Chapter 2. Effectiveness

Contents

Cancer
Diabetes
End Stage Renal Disease (ESRD)
Heart Disease
HIV and AIDS
Maternal and Child Health
Mental Health and Substance Abuse
Respiratory Diseases
Lifestyle Modification
Functional Status Preservation and Rehabilitation
Supportive and Palliative Care

As better understanding of health and sickness has led to superior ways of preventing, diagnosing, and treating diseases, the health of most Americans has improved dramatically. However, ample evidence indicates that some Americans do not receive the full benefits of high-quality care. As noted in Chapter 1, Introduction and Methods, this year's findings include an assessment of the effects of health insurance on quality of care.

When possible, findings in this chapter show measures of effectiveness of care for individuals with different types of insurance. For those under age 65, individuals with any private insurance, public insurance only, and no insurance are typically compared. For those age 65 and over, individuals with Medicare and private insurance, Medicare and other public insurance, and Medicare only are typically compared. Differences in care according to insurance status may reflect the direct impact of insurance coverage on access to and quality of services. But other factors may play a part, such as differences in personal decisions, social norms, and communication styles across groups with differing levels of insurance.

In addition, this year's sections on effectiveness of care have been reorganized. This chapter is organized around eight clinical areas (cancer, diabetes, end stage renal disease, heart disease, HIV and AIDS, maternal and child health, mental health and substance abuse, and respiratory diseases) and three types of health care services that typically cut across clinical conditions (lifestyle modification, functional status preservation and rehabilitation, and supportive and palliative care). The 11 sections of this chapter highlight a small number of core measures.

In this chapter, process measures are organized into several categories related to the patient's need for preventive care, treatment of acute illness, and chronic disease management. These are derived from the original Institute of Medicine categories: staying healthy, getting better, living with illness or disability, and coping with the end of life. There is sizable overlap among these categories, and some measures may be considered to belong in more than one category. Outcome measures are organized separately because prevention, treatment, and management can all play important roles in affecting outcomes.

Prevention

Caring for healthy people is an important component of health care. Educating people about health and promoting healthy behaviors can help postpone or avoid illness and disease. In addition, detecting health problems at an early stage increases the chances of effectively treating them, often reducing suffering and costs.

Treatment

Even when preventive care is ideally implemented, it cannot entirely avert the need for acute care. Delivering optimal treatments for acute illness can help reduce the consequences of illness and promote the best recovery possible.

Management

Some diseases, such as diabetes and end stage renal disease, are chronic, which means they cannot simply be treated once; they must be managed across a lifetime. Management of chronic disease often involves promotion and maintenance of lifestyle changes and regular contact with a provider to monitor the status of the disease. For patients, effective management of chronic diseases can mean the difference between normal, healthy living and frequent medical problems.

Outcomes

Many factors other than health care influence health outcomes, including a person's genes, lifestyle, and social and physical environment. However, for many individuals, appropriate preventive services, timely treatment of acute illness and injury, and meticulous management of chronic disease can positively affect mortality, morbidity, and quality of life.

The measures highlighted in this chapter are categorized as follows:

* Noncore measure.  

Cancer

Importance

Measures

Evidence-based consensus defining good quality care and how to measure it currently exists for only a few cancers and a few aspects of care. Breast and colorectal cancers have high incidence rates and are highlighted in alternate years of the report. The 2008 National Healthcare Quality Report (NHQR) highlighted colorectal cancer; this year's focus is on breast cancer. The core report measures are:

• Breast cancer screening (mammography).
• Breast cancer first diagnosed at advanced stage.
• Breast cancer deaths.

As in previous reports, the 2009 NHQR includes two noncore measures for breast cancer care from the National Cancer Data Base that have been endorsed by the National Quality Forum:

• Women with clinical Stage I-IIb breast cancer who received either axillary node dissection or sentinel lymph node biopsy at the time of surgery.
• Women under age 70 treated with breast-conserving surgery who received radiation therapy within 1 year of diagnosis.

