2012 National Healthcare Disparities Report

Chapter 8. Health Systems Infrastructure

In its 2010 report, Future Directions for the National Healthcare Quality and Disparities Reports, the Institute of Medicine (IOM, 2010) recommended that future editions of the National Healthcare Quality Report (NHQR) and National Healthcare Disparities Report (NHDR) include data on the health care system's infrastructure capabilities. According to the IOM:

These components are not necessarily health care aims/attributes in themselves, but are a means to those aims since they are elements of the health care system that better enable the provision of quality care….and health systems infrastructure are of interest to the extent that they improve effectiveness, safety, timeliness, patient-centeredness, access, or efficiency.

Acknowledging that the measures and data required to assess the strength and capabilities of the health care infrastructure have not been well developed, the IOM identified structural elements that may affect quality improvement. Key elements include:

  • Information systems for data collection, quality improvement analysis, and clinical communication support.
  • An adequate and well-distributed workforce.
  • Organizational capacity to support emerging models of care, cultural competence services, and ongoing improvement efforts.

Of significance, inadequacies in health system infrastructure may limit access and contribute to poor quality of care and outcomes, particularly among vulnerable population groups that include racial and ethnic minority groups and people residing in areas with health professional shortages.

This chapter presents data to illustrate the strength of the U.S. health system infrastructure and how this infrastructure may influence quality of care. The chapter is divided into three sections, each addressing a unique aspect of the health care system:

  • Health information technology (IT).
  • Workforce distribution.
  • Health care safety net.

The chapter begins with data to describe the adoption and use of health IT. Use of health IT can be an effective way to manage health care costs and improve the quality of care.

Since the publication of the IOM report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare,i which emphasized the need for standardized collection and reporting of racial and ethnic data, the need for more granular detail on racial and ethnic subgroups has become apparent. This is an area where the adoption and use of health IT can be beneficial.

Another area of patient care that could be improved with the adoption and use of health IT is care coordination. A Commonwealth Fund study found that health IT can facilitate care coordination within a practice, but a lack of interoperability makes exchange of information between health care facilities difficult (Shih, et al., 2008).

Evidence has also shown that the adoption and effective use of health IT can help reduce medical errors and adverse events, enable better documentation and file organization, provide patients with information that assists their adherence to medication regimens and scheduled appointments, and assist doctors in tracking their treatment protocols (IOM, 2010).

Following presentation of measures of the use of health IT, data on health care workforce diversity are presented. An adequate supply of health care providers is an important indicator of health care quality. Aside from a provider-to-population ratio that effectively meets demand for care, it is important that the workforce be appropriately distributed.

In previous quality and disparities reports, data have been presented on diversity in the nursing, dental, pharmacy, and allied health professional workforce. This year, the NHQR and NHDR present data on the geographic and racial/ethnic distribution of primary care physicians and primary care specialists.

The distribution and availability of a culturally competent health care workforce has significant repercussions for access to care, particularly among the Nation's most vulnerable populations—racial and ethnic minorities, low-income populations, and uninsured or underinsured people. People who cannot access health care services, either because of financial considerations or inadequacy in the local health care infrastructure, often rely on safety net providers for essential health care services. The final section presents measures related to the performance of safety net providers, including people served, characteristics of selected safety net providers, and patient outcomes.

Measures

The IOM acknowledges that health system infrastructure measures such as adoption and effective use of health IT are likely to be in the developmental stage, and evidence of the impact on quality improvement has not yet been strongly established. The IOM highlighted three infrastructure capabilities that should be further evaluated for reporting. These capabilities include adoption and use of health IT, workforce distribution and its relevance to minority and other underserved populations, and care management processes.

Findings

Health Information Technology: Focus on Electronic Health Records

According to the Office of the National Coordinator for Health IT, an electronic health record (EHR) is a real-time patient health record with access to evidence-based decision support tools that can be used to aid clinicians in decisionmaking. The EHR can automate and streamline a clinician's workflow, ensuring that all clinical information is communicated. The EHR can also support the collection of data for uses other than clinical care, such as billing, quality management, outcome reporting, and disease surveillance and reporting for public health purposes.

