2012 National Healthcare Quality Report

Chapter 2. Effectiveness of Care

As better understanding of health and sickness has led to superior ways of preventing, diagnosing, and treating diseases, the health of most Americans has improved dramatically. However, many Americans do not receive the full benefits of high-quality care.

This chapter is organized around nine clinical areas (cancer, cardiovascular disease, chronic kidney disease, diabetes, HIV disease, maternal and child health, mental health and substance abuse, musculoskeletal diseases, and respiratory diseases) and three types of health care services that typically cut across clinical conditions (lifestyle modification, functional status preservation and rehabilitation, and supportive and palliative care).

Two sections in this chapter focus on national priorities identified in the National Strategy for Quality Improvement in Health Care. The Cardiovascular Disease section addresses the priority "promoting the most effective prevention and treatment of the leading causes of mortality, starting with cardiovascular disease." The Lifestyle Modification section addresses the priority "working with communities to promote wide use of best practices to enable healthy living."

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

Prevention

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

Treatment

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

Management

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

Outcomes

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

 Cancer

Importance

Mortality
Number of deaths (2012 est.)577,190 (ACS, 2012)
Cause of death rank (2010 prelim.)2nd (Murphy, et al., 2012)
Prevalence
Americans diagnosed and living with cancer (2008)12 million (ACS, 2012)
Incidence
New cases of cancer (2012 est.)1,638,910 (ACS, 2012)
New cases of breast cancer (2012 est.)226,870 (ACS, 2012)
New cases of colorectal cancer (2012 est.)143,460 (ACS, 2012)
Cost
Total costi (2007 est.)$226.8 billion (ACS, 2012)
Direct costsii (2007 est.)$103.8 billion (ACS, 2012)
Indirect costs (2007 est.)$123 billion (ACS, 2012)
Cost-effectivenessiii of breast cancer screening$35,000-$165,000/QALY (Maciosek, et al., 2006)
Cost-effectiveness of colorectal cancer screening$0-$14,000/QALY (Maciosek, et al., 2006)

Measures

Evidence-based consensus defining good quality care and how to measure it currently exists for only a few cancers and a few aspects of care. Breast and colorectal cancers have high incidence rates and are highlighted in alternate years of the National Healthcare Quality Report (NHQR) and National Healthcare Disparities Report (NHDR). In even years, the reports focus on colorectal cancer, and in odd years, the reports focus on breast cancer.

This year, the report measures are:

  • Colorectal cancer screening.
  • Colorectal cancer first diagnosed at advanced stage.
  • Surgical resection of colon cancer that includes at least 12 lymph nodes.
  • Colorectal cancer deaths.

Findings

New! Prevention: Colorectal Cancer Screening

Colorectal cancer is the third most common cancer in adults. Prevention of colorectal cancer includes modifying risk factors such as weight, physical activity, smoking, and alcohol use, as well as screening for early disease. Screening can detect abnormal growths before they develop into cancer. Early detection increases treatment options and the chances for survival. Effective screening modalities include fecal occult blood testing, flexible sigmoidoscopy, and colonoscopy.

Previous reports tracked receipt of colorectal cancer screening among adults age 50 and over. The colorectal cancer screening measure used in the 2012 NHQR and NHDR reflects a more recent recommendation of the U.S. Preventive Services Task Force showing the strongest support for screening among adults ages 50-75.

 Figure 2.1. Adults ages 50-75 who reported having colorectal cancer screening, by age and insurance, 2000, 2003, 2005, 2008, and 2010

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Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2000, 2003, 2005, 2008, and 2010.
Denominator: Civilian noninstitutionalized population ages 50-75.
Note: Rates are age adjusted to the 2000 U.S. standard population. Colorectal cancer screening includes blood stool test in the past year or sigmoidoscopy in the past 5 years and blood stool test in the past 3 years or colonoscopy in the past 10 years.

  • The overall percentage of adults ages 50-75 who reported receiving colorectal cancer screening significantly increased, from 34.1% in 2000 to 59.2% in 2010 (data not shown). Rates increased among all insurance groups (Figure 2.1).
  • In all years, adults ages 50-64 were less likely to receive colorectal cancer screening than adults ages 65-75.
  • In all years, among adults ages 50-64, those who were uninsured were less likely to receive colorectal cancer screening than those with private insurance. In 2008 and 2010, adults with public insurance only were also less likely to receive screening than adults with private insurance.
  • Among adults ages 65-75, those with Medicare only were less likely to receive colorectal cancer screening than those with Medicare and any private supplemental insurance in all years.
  • In 2003, adults with Medicare and other public insurance were also less likely to receive screening than those with Medicare and any private supplemental insuranceiv.
  • The 2010 top 5 State achievable benchmark was 68%v. Among adults ages 50-64, those with private insurance will need 2 years and those with public insurance only will need 5 years to attain the benchmark, while those who were uninsured will not attain the benchmark for 68 years. Among adults ages 65-75, those with Medicare and private insurance have attained this benchmark, while those with Medicare and public insurance will need another year and those with Medicare only will need 3 years.