Findings

Prevention: Breast Cancer Screening (Mammography)

Early detection of cancer increases treatment options and often improves outcomes. Mammography, the most effective method for detecting breast cancer at its early stages,⁶ can identify malignancies before they can be felt and before symptoms develop. For available data years, the U.S. Preventive Services Task Force recommended mammograms every 1 to 2 years for women age 40 and over.⁷

Figure 2.1. Women age 40 and over who reported they had a mammogram within the past 2 years, by insurance status, 2000, 2003, and 2005

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2000, 2003, and 2005.
Denominator: Civilian noninstitutionalized women age 40 and over.
Note: Insurance-specific rates are age adjusted to the 2000 U.S. standard population.

• The percentage of women ages 40-64 who reported they had a mammogram in the past 2 years decreased from 71.5% in 2000 to 67.9% in 2005 (Figure 2.1).
• The percentage of women ages 40-64 with public insurance only who had a mammogram decreased from 64.7% in 2000 to 57.9% in 2005, while rates did not change significantly for privately insured or uninsured women.
• In all 3 years, uninsured women and women with public insurance only ages 40-64 were less likely to have a mammogram than privately insured women.
• The percentage of women age 65 and over who reported they had a mammogram in the past 2 years decreased from 67.9% in 2000 to 63.8% in 2005.
• In all 3 years, women with Medicare and public insurance and women with Medicare only were less likely to have a mammogram than women with Medicare and private supplemental insurance.ⁱⁱⁱ
• The percentage of women age 65 and over with Medicare and private supplemental insurance who had a mammogram decreased from 71.7% in 2000 to 67.4% in 2005, while rates did not change significantly for women with Medicare and public insurance or Medicare only.

Figure 2.2. State variation: Women age 40 and over who reported they had a mammogram within the past 2 years, 2006

Key: Best quartile indicates States with highest rates of mammography; worst quartile indicates States with lowest rates.
Source: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System, 2006.

• Twelve States^iv and the District of Columbia were in the best quartile (highest rates of mammography) in 2006 and had rates that ranged from 79.0% to 84.8%. All New England States are included in this quartile (Figure 2.2).
• The 12 States^v in the worst quartile (lowest rates) in 2006 had rates of mammography that ranged from 66.7% to 71.4%. These States are primarily located in the West South Central and Mountain areas.

Outcome: Advanced Stage Breast Cancer

Cancers can be diagnosed at different stages of development. Cancers diagnosed early before spread has occurred are generally more amenable to treatment and cure; cancers diagnosed late with extensive spread often have poor prognoses. The rate of cancer cases that are diagnosed at late or advanced stages is a measure of the effectiveness of cancer screening efforts and of adherence to followup care after a positive screening test. Because many cancers often take years to develop, changes in rates of late-stage cancer may lag behind changes in rates of screening.

Figure 2.3. Age-adjusted rate of advanced stage breast cancer per 100,000 women age 40 and over, by age, 2000-2006

Source: National Cancer Institute, Surveillance, Epidemiology, and End Results Program, 2000-2006.
Denominator: Women age 40 and over.
Note: Age adjusted to the 2000 U.S. standard population. Advanced stage breast cancer is defined as local stage with tumor size greater than 2 cm diameter, regional stage, or distant stage.

• Between 2000 and 2006, the overall rate of advanced stage breast cancer in women age 40 and over decreased from 104.3 to 92.9 per 100,000 women (Figure 2.3).
• From 2000 to 2006, the rate of advanced stage breast cancer in women ages 40-64 decreased from 90.8 to 80.6 per 100,000 women. During the same period, women age 65 and over also saw a decrease, from 136.8 to 122.5 per 100,000 women. These decreases may reflect improvements in mammography rates during the 1990s.
• In all years, women age 65 and over had higher rates of advanced stage breast cancer than women ages 40-64.