The IOM report, Future Directions for the National Healthcare Quality and Disparities Reports highlights the adoption and use of health IT as a tool to manage cost and improve the quality of care delivered (IOM, 2010). Meaningful use of an EHR, for instance, is increasingly viewed as essential to improving both the efficiency of service delivery and health care quality (Resnick & Alwan, 2010).

Health providers using EHRs have reported improvement in clinical decisionmaking and communication with other providers and patients, as well as faster and more accurate access to medical records and avoidance of medical errors (Romano & Stafford, 2011). Components of EHRs, such as computerized provider order entry (CPOE) and clinical decision support (CDS), have been found to be associated with significant reductions in medication errors (Devine, et al., 2010).

CPOE systems are computer applications that allow direct electronic entry of orders for medications, laboratory tests, radiology services, referrals, and procedures. CDS encompasses a wide range of computerized tools directed at improving patient care, including alerts, reminders, order sets, drug dose calculations that automatically remind the clinician of a specific action, or care summary dashboards that provide feedback on quality indicators (Bright, et al., 2012).

Electronic Health Records in Hospitals

The 2012 Commonwealth Fund report, Using Electronic Health Records To Improve Quality and Efficiency: The Experience of Leading Hospitals found that successful implementation of EHRs depends on strong leadership, full involvement of clinical staff in design and implementation, and mandatory staff training. EHRs can improve health care quality and patient safety through the use of checklists and alerts and by promoting evidence-based practices. EHRs can increase efficiency by alerting physicians to duplicate orders and enabling faster prescribing and test ordering while reducing errors and redundancy. This year's NHDR tracks overall EHR use in hospitals.

EHRs can improve the quality and safety of care in all types of hospitals and in departments within hospitals. In emergency departments, for instance, electronic clinical documentation and decision support can help mitigate problems of treating new patients with complicated medical histories and gaps in their medical records. EHRs can also provide effective decision support and clinical reminders to facilitate a seamless transition of care by reducing communication breakdown between different providers.

Overall EHR use is presented by hospital ownership because many not-for-profit hospitals serve large populations who experience health care disparities, including racial and ethnic minorities and Medicaid recipients. The Government Accountability Office found that government and not-for-profit hospitals account for a larger percentage of total uncompensated cost compared with for-profit hospital groups (GAO, 2005).

  Figure 8.1. Electronic medical record use in hospitals, by hospital control and hospital type, 2010

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Source: American Hospital Association, 2010 Annual Survey Information Technology Supplement.

Patient Demographics
  • In 2010, 82.5% of hospitals with an EHR system had a component for patient demographics (Figure 8.1).
  • Nearly 93% of hospitals run by the Federal Government, 90.0% of not-for-profit, 74.4% of non-Federal, and 65.0% of investor-owned hospitals with an EHR system had a component for patient demographics.
  • Ninety percent of children's general hospitals, 85.5% of general medical and surgical, and 64.8% of psychiatric hospitals had an electronic system with a patient demographics component.
  • Between 53% and 59% of rehabilitation and acute long-term care hospitals had an electronic system that supports patient demographics.
Physician Notes and Nursing Assessments
  • In hospitals with an EHR system, 25% support physician notes and 53.0% support nursing assessments.
  • The percentage of hospitals with electronic systems that support both physician notes and nursing assessments also was much higher for Federal hospitals than for non-Federal, not-for-profit, and investor-owned hospitals.
  • Forty-five percent of children's general hospitals, 26.3% of psychiatric hospitals, and 24.8% of general medical and surgical hospitals had an electronic system that supports physician notes. More than 60% of children's general hospitals (62.5%), 56.3% of general medical and surgical hospitals, and 30.1% of rehabilitation hospitals had an electronic system that supports nursing assessments.
  • Between 20% and 22% of rehabilitation and acute long-term care hospitals had an electronic system that supports physician notes. Between 27% and 30% of psychiatric and acute long-term care hospitals had a system that supports nursing assessments.
Problem Lists and Medication Lists
  • In hospitals with an EHR system, 39.6% support problem lists and 58.2% support medication lists.
  • The percentage of hospitals with electronic systems that support both problem and medication lists was much higher for Federal hospitals than for non-Federal, not-for-profit, and investor-owned hospitals.
  • Sixty percent of children's general hospitals, 41.1% of general medical and surgical hospitals, and 28.4% of psychiatric hospitals had an electronic system that supports problem lists. Seventy-five percent of children's general hospitals, 60.6% of general medical and surgical hospitals, and 41.2% of acute long-term care hospitals had an electronic system that supports medication lists.
  • Between 23% and 24% of rehabilitation and acute long-term care hospitals had an electronic system that supports problem lists. Between 37% and 40% of psychiatric and rehabilitation hospitals had an electronic system that supports medication lists.
Discharge Summaries and Advance Directives
  • In hospitals with an EHR system, 53% support discharge summaries and advance directives.
  • The percentage of hospitals with electronic systems that support both discharge summaries and advance directives was much higher for Federal hospitals than for non-Federal, not-for-profit, and investor-owned hospitals.
  • Nearly 72% of children's general hospitals, 55.4% of general medical and surgical hospitals, and 38.2% of rehabilitation hospitals had an electronic system that supports discharge summaries. Two-thirds of children's general hospitals, 57.4% of general medical and surgical hospitals, and 30.0% of acute long-term care hospitals had an electronic system that supports advance directives.
  • Nearly one-third of psychiatric hospitals (32.0%) and 35.0% of acute long-term care hospitals had an electronic system that supports discharge summaries. Fifteen percent of psychiatric hospitals and 28.0% of rehabilitation hospitals had an electronic system that supports advance directives.

