Chapter 2. Effectiveness of Care (continued)
National Healthcare Quality Report, 2011
Chronic Kidney Disease
|Total end stage renal disease (ESRD) deaths (2009)||87,812 (USRDS, 2009)|
|Total cases (2007)||514,642 (NCHS, 2011)|
|Number of new cases (2007)||110,996 (USRDS, 2009)|
|Total ESRD Medicare program expenditures (2007)||$23.9 billion (USRDS, 2009)|
The National Healthcare Quality Report (NHQR) and National Healthcare Disparities Report (NHDR) track several measures of management of chronic kidney disease to assess the quality of care provided to renal dialysis patients. A previous core measure, adequacy of dialysis, was retired because it achieved a rate above 95%. Four measures are highlighted here:
- Nephrology care before kidney failure.
- Use of arteriovenous fistula (AVF) at first outpatient dialysis.
- Mortality on dialysis.
- Registration for transplantation.
New! Management: Nephrology Care Before Kidney Failure
Early referral to a nephrologist is important for patients with progressive chronic kidney disease approaching kidney failure. Mindful management during the transition to ESRD permits informed selection of renal replacement therapy, placement and maturation of vascular access, and workup for kidney transplantation. Patients who begin nephrology care more than a year before kidney failure are less likely to begin dialysis with a catheter, experience infections related to vascular access, or die during the months after dialysis initiation (USRDS, 2010).
Figure 2.10. Patients beginning nephrology care more than 12 months before start of dialysis, by age and gender, 2006-2008
Source: National Institute of Diabetes and Digestive and Kidney Diseases, U.S. Renal Data System, 2006-2008.
Denominator: New end stage renal disease patients.
- In 2008, only 28% of new end stage renal disease patients began nephrology care more than 12 months before start of dialysis (Figure 2.10).
- In all years, patients ages 0-19, 45-64, 65-74, and 75 and over were more likely to receive timely nephrology care than patients ages 20-44.
Also, in the NHDR:
- In all years, Blacks and APIs were less likely than Whites and Hispanics were less likely than non-Hispanic Whites to receive timely nephrology care.
Management: Use of Arteriovenous Fistula for Vascular Access
For people with ESRD, dialysis can accommodate for lost kidney function by balancing minerals and water in the blood and removing waste. Vascular access is needed to reach blood vessels so dialysis can be performed. An AVF is the preferred type of access for most hemodialysis patients for three reasons: It provides adequate blood flow for dialysis, it lasts a long time, and it has a low complication rate compared with other methods.
Although there is consensus that AVF should be the primary method of vascular access, AVF utilization has historically been very low. Therefore, the Centers for Medicare & Medicaid Services (CMS) has sought to increase rates of AVF for primary access by forming a nationwide initiative and collaborative effort to increase overall use of AVF. In 2005, the CMS Fistula First Breakthrough Initiative set the goal for national prevalence of AVF at 66%.
Figure 2.11. Incident adult hemodialysis patients who used an arteriovenous fistula at first outpatient dialysis, by age and gender, 2008-2010
Source: Centers for Medicare & Medicaid Services, Fistula First Incident AVF Dataset, 2008-2010.
Denominator: New end stage renal disease hemodialysis patients.
- In 2010, only 15% of dialysis patients used an AVF at first dialysis (Figure 2.11).
- In all years, patients ages 65-74 had higher rates of AVF at first dialysis than those younger than age 65. Female patients had significantly lower rates of AVF at first dialysis than males.
- The 2009 top 5 State achievable benchmark was 27%, far higher than any age or gender group reached.xii No group has attained this benchmark.
Also, in the NHDR:
- In all years, Blacks had lower rates of AVF at first dialysis than Whites, and Hispanics had lower rates than non-Hispanic Whites.
Outcome: Survival on Dialysis
Survival on dialysis may be related in part to the quality of care dialysis providers deliver. This measure compares actual patient survival with expected patient survival based on patients' age, race, sex, diabetes, years on dialysis, and comorbid conditions. Values greater than 1 indicate worse than expected survival; values less than 1 indicate better than expected survival.
