs and use of health service resources, others have shown that patient centeredness increases providers' costs, especially in the short run (Bechel, et al., 2000).

Measures

The National Healthcare Quality Report (NHQR) and the National Healthcare Disparities Report (NHDR) track several measures of patients' experience of care. The reports also address the priority of ensuring that each person and family is engaged as partners in their care, found in the National Strategy for Quality Improvement in Health Care (National Quality Strategy).v The rationale is that "[h]ealth care should give each individual patient and family an active role in their care. Care should adapt readily to individual and family circumstances, as well as differing cultures, languages, disabilities, health literacy levels, and social backgrounds." Examples of person-centered care could be ensuring that patients' feedback on their preferences, desired outcomes, and experiences of care is integrated into care delivery and enabling patients to effectively manage their care.

The NHDR has tracked a growing number of patient centeredness measures. Organized around the National Quality Strategy, the 2012 NHDR presents the following measures that relate to the goal to provide patient-centered care:

  • Adults and children who reported poor communication at the doctor's office (composite).
  • Adults who reported poor communication with nurses and doctors at the hospital.
  • Adults with LEP, by whether they had a usual source of care with or without language assistance.
  • Adults who needed an interpreter during last office visit.
  • Provider's involvement of the patient in making treatment decisions.

The last measure also relates to the National Quality Strategy goal of patient engagement.

Findings

Patients' Experience of Care—Adults

Optimal health care requires good communication between patients and providers, yet barriers to provider-patient communication are common. To provide all patients with the best possible care, providers need to understand patients' diverse health care needs and preferences and communicate clearly with patients about their care.

  Figure 5.1. Composite: Adults who had a doctor's office or clinic visit in the last 12 months who reported poor communication with health providers, by race/ethnicity 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 who had a doctor's office or clinic visit in the last 12 months.
Note: For this measure, lower rates are better. White and Black are non-Hispanic. Hispanic includes all races. Patients who report that their health providers sometimes or never listened carefully, explained things clearly, showed respect for what they had to say, or spent enough time with them are considered to have poor communication.

  • Between 2002 and 2009, there was no statistically significant decrease in the percentage of adults who reported poor communication with their health providers for racial/ethnic groups or for income groups (Figure 5.1).
  • From 2002 to 2009, Hispanics were significantly more likely than Whites to report poor communication. In 2009, the percentage who reported poor communication was significantly higher for Black and Hispanic adults than for White adults.
  • From 2002 to 2009, poor and low-income adults were more likely than high-income adults to report poor communication with health providers.
  • In 2009, the percentage of patients reporting poor communication was higher for poor, low-income, and middle-income groups than for the high-income group (15.9%, 11.6%, 9.3%, and 6.3%, respectively).

Also, in the NHQR:

  • From 2002 to 2009, a significantly lower percentage of adults with private insurance reported poor communication with their health providers compared with adults who were uninsured and those with public insurance.

Racial and ethnic minorities are disproportionately of lower income levels. To distinguish the effects of race, ethnicity, and income on provider-patient communication, this measure is stratified by income.

  Figure 5.2. Adult ambulatory patients who reported poor communication with health providers, by race/ethnicity, stratified by income, 2009

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Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2009.
Denominator: Civilian noninstitutionalized population age 18 and over.
Note: For this measure, lower rates are better. White and Black are non-Hispanic. Hispanic includes all races. Patients who report that their health providers sometimes or never listened carefully, explained things clearly, showed respect for what they had to say, or spent enough time with them are considered to have poor communication.

  • In 2009, a higher percentage of poor Hispanics and Blacks reported poor communication compared with poor Whites (18.3% and 17.8%, respectively, compared with 14%; Figure 5.2).

Patients' Experience of Care—Children

Communication in children's health care can be challenging since the child's experiences are interpreted through the eyes of a parent or guardian. During a health care encounter, a responsible adult caregiver will be involved in communicating with the provider and interpreting decisions to the patient in an age-appropriate manner. Optimal communication in children's health care can therefore have a significant impact on receipt of high-quality care and subsequent health status.

  Figure 5.3. Composite: Children who had a doctor's office or clinic visit in the last 12 months whose parents reported poor communication with health providers, by race and geographic location, 2002-2009

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Key: MSA = metropolitan statistical area.
Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2009.
Denominator: Civilian noninstitutionalized population under age 18 who had a doctor's office or clinic visit in the last 12 months.
Note: For this measure, lower rates are better. White and Black are non-Hispanic. Hispanic includes all races. Data for children in noncore areas in 2006 and 2008 did not meet criteria for statistical reliability. Parents who report that their child's health providers sometimes or never listened carefully, explained things clearly, showed respect for what they had to say, or spent enough time with them are considered to have poor communication.