Also, in the (NHQR):

  • In 2010, the percentage of hospitals with 400 beds or more with an electronic system that supports patient demographics, physician notes, nursing assessments, problem lists, medication lists, discharge summaries, and advance directives was higher than for hospitals with fewer than 400 beds.

Electronic Health Records in Physician Practices

In addition to alerts, guidelines, and electronic ordering, the ability to exchange health information efficiently between providers leads to better access to quality care and improved patient safety. Many factors outside of the physician's control may help determine his or her ability to adopt an EHR system. Unfortunately, practice size and availability of resources affect EHR adoption rates. Thus, the potential quality and efficiency benefits of an EHR system may be unavailable to resource-constrained organizations that are constantly challenged to "do more with less" (McAlearney, et al., 2010).

The most frequent reason cited for not adopting health IT is cost and potential loss of productivity. EHRs cost almost $44,000 per full-time-equivalent provider, with ongoing costs of $8,400 annually (Samantaray, et al., 2011).

  Figure 8.2. Electronic health record use in physician offices, by ownership and specialty, 2011

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Key: HMO = health maintenance organization.
Source: Jamoom E, Beatty P, Bercovitz, et al. Physician adoption of electronic health record systems: United States, 2011. NCHS data brief, no 98. Hyattsville, MD: National Center for Health Statistics; 2012.

  • In 2011, nearly all physicians in health maintenance organizations (HMOs), 73% of physicians in community health centers, and 69% of physicians in academic health centers had adopted an EHR system. Only 49% of providers in physician-owned practices had adopted EHRs (Figure 8.2).
  • In 2011, 58% of primary care specialists, 54% of medical subspecialists, and 48% of surgical specialists had adopted an EHR system.

Also, in the NHQR:

  • In 2011, 64% of physicians under age 50 had an EHR system but only 49% of physicians age 50 and over had an EHR system.
  • In 2011, the percentage of physicians working in practices of 11 or more who had an EHR system was nearly three times as high as the percentage of physicians in solo practices who had an EHR system.

  Figure 8.3. Electronic health record use in physician offices, by ethnicity of population, metropolitan status, and specialty, 2011

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Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Ambulatory Medical Care Survey, 2011 Electronic Medical Record Mail Survey Supplement.

