Chapter 2. Effectiveness of Care (continued, 3)

National Healthcare Quality Report, 2011

Respiratory Diseases

Importance

Mortality
Number of deaths due to chronic lower respiratory diseases (2009)137,082 (Kochanek, et al., 2011)
Number of deaths, influenza and pneumonia combined (2009)53,582 (Kochanek, et al., 2011)
Cause of death rank for chronic lower respiratory diseases (2009)3rd (Kochanek, et al., 2011)
Cause of death rank for influenza and pneumonia combined (2009)8th (Kochanek, et al., 2011)
Prevalence
Adults age 18 and over with current asthma (2009)17.5 million (Akinbami, et al., 2011)
Children under age 18 with current asthma (2009)7.1 million (Akinbami, et al., 2011)
Incidence
Number of discharges attributable to pneumonia (2007)1.2 million (Hall, et al., 2010)
New cases of tuberculosis (2010)11,181 (MMWR, 2011a)
Cost
Total cost of lung diseases (2010)$173.4 billion (NHLBI, 2009)
Total cost of upper respiratory infections (annual est.)$40 billion (Fendrick, et al., 2003)
Total cost of asthma (2010)$20.7 billion (NHLBI, 2009)
Cost-effectiveness of influenza immunization (2006)$0-$14,000/QALY (Maciosek, et al., 2006)

Measures

The NHQR and NHDR track several quality measures for prevention and treatment of this broad category of illnesses that includes pneumonia, tuberculosis, and asthma. The four measures highlighted in this section are:

  • Pneumococcal vaccination.
  • Receipt of recommended care for pneumonia.
  • Completion of tuberculosis therapy.
  • Daily asthma medication.

Findings

Prevention: Pneumococcal Vaccination

Vaccination is a cost-effective strategy for reducing illness, death, and disparities associated with pneumonia and influenza.

 

Figure 2.38. Adults age 65 and over who reported ever having pneumococcal vaccination, by insurance and income, 2000-2009

Figure 2.38. Adults age 65 and over who reported ever having pneumococcal vaccination, by insurance and income, 2000-2009. For details, go to [D] Text Description below.     Figure 2.38. Adults age 65 and over who reported ever having pneumococcal vaccination, by insurance and income, 2000-2009.

[D] Select for Text Description.

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2000-2009.
Denominator: Civilian noninstitutionalized population age 65 and over.
Note: Age adjusted to the 2000 U.S. standard population. Benchmark is derived from the Behavioral Risk Factor Surveillance System (BRFSS); go to Chapter 1, Introduction and Methods, for details.

  • Overall, the percentage of adults age 65 and over who reported ever having pneumococcal vaccination increased from 53% in 2000 to 61% in 2009 (Figure 2.38). Improvements were observed among all insurance and income groups.
  • In all years, adults with Medicare only were less likely than adults with Medicare and private supplemental health insurance to have pneumococcal vaccination. Poor adults were less likely than high-income adults to have pneumococcal vaccination. In 8 of 10 years, adults with Medicare and other public insurance were also less likely to have pneumococcal vaccination than adults with Medicare and private supplemental insurance.
  • The 2008 top 5 State achievable benchmark was 67%.xxi At the current annual rate of increase, this benchmark could be attained overall in about 8 years. Adults with Medicare and private supplemental insurance or with Medicare and other public insurance as well as middle- and high-income adults could achieve the benchmark sooner. Adults with Medicare only would take 11 years to reach the benchmark while poor adults would need more than 25 years.

Also, in the NHDR:

  • In all years, Blacks and Asians were less likely than Whites and Hispanics were less likely than non-Hispanic Whites to have pneumococcal vaccination.
Treatment: Receipt of Recommended Care for Pneumonia

CMS tracks a set of measures for quality of pneumonia care for hospitalized patients from the CMS Quality Improvement Organization Program. This set of measures has been adopted by the Hospital Quality Alliance. Recommended care for patients with pneumonia includes receipt of (1) initial antibiotics within 6 hours of hospital arrival, (2) antibiotics consistent with current recommendations, (3) blood culture before antibiotics are administered, (4) influenza vaccination status assessment or provision, and (5) pneumococcal vaccination status assessment or provision. An opportunities model composite of these five measures is presented here.