  • From 2002 to 2009, the percentage of children whose parents or guardians reported poor communication significantly decreased among Hispanics (Figure 5.3). There were no other statistically significant changes in the percentage of children whose parents or guardians reported poor communication with their health providers.
  • In 2009, there were no statistically significant differences by location in the percentage of children whose parents or guardians reported poor communication with their health providers.

Also, in the NHQR:

  • In 2009, the percentage of children whose parents reported poor communication was higher for those with public insurance only than for those with any private insurance.

Insurance status varies by income. To distinguish the effects of various insurance groups on provider-patient communication, this measure is stratified by income.

  Figure 5.4. Composite: Children who had a doctor's office or clinic visit in the last 12 months whose parents reported poor communication with health providers, by insurance status, stratified by income, 2009

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Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2009.
Denominator: Civilian noninstitutionalized population under age 18.
Note: For this measure, lower rates are better. Data were not available for high-income people with public insurance only. Parents who report that their child's health providers sometimes or never listened carefully, explained things clearly, showed respect for what they had to say, or spent enough time with them are considered to have poor communication.

  • When data are stratified by income, there are no statistically significant differences between those with any private insurance and those with public insurance only who reported poor communication with their health providers (Figure 5.4).

Patients' Experience of Care—Hospital

Using methods developed for the CAHPS® (Consumer Assessment of Healthcare Providers and Systems) survey (Hargraves, et al., 2003), the NHQR and NHDR use a composite measure that combines three measures of provider-patient communication into a single core measure. The composite measure presented includes data on providers who sometimes or never listened carefully, explained things clearly, and respected what patients had to say. These data are presented separately for communication with nurses and communication with doctors.

  Figure 5.5. Adult hospital patients who reported poor communication with nurses and doctors, by race, ethnicity, and education, 2010

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Key: NHOPI = Native Hawaiian or Other Pacific Islander; AI/AN = American Indian or Alaska Native.
Source: Agency for Healthcare Research and Quality, Hospital CAHPS (Consumer Assessment of Healthcare Providers and Systems) Survey, 2010.
Denominator: Adult hospitalized patients.
Note: For this measure, lower rates are better. Non-Hispanic and Hispanic include all races. Poor communication is defined as responded sometimes or never to the set of survey questions: "During this hospital stay, how often did doctors/nurses treat you with courtesy and respect?" "During this hospital stay, how often did doctors/nurses listen carefully to you?" and "During this hospital stay, how often did doctors/nurses explain things in a way you could understand?"

  • In 2010, overall, 5.3% of adult hospital patients reported poor communication with nurses during their hospital stay, and 5.2% reported poor communication with doctors (Figure 5.5).
  • In 2009, compared with Whites, all minority groups were more likely to report poor communication with nurses.
  • Blacks, American Indians and Alaska Natives, and patients of more than one race were more likely than Whites to report poor communication with doctors.
  • Adults with less than a high school education were more likely than those with any college education to report poor communication with nurses and doctors.

Also, in the NHQR:

  • In 2010, patients age 65 and over were less likely to report poor communication with nurses compared with patients ages 18-44.

Patient and Family Engagement: Enabling Effective Patient Navigation and Management of Care

To effectively navigate the complicated health care system, health care providers need to give patients access to culturally and linguistically appropriate tools to support patient engagement. Culturally and linguistically appropriate services (CLAS) are important components of effective health care delivery. It is vital for providers to understand patients' health care needs and for patients to understand providers' diagnoses and treatment recommendations. Communication barriers can relate to language, culture, and health literacy. This year, we provide data on language diversity.

For people with LEP, having language assistance is of particular importance, so they may choose a usual source of care in part based on language concordance. Not having a language-concordant provider may limit or discourage some patients from establishing a usual source of care.

To fill the data gap that currently exists, we examined subnational data-gathering activities and identified the California Health Interview Survey (CHIS) as a unique source of this type of information. CHIS is conducted by the UCLA Center for Health Policy Research in collaboration with the California Department of Public Health, the Department of Health Care Services, and the Public Health Institute.

Every 2 years, CHIS involves random-dial telephone interviews with up to 50,000 California households. The people included in CHIS are a statistically representative sample of the entire State's diverse population. With each survey cycle, new households are selected to participate. Beginning in 2007, CHIS also includes a sample of cell-phone-only households, which are often younger and more mobile Californians frequently overlooked in land-line surveys.