Patient Demographics
  • In 2011, 76.7% of physician offices in areas with a non-Hispanic White population of 80% or greater, 73.6% of physician offices in areas with a non-Hispanic White population between 70% and 79%, 72.3% of physician offices in areas with a non-Hispanic White population between 50% and 69%, and 67.5% of physician offices in areas with a non-Hispanic White population below 50% who adopted EHRs had a component for patient demographics (Figure 8.3).
  • In 2011, 75.7% of primary care practices, 71.4% of surgical practices, and 68.3% of medical subspecialty practices with an EHR system had a component for patient demographics.
Clinical Notes
  • In 2011, 66.6% of physician offices in areas with a non-Hispanic White population of 80% or greater, 61.4% of physician offices in areas with a non-Hispanic White population between 70% and 79%, 60.3% of physician offices in areas with a non-Hispanic White population between 50% and 69%, and 58.1% of physician offices in areas with a non-Hispanic White population below 50% who adopted EHRs had a component for clinical notes.
  • In 2011, 64.2% of primary care practices, 61.3% of medical subspecialty practices, and 56.1% of surgical practices with an EHR system had a component for clinical notes.
Prescription Ordering
  • In 2011, 69.1% of physician offices in areas with a non-Hispanic White population of 80% or greater, 67.6% of physician offices in areas with a non-Hispanic White population between 70% and 79%, 64.0% of physician offices in areas with a non-Hispanic White population between 50% and 69%, and 59.3% of physician offices in areas with a non-Hispanic White population below 50% who adopted EHRs had a component for prescription ordering.
  • In 2011, 70.0% of primary care practices, 58.4% of medical subspecialty practices, and 62.7% of surgical practices with an EHR system had a component for prescription ordering.
Clinical Decision Support
  • In 2011, 37.4% of physician offices in areas with a non-Hispanic White population of 80% or greater, 30.2% of physician offices in areas with a non-Hispanic White population between 70% and 79%, 32.4% of physician offices in areas with a non-Hispanic White population between 50% and 69%, and 30.4% of physician offices in areas with a non-Hispanic White population below 50% who adopted EHRs had a CDS component.
  • In 2011, 42.7% of primary care practices, 25.7% of medical subspecialty practices, and 21.0% of surgical practices with an EHR system had a CDS component.
Clinical Reminders
  • In 2011, 44.7% of physician offices in areas with a non-Hispanic White population of 80% or greater, 38.0% of physician offices in areas with a non-Hispanic White population between 70% and 79%, 39.0% of physician offices in areas with a non-Hispanic White population between 50% and 69%, and 38.0% of physician offices in areas with a non-Hispanic White population below 50% who adopted EHRs had a component for clinical reminders.
  • In 2011, 49.8% of primary care practices, 32.0% of medical subspecialty practices, and 30.3% of surgical practices with an EHR system had a component for clinical reminders.

Also, in the NHQR:

  • In 2011, the percentage of practices with EHRs with a component for patient demographics, clinical notes, prescription ordering, clinical decision support, and clinical reminders was highest for physicians under age 35 and practices with 11 or more physicians.

New! Electronic Health Records in Health Centers

Health Resources and Services Administration (HRSA) supported health centers (HSHCs) are nonprofit private or public entities that serve designated medically underserved populations/areas or special medically underserved populations composed of migrant and seasonal agricultural workers, homeless people, or residents of public housing. Health centers provide comprehensive, culturally competent, primary health care services to medically underserved communities and vulnerable populations.

There are already 65 million Americans living in areas officially deemed primary care shortage areas and many adults have difficulty obtaining prompt access to primary care (Bodenheimer & Pham, 2010). To improve the capacity to provide care to people living in shortage areas as well as a growing insured population, the Federal Government, through the Affordable Care Act, provides a stream of mandatory funds to expand health center capacity and capital infrastructure. As more people become covered by Medicaid, the role of health centers becomes more critical.

  Figure 8.4. Electronic health record use in HRSA supported health centers, 2011

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Key: CPOE = computerized provider order entry.
Source: Health Resources and Services Administration, Bureau of Primary Health Care, Uniform Data System, 2011.

  • In 2011, 79.6% of HSHCs had an EHR system installed, and nearly all of those health centers had an EHR with a component for patient history and demographics and clinical notes (Figure 8.4).
  • Nearly all HSHCs with EHRs had a component for electronic prescription entry, 97.1% had a CPOE component for lab tests, 93.9% had a component for reminders for guideline-based intervention or screening tests, and 76.4% had a CPOE component for radiology tests.

Workforce Diversity

Diversity in the composition of the health care workforce is important because it affects outcomes, quality, safety, and satisfaction.

Racial and ethnic disparities in health outcomes and the lack of health providers highlight the need for family physicians. Members of racial and ethnic minority groups, who make up the majority of inner city residents, are less likely than others to receive needed services, including treatment for HIV infection, mental health problems, cardiovascular disease, and cancer.