 

Figure 2.39. Hospital patients with pneumonia who received recommended hospital care, by age, 2007-2009

Figure 2.39. Hospital patients with pneumonia who received recommended hospital care, by age, 2007-2009. For details, go to [D] Text Description below.

[D] Select for Text Description.

Source: Centers for Medicare & Medicaid Services, Medicare Quality Improvement Organization Program, 2007-2009.
Denominator: Patients hospitalized with a principal discharge diagnosis of pneumonia or a principal discharge diagnosis of either septicemia or respiratory failure and secondary diagnosis of pneumonia.
Note: Recommended care includes initial antibiotics within 6 hours of hospital arrival, antibiotics consistent with current recommendations, blood culture before antibiotics are administered, influenza vaccination status assessment or provision, and pneumococcal vaccination status assessment or provision.

  • In 2009, 93% of hospital patients with pneumonia received recommended hospital care (Figure 2.39).
  • In 2009, patients ages 75-84 and 85 and over were more likely to receive recommended hospital care for pneumonia compared with patients under age 65.
  • In 2008, the top 5 State achievable benchmark was 94%.xxii By 2009, all age groups were close to the benchmark.

Also, in the NHDR:

  • In all years, the percentage of patients with pneumonia who received recommended hospital care was significantly lower for Blacks, Asians, AI/ANs, and Hispanics compared with Whites.
Outcome: Completion of Tuberculosis Therapy

Failure to complete tuberculosis therapy puts patients at increased risk for treatment failure and for spreading the infection to others. Even worse, it may result in the development of drug-resistant strains of tuberculosis.

 

Figure 2.40. Patients with tuberculosis who completed a curative course of treatment within 1 year of initiation of treatment, by age and gender, 2000-2007

Figure 2.40. Patients with tuberculosis who completed a curative course of treatment within 1 year of initiation of treatment, by age and gender, 2000-2007. For details, go to [D] Text Description below.     Figure 2.40. Patients with tuberculosis who completed a curative course of treatment within 1 year of initiation of treatment, 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 Tuberculosis Surveillance System, 2000-2007.
Denominator: U.S. civilian noninstitutionalized population treated for tuberculosis.

  • The percentage of patients who completed tuberculosis therapy within 1 year increased from 80% in 2000 to 84% in 2007 (Figure 2.40). Improvements were observed among all age and sex categories.
  • In all years, children ages 0-17 with tuberculosis were more likely than adults ages 18-44 to complete a curative course of treatment within 1 year of initiation of treatment.
  • In 6 of 8 years, males were less likely to complete tuberculosis treatment than females.
  • The 2006 top 5 State achievable benchmark was 92%.xxiii At the current 0.6% annual rate of increase, this benchmark could be attained overall in about 12 years.
  • Children ages 0-17 have already achieved the benchmark. Patients ages 18-44 and 45-64 could achieve the benchmark in about 12 years while patients age 65 and over would need more than 20 years. Females could achieve the benchmark in about 8 years while males would need about 16 years.

Also, in the NHDR:

  • In 6 of 8 years, Hispanics were less likely to complete tuberculosis treatment than non-Hispanic Whites.
Management: Daily Asthma Medication

Improving quality of care for people with asthma can reduce the occurrence of asthma attacks and avoidable hospitalizations. The National Asthma Education and Prevention Program, coordinated by the National Heart, Lung, and Blood Institute, develops and disseminates science-based guidelines for asthma diagnosis and management (NHLBI, 2007). These recommendations are built around four essential components of asthma management critical for effective long-term control of asthma: assessment and monitoring, control of factors contributing to symptom exacerbation, pharmacotherapy, and education for partnership in care.

While not all patients with asthma need medications, patients with persistent asthma need daily long-term controller medication to prevent exacerbations and chronic symptoms. Appropriate preventive medications for people with persistent asthma include inhaled corticosteroids, inhaled long-acting beta-2-agonists, cromolyn, theophylline, and leukotriene modifiers.

 

Figure 2.41. People with current asthma who reported taking preventive asthma medicine daily or almost daily, by age and insurance, 2003-2008

Figure 2.41. People with current asthma who reported taking preventive asthma medicine daily or almost daily, by age and insurance, 2003-2008. For details, go to [D] Text Description below.     Figure 2.41. People with current asthma who reported taking preventive asthma medicine daily or almost daily, by age and insurance, 2003-2008. For details, go to [D] Text Description below.