Language Assistance

Language barriers in health care are associated with decreases in quality of care, safety, and patient and clinician satisfaction and contribute to health disparities, even among people with insurance.

To address these barriers, the HHS OCR enforces Title VI of the Civil Rights Act of 1964, 42 U.S.C. 2000d et seq. Title VI prohibits discrimination on the basis of race, color, or national origin in any program that receives Federal financial assistance. Title VI requires that recipients of Federal funds, like most hospitals and health care providers, take reasonable steps to ensure meaningful access to their programs and services by individuals with LEP.

As part of its Title VI enforcement activities, OCR recently entered into a voluntary compliance agreement with the North Carolina Department of Health and Human Services (NCDHHS), which administers an annual budget of $18.3 billion, including the State's Medicaid; Early and Periodic Screening, Diagnosis and Treatment; and Children's Health Insurance Programs. To comply with Title VI, NCDHHS has agreed to provide timely and competent language assistance services, including oral interpreters and written translations of vital documents, at no cost to individuals with LEP.

In addition, the HHS Office of Minority Health has issued 14 National Standards for Culturally and Linguistically Appropriate Services in Health Care. These standards, which are directed at health care organizations, are also encouraged for individual providers to improve accessibility of their practices. The 14 standards are organized by themes: Culturally Competent Care (Standards 1-3), Language Access Services (Standards 4-7), and Organizational Supports for Cultural Competence (Standards 8-14). For people with LEP, having CLAS is of particular importance and may influence the patient's choice of a usual source of care.

  Figure 5.6. Adults with limited English proficiency, by whether they had a usual source of care with or without language assistance, Hispanics (top) and non-Hispanics (bottom), 2002-2009

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Key: USC = usual source of care.
Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2009.

  • From 2002 to 2009, the percentage of adults with LEP who did not have a usual source of care was higher for Hispanics than for non-Hispanics (Figure 5.6).
  • During the same period, non-Hispanics were more likely than Hispanics to have a usual source of care that did not provide language assistance.

Need for an Interpreter

The ability of providers and patients to communicate clearly with each other can be compromised if they do not speak the same language. Quality may suffer if patients with LEP cannot express their care needs to providers who speak English only or who do not have an interpreter's assistance. Communication problems between the patient and provider can lead to lower patient adherence to medication regimens and decreased participation in medical decisionmaking. It also can exacerbate cultural differences that impair the delivery of quality health care.

  Figure 5.7. Adults age 18 and over who needed an interpreter during last doctor visit (California only), by race/ethnicity and granular ethnicities, 2005, 2007, and 2009 (combined/pooled)

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Key: AI/AN = American Indian or Alaska Native.
Source: University of California, Los Angeles, Center for Health Policy Research, California Health Interview Survey, 2005, 2007, and 2009.
Denominator: Adults with previous doctor visit.
Note: Racial groups are non-Hispanic; Hispanic groups include all races.

  • To allow estimates for more granular ethnicity groups, California data for 2005, 2007, and 2009 were combined. During this time, Blacks, American Indians and Alaska Natives, people of more than one race, Asians, and Hispanics were more likely than Whites to need an interpreter (Figure 5.7).
  • All Asian granular ethnicities were also more likely than Whites to need an interpreter, but rates ranged from 1.6% among Filipinos to 5.7% among Vietnamese people.
  • All Hispanic granular ethnicities were more likely than Whites to need an interpreter, but rates ranged from 7.5% among Mexicans to 10.1% among Central Americans.

Providers Asking Patients To Assist in Making Treatment Decisions

The increasing prevalence of chronic diseases has placed more responsibility on patients, since conditions such as diabetes and hypertension require self-management. Patients need to be provided with information that allows them to make educated decisions and feel engaged in their treatment. Treatment plans also need to incorporate their values and preferences.

  Figure 5.8. Adults with a usual source of care whose health providers sometimes or never asked for the patient's help to make treatment decisions, by race/ethnicity, 2002-2009

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Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2009.
Denominator: Civilian noninstitutionalized population with a usual source of care.
Note: For this measure, lower rates are better.

  • In 2009, Black and Hispanic patients were significantly more likely than White patients to have a usual source of care who did not ask for their help in making treatment decisions (17.7% and 18.9%, respectively, compared with 14.2%; Figure 5.8).
  • From 2002 to 2009, the percentage of patients whose usual source of care did not ask for their help in making treatment decisions decreased overall (from 21.9% to 15.4%; data not shown) and for all racial/ethnic groups presented.