Focus on U.S. Territories
Few data sources can assess quality of care received by residents of U.S. territories. Available data suggest that care in U.S. territories is suboptimal (Nunez-Smith, et al., 2011). Data collected by CMS on dialysis facilities are unusual because they include such residents and are valuable for measuring quality received by U.S. citizens residing outside of the United States.
Figure 2.12. Standardized mortality rates on dialysis, by State or territory, 2009
Source: University of Michigan Kidney Epidemiology and Cost Center, 2010 Dialysis Facility Report.
Denominator: End stage renal disease hemodialysis patients age 20 and over.
Note: For this measure, lower rates are better.
- Standardized mortality rates vary widely across U.S. States and territories (Figure 2.12).
- The five jurisdictions with the highest standardized mortality rates are all territories.
Management: Registration for Transplantation
Kidney transplantation is a procedure that replaces a failing kidney with a healthy kidney. Transplantation is not best for all patients. If a patient is deemed a good candidate for transplant, he or she is placed on the transplant program's waiting list. Dialysis patients wait for transplant centers to match them with the most suitable donor. Registration for transplantation is an initial step toward kidney transplantation. Early transplantation that decreases or eliminates the need for dialysis can also lessen the occurrence of acute rejection and patient mortality.
Figure 2.13. Dialysis patients who were registered on a waiting list for transplantation, by age and gender, 2000-2007
Source: National Institute of Diabetes and Digestive and Kidney Diseases, U.S. Renal Data System, 2000-2007.
Denominator: End stage renal disease hemodialysis patients and peritoneal dialysis patients under age 70.
- From 2000 to 2007, the percentage of dialysis patients who were registered on a waiting list for transplantation increased from 15% to 17% (Figure 2.13). Improvements were observed among all age groups except patients ages 20-39 and among both males and females.
- In all years, patients ages 20-69 were less likely than patients ages 0-19 to be registered on a waiting list. Females were less likely than males to be registered on a waiting list.
- The 2006 top 5 State achievable benchmark was 27%.xiii At the current rate of improvement, the benchmark would not be attained overall for almost 23 years. At their current rates of improvement, male patients would not attain the benchmark for about 21 years, whereas female patients could not attain the benchmark for 26 years.
Also, in the NHDR:
- In all years, Blacks and AI/ANs were less likely to be registered on a waiting list than Whites. However, Asians were more likely to be registered on a waiting list than Whites.
|Number of deaths (2007)||70,905 (Kochanek, et al., 2011)|
|Cause of death rank (2010)||7th (NHLBI, 2010)|
|Total number of people with diabetes (2010)||25.8 million (CDC, 2011d)|
|Number of people with diagnosed diabetes (2010)||18.8 million (CDC, 2011d)|
|Number of people with undiagnosed diabetes (2010)||7.0 million (CDC, 2011d)|
|New cases (age 20 and over, 2010)||1.9 million (CDC, 2011d)|
|Total cost (2007)||$174 billion (CDC, 2011d)|
|Direct medical costs (2007)||$116 billion (CDC, 2011d)|
|Indirect costs (2007)||$58 million (CDC, 2011d)|
Routine monitoring of blood glucose levels with hemoglobin A1c (HbA1cxiv ) tests and foot and dilated eye examinations have been shown to help prevent or mitigate complications of diabetes, such as diabetic neuropathy, retinopathy, and vascular and kidney disease. With more than half a million discharges in 2006, diabetes is one of the leading causes of hospitalization in the United States (CDC, 2009). However, with appropriate and timely ambulatory care, it may be possible to prevent many hospitalizations for diabetes and related complications.
The measures reported in this section examine the extent to which individuals with diabetes receive care needed to prevent complications and the development of kidney failure, a serious complication of diabetes:
- Receipt of four recommended diabetes services.
- Hospitalization for short-term diabetes complications.
- Development of kidney failure due to diabetes.
New! Management: Receipt of Four Recommended Diabetes Services
A composite measure is used to track the national rate of receipt of four recommended annual diabetes interventions: at least two HbA1c tests, a foot examination, an eye examination, and a flu shot. These are basic process measures that provide an assessment of the quality of diabetes management. This diabetes composite measure differs from the composite presented last year. To be more consistent with current recommendations, the required frequency of HbA1c testing has been increased to two per year and receipt of a flu shot has been added.