Health disparities affecting minorities have been traced to many causes, including language and cultural barriers that can deter minorities from seeking care or lead to suboptimal care. Racial and ethnic concordance in physician-patient relationships has been shown to improve care. Such positive relationships are more likely to occur when an area contains enough physicians of a given race/ethnicity to serve the local population who are of corresponding race/ethnicity (Brown, et al., 2009).

Additional research has found that physicians from groups underrepresented in the health professions are more likely to serve minority and economically disadvantaged patients. It has also been found that Black and Hispanic physicians practice in areas with larger Black and Hispanic populations than other physicians (Brown, et al., 2009).

Language differences between patients and clinicians jeopardize communication, leading to compromised care, increased health disparities and inequalities, dissatisfaction with care, and inefficiency in the health care system (Tang, et al., 2011). Research has also shown that linguistic minorities suffer more serious adverse outcomes from medical errors and receive worse care than do English-speaking patients (Tang, et al., 2011).

Patient-clinician language concordance can enhance health care quality and equity, patient safety and satisfaction, and resource stewardship. Workforce diversity has been associated with both greater satisfaction with care received and improved patient-provider communication. Conversely, the lack of a diverse workforce may foster linguistic and cultural barriers, bias, and clinical uncertainty within the patient-provider relationship (Mitchell & Lassiter, 2012).

  Figure 8.5. Rate of physicians and surgeons per 100,000 population, by race and ethnicity, 2006-2010

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Key:AI/AN: American Indian or Alaska Native.
Source: U.S. Census, American Community Survey, 2006-2010.
Note: Data for AI/ANs in 2008 did not meet criteria for statistical reliability.

  • From 2006 to 2010, Whites had significantly higher rates of physicians and surgeons than Blacks, AI/ANs, and multiple-race individuals in all years (Figure 8.5).
  • In all years, Asians had significantly higher rates of physicians and surgeons than all other racial groups. In 2010, the rate of Asian physicians and surgeons was 4 times the rate for Whites, 10 times the rate for Blacks, 14 times the rate for AI/ANs, and more than 5 times the rate for multiple-race individuals.
  • In all years, the rates for non-Hispanic Whites were about three times the rates for Hispanic physicians and surgeons.

Also, in the NHQR:

  • In 2008, the Midwest, South, and West all had higher rates of general family medicine physicians than the Northeast but only the Midwest had a significantly higher rate of family medicine subspecialists than the Northeast. Nonmetropolitan areas had a slightly higher rate of general family medicine physicians but the difference was not statistically significant.
  • In 2008, the Northeast had higher rates of pediatricians and pediatric subspecialists than the Midwest, South, and West. The rate of pediatricians in metropolitan areas was more than five times the rate for nonmetropolitan areas, and the metropolitan rate of pediatric subspecialists was nine times the nonmetropolitan rate.

Organizational Capacity: Focus on the Health Care Safety Net

Concern has arisen about the composition and distribution of the health workforce and whether the Nation's health workforce will be able to meet the increasing demand for care that a growing and aging U.S. population will have. In his seminal work on health care quality, Donabedian (1980) describes a robust health care "structure"—the setting or infrastructure supporting the delivery of care (e.g., hospitals, providers)—as necessary to ensure that processes of care contribute to good outcomes. Structural deficiencies in the United States health care delivery system resulting from shortages of providers, growing demand, and a high rate of uninsurance and underinsurance have contributed to unmet need and could result in increased morbidity and health care costs.

Safety net providers play an integral role in relieving unmet needs. As defined in an IOM report, the U.S. health care safety net is composed of "[t]hose providers that organize and deliver a significant level of health care and other health-related services to the uninsured, Medicaid, and other vulnerable populations" (IOM, 2010). Safety net providers act as a default system, or providers "of last resort," by ensuring access to care for millions of Americans lacking medical coverage or provider access, regardless of education, social status, language competency, or ability to pay.

The safety net includes many different types of providers, including public health departments, hospitals, and HSHCs. For the 50 million uninsured people and individuals with low income, safety net providers serve an essential function, eliminating financial barriers to care and enhancing access to services. As workforce shortages escalate, demand for safety net services is likely to increase.

This section includes measures that show how well the health care safety net is meeting the needs of the Nation's vulnerable populations, particularly low-income populations and racial/ethnic subgroups. This section focuses on two types of safety net providers: hospitals and HSHCs.