[D] Select for Text Description.

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2003-2007.
Denominator: Civilian noninstitutionalized population with asthma.
Note: Age adjusted to the 2000 U.S. standard population. People with current asthma report that they still have asthma or had an asthma attack in the last 12 months. Insurance groups presented are for patients under age 65.

  • From 2003 to 2008, the percentage of people with current asthma who reported taking preventive asthma medicine daily or almost daily did not change significantly (Figure 2.41). Declines were observed among people ages 45-64 and people with private or public health insurance.
  • In all years, people ages 18-44 were less likely than other age groups to take daily preventive asthma medicine. Uninsured people under age 65 were less likely than people under age 65 with any private health insurance to take daily preventive asthma medicine.

Also, in the NHDR:

  • In 3 of 6 years, non-Hispanic Blacks were less likely to take daily preventive asthma medicine than non-Hispanic Whites.

 

 

Lifestyle Modification

Importance

Mortality
Number of deaths per year attributable to smoking (2000-2004)443,000 (MMWR, 2008)
Prevalence
Number of adult current cigarette smokers (2010)45.3 million (MMWR, 2011b)
Number of obese adults (2007-2008)72.5 million (MMWR, 2010b)
Percentage of adults with no leisure-time physical activity (2009)40% (Barnes, 2010)
Percentage of children who are overweight16.9% (Ogden & Carroll, 2010)
Cost
Total cost of smoking (2000-2004 est.)$193 billion (MMWR, 2008)
Total health care cost related to obesity (2008 est.)$147 billion (MMWR, 2008)

Measures

Unhealthy behaviors place many Americans at risk for a variety of diseases. Lifestyle practices account for more than 40% of the differences in health among individuals (Satcher & Higginbotham, 2008). A recent study examined the effects on incidence of coronary heart disease (CHD), stroke, diabetes, and cancer of four healthy lifestyles: never smoking, not being obese, engaging in at least 3.5 hours of physical activity per week, and eating a healthy diet (higher consumption of fruits, vegetables, and whole grain bread and lower consumption of red meat).

Engaging in one healthy lifestyle compared with none cut the risk of developing these diseases in half while engaging in all four cut risk by 78%. Unfortunately, healthy lifestyle practices have declined over the past two decades (Ford, et al., 2009).

Helping patients choose and maintain healthy lifestyles is a critical role of health care professionals. This year, the Lifestyle Modification section includes measures for both adults and children. Whenever children are mentioned in the section, the report is actually referencing the parents or guardians who were interviewed on behalf of the children. The NHQR tracks several quality measures for modifying unhealthy lifestyles, including the following six core report measures:

  • Counseling smokers to quit smoking.
  • Counseling obese adults about exercise.
  • Obese adults who do not exercise.
  • Counseling children about exercise.
  • Counseling obese adults about healthy eating.
  • Counseling children about healthy eating.

Findings

Prevention: Counseling Smokers To Quit Smoking

Smoking harms nearly every organ of the body and causes or exacerbates many diseases. Smoking causes more than 80% of deaths from lung cancer and more than 90% of deaths from chronic obstructive pulmonary disease (MMWR, 2008). Heart disease is the leading cause of death in the United States for both men and women (Hoyert, et al., 2005), with approximately 135,000 deaths due to smoking. Cigarette smoking increases the risk of dying from CHD two- to threefold (MMWR, 2008).

Quitting smoking has immediate and long-term health benefits. The risk of a heart attack and death from CHD are reduced by 50% in the first year after smoking cessation. The risk of mortality declines most rapidly in the first 3 years after smoking cessation, taking about 3 to 5 years of abstaining from smoking for cardiovascular risk to disappear (HHS, 2010). Smoking is a modifiable risk factor, and health care providers can help encourage patients to change their behavior and quit smoking.

 

Figure 2.42. Adult current smokers with a checkup in the last 12 months who received advice to quit smoking, by age and gender, 2002-2008

Figure 2.42. Adult current smokers with a checkup in the last 12 months who received advice to quit smoking, by age and gender, 2002-2008. For details, go to [D] Text Description below.     Figure 2.42. Adult current smokers with a checkup in the last 12 months who received advice to quit smoking, by age and gender, 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: Civilian noninstitutionalized adult current smokers who had a checkup in the last 12 months.