Also, in the NHQR:

  • In 2009, patients with a high school education and less than a high school education were significantly more likely than patients with any college education to have a usual source of care who did not ask for their help in making treatment decisions.

References

Anderson EB. Patient-centeredness: a new approach. Nephrol News Issues 2002;16(12): 80-82.

Bechel DL, Myers WA, Smith DG. Does patient-centered care pay off? Jt Comm J Qual Improv 2000;26(7):400-9.

Beck RS, Daughtridge R, Sloane PD. Physician-patient communication in the primary care office: a systematic review. J Am Board Fam Pract 2002;15(1):25-38.

Berry LL, Seiders K, Wilders SS. Innovations in access to care: a patient-centered approach. Ann Intern Med 2003;139(7):568-74.

DiMatteo MR. The role of the physician in the emerging health care environment. West J Med 1998;168(5):328-33.

Hargraves JL, Hays RD, Cleary PD, et al. Psychometric properties of the Consumer Assessment of Health Plans Study (CAHPS) 2.0 adult core survey. Health Serv Res 2003;38(6 Pt 1):1509-27.

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

Institute of Medicine. Envisioning the National Health Care Quality Report. Washington, DC: National Academy Press; 2001b.

Little P, Everitt H, Williamson I, et al. Observational study of effect of patient centredness and positive approach on outcomes of general practice consultations. BMJ 2001;323(7318):908-11.

Rhoades DR, McFarland KF, Finch WH, et al. Speaking and interruptions during primary care office visits. Fam Med 2001;33(7):528-32.

Stewart M, Brown JB, Donner A, et al. The impact of patient-centered care on outcomes. J Fam Pract 2000;49(9):796-804.

U.S. Department of Health and Human Services. Language Access Plan 2013. Available at: http://www.hhs.gov/open/execorders/13166/. Accessed February 27, 2013.

U.S. Department of Health and Human Services, Office for Civil Rights. Guidance to federal financial assistance recipients regarding Title VI prohibition against national origin discrimination affecting limited English proficient persons. 68 Fed Reg 47311-47323; August 8, 2003. Available at: http://www.gpo.gov/fdsys/pkg/FR-2003-08-08/pdf/03-20179.pdf [Plugin Software Help]. Accessed February 22, 2013.

U.S. Department of Health and Human Services, Office of Minority Health. Think cultural health: advancing health equity at every point of contact. Available at: http://www.thinkculturalhealth.hhs.gov. Accessed August 11, 2011.

U.S. Department of Justice, Civil Rights Division, Federal Coordination and Compliance Section. Common language access questions, technical assistance, and guidance for federally conducted and federally assisted programs; August 2011. Available at: http://www.lep.gov/resources/081511_Language_Access_CAQ_TA_Guidance.pdf [Plugin Software Help]. Accessed February 22, 2013.

White House. Executive Order 13166: Improving access to services for persons with limited English proficiency. 65 Fed Reg 50121; August 16, 2000. Available at: http://www.gpo.gov/fdsys/pkg/FR-2000-08-16/pdf/00-20938.pdf [Plugin Software Help]. Accessed February 27, 2013.


i. For example, Title VI of the Civil Rights Act of 1964, 42 U.S.C. 2000d, may require the practitioner or hospital to provide language interpreters and translate vital documents for limited-English-proficient persons. Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. 794, may require the practitioner or hospital to provide sign language interpreters, materials in Braille, and/or accessible electronic formats for individuals with disabilities.
ii. This free, online educational program (available at http://www.thinkculturalhealth.hhs.gov) is accredited for Continuing Medical Education credits for physicians, as well as Continuing Education Units for physician assistants, nurse practitioners, registered nurses, social workers, and emergency response personnel.
iii. This online program (available at http://www.hrsa.gov/publichealth/healthliteracy/) is accredited for Continuing Medical Education credits for physicians and Continuing Education Units for nurses, physician assistants, pharmacists, and Certified Health Education Specialists.
iv. This course (available in the Association of American Medical Colleges' MedEdPORTAL, https://www.mededportal.org/publication/7740 ) has been presented at five national medical schools. Emory University School of Medicine and the University of Colorado School of Medicine have incorporated this course into their fourth year curriculums.
v. Available at http://www.ahrq.gov/workingforquality/nqs/nqs2011annlrpt.htm.

Page last reviewed May 2013
Internet Citation: 2012 National Healthcare Disparities Report: Chapter 5. Patient Centeredness. May 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/nhqrdr/nhdr12/chap5.html