New! Trauma Center Utilization for Severe Injuries

Trauma remains a considerable cause of mortality and morbidity worldwide, constituting a tangible public health burden with significant associated social and economic cost (Mansoor & DuBose, 2012). Trauma care systems, which were developed because it was recognized that trauma requires complex medical care, include a network of care facilities that provides a range of care for all injured patients. Trauma systems usually have a lead hospital, which should be the highest level available within the system. Levels range from level I to level III, with level I denoting the most clinically sophisticated hospitals.

Level I facilities are required to have a specific number of surgeons and anesthesiologists on duty at all times, as well as education, prevention, and outreach programs. The 24-hour coverage of surgery provides trauma patients with many surgical specialties as well, including neurosurgery, radiology, internal medicine, and critical care.

Level II trauma centers provide initial definitive trauma care regardless of the severity of the injury. When a level II center cannot provide the required care, the patient is transferred to a level I center.

Level III trauma centers are often considered community or rural-based hospitals and provide prompt assessment, resuscitation, emergency operations, and stabilizations and also arrange for transfer to a facility that can provide necessary care.

  Figure 8.6. Trauma center utilization for severe injuries in the United States, by gender and income, 2009

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Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Emergency Department Sample, 2009.

  • In 2009, males were more likely to use level I and II trauma centers than females (Figure 8.6).
  • In 2009, there were no statistically significant differences in the level I and II utilization rates of people living in communities at different income levels.
  • In 2009, people living in communities with income in the second and third quartiles were more likely to use level III trauma centers than residents of communities with the highest income.

Also, in the NHQR:

  • In 2009, level I and II trauma centers located in large fringe metropolitan areas had significantly higher utilization rates than centers in small metropolitan, micropolitan, and nonmetropolitan areas.
  • In 2009, level III trauma centers located in small metropolitan areas were used for severe injuries at 10 times the rate of trauma centers located in large fringe metropolitan areas, 7 times the rate for medium metropolitan areas, and more than twice the rate for micropolitan and nonmetropolitan areas.

Patients Using HRSA Supported Health Centers

HSHCs include health care organizations that receive a grant under Section 330 of the Public Health Service Act, including community health centers, migrant health centers, Health Care for the Homeless programs, and Public Housing Primary Care programs. These organizations typically render services to low-income populations, uninsured people, people with limited English proficiency, migrant and seasonal agricultural workers, individuals and families experiencing homelessness, and public housing residents.

To obtain Federal grant funding, these public and nonprofit organizations agree to provide a minimum set of services, including primary and preventive care, referrals to mental health care, and dental services. Access to care is available to all persons, regardless of ability to pay. Charges for services rendered are based on a sliding scale linked to patients' family income. More than 20 million people visited an HSHC in 2011.

  Figure 8.7. Race, ethnicity, and income of patients receiving care in an HSHC, United States, 2011

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Key: AI/AN: American Indian or Alaska Native.
Source: Health Resources and Services Administration, Bureau of Primary Health Care, Uniform Data System, 2011.
Note: Racial groups shown are non-Hispanic. Data were obtained from 1,128 Section 330 grantee recipients. Income shown only includes known income. Income for nearly 23% of patients is unknown.

  • In 2011, approximately two-thirds (64.8%) of patients seen at an HSHC were White (Hispanics and non-Hispanics), and one-quarter were Black (Figure 8.7).
  • In 2011, 34.5% of HSHC patients were Hispanic and about one-quarter of patients were determined by the HSHC to be best served in a language other than English.
  • For those for whom income is known, almost three-quarters of patients seen in an HSHC in 2011 had income at or below the Federal poverty level but only 7.5% of patients had an income over 200% of the poverty level.

Also, in the NHQR:

  • In 2011, 36.4% of patients seen at an HSHC were uninsured and 39.3% had Medicaid.

Control of Hypertension and Diabetes in HSHC Patients

More than 2.5 million adults treated at an HSHC in 2011 had a hypertension diagnosis, and almost 1.3 million had either type I or type II diabetes. The population with hypertension and diabetes may overlap, so the two numbers should not be added together. Control of hypertension and diabetes can help indicate quality of care at HSHCs since people with these conditions require frequent monitoring.

