Chapter 2. Effectiveness of Care (continued, 2)

National Healthcare Quality Report, 2011

Maternal and Child Health

Importance

Mortality
Number of maternal deaths (2007)548 (Xu, et al., 2010)
Number of infant deaths (2009)29,138 (Xu, et al., 2010)
Demographics
Number of childrenxvi (2009)74,225,447 (U.S. Census Bureau, 2009)
Number of babies born in United States (2009)4,130,665 (Martin, et al., 2011)
Cost
Total cost of health care for children (2007)$102.4 billion (MEPS, 2007)
Cost-effectiveness of vision screening for children$0-$14,000/QALY (Maciosek, et al., 2006)
Cost-effectiveness of childhood immunization series (2001)approx $16 (Zhou, et al., 2005)

Measures

The NHQR and NHDR track several prevention, treatment, and outcome measures related to maternal and child health care. The measures highlighted in this section are:

  • Obstetric trauma.
  • Recommended immunizations for young children.
  • Emergency department visits for asthma.
  • Dental visits.
  • Untreated dental caries.

In addition, this year we include a focus on health care for adolescents. Measures for adolescents include:

  • Well visit in the last year.
  • Receipt of meningococcal vaccine.
  • Chlamydia testing among adolescent females.

Findings

New! Outcome: Obstetric Trauma

Childbirth and reproductive care are the most common reasons for women of childbearing age to use health care services. As there are roughly 11,300 births each day in the United States (Martin, et al., 2011), childbirth is the most common reason for hospital admission among women.

Obstetric trauma involving a severe tear to the vagina or surrounding tissues during delivery is a common complication of childbirth. Higher risks of severe (i.e., 3rd or 4th degree) perineal laceration may be related to the degree of fetal-maternal size disproportion. Adolescents, who often have smaller body sizes because they have not finished growing, may be more likely to experience obstetric trauma than older women. In addition, although any delivery can result in trauma, existing evidence shows that severe perineal trauma can be reduced by restricting the use of episiotomies and forceps (Kudish, et al., 2008).

Previous reports used AHRQ Quality Indicators version 3.1 to generate obstetric trauma rates. The 2011 reports use a modified version 4.1 of the software. While the effects of version change are extremely small, these estimates should not be compared with estimates in previous reports.

 

Figure 2.21. Obstetric trauma with 3rd or 4th degree laceration per 1,000 vaginal deliveries without instrument assistance, by age and payment source, 2004-2008

Figure 2.21. Obstetric trauma with 3rd or 4th degree laceration per 1,000 vaginal deliveries without instrument assistance, by age and payment source, 2004-2008. For details, go to [D] Text Description below.     

Figure 2.21. Obstetric trauma with 3rd or 4th degree laceration per 1,000 vaginal deliveries without instrument assistance, by age and payment source, 2004-2008. For details, go to [D] Text Description below.

[D] Select for Text Description.

Key: Private indicates private health insurance as the payment source; self-pay indicates self-pay, uninsured, and no charge as the payment source.
Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample and AHRQ Quality Indicators, version 4.1.
Denominator: All patients hospitalized for vaginal delivery without indication of instrument assistance.
Note: For this measure, lower rates are better. Rates are adjusted by age. Rates by age are not age adjusted.

  • From 2004 to 2008, rates of obstetric trauma with 3rd or 4th degree laceration decreased from 30 to 24 per 1,000 vaginal deliveries without instrument assistance (Figure 2.21). Declines were observed in all age and payment source groups except Medicare beneficiaries.
  • In all years, mothers ages 18-24 and 35-54 had lower rates of obstetric trauma than mothers ages 25-34. Mothers whose payment source was Medicare, Medicaid, or self pay/unininsured/no charge had lower rates of obstetric trauma than mothers whose payment source was private health insurance.
  • The 2008 top 3 State achievable benchmark was 17 per 1,000 deliveries.xvii At the current annual rate of decrease, this benchmark could be attained overall and by most age and payment source groups in about 4 years. Mothers ages 25-34 or whose payment source is private insurance would need 5 to 7 years. Mothers whose payment source is Medicaid have already attained the benchmark.

Also, in the NHDR:

  • In all years, Black and Hispanic mothers had lower rates of obstetric trauma than non-Hispanic White mothers and residents of the lower three area income quartiles had lower rates than residents of the highest area income quartile.
  • API mothers had higher rates than non-Hispanic White mothers.
Prevention: Receipt of Recommended Immunizations by Young Children

Immunizations are important in reducing mortality and morbidity. They protect recipients from illness and protect others in the community who are not vaccinated. Beginning in 2007, recommended vaccines for children that should have been completed by ages 19-35 months included diphtheria-tetanus-pertussis vaccine, polio vaccine, measles-mumps-rubella vaccine, Haemophilus influenzae type B vaccine, hepatitis B vaccine, varicella vaccine, and pneumococcal conjugate vaccine (PCV). These vaccines constitute the 4:3:1:3:3:1:4 vaccine series tracked in Healthy People 2020.