Treatment: Receipt of Recommended Care for Breast Cancer

Different diagnostic and treatment options exist for various types of cancer. Some aspects of cancer care are well established as beneficial and are commonly recommended. The appropriateness of recommended care depends on different factors, such as the stage or the extent of the cancer within the body (especially whether the disease has spread from the original site to other parts of the body). Other types of care are important for accurate diagnosis, such as ensuring adequate examination of lymph nodes when surgery is performed.

Figure 2.4. Women with clinical Stage I-IIb breast cancer who received axillary node dissection or sentinel lymph node biopsy at the time of surgery (lumpectomy or mastectomy), by insurance status, 2000-2006

Source: Commission on Cancer, American College of Surgeons and American Cancer Society, National Cancer Data Base, 2000-2006.
Denominator: U.S. population, women with Stage I-IIb breast cancer.

• The percentage of women under age 65 with clinical Stage I-IIb breast cancer who received axillary node dissection or sentinel lymph node biopsy at the time of surgery (lumpectomy or mastectomy) increased from 78.0% in 2000 to 87.8% in 2006 (Figure 2.4). Improvement was observed among all insurance groups.
• In all years, women under age 65 with public health insurance only were less likely than those with private insurance to receive axillary node dissection or sentinel lymph node biopsy.
• Between 2000 and 2006, the percentage of women age 65 and over who received axillary node dissection or sentinel lymph node biopsy increased from 66.4% to 80.8%. Improvement was observed among both women with Medicare and supplemental insurance and women with Medicare only.
• In all years, women age 65 and over with Medicare only and with Medicare and supplemental insurance had similar rates of axillary node dissection or sentinel lymph node biopsy.

Figure 2.5. Women under age 70 treated for breast cancer with breast-conserving surgery who received radiation therapy to the breast within 1 year of diagnosis, by insurance status, 2000-2006

Source: Commission on Cancer, American College of Surgeons and American Cancer Society, National Cancer Data Base, 2000-2006.
Denominator: U.S. population, women under age 70 treated for breast cancer (American Joint Committee on Cancer Stage I, II, or III primary invasive epithelial breast cancer) with breast-conserving surgery.

• Between 2000 and 2006, the percentage of women under age 65 treated for breast cancer with breast-conserving surgery who received radiation therapy to the breast within 1 year of diagnosis remained stable with no statistically significant changes (Figure 2.5).
• In 2006, uninsured women under age 65 were less likely than women with private insurance to receive radiation therapy following breast-conserving surgery.
• Between 2000 and 2006, the percentage of women ages 65-69 treated for breast cancer with breast-conserving surgery who received radiation therapy to the breast within 1 year of diagnosis remained stable with no statistically significant changes.
• In all years, women ages 65-69 with Medicare only were less likely than those with Medicare and supplemental insurance to receive radiation therapy.

Outcome: Breast Cancer Deaths

The death rate from a disease is a function of many factors, including the causes of the disease; social forces; and the effectiveness of the health care system in providing prevention, treatment, and management of the disease. Breast cancer deaths reflect the impact of breast cancer screening, diagnosis, and treatment. Mortality is measured as the number of deaths per 100,000 women. Declines in breast cancer deaths can be attributed, in part, to improvements in early detection and treatment.

Figure 2.6. Age-adjusted breast cancer deaths per 100,000 women, by age, 2000-2006

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System-Mortality, 2000-2006.
Denominator: U.S. population, women.
Note: Total rate is age adjusted to the 2000 U.S. standard population.

• Between 2000 and 2006, the rate of breast cancer deaths decreased from 26.8 to 23.5 per 100,000 women (Figure 2.6).
• At 23.5 deaths per 100,000 women, the overall breast cancer death rate in 2006 was higher than the Healthy People 2010 target of 21.3. At the present rate of change, this target could be met by 2010.
• From 2000 to 2006, the rate of breast cancer deaths decreased significantly for all age groups.
• For all data years, women age 65 and over were more likely to die from breast cancer than those under age 65. 