  • From 2002 to 2008, there were no statistically significant changes in the percentage of current adult smokers who were advised to quit smoking overall or by age or gender (Figure 2.42).
  • In all years, adult current smokers ages 18-44 were less likely to receive advice to quit smoking compared with other age groups.
  • In 3 out of 7 years, female adult current smokers were more likely than males to receive advice to quit smoking.

Also, in the NHDR:

  • From 2002 to 2008, there were no statistically significant changes in the percentage of current adult smokers who were advised to quit smoking overall or by race/ethnicity or income.
Prevention: Counseling Obese Adults About Exercise

Approximately one-third of adults are obese and about 17% of children and adolescents ages 2-19 are obese (CDC, 2011e). A large proportion of individuals who are overweight or obese are from lower socioeconomic groups; Blacks, Mexican Americans, and women tend to have higher obesity rates than men (Truong & Sturm, 2005). Obesity increases the risk for many chronic, often deadly conditions, such as hypertension, cancer, diabetes, and CHD.

Although physician guidelines recommend that health care providers screen all adult patients for obesity (USPSTF, 2003) obesity remains underdiagnosed among U.S. adults (Diaz, et al., 2004). Physicians have direct access to many high-risk individuals, increasing the opportunity to educate patients about their personal risks, as well as suggesting realistic and sustainable lifestyle changes that can lead to a healthier weight and more active life (Manson, et al., 2004).

Physician-based exercise and diet counseling is an important component of effective weight loss interventions (USPSTF, 2003). Such interventions have been shown to increase levels of physical activity among sedentary patients, resulting in a sustained favorable body weight and body composition (Lin, et al., 2010). Although every obese person may not need counseling about exercise and diet, many would likely benefit from improvements in these activities.

Regular exercise and a healthy diet aid in maintaining normal blood cholesterol levels, weight, and blood pressure, reducing the risk of heart disease, stroke, diabetes, and other comorbidities of obesity. Populations at risk for overweight and obesity may not receive adequate advice about lifestyle changes for many reasons. For instance, access to information, including physician knowledge of the latest recommendations, may be limited. The 2008 Physical Activity Guidelines for Americans recommend that adults engage in 2 hours and 30 minutes a week of moderate-intensity or 1 hour and 15 minutes a week of vigorous-intensity aerobic physical activity.xxiv

In addition to physician-based exercise and diet counseling, many national endeavors encourage lifestyle modification. For example, the President's Challenge is a program of the President's Council on Fitness, Sports and Nutrition that promotes an active and fit lifestyle through a suite of recognition programs available to anyone age 6 and over. Several initiatives have used the President's Challenge Presidential Active Lifestyle Award to promote healthy lifestyles, including Box Tops for Education's Family Fitness Night and Let's Move!xxv

 

Figure 2.43. Adults with obesity who ever received advice from a health provider to exercise more, by age and gender, 2002-2008

Figure 2.43. Adults with obesity who ever received advice from a health provider to exercise more, by age and gender, 2002-2008. For details, go to [D] Text Description below.     Figure 2.43. Adults with obesity who ever received advice from a health provider to exercise more, by age and gender, 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: Civilian noninstitutionalized adults age 18 and over with obesity.
Note: Obesity is defined as a body mass index of 30 or higher.

  • Overall, in 2008, 57% of adults with obesity reported ever receiving advice from a health provider to exercise more (Figure 2.43).
  • From 2002 to 2008, there were no statistically significant changes in any age or gender group in the percentage of adults with obesity who were advised to exercise.
  • In all years, adults with obesity ages 18-44 were less likely to receive advice to exercise compared with other age groups. Female adults with obesity were more likely than males to receive advice to exercise.

Also, in the NHDR:

  • From 2002 to 2008, there were no statistically significant changes by ethnicity in the percentage of obese adults who received advice to exercise, except for obese Hispanic adults (from 46% to 57%).
  • In 6 out of the 7 years, the percentage of obese adults who had ever received advice to exercise was lower for people with less than a high school education and high school graduates compared with those with any college.
New! Outcome: Obese Adults Who Do Not Exercise

Figure 2.44. Adults with obesity who did not spend half an hour or more in moderate or vigorous physical activity at least three times a week, by age and gender, 2002-2008

Figure 2.44. Adults with obesity who did not spend half an hour or more in moderate or vigorous physical activity at least three times a week, by age and gender, 2002-2008. For details, go to [D] Text Description below.     Figure 2.44. Adults with obesity who did not spend half an hour or more in moderate or vigorous physical activity at least three times a week, by age and gender, 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: Civilian noninstitutionalized population age 18 and over.
Note: Obesity is defined as a body mass index of 30 or higher.