 

Figure 2.22. Children ages 19-35 months who received the 4:3:1:3:3:1:4 vaccine series, by income, 2007-2009

Figure 2.22. Children ages 19-35 months who received the 4:3:1:3:3:1:4 vaccine series, by income, 2007-2009. For details, go to [D] Text Description below.

[D] Select for Text Description.

Source: Centers for Disease Control and Prevention, National Center for Health Statistics and National Center for Immunization and Respiratory Diseases, National Immunization Survey, 2007-2009.
Denominator: U.S. civilian noninstitutionalized population ages 19-35 months.

  • In all years, fewer than 70% of children ages 19-35 months received all recommended vaccinations (Figure 2.22).
  • In 2008 and 2009, children with family incomes below the poverty level were less likely to receive all recommended vaccinations compared with children with family incomes at or above the poverty level.
  • The 2009 top 5 State achievable benchmark was 72%.xviii No income group has attained this benchmark.

Also, in the NHDR:

  • In 2007 and 2009, Black children were less likely than White children to receive all recommended vaccinations.
Outcome: Emergency Department Visits for Asthma

Asthma is a chronic respiratory disease that causes wheezing, coughing, chest tightness, and shortness of breath. In 2009, approximately 7.1 million children (0-17 years of age) had a diagnosis of asthma in the United States, and 4.0 million had had at least one asthma attack in the previous year (Akinbami, et al., 2011). However, asthma attacks can largely be prevented using medications and avoiding the triggers that cause attacks. Visits to the emergency department (ED) for asthma attacks are, therefore, generally considered to be markers of inadequate preventive asthma care.

 

Figure 2.23. Rate of emergency department visits for asthma per 10,000 population ages 2-19 years, by gender and insurance, 2005-2007 combined

Figure 2.23. Rate of emergency department visits for asthma per 10,000 population ages 2-19 years, by gender and insurance, 2005-2007 combined. For details, go to [D] Text Description below.     

Figure 2.23. Rate of emergency department visits for asthma per 10,000 population ages 2-19 years, by gender and insurance, 2005-2007 combined. For details, go to [D] Text Description below.

[D] Select for Text Description.

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Ambulatory Care Survey-Emergency Department, 2005-2007.
Note: For this measure, lower rates are better.

  • In 2005-2007, children ages 2-19 had 81 ED visits for asthma per 10,000 population (Figure 2.23). Children ages 2-9 had higher rates than adolescents ages 10-19.
  • Among children ages 2-9, males had higher rates than females.
  • Overall and among both age groups, children with public health insurance had higher rates of ED visits for asthma than children with private health insurance.

Also, in the NHDR:

  • Overall and among both age groups, non-Hispanic Black children had higher rates of ED visits for asthma than non-Hispanic White children.
Prevention: Children's Dental Care

According to the National Institute of Dental and Craniofacial Research, presence of dental caries is the single most common chronic disease of childhood, occurring five to eight times as frequently as asthma (HHS, 2000), the second most common chronic disease in children. Regular dental visits help to improve overall oral health and prevent dental caries.

 

Figure 2.24. Children ages 2-17 with a dental visit in the calendar year, by age and insurance status, 2002-2008

Figure 2.24. Children ages 2-17 with a dental visit in the calendar year, by age and insurance status, 2002-2008. For details, go to [D] Text Description below.   

  Figure 2.24. Children ages 2-17 with a dental visit in the calendar year, by age and insurance status, 2002-2008. For details, go to [D] Text Description below.

[D] Select for Text Description.

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2008.
Denominator: U.S. civilian noninstitutionalized population ages 2-17.

  • From 2002 to 2008, there was no statistically significant change in the percentage of children ages 2-17 who had a dental visit in the calendar year (Figure 2.24). Increases were observed among children ages 2-5 and among children with public health insurance only.
  • In all years, children ages 2-5 were less likely than adolescents ages 13-17 and children with public insurance only or no insurance were less likely than children with any private insurance to have a dental visit. In 2004 and 2005, children ages 6-12 were also more likely than adolescents ages 13-17 to have a dental visit.