Diabetes

Importance

Measures

Effective management of diabetes includes appropriate receipt of recommended processes, such as hemoglobin A1c (HbA1c)^vi tests, eye examinations, and foot examinations. Effective management also promotes outcomes expected to correlate positively with these processes, such as control of cholesterol, blood pressure, and HbA1c levels.

The core report measure highlighted in this section is:

• Receipt of three recommended diabetes services.

In addition, three noncore measures are presented:

• Control of HbA1c, cholesterol, and blood pressure.

Findings

Management: Receipt of Three Recommended Diabetes Services

The NHQR uses a composite measure to track the national rate of the receipt of all three recommended annual diabetes interventions: an HbA1c test, an eye examination, and a foot examination. These are basic process measures that provide an assessment of the quality of diabetes management.

Figure 2.7. Composite measure: Adults age 40 and over with diagnosed diabetes who received three recommended services for diabetes in the calendar year (hemoglobin A1c measurement, dilated eye examination, and foot examination), by insurance status, 2002-2006

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2006.
Denominator: Civilian noninstitutionalized population with diagnosed diabetes, age 40 and over.
Note: Data include people with both type 1 and type 2 diabetes.

• Between 2002 and 2006, the percentages of adults ages 40-64 and age 65 and over with diagnosed diabetes who received three recommended services for diabetes did not change significantly overall or for any insurance group (Figure 2.7).
• In 3 of 5 years, adults ages 40-64 with public insurance were significantly less likely than those with private insurance to receive recommended services. In 2 of 5 years, adults age 65 and over with Medicare and other public insurance were significantly less likely than those with Medicare and private insurance to receive recommended services. There were no statistically significant differences between insurance groups in 2006.

Management and Outcome: Receipt of HbA1c Measurement and Admissions for Short-Term Diabetes Complications

This year, the NHQR introduces a new type of State variation map. Rather than focus on a single process or outcome measure, these maps seek to identify States that perform poorly on both a process measure and a related outcome measure. These maps do not imply causality; improvements in processes of care typically affect outcomes many years in the future. Rather, these maps are intended to help identify those States that may have the greatest opportunity to improve performance in this area.

For diabetes, HbA1c measurement is critical for guiding treatment and achieving good control of glucose. Individuals who do not achieve good control are more prone to develop diabetic ketoacidosis and other short-term complications requiring hospitalization.

Figure 2.8. State variation: Adults age 40 and over with diagnosed diabetes who received a hemoglobin A1c measurement (2006) and admissions for diabetes with short-term complications per 100,000 population age 18 and over (2006)

Key: Process measure in worst quartile indicates States with the lowest rates of HbA1c measurement; outcome measure in worst quartile indicates States with the highest rates of admission for short-term complications of diabetes.

Source: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System, 2006 (HbA1c measurement); Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, 2006 (admissions for diabetes with short-term complications).

• The 11 States^vii in the worst quartile (lowest rate) in 2006 for patients with diagnosed diabetes who received an HbA1c measurement had rates that ranged from 70.6% to 79.9% (Figure 2.8).
• The 10 States^viii in the worst quartile (highest rate) in 2006 for admissions for diabetes with short-term complications had admission rates that ranged from 66.7 to 85.1 per 100,000 population age 18 and over.
• Four States^ix were in the worst quartile for both measures in 2006 with both low rates of HbA1c measurement among patients with diagnosed diabetes and high rates of admissions for diabetes with short-term complications.

Outcome: Controlled Hemoglobin, Cholesterol, and Blood Pressure

People diagnosed with diabetes are often at higher risk for other cardiovascular risk factors, such as high blood pressure and high cholesterol. Having these conditions in combination with diagnosed diabetes increases the likelihood of complications, such as heart and kidney diseases, blindness, nerve damage, and stroke. Patients who manage their diagnosed diabetes and maintain an HbA1c level of <7%, total cholesterol of <200 mg/dL, and blood pressure of <140/80 mm Hg^x can decrease these risks.