  Figure 8.8. HSHC patients with hypertension or diabetes whose conditions are controlled, by race, 2011

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Source: Health Resources and Services Administration, Bureau of Primary Health Care, Uniform Data System, 2011.
Note: Racial groups shown are non-Hispanic. Data were obtained from 1,128 Section 330 grantee recipients. Patients with hypertension include those ages 18-85. Hypertension is determined to be controlled if the patient's last blood pressure reading was less than 140/90 mm Hg. Patients with diabetes include those ages 18-75. Diabetes is determined to be controlled if the patient's most recent hemoglobin A1c level was 7% or less.

  • In 2011, 70.8% of Asian, 65.5% of White, 64.8% of Pacific Islander, 64.2% of multiple-race, 60.2% of AI/AN, 60.1% of Native Hawaiian, and 56.7% of Black patients had their hypertension under control (Figure 8.8).
  • Control of diabetes was found to be worse among Pacific Islanders (25.6%) and Native Hawaiians (32.8%) and best among Asians (45.1%).
  • Among Hispanic HSHC patients with hypertension, almost two-thirds had controlled blood pressure; more than one-third of Hispanics with diabetes had their hemoglobin A1c under control (data not shown).

Also, in the NHQR:

  • In 2011, about 63% of HSHC patients with hypertension had controlled blood pressure at the time of their last reading.
  • Almost 40% had their diabetes under control.

Hospital Admissions of Vulnerable Populations

Hospitals continue to play a major role in the health care safety net and, increasingly, safety net hospitals are defined by their low-income population as opposed to control or governance (e.g., public hospitals).ii This section includes one measure suggestive of hospitals' willingness or ability to provide care to low-income populations: hospital inpatient discharges and aggregate cost accounted for by Medicaid and uninsured patients. This measure offers insight into hospitals' contribution to the health care safety net, by selected hospital characteristics. These measures were estimated as follows:

  1. (Number of Medicaid and uninsured discharges ÷ total number of discharges) × 100.
  2. (Total Medicaid and uninsured costs ÷ total costs across all payers) × 100.

As indicated in Figure 8.9, the proportion of inpatient days and discharges provided to these vulnerable groups varied by hospital characteristics.

  Figure 8.9. Medicaid and uninsured discharges, by facility characteristics, U.S. short-term acute hospitals, 2010

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Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, HCUPnet, 2010. Available at http://hcupnet.ahrq.gov/.

  • On average, Medicaid recipients and medically uninsured people accounted for about one in four discharges from acute care hospitals in 2010 (data not shown).
  • The percentage of Medicaid and uninsured patients discharged from government hospitals was significantly higher than from private hospitals (Figure 8.9).
  • Compared with hospitals with 500 or more beds, a smaller percentage of Medicaid or uninsured patients was discharged from hospitals with bed sizes under 300.
  • About 31% of patients discharged from teaching hospitals were uninsured or covered by Medicaid, compared with 24% of patients in nonteaching facilities.
  • Hospitals in the South discharged a greater proportion of Medicaid and uninsured patients (29.1%), while hospitals in the Midwest discharged the lowest percentage of these patients (23.7%).

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i. Available at the National Academies Press Web site at http://www.nap.edu/openbook.php?isbn=030908265X.  
ii. Concerned with the impact of hospital closures on the health care safety net, the Department of Health and Human Services Office for Civil Rights (OCR) has expanded its enforcement efforts to prevent ethnic and racial minority communities from suffering race or national origin discrimination when local hospital facilities close or are relocated. Recently, OCR entered into a voluntary compliance agreement with the University of Pittsburgh Medical Center (UPMC), which agreed to provide additional support for primary and urgent care services in the borough of Braddock, Pennsylvania. UPMC entered into the voluntary agreement with OCR to resolve a complaint alleging that it had violated provisions of Title VI of the Civil Rights Act of 1964, 42 U.S.C. 2000d et seq., when UPMC decided to close Braddock Hospital. Public response to the closure of Braddock Hospital focused on the closure's impact on access to health care for African Americans due to residents' widespread dependence on public transportation. Accordingly, the agreement required UPMC to provide door-to-door transportation services from Braddock to new outpatient facilities and the more distant UPMC McKeesport Hospital, as well as health screening, wellness, and community outreach programs.

Page last reviewed May 2013
Internet Citation: 2012 National Healthcare Disparities Report: Chapter 8. Health Systems Infrastructure. May 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/nhqrdr/nhdr12/chap8.html