Also, in the NHDR:

  • In all years, non-Hispanic Black and Hispanic children were less likely than non-Hispanic White children to have a dental visit. Poor, low-income, and middle-income children were less likely than high-income children to have a dental visit.
Outcome: Untreated Dental Caries

Figure 2.25. Adolescents ages 13-17 with untreated dental caries, by insurance status, 2005-2008 combined

Figure 2.25. Adolescents ages 13-17 with untreated dental caries, by insurance status, 2005-2008 combined. For details, go to [D] Text Description below.

[D] Select for Text Description.

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health and Nutrition Examination Survey, 2005-2008.
Denominator: U.S. civilian noninstitutionalized population ages 13-17.
Note: For this measure, lower rates are better.

  • Overall, 11% of adolescents ages 13-17 had untreated dental caries (Figure 2.25).
  • Uninsured adolescents and adolescents with public insurance were more likely to have untreated caries than privately insured adolescents.

Also, in the NHDR:

  • Mexican-American and non-Hispanic Black adolescents were more likely than non-Hispanic White adolescents to have untreated dental caries. Adolescents in families with incomes below the poverty line were more likely to have untreated dental caries than adolescents in families with incomes 400% or more of the poverty line.

Focus on Adolescents

Individuals 10-14 years old made up 6.7% of the 2010 U.S. population while those 15-19 years old made up 7.1% (U.S. Census Bureau, 2010). Survey data indicate that roughly 21% of children ages 12-17 have special health care needs (Bethell, et al., 2008). Adolescents frequently engage in high-risk behaviors resulting in morbidity and mortality, including injuries, unintended pregnancies, sexually transmitted diseases, and alcohol, tobacco, and substance abuse. Many adult chronic diseases and adverse health behaviors begin in adolescence (Forrest & Riley, 2004).

Prevention: Well Visits in the Last Year

The American Academy of Pediatrics recommends annual preventive health care visits for all individuals between ages 11 and 21 years (AAP, 2008). For the purposes of this measure, adolescents are children ages 10-17.

 

Figure 2.26. Adolescents ages 10-17 with a well visit in the last 12 months, by insurance status, 2009

Figure 2.26. Adolescents ages 10-17 with a well visit in the last 12 months, by insurance status, 2009. For details, go to [D] Text Description below.

[D] Select for Text Description.

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2009.
Denominator: U.S. civilian noninstitutionalized population ages 10-17.

  • Compared with adolescents with private health insurance, a lower percentage of uninsured adolescents had a well visit in the last 12 months (Figure 2.26).

Also, in the NHDR:

  • Non-Hispanic Black adolescents had higher rates of well visits than non-Hispanic White adolescents or Hispanic adolescents. A lower percentage of adolescents with family incomes less than 400% of the poverty level had a well visit compared with adolescents with family incomes of 600% of the poverty level and over.
Prevention: Receipt of Meningococcal Vaccine Among Adolescents

Meningitis is an infection of the membranes that cover the brain and spinal cord. If meningitis is caused by bacteria, it is often life threatening. Meningococcal diseases are infections caused by the bacteria Neisseria meningitidis. Although Neisseria meningitidis can cause various types of infections, it is most important as a potential cause of meningitis. The meningococcal vaccine can prevent most cases of meningitis caused by Neisseria meningitidis and is recommended for all children ages 11-12 years. Effective in January 2011, a second dose has been recommended at age 16.

 

Figure 2.27. Adolescents ages 13-17 who ever received at least 1 dose of the meningococcal vaccine as of 2009, by State quartiles

Figure 2.27. Adolescents ages 13-17 who ever received at least 1 dose of the meningococcal vaccine as of 2009, by State quartiles. For details, go to [D] Text Description below.

[D] Select for Text Description.

Source: Centers for Disease Control and Prevention, National Center for Health Statistics and National Center for Immunization and Respiratory Diseases, National Immunization Survey, 2009.

  • In 2009, only 54% of adolescents ages 13-17 had ever received meningococcal vaccine (data not shown).
  • The 2009 top 5 State achievable benchmark was 74%,xix but percentages varied considerably by State, ranging from 19% to 78%. Interquartile ranges were:
    • Worst quartile: 19-42%.
    • 2nd worst quartile: 42-51%.
    • 2nd best quartile: 51-58%.
    • Best quartile: 58-78%.
  • The Northeast tended to have higher rates while the South tended to have lower rates (Figure 2.27).

Also, in the NHDR:

  • No differences were observed related to race/ethnicity or income.
Prevention: Chlamydia Testing Among Adolescent Females

Chlamydia is a sexually transmitted disease (STD) caused by the bacterium Chlamydia trachomatis, which can damage a woman's reproductive organs. Although symptoms of chlamydia are usually mild or absent, serious complications that cause irreversible damage, including infertility, can occur "silently" before a woman ever recognizes a problem. Chlamydia also can cause discharge from the penis of an infected man.