Figure 2.14. Adults age 40 and over with diagnosed diabetes who reported receiving four recommended services for diabetes in the calendar year (2+ hemoglobin A1c tests, foot exam, dilated eye exam, and flu shot), by age, 2008
Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2008.
Denominator: Civilian noninstitutionalized population with diagnosed diabetes, age 40 and over.
Note: Data include people with both type 1 and type 2 diabetes. Rates are age adjusted to the 2000 U.S. standard population.
- Among adults age 40 and over with diagnosed diabetes, report of receipt of recommended services ranged from 50% to 76%. However, only 21% of adults with diabetes received all four recommended services in 2008 (Figure 2.14).
- Adults with diabetes ages 40-59 were less likely than those age 60 and over to receive a foot examination, an eye examination, and a flu shot as well as the composite of four recommended services.
Also, in the NHDR:
- Among adults with diabetes, Hispanics were less likely than non-Hispanic Whites to receive at least two HbA1c tests, a foot examination, and an eye examination while non-Hispanic Blacks were less likely than non-Hispanic Whites to receive a flu shot.
- There were no statistically significant differences between groups in rates of receipt of all four recommended services.
Outcome: Admissions for Short-Term Diabetes Complications
Individuals who do not achieve good control of their diabetes are more prone to short-term complications that can reduce quality of life, increase chances of death, and increase health care costs both directly and indirectly. The acute metabolic complications of diabetes typically require hospitalization for treatment and include diabetic ketoacidosis and hyperosmolar nonketotic coma.
Figure 2.15. Hospital admissions for diabetes with short-term complications per 100,000 population age 18 and over, by age and residence location, 2004-2008
Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample and AHRQ Quality Indicators, version 4.1, 2004-2008.
Denominator: U.S. resident population age 18 and over.
Note: For this measure, lower rates are better. Short-term complications include ketoacidosis, hyperosmolarity, or coma and exclude obstetric admissions and transfers from other institutions. Data are adjusted for age and gender. Rates by age are not age adjusted.
- Between 2004 and 2008, the overall rate of admission for adults with short-term complications of diabetes increased from 55 to 61 per 100,000 population (Figure 2.15). Among patients age 65 and over, the admission rate for short-term complications of diabetes fell. Increases were observed among all other age groups and among residents of large central and large fringe MSAs.
- In all years, adults ages 45-64 and age 65 and over had lower rates than adults ages 18-44. Residents of micropolitan areas had higher rates of admission for short-term complications of diabetes than residents of large fringe MSAs. In 3 of 4 years, residents of large central metropolitan areas had higher rates than residents of large fringe MSAs.
- The 2008 top 4 State achievable benchmark was 38 per 100,000 population.xv Patients age 65 and over achieved this benchmark. All other age and residence location groups were moving away from this benchmark.
Also, in the NHDR:
- In all years, the rate of hospital admissions for short-term complications was significantly higher for Blacks and lower for APIs compared with Whites.
- Hispanics had higher rates than Whites between 2001 and 2006, but this difference was not statistically significant in 2007 and 2008.
- In all years, the rate of hospital admissions for short-term complications was significantly higher for adults living in communities with median household incomes in the lowest, second, and third quartile than for people living in communities with median household incomes in the highest quartile.
New! Outcome: End Stage Renal Disease Due to Diabetes
Diabetes is the most common cause of kidney failure. Keeping blood sugar levels under control can prevent or slow the progression of kidney disease due to diabetes. In addition, when kidney disease is detected early, medication can slow the disease's progress. If it is detected late, progression to ESRD requiring dialysis is common. While some cases of kidney failure due to diabetes cannot be avoided, other cases reflect inadequate control of blood sugar or delayed detection and treatment of early kidney disease due to diabetes.
Figure 2.16. End stage renal disease due to diabetes per million population, by age and gender, 2000-2008
Source: National Institute of Diabetes and Digestive and Kidney Diseases, U.S. Renal Data System, 2000-2008.
Denominator: U.S. resident population.
Note: For this measure, lower rates are better. Rates are age adjusted.