Figure 2.9. Adults age 40 and over with diagnosed diabetes with hemoglobin A1c, total cholesterol, and blood pressure under control, by age, 2003-2006

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health and Nutrition Examination Survey, 2003-2006.
Denominator: Civilian noninstitutionalized population with diagnosed diabetes, age 40 and over.
Note: Age adjusted to the 2000 U.S. standard population. Survey respondents were classified as having diabetes only if they had a previous diagnosis of diabetes from a doctor other than during a period of pregnancy (i.e., gestational diabetes was excluded). This is determined by a "Yes" response to the question: "Other than during pregnancy, have you ever been told by a doctor or health professional that you have diabetes or sugar diabetes?"

• In 2003-2006, only 54.6% of adults age 40 and over diagnosed with diabetes had their HbA1c level under optimal control (<7%) (Figure 2.9). Only 54.9% had total cholesterol <200, and only 58.5% had blood pressure <140/80.
• In 2003-2006, adults age 60 and over were more likely to have their HbA1c levels under optimal control compared with adults ages 40-59.
• In 2003-2006, adults age 60 and over were more likely to have cholesterol levels <200 mg/dL compared with adults ages 40-59.

ⁱ Throughout this report, total cost equals cost of medical care (direct cost) and economic costs of morbidity and mortality (indirect cost). Direct costs are defined as "personal health care expenditures for hospital and nursing home care, drugs, home care, and physician and other professional services."^4
ii Cost-effectiveness is measured here by the average net cost of each quality-adjusted life year (QALY) that is saved by the provision of a particular health intervention. QALYs are a measure of survival adjusted for its value: 1 year in perfect health is equal to 1.0 QALY, while a year in poor health would be something less than 1.0. A lower cost per QALY saved indicates a greater degree of cost-effectiveness.
ⁱⁱⁱ Medicare does not cover all health care costs. Medicare beneficiaries can purchase supplemental insurance from private insurance companies to help pay for coinsurance, copayments, deductibles, and noncovered services. Low-income beneficiaries may receive assistance from Medicaid and other public insurance programs to help pay for costs not covered by Medicare. Beneficiaries with Medicare typically pay out of pocket for costs related to premiums, deductibles, coinsurance, copayments, and noncovered services.
^iv The States are Connecticut, Delaware, Maine, Maryland, Massachusetts, Michigan, Minnesota, New Hampshire, New York, Rhode Island, Tennessee, and Vermont.
^v The States are Arkansas, Idaho, Indiana, Mississippi, Missouri, Montana, Nevada, New Mexico, Oklahoma, Texas, Utah, and Wyoming.
^vi HbA1c, or glycosylated hemoglobin, is a measure of average levels of glucose in the blood.
^vii The States are Alaska, California, Florida, Louisiana, Mississippi, Nevada, New Mexico, Ohio, Oklahoma, South Carolina, and Texas. Data on this measure were not available for Connecticut, District of Columbia, Illinois, Kansas, Maryland, Massachusetts, Nebraska, Puerto Rico, Rhode Island, and Wisconsin.
^viii The States are Arkansas, Georgia, Kentucky, Nevada, North Carolina, Ohio, Oklahoma, South Carolina, Tennessee, and West Virginia. Data on this measure were not available for Alabama, Alaska, Delaware, District of Columbia, Idaho, Louisiana, Mississippi, Montana, New Mexico, North Dakota, Pennsylvania, Puerto Rico, and Wyoming.
^ix The States are Nevada, Ohio, Oklahoma, and South Carolina.
^x Blood pressure control guidelines were updated in 2005. Previously, having a blood pressure reading of <140/90 mm Hg was considered under control. For this measure, the new threshold of <140/80 mm Hg has been applied to historic data for the sake of consistency and comparability.

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