Chlamydia is the most frequently reported bacterial STD in the United States. The U.S. Preventive Services Task Force recommends chlamydia screening (testing in asymptomatic individuals) for all sexually active nonpregnant young women age 24 and younger and for older nonpregnant women who are at increased risk (USPSTF, 2007).

 

Figure 2.28. Sexually active female managed care plan enrollees ages 16-20 years with one or more chlamydia tests performed in the plan year, by insurance plan type, 2001-2009

Figure 2.28. Sexually active female managed care plan enrollees ages 16-20 years with one or more chlamydia tests performed in the plan year, by insurance plan type, 2001-2009. For details, go to [D] Text Description below.

[D] Select for Text Description.

Source: National Committee for Quality Assurance, 2001-2009.
Denominator: Female managed care enrollees ages 16-20 who were sexually active based on claims for contraception, gynecological exams, and STD- or pregnancy-related services.
Note: The chlamydia tests counted in the numerator include tests performed during workups for suspected STDs, as well as screening tests performed in asymptomatic patients. In addition, claims-based estimates of sexually active women identify smaller proportions of women as sexually active compared with self-report. Thus, the chlamydia screening rates reported here were likely overestimated.

  • The percentages of sexually active women tested for chlamydia increased over time within each enrollee group (Figure 2.28).
  • In all years, Medicaid enrollees were more likely than commercial plan enrollees to be tested for chlamydia.

 

 

Mental Health and Substance Abuse

Importance

Mortality
Number of deaths due to suicide (2009)34,598 (Kochanek, et al., 2011)
Rank among causes of death in the United States—suicide (2009)10th (Kochanek, et al., 2011)
Alcohol-impaired driving fatalities (2009)10,839 (NHTSA, 2009)
Prevalence
People age 12 and over with alcohol and/or illicit drug dependence or abuse in the past year (2009)22.5 million (8.9%) (SAMHSA, 2010)
Youths ages 12-17 with a major depressive episode during the past year (2009)2.0 million (8.1%) (SAMHSA, 2010)
Adults age 18 and over with a major depressive episode during the past year (2009)14.8 million (6.5%) (SAMHSA, 2010)
Adults with at least one major depressive episode in their lifetime (2006)30.4 million (13.9%) (SAMHSA, 2007)
Cost
National expenditures for treatment of mental health and substance abuse disorders (2014 est.)$239 billion (SAMHSA, 2008)
Cost-effectiveness of screening and brief counseling for problem drinking$0-$14,000/QALY (Maciosek, et al., 2006)

Measures

The NHQR and NHDR track measures of the quality of treatment for major depression and substance abuse. Mental health treatment includes counseling, inpatient care, outpatient care, and prescription medications. This section highlights five measures of mental health and substance abuse treatment:

  • Receipt of treatment for depression.
  • Suicide deaths.
  • Receipt of treatment for illicit drug use or alcohol problem.
  • Completion of substance abuse treatment.
  • Emergency treatment for mental illness or substance abuse.

Findings

Treatment: Receipt of Treatment for Depression

In 2006, approximately 1.4 million hospitalizations were specifically for mental health conditions and one in five hospital stays included some mention of a mental health condition as either a principal or secondary diagnosis (Saba, et al., 2008). Mood disorders were the most common principal diagnosis for all nonelderly people.

Treatment for depression can be very effective in reducing symptoms and associated illnesses and returning individuals to a productive lifestyle. The Sequenced Treatment Alternatives to Relieve Depression study, funded by the National Institute of Mental Health, was the largest clinical trial ever conducted to help determine the most effective treatment strategies for major depressive disorder. It involved both primary care and specialty care settings. Participants included people with complex health conditions, such as multiple concurrent medical and psychiatric conditions.

This study found that between 28% and 33% of participants achieved a symptom-free state after the first round of medication, and nearly 70% achieved remission after 12 months (Insel & Wang, 2009). Strategies for treating depression in primary care settings such as the collaborative care model have also been shown to generate positive net social benefits in cost-benefit analyses compared with usual care (Glied, et al., 2010).

Barriers to high-quality mental health care include cost of care, lack of sufficient insurance for mental health services, social stigma, fragmented organization of services, and mistrust of providers. In rural and remote areas, limited availability of skilled care providers is also a major problem. For racial and ethnic populations, these problems are compounded by the lack of culturally and linguistically competent providers.