- Between 2000 and 2008, the overall incidence of ESRD due to diabetes did not change (Figure 2.16). The rate increased among people ages 20-44 and age 75 and over. It also increased among males and fell among females.
- In all years, people ages 45-64, 65-74, and 75 and over had higher rates than people ages 20-44. Males had higher rates than females.
Also, in the NHDR:
- In all years, Hispanics had higher rates of ESRD due to diabetes than non-Hispanic Whites. AI/ANs, APIs, and Blacks had higher rates than Whites.
HIV and AIDS
|Number of deaths of people with AIDS (2008)||16,605 (CDC, 2011a)|
|Number of people living with HIV infection (2008)||682,668 (CDC, 2011a)|
|Number of people living with AIDS (2008)||490,696 (CDC, 2011a)|
|Number of new HIV diagnoses (2009)||42,959 (CDC, 2011a)|
|Number of new AIDS diagnoses (2009)||34,993 (CDC, 2011a)|
|Federal spending on HIV/AIDS care, cash and housing assistance, prevention, and research (fiscal year 2012 est.)||.$21.4 billion (KFF, 2011)|
HIV is a virus that kills or damages cells of the body's immune system. AIDS is the most advanced stage of HIV infection. HIV can be spread through unprotected sex with an infected person, sharing of drug needles, or contact with the blood of an infected person. In addition, women with HIV can give it to their babies during pregnancy, childbirth, or breastfeeding.
The impact of HIV infection and AIDS is disproportionately higher for racial and ethnic minorities and people of lower income and education levels. Although access to care has improved, research shows that Blacks, Hispanics, women, and uninsured people with HIV remain less likely to have access to care and less likely to have optimal patterns of care (Shapiro, et al., 1999).
The spread of HIV is linked to complex social and economic factors, including poverty, concentration of the virus in specific geographic areas and smaller sexual networks, sexually transmitted co-infections, stigma (negative attitudes, beliefs, and actions directed at people living with HIV/AIDS or directed at people who engage in behaviors that might put them at risk for HIV), and injection and noninjection drug use and associated behaviors (CDC, 2010).
According to the Centers for Disease Control and Prevention (CDC), HIV and AIDS disproportionately affects Blacks in the United States. In 2009, Blacks represented 14% of the U.S. population but accounted for 44% of all diagnoses of new HIV infections (2011c). The HIV/AIDS epidemic is also a serious threat to the Hispanic community. About 20% of new HIV infections occurred among Hispanics in 2009, which is three times the rate of Whites (CDC, 2011b). In addition to being seriously affected by HIV, Hispanics continue to face challenges in accessing health care, especially preventive services, and HIV treatment.
Undocumented immigrants face an even greater challenge in accessing care and information regarding HIV and AIDS, but data are limited on HIV infection rates of undocumented immigrants (Carrillo & DeCarlo, 2003). In 2006, HIV/AIDS was the fourth leading cause of death among Hispanic men and women ages 35-44 (CDC, 2011b). Having Medicaid and a usual source of care decreased the likelihood of delaying care for HIV, but research shows that delay in care is still greater for Hispanics and Blacks (Turner, et al., 2000).
Another group that is severely affected by HIV includes gay, bisexual, and other men who have sex with men (MSM). MSM represent 2% of the U.S. population and is the only risk group in which new HIV infections have been gradually increasing since the 1990s. MSM have constantly represented the largest percentage of people diagnosed with AIDS and people with an AIDS diagnosis who have died. In 2009, MSM accounted for more than half (61%) of all new HIV infections in the United States (CDC, 2011d).
The White House Office of National AIDS Policy launched the National HIV/AIDS Strategy (NHAS) in July 2010. The NHAS is a comprehensive plan focused on: (1) reducing the number of people who become infected with HIV, (2) increasing access to care and optimizing health outcomes for people living with HIV, and (3) reducing HIV-related health disparities. The plan will serve as a roadmap for policymakers, partners in prevention, and the public on steps the United States must take to lower HIV incidence, get people living with HIV into care, and reduce HIV-related health disparities.
This year, a measure is presented on HIV testing, and five supporting measures are presented on the prevention of opportunistic infections in HIV and AIDS patients:
- Adult HIV patients who had at least two outpatient visits during the year.