  • Overall in 2008, 53% of obese adults did not spend half an hour or more engaged in moderate or vigorous physical activity at least three times a week (Figure 2.44).
  • From 2002 to 2008, there were no statistically significant changes in any age or gender group in the percentage of adults with obesity who did not engage in half an hour or more of moderate or vigorous physical activity at least three times a week.
  • In 6 out of 7 years, adults with obesity age 65 and over were more likely than other age groups not to engage in half an hour or more of moderate or vigorous physical activity at least three times a week.
  • Across all years, female adults with obesity were more likely than males not to engage in half an hour or more of moderate or vigorous physical activity at least three times a week.

Also, in the NHDR:

  • From 2002 to 2008, there were no statistically significant changes by race/ethnicity in the percentage of adults with obesity who did not spend half an hour or more engaged in moderate or vigorous physical activity.
  • In all years, the percentage of adults with obesity who did not spend half an hour or more engaged in moderate or vigorous physical activity was higher for people with basic and complex activity limitations than for people with no activity limitations.
Prevention: Counseling for Children About Physical Activity

Childhood is often a time when people establish healthy lifelong habits. Physicians can play an important role in encouraging healthy behaviors from a young age. For example, they can educate children and parents about the importance of regular exercise and healthy eating.

Overweight and obese children often become overweight and obese adults, with numerous and costly consequences. Unfortunately, as children have become more sedentary, the incidence of overweight and obesity has risen dramatically in the past two decades (Krebs & Jacobson, 2003), necessitating weight management through increased physical activity. The 2008 Physical Activity Guidelines for Americans recommend that children and adolescents engage in 1 hour or more of physical activity everyday.xxvi

 

Figure 2.45. Children ages 2-17 for whom a health provider gave advice within the past 2 years about exercise, by age and special health care needs, 2002-2008

Figure 2.45. Children ages 2-17 for whom a health provider gave advice within the past 2 years about exercise, by age and special health care needs, 2002-2008. For details, go to [D] Text Description below.     Figure 2.45. Children ages 2-17 for whom a health provider gave advice within the past 2 years about exercise, by age and special health care needs, 2002-2008. For details, go to [D] Text Description below.

[D] Select for Text Description.

Key: CSHCN = children with special health care needs. See Medical Expenditure Panel Survey (MEPS) documentation for the 2008 Full Year Consolidated Data File at http://www.meps.ahrq.gov/mepsweb/data_stats/download_data_files_detail.jsp?cboPufNumber=HC-121 for details.
Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2008.
Denominator: U.S. civilian noninstitutionalized population ages 2-17.
Note: Exercise advice includes the amount and kind of sports or physically active hobbies children should engage in.

  • Overall, in 2008, 34% of parents or guardians reported receiving advice within the past 2 years about the amount and kind of sports or physically active hobbies their children should engage in (Figure 2.45).
  • From 2002 to 2008, the percentage of children given advice about exercise improved for children ages 2-5 (from 25% to 30%) and those ages 6-17 (from 31% to 35%).
  • In 5 of the 7 years, children ages 6-17 were more likely than those ages 2-5 to receive advice to exercise.
  • From 2002 to 2008, the percentage of children given advice about exercise improved for children with special health care needs (from 40% to 43%) and those without such needs (from 28% to 31%).
  • In all years, children with special health care needs were more likely to receive advice to exercise than those without such needs.