 

Figure 2.29. Adults with a major depressive episode in the past year who received treatment for depression in the past year, by age and gender, 2008-2009

Figure 2.29. Adults with a major depressive episode in the past year who received treatment for depression in the past year, by age and gender, 2008-2009. For details, go to [D] Text Description below.

Figure 2.29. Adults with a major depressive episode in the past year who received treatment for depression in the past year, by age and gender, 2008-2009. For details, go to [D] Text Description below.

[D] Select for Text Description.

Source: Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2008-2009.
Denominator: Adults age 18 and over with a major depressive episode in the last 12 months.
Note: Total includes adults age 65 and over, but sample sizes are too small to allow separate estimates for this age group. Major depressive episode is defined as a period of at least 2 weeks when a person experienced a depressed mood or loss of interest or pleasure in daily activities and had a majority of the symptoms of depression described in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders. Treatment for depression is defined as seeing or talking to a medical doctor or other professional or using prescription medication in the past year for depression.

  • In 2009, less than two-thirds of adults with a major depressive episode received treatment for depression (Figure 2.29).
  • In both years, adults ages 18-44 were less likely than those ages 45-64 and men were less likely than women to receive treatment for depression.

Also, in the NHDR:

  • In both years, Blacks and Hispanics were less likely to receive treatment for depression than Whites.
  • In 2009, people with less than a high school education and high school graduates were less likely to receive treatment for depression than people with any college education.
Outcome: Suicide Deaths

Most individuals who die by suicide have mental illnesses, such as depression or schizophrenia, or have substance abuse problems (Moscicki, 2001). Suicide may be prevented when its warning signs are detected and treated. A previous suicide attempt is among the strongest predictors of subsequent suicide. Cognitive-behavioral therapy can significantly help those who have attempted suicide consider alternative actions when thoughts of self-harm arise and may reduce suicide attempts (Tarrier, et al., 2008).

 

Figure 2.30. Suicide deaths per 100,000 population, by age and gender, 2000-2007

Figure 2.30. Suicide deaths per 100,000 population, by age and gender, 2000-2007. For details, go to [D] Text Description below.     Figure 2.30. Suicide deaths per 100,000 population, by age and gender, 2000-2007. For details, go to [D] Text Description below.

[D] Select for Text Description.

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System—Mortality, 2000-2007.
Denominator: U.S. population.
Note: For this measure, lower rates are better. Estimates are age adjusted to the 2000 standard population.

  • Overall, from 2000 to 2007, the suicide death rate did not change significantly. Increases were observed among females and people ages 45-64; decreases were observed among people ages 0-17 and age 65 and over (Figure 2.30).
  • In all years, people ages 0-17 had lower suicide death rates than people ages 18-44. Since 2002, people ages 45-64 have had higher suicide death rates than people ages 18-44. Females had lower rates than males.

Also, in the NHDR:

  • In all years, Blacks and APIs had lower suicide death rates than Whites, and Hispanics had lower suicide death rates than non-Hispanic Whites.
Treatment: Receipt of Treatment for Illicit Drug Use or Alcohol Problem

Illicit drugxx use is a medical problem that can have a direct toxic effect on a number of bodily organs and exacerbate numerous health and mental health conditions. Alcohol problems also can lead to serious health risks. Heavy drinking can increase the risk of certain cancers and cause damage to the liver, brain, and other organs. In addition, alcohol can cause birth defects, including fetal alcohol syndrome. Alcoholism and illicit drug use increase the risk of death from car crashes and other injuries (Ringold, et al., 2006). Illicit drug use and alcohol problems can be effectively treated at specialty facilities.

 

Figure 2.31. People age 12 and over who needed treatment for illicit drug use or an alcohol problem and who received such treatment at a specialty facility in the last 12 months, by age and education, 2008-2009

 Figure 2.31. People age 12 and over who needed treatment for illicit drug use or an alcohol problem and who received such treatment at a specialty facility in the last 12 months, by age and education, 2008-2009. For details, go to [D] Text Description below.    Figure 2.31. People age 12 and over who needed treatment for illicit drug use or an alcohol problem and who received such treatment at a specialty facility in the last 12 months, by age and education, 2008-2009. For details, go to [D] Text Description below.

[D] Select for Text Description.

Source: Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2008-2009.
Denominator: Civilian noninstitutionalized population age 12 and over who needed treatment for any illicit drug use or alcohol problem.
Note: Total includes people age 65 and over, but data were not statistically reliable enough to produce specific estimates for this group. Treatment refers to treatment at a specialty facility, such as a drug and alcohol inpatient and/or outpatient rehabilitation facility, inpatient hospital setting, or mental health center.