- Adult HIV patients who received two or more CD4 tests during the year.
- Adult HIV patients who received highly active antiretroviral therapy (HAART).
- Eligible AIDS patients receiving prophylaxis for Pneumocystis pneumonia (PCP).
- Eligible AIDS patients receiving prophylaxis for Mycobacterium avium complex (MAC).
In addition, a measure is included on HIV infection deaths.
New! Prevention: HIV Testing
According to CDC, approximately 20 percent of the 1.2 million people living with HIV are unaware of their infection (CDC, 2011d). CDC recommends routine voluntary HIV testing as part of normal medical practice in all health care settings (Branson, et al., 2006). HIV infection is a serious health disorder that can be diagnosed before symptoms develop. HIV can be detected by reliable, inexpensive, and noninvasive screening tests. Although blood donations are routinely tested for HIV, it is important to track HIV testing in a health care setting to determine the impact of preventive care for the population. HIV-infected patients have years to gain if treatment is initiated early, before symptoms develop.
To normalize HIV testing as a routine part of medical care, in September 2006, CDC published revised recommendations that all patients ages 13-64 be tested on a voluntary basis. The revised recommendations also expanded the existing recommendations for screening pregnant women (Branson, et al., 2006).
Figure 2.17. Population ages 15-44 years who ever had an HIV test outside of blood donation, by age and gender, 2006-2010
Source: Special tabulations based on National Survey of Family Growth, 2006-2010, conducted by the National Center for Health Statistics.
- Overall, in the period between 2006 and 2010, 50% of people ages 15-44 had ever been tested for HIV outside of blood donation (data not shown).
- In the period between 2006 and 2010, HIV testing outside of blood donation was reported most often among people ages 35-39 (65%) and least often among those ages 15-19 (16%) (Figure 2.17).
- In the period between 2006 and 2010, females (59%) reported more HIV testing outside of blood donation than males (42%).
Also, in the NHDR:
- In the period between 2006 and 2010, the percentage of people ages 15-44 who had been tested for HIV outside of blood donation was higher for non-Hispanic Blacks (68%) than for non-Hispanic Whites (48%).
- In the period between 2006 and 2010, there were no statistically significant differences by educational attainment in the percentage of people ages 20-44 who were tested for HIV outside of blood donation.
Figure 2.18. Percentage of women ages 15-44 years with a completed pregnancy within the past 12 months who were tested for HIV as part of prenatal care, United States, by age, 2006-2010
Source: Special tabulations based on National Survey of Family Growth, 2006-2010, conducted by the National Center for Health Statistics.
- Overall, in the period between 2006 and 2010, 67% of women with a recently completed pregnancy ages 15-44 had an HIV test as part of prenatal care (Figure 2.18).
- In the period between 2006 and 2010, there were no statistically significant differences between age groups in the percentage of women with a recently completed pregnancy who had an HIV test as part of prenatal care.
Also in the NHDR:
- In the period between 2006 and 2010, roughly 75% of recently pregnant Hispanic and non-Hispanic Black women had prenatal HIV testing, compared with 64% of recently pregnant non-Hispanic White women.
- In the period between 2006 and 2010, 75% of recently pregnant women with less than a high school education had prenatal HIV testing, compared with 63% of those with any college.
Management: HIV Patients Receiving Care
Management of chronic HIV disease includes outpatient and inpatient services. Without adequate treatment, as HIV disease progresses, CD4 cell counts fall and patients become increasingly susceptible to opportunistic infections.
HIV/AIDS core clinical performance measures are indicators used to monitor the quality of care provided to adults and adolescents living with HIV. Based on the set of quality measures developed by the HIV/AIDS Bureau of the Health Resources and Services Administration (HRSA), performance can be measured for various HIV prevention and treatment services. Services needed by patients with HIV include:
- Two or more CD4 T-cell counts performed in the measurement year.
- HAART for patients with AIDS.
- Two or more medical visits in an HIV care setting in the measurement year.
- PCP prophylaxis for patients with CD4 T-cell count below 200.