Also, in the NHDR:

  • In all years, no statistically significant differences in the percentage of children who were given advice about exercise were observed between non-Hispanic Black and Hispanic children compared with non-Hispanic White children.
  • From 2002 to 2008, the percentage of children given advice about exercise improved for all income groups.
Prevention: Counseling Obese Adults About Healthy Eating

In addition to increased physical activity, an important factor in maintaining a healthy body weight is modifying eating habits to include a diet that incorporates nutritional food and beverages. It is essential for physicians to emphasize to patients the importance of consuming foods from all food groups, including whole grains and fibers, lean proteins, complex carbohydrates, fruits, and vegetables, as well as providing education about balancing energy intake and energy expenditure. The U.S. Department of Agriculture created the Dietary Guidelines for Americans 2010 to aid people in understanding the complexity of healthy eating for both children and adults.xxvii

 

Figure 2.46. Adults with obesity who ever received advice from a health provider about eating fewer high-fat or high-cholesterol foods, by age and gender, 2002-2008

Figure 2.46. Adults with obesity who ever received advice from a health provider about eating fewer high-fat or high-cholesterol foods, by age and gender, 2002-2008. For details, go to [D] Text Description below.     Figure 2.46. Adults with obesity who ever received advice from a health provider about eating fewer high-fat or high-cholesterol foods, by age and gender, 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: Civilian noninstitutionalized population age 18 and over.
Note: Obesity is defined as a body mass index of 30 or higher.

  • Overall, in 2008, only 49% of adults with obesity received advice from a health provider about healthy eating (Figure 2.46).
  • From 2002 to 2008, there were no statistically significant changes in any age or gender group in the percentage of adults with obesity who received advice about healthy eating.
  • In all years, adults with obesity ages 18-44 were less likely to receive advice about healthy eating compared with other age groups.

Also, in the NHDR:

  • From 2002 to 2008, obese Hispanic adults who received advice about healthy eating improved from 39% to 53%, but no changes were observed for other groups.
  • From 2002 to 2008, there were no statistically significant changes in any income group in the percentage of obese adults advised about healthy eating.
Prevention: Counseling for Children About Healthy Eating

An increasing number of children consume diets with too many calories and little nutritional value. Growing evidence has shown the integral role nutrition plays throughout one's lifetime. Eating patterns that are established early in childhood are often adopted later in life, making early interventions important. The Dietary Guidelines for Americans encourage children and adolescents to maintain a calorie-balanced diet to support normal growth and development without gaining excess weight. The American Academy of Pediatrics recommends that pediatricians discuss and promote healthy diets with all children and their parents or guardians, for those who are overweight and those who are not (Krebs & Jacobson, 2003).

 

Figure 2.47. Children ages 2-17 for whom a health provider ever gave advice about healthy eating, by age and insurance, 2002-2008

Figure 2.47. Children ages 2-17 for whom a health provider ever gave advice about healthy eating, by age and insurance, 2002-2008. For details, go to [D] Text Description below.     Figure 2.47. Children ages 2-17 for whom a health provider ever gave advice about healthy eating, by age and insurance, 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.

  • Overall, in 2008, 50% of parents or guardians reported receiving advice within the past 2 years about their children eating a healthy diet (Figure 2.47).
  • From 2002 to 2008, the percentage of children ages 6-17 who received advice about healthy eating improved (from 44% to 47%).
  • In all years, children ages 6-17 were less likely than children ages 2-5 to receive advice about healthy eating.
  • From 2002 to 2008, the percentage of children with any private or public health insurance who received advice about healthy eating improved.
  • In all years, children without insurance were less likely than children with any private insurance to receive advice about healthy eating.

Also, in the NHDR:

  • From 2002 to 2008, the percentage of children who were given advice about healthy eating improved for White, Black, and poor children.

xxi. The top 5 States that contributed to the achievable benchmark are Colorado, Delaware, Maine, New Hampshire, and Oklahoma.
xxii. The top 5 States contributing to the achievable benchmark are Iowa, Maine, New Hampshire, New Jersey, and Vermont.
xxiii. The top 5 States contributing to the achievable benchmark are Alaska, Indiana, Kansas, Maryland, and Oregon.
xxiv. More information about the 2008 Physical Activity Guidelines for Americans is available at http://www.health.gov/paguidelines/guidelines/default.aspx.
xxv. For more information about the President's Challenge, visit http://www.presidentschallenge.org .
xxvi. For more information about the 2008 Physical Activity Guidelines for Americans, go to http://www.health.gov/paguidelines/guidelines/default.aspx.
xxvii. For more information about the Dietary Guidelines for Americans, go to http://www.dietaryguidelines.gov.

Page last reviewed February 2011
Internet Citation: Chapter 2. Effectiveness of Care (continued, 3): National Healthcare Quality Report, 2011. February 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/nhqrdr/nhqr11/chap2c.html