  • In 2009, only 11% of people age 12 and over who needed treatment for illicit drug use or an alcohol problem received such treatment at a specialty facility in the last 12 months (Figure 2.31).
  • In 2008 and 2009, people with any college were less likely to receive needed treatment for illicit drug use or an alcohol problem than people with less than a high school education. Individuals with a lower socioeconomic status may be more likely to receive needed substance abuse treatment due to linkages in service delivery between substance abuse and public assistance services in many States.
  • In 2009, people ages 12-17 were less likely to receive treatment than people ages 45-64.

Also, in the NHDR:

  • From 2002 to 2009, Blacks were more likely to receive needed treatment for illicit drug use or an alcohol problem than Whites in 6 of the 8 years. Hispanics were less likely to receive treatment than non-Hispanics in 4 of the 8 years.
Treatment: Completion of Substance Abuse Treatment

Completion of substance abuse treatment is strongly associated with improved outcomes, such as long-term abstinence from substance use. Dropout from treatment often leads to relapse and return to substance use.

 

Figure 2.32. People age 12 and over treated for substance abuse who completed treatment course, by age and gender, 2005-2008

Figure 2.32. People age 12 and over treated for substance abuse who completed treatment course, by age and gender, 2005-2008. For details, go to [D] Text Description below.     Figure 2.32. People age 12 and over treated for substance abuse who completed treatment course, by age and gender, 2005-2008. For details, go to [D] Text Description below.

[D] Select for Text Description.

Source: Substance Abuse and Mental Health Services Administration, Treatment Episode Data Set, Discharge Data Set, 2005-2008.
Denominator: Discharges age 12 and over from publicly funded substance abuse treatment facilities.

  • From 2005 to 2008, there were no statistically significant changes in the overall percentage of people age 12 and over treated for substance abuse who completed the treatment course (Figure 2.32).
  • In all years, people ages 12-19 and 20-39 were less likely than those age 40 and over to complete substance abuse treatment. Females who were treated for substance abuse were significantly less likely than males to complete treatment.

Also, in the NHDR:

  • In all years, non-Hispanic Blacks were less likely than non-Hispanic Whites and people with less than a high school education were significantly less likely than people with a college education to complete treatment.
New! Outcome: Emergency Treatment for Mental Illness or Substance Abuse

Patients with mental illness overuse emergency rooms when high-quality outpatient mental health care is not available in the community (Alakeson, et al., 2010). EDs are often not staffed or equipped to provide optimal psychiatric care and patients with mental illness often wait long periods before receiving appropriate care. ED staff observing patients waiting for psychiatric care cannot care for patients with other medical emergencies.

This measure provides information on the quality of the local mental health care system and the degree to which EDs function as safety net providers to people with mental health and substance abuse problems.

 

Figure 2.33. Rate of emergency department visits with a principal diagnosis related to mental health, alcohol, or substance abuse, per 100,000 population, by age, gender, area income, and region, 2008

Figure 2.33. Rate of emergency department visits with a principal diagnosis related to mental health, alcohol, or substance abuse, per 100,000 population, by age, gender, area income, and region, 2008. For details, go to [D] Text Description below.

[D] Select for Text Description.

Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Emergency Department Sample, 2008.
Denominator: U.S. population.
Note: For this measure, lower rates are better.

  • ED visit rates varied significantly by age, with rates lowest for those ages 0-17 (604/100,000 population) and highest for those ages 18-44 (2,118/100,000 population) (Figure 2.33).
  • Rates of ED visits for conditions related to mental health, alcohol, and substance abuse were higher for males (1,593/100,000) than for females 1,377/100,000).
  • Rates of ED use were lowest for people residing in areas with high income levels and highest for those residing in areas with the lowest income levels. Rates for those in the lowest income quartile were approximately 1.6 times that of people in the highest income quartile.
  • The rate of ED utilization in the Northeast was 2.1 times as high as in the West (2,312/100,000 compared with 1,121/100,000).