Currently, national data on HIV care are not routinely collected. HIV measures tracked in the NHQR and NHDR are from the HIV Research Network, which consists of 18 medical practices across the United States that treat large numbers of patients living with HIV. Data from the voluntary HIV Research Network are not nationally representative of the level of care received by everyone in the United States living with HIV.
HIV Network data represent only patients with HIV who are actually receiving care (about 14,000 HIV patients per year) and do not represent patients who do not receive care. Furthermore, data shown below are not representative of the HIV Research Network as a whole because they represent only a subset of network sites that have the best data.
Below are data from the HIV Research Network that capture four of the HRSA quality measures. In addition, when CD4 cell counts fall below 50, medicine to prevent development of disseminated MAC infection is routinely recommended, and we track this measure as well (Yeargin, et al., 2003).
Figure 2.19. Adults with HIV who received recommended care, by age, 2008
Key: HAART = highly active antriretroviral therapy; PCP = Pneumocystis pneumonia; MAC = Mycobacterium avium complex.
Source: Agency for Healthcare Research and Quality, HIV Research Network, 2008.
Note: For HAART measure, adult HIV patients had to be enrolled in an HIV Network clinic, receive at least one CD4 test, and have at least one outpatient visit in addition to having at least one CD4 test result of 350 or less.
- Overall, in 2008, nearly 90% of people with HIV had two or more outpatient visits during the year, and 83% of people with HIV had two or more CD4 tests during the year (Figure 2.19). In addition, 89% of people with HIV in care received HAART, 95% of people with HIV with CD4 count less than 200 received PCP prophylaxis, and 90% of people with HIV with CD4 count less than 50 received MAC prophylaxis.
- In 2008, there were no statistically significant differences by age observed for the recommended HIV services.
Also, in the NHDR:
- In 2008, there were no statistically significant differences by ethnicity or gender observed for the recommended HIV services.
- In 2008, the rates for patients with HIV who had two or more CD4 tests during the year were lower than the rates for all other recommended services for HIV care, at approximately 83% for both males and females.
Outcome: Deaths of People With HIV Infection
Improved management of HIV infection has contributed to declines in the number of new AIDS cases in the United States since the 1990s (CDC, 2005). HIV infection deaths reflect a number of factors, including underlying rates of HIV risk behaviors, prevention of HIV transmission, early detection and treatment of HIV disease, and management of AIDS and its complications.
Figure 2.20. HIV infection deaths per 100,000 population, by age and gender, 2004-2007
Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System—Mortality, 2004-2007.
Denominator: U.S. population.
Note: For this measure, lower rates are better. Rates are age adjusted to 2000 U.S. standard population. Age data are unadjusted. Respondents for which age is not reported are not included in the age adjustment calculations and are excluded from numerators.
- Overall, from 2004 to 2007, the total rate of HIV infection deaths decreased from nearly 5 per 100,000 population to about 4 per 100,000 population (Figure 2.20).
- From 2004 to 2007, the rate of HIV infection deaths decreased for adults ages 18-44 (from 6 to 4 deaths per 100,000 population) and 45-64 (from 9 to 8 deaths per 100,000 population).
- From 2004 to 2007, males were more likely to have higher HIV death rates compared with women.
Also, in the NHDR:
- In 2007, the rate of HIV infection deaths was higher for non-Hispanic Black males (25 deaths per 100,000 population) and Hispanic males (6 deaths per 100,000 population) compared with non-Hispanic White males (3 deaths per 100,000 population).
- In 2007, non-Hispanic Black females (12 deaths per 100,000 population) and Hispanic females (2 deaths per 100,000 population) had higher HIV infection death rates than non-Hispanic White females (1 death per 100,000 population).
- In 2007, non-Hispanic Blacks had higher HIV death rates than non-Hispanic Whites for all age groups.
xii. The top 5 States that contributed to the achievable benchmark are Hawaii, Maine, Montana, New Hampshire, and Oregon.
xiii. The top 5 States that contributed to the achievable benchmark are California, Minnesota, New Hampshire, Pennsylvania, and South Dakota.
xiv. HbA1c, or glycosylated hemoglobin, is a measure of average levels of glucose in the blood.
xv. The top 4 States contributing to the achievable benchmark are Hawaii, Minnesota, Nebraska, and Utah.