 

 

New! Musculoskeletal Diseases

Importance

Prevalence
People diagnosed with arthritis, rheumatoid arthritis, lupus, or fibromyalgia (2007-2009)50 million (22%) (MMWR, 2010a)
Number of people with low bone density34 million (NOF, 2011)
Morbidity
Activity limitations attributable to diagnosed arthritis among U.S. population (2007)21 million (42%) (MMWR, 2010a)
Lifetime osteoporosis-related fractures among women over age 50approx. 50% (NOF, 2011)
Lifetime osteoporosis-related fractures among men over age 50approx. 25% (NOF, 2011)
Cost
Total cost of arthritis and other rheumatic conditions (2003)$128 billion (MMWR, 2007)
Direct medical cost of arthritis and other rheumatic conditions (2003)$81 billion (MMWR, 2007)
Indirect costs of arthritis and other rheumatic conditions (2003)$47 billion (MMWR, 2007)
Total cost of osteoporosis-related fractures (2005)$19 billion (NOF, 2011)

Measures

This section on musculoskeletal diseases is new in the 2011 NHQR and NHDR. It tracks several quality measures for prevention and management of this broad category of illnesses that includes osteoporosis and arthritis. One measure was moved from the section on functional status and highlighted here:

  • Osteoporosis screening among older women.

In addition, three new measures related to the management of arthritis are shown. These measures are part of the Arthritis Foundation's Quality Indicator Set for Osteoarthritis. A multidisciplinary panel of experts on arthritis and pain reviewed scientific evidence to help develop the Quality Indicator Set (Pencharz & MacLean, 2004). The measures were tracked as part of Healthy People 2010 and continue to be tracked in Healthy People 2020:

  • Arthritis education among adults with arthritis.
  • Counseling about physical activity among adults with arthritis.
  • Counseling about weight reduction among overweight adults with arthritis.

Findings

Prevention: Osteoporosis Screening Among Older Women

Osteoporosis is a disease characterized by loss of bone tissue. Osteoporosis increases the risk of fractures of the hip, spine, and wrist. About half of all postmenopausal women will experience an osteoporotic fracture. Osteoporotic fractures cause considerable morbidity and mortality. For example, of patients with hip fractures, one-fifth will die during the first year, one-third will require nursing home care, and only one-third will return to the functional status they had before the fracture. The remaining 13 percent have other outcomes (Lane, 2006).

Because older women are at highest risk for osteoporosis, the U.S. Preventive Services Task Force recommends routine osteoporosis screening of women age 65 and over. Women with low bone density can reduce their risk of fracture and subsequent functional impairment by taking appropriate medications and engaging in weight-bearing exercise (USPSTF, 2002).

 

Figure 2.34. Female Medicare beneficiaries age 65 and over who reported ever being screened for osteoporosis with a bone mass or bone density measurement, by age and insurance, 2000, 2003, 2006, and 2008

Figure 2.34. Female Medicare beneficiaries age 65 and over who reported ever being screened for osteoporosis with a bone mass or bone density measurement, by age and insurance, 2000, 2003, 2006, and 2008. For details, go to [D] Text Description below.     Figure 2.34. Female Medicare beneficiaries age 65 and over who reported ever being screened for osteoporosis with a bone mass or bone density measurement, by age and insurance, 2000, 2003, 2006, and 2008. For details, go to [D] Text Description below.

[D] Select for Text Description.

Key: HMO = health maintenance organization; FFS = fee for service.
Source: Medicare Current Beneficiary Survey, 2000, 2003, 2006, and 2008.
Denominator: Female Medicare beneficiaries age 65 and over living in the community.

  • From 2000 to 2008, the percentage of female Medicare beneficiaries age 65 and over who reported ever being screened for osteoporosis with a bone mass or bone density measurement increased from 34% to 71% (Figure 2.34).
  • In all years, women age 85 and over were less likely to be screened for osteoporosis than women ages 65-74. Women with Medicare HMO, Medicare and Medicaid, or Medicare fee for service only were less likely to be screened for osteoporosis than women with Medicare and private supplemental insurance.

Also, in the NHDR:

  • In all years, Hispanic and non-Hispanic Black women were less likely than non-Hispanic White women to be screened for osteoporosis. Poor, low-income, and middle-income women were less likely than high-income women to be screened for osteoporosis.
New! Management: Arthritis Education Among Adults With Arthritis

Osteoarthritis is the most common form of arthritis, affecting about 12% of the general population. Patients with symptomatic osteoarthritis who receive education about the natural history, treatment, and self-management of the disease have better knowledge and self-efficacy and experience less pain and functional impairment (Pencharz & MacLean, 2004).

 

Figure 2.35. Adults with doctor-diagnosed arthritis who reported they had effective, evidence-based arthritis education as an integral part of the management of their condition, by age and gender, 2006 and 2009

Figure 2.35. Adults with doctor-diagnosed arthritis who reported they had effective, evidence-based arthritis education as an integral part of the management of their condition, by age and gender, 2006 and 2009. For details, go to [D] Text Description below.     Figure 2.35. Adults with doctor-diagnosed arthritis who reported they had effective, evidence-based arthritis education as an integral part of the management of their condition, by age and gender, 2006 and 2009. For details, go to [D] Text Description below.

[D] Select for Text Description.

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2006 and 2009.
Denominator: Adults with doctor-diagnosed arthritis.
Note: Estimates are age adjusted to the 2000 standard population.

  • In 2009, 11% of adults with doctor-diagnosed arthritis received effective, evidence-based arthritis education (Figure 2.35).
  • In both years, adults age 65 and over were less likely to receive arthritis education than adults ages 45-64.
  • In 2009, men were less likely to receive arthritis education than women.

Also, in the NHDR:

  • In 2006, Hispanics were more likely than non-Hispanic Whites to receive arthritis education.
New! Management: Counseling About Physical Activity Among Adults With Arthritis

Patients with symptomatic osteoarthritis should also receive counseling about muscle strengthening and aerobic exercise programs. Such programs can reduce pain and improve functional ability (Pencharz & MacLean, 2004).

 

Figure 2.36. Adults with doctor-diagnosed arthritis who reported they received health care provider counseling about physical activity or exercise, by age and gender, 2006 and 2009

Figure 2.36. Adults with doctor-diagnosed arthritis who reported they received health care provider counseling about physical activity or exercise, by age and gender, 2006 and 2009. For details, go to [D] Text Description below.     Figure 2.36. Adults with doctor-diagnosed arthritis who reported they received health care provider counseling about physical activity or exercise, by age and gender, 2006 and 2009. For details, go to [D] Text Description below.

[D] Select for Text Description.

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2006 and 2009.
Denominator: Adults with doctor-diagnosed arthritis.
Note: Estimates are age adjusted to the 2000 standard population.

  • In 2009, 57% of adults with doctor-diagnosed arthritis received health care provider counseling about physical activity or exercise (Figure 2.36).
  • In 2006, adults age 65 and over were less likely than adults ages 45-64 to receive exercise counseling.
  • In both years, men were less likely than women to receive exercise counseling.

Also, in the NHDR:

  • In both years, Hispanics were more likely than non-Hispanic Whites to receive exercise counseling.
New! Management: Counseling About Weight Reduction Among Overweight Adults With Arthritis

Weight is a risk factor for osteoarthritis and weight reduction can be used to prevent the development of osteoarthritis among overweight people. Moreover, overweight people with osteoarthritis who lose weight experience less joint pain and improved function (Pencharz & MacLean, 2004).

 

Figure 2.37. Overweight adults with doctor-diagnosed arthritis who reported they received health care provider counseling about weight reduction, by age and gender, 2006 and 2009

Figure 2.37. Overweight adults with doctor-diagnosed arthritis who reported they received health care provider counseling about weight reduction, by age and gender, 2006 and 2009. For details, go to [D] Text Description below.     Figure 2.37. Overweight adults with doctor-diagnosed arthritis who reported they received health care provider counseling about weight reduction, by age and gender, 2006 and 2009. For details, go to [D] Text Description below.

[D] Select for Text Description.

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2006 and 2009.
Denominator: Adults with doctor-diagnosed arthritis.
Note: Estimates are age adjusted to the 2000 standard population. Rates by age are not age adjusted.

  • In 2009, only 42% of overweight adults with doctor-diagnosed arthritis received health care provider counseling about weight reduction (Figure 2.37).
  • In both years, overweight adults age 65 and over were less likely to receive weight reduction counseling than adults ages 45-64. In 2006, overweight adults ages 18-44 were also less likely to receive weight reduction counseling than adults ages 45-64.
    Overweight men were less likely than women to receive weight reduction counseling.

Also, in the NHDR:

  • In 2006 and 2009, overweight non-Hispanic Blacks were more likely than non-Hispanic Whites to receive weight reduction counseling.

xvi. In this report, children are defined as individuals under age 18.
xvii. The top 3 States contributing to the achievable benchmark are Utah, West Virginia, and Wyoming.
xviii. The top 5 States that contributed to the achievable benchmark are Louisiana, Maryland, Massachusetts, New Hampshire, and Ohio.
xix. The top 5 States that contributed to the achievable benchmark are the District of Columbia, Massachusetts, New Jersey, Pennsylvania, and Rhode Island.
xx. Illicit drugs included in this measure are marijuana/hashish, cocaine (including crack), inhalants (e.g., inhalation of various substances other than for intended use, such as toluene), hallucinogens, heroin, and prescription-type psychotherapeutic drugs (nonmedical use).

Current as of February 2011
Internet Citation: Chapter 2. Effectiveness of Care (continued, 2): National Healthcare Quality Report, 2011. February 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/nhqrdr/nhqr11/chap2b.html