Also, in the NHDR:

  • In all years, poor, low-income, and middle-income adults were less likely to receive colorectal cancer screening than high-income adults.

 Figure 2.2. State variation: Adults ages 50-75 who reported having colorectal cancer screening, 2010

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Key: Lowest Quality Quartile identifies States with the lowest rates of colorectal cancer screening; Highest Quality Quartile identifies States with the highest rates of colorectal cancer screening.
Source: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System, 2010.

  • The States in the lowest quality quartile had cancer screening rates under 58.3% while the States in the highest quality quartile had cancer screening rates over 67.6%.
  • States in the East South Central, West South Central, Mountain, and Pacific census divisions tended to have lower rates of colorectal cancer screening while States in the New England, Middle Atlantic, and South Atlantic census divisions tended to have higher rates of colorectal cancer screening (Figure 2.2).

Also, in the NHDR:

  • States in the West South Central, Mountain, and Pacific census divisions tended to have larger income-related disparities in colorectal cancer screening.

Outcome: Advanced Stage Colorectal Cancer

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

 Figure 2.3. Adults age 50 and over who have advanced stage colorectal cancer, per 100,000 population, by age and gender, 2000-2008

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Source: Centers for Disease Control and Prevention, National Program of Cancer Registries and National Cancer Institute, Surveillance, Epidemiology, and End Results (SEER) Program, 2000-2008.
Denominator: Adults age 50 and over.
Note: For this measure, lower rates are better. Age adjusted to the 2000 U.S. standard population. Advanced stage colorectal cancer is defined as regional or distant stage. Registries meeting United States Cancer Statistics publication criteria for every year, 2000-2008, are included and cover 90.1% of the total U.S. population. States excluded are Arkansas, District of Columbia, Mississippi, North Carolina, South Dakota, Tennessee, and Virginia.

  • From 2000 to 2008, the rate of advanced stage colorectal cancer fell among all age groups and both genders (Figure 2.3).
  • In all years, adults age 65 and over had higher rates of advanced stage colorectal cancer than adults ages 50-64 and men had higher rates than women.
  • The 2008 top 5 State achievable benchmark was 59 per 100,000 population.vi Adults ages 50-64 have attained the benchmark. At the current rates of decrease, women could achieve the benchmark in a year, while men would need 5 years and adults age 65 and over would need 8 years.

Also, in the NHDR:

  • In all years, Blacks had higher rates of advanced stage colorectal cancer than Whites.
  • In all years, American Indians and Alaska Natives (AI/ANs) and Asians and Pacific Islanders (APIs) had lower rates than Whites, and Hispanics had lower rates than non-Hispanic Whites.

Treatment: Receipt of Recommended Care for Colorectal Cancer

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

 Figure 2.4. Patients with colon cancer who received surgical resection of colon cancer that included at least 12 lymph nodes pathologically examined, by residence location and insurance, 2004-2009

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Source: Commission on Cancer, American College of Surgeons and American Cancer Society, National Cancer Data Base, 2004-2009.
Denominator: U.S. population.

  • The overall percentage of adults diagnosed with colorectal cancer who received recommended care significantly increased from 55.4% in 2004 to 83.9% in 2009 (data not shown). Significant improvement was observed in all residence locations and among all insurance groups (Figure 2.4).
  • In all years, residents of micropolitan areas were less likely to receive recommended care than residents of large metropolitan areas. Until 2009, residents of noncore areas were also less likely to receive recommended care.
  • In all years, patients with public insurance only were less likely to receive recommended care than patients with private insurance.
  • The 2008 top 5 State achievable benchmark was 90%.vii At current rates of improvement, all groups could achieve the benchmark within 2 years.

Also, in the NHDR:

  • In all years, low-income patients were less likely to receive recommended care than high-income patients.

Outcome: Colorectal Cancer Deaths

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

 Figure 2.5. Age-adjusted colorectal cancer deaths per 100,000 population, by gender and residence location, 2004-2009

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Key: MSA = metropolitan statistical area.
Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System—Mortality, 2004-2009.
Denominator: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System—Mortality, 2004-2009.
Note: For this measure, lower rates are better. Total rate is age adjusted to the 2000 U.S. standard population.

  • Between 2004 and 2009, the rate of colorectal cancer deaths significantly decreased, from 17.5 to 16 per 100,000 population (Figure 2.5).
  • In all years, males had higher colorectal cancer death rates than females and residents of noncore areas had higher death rates than residents of large fringe metropolitan areas. Since 2007, residents of micropolitan areas have also had higher death rates than residents of large fringe metropolitan areas.
  • The 2008 top 5 State achievable benchmark was 13 colorectal cancer deaths per 100,000 population.viii Females could achieve the benchmark in 2 years while males would need 14 years. Residents of large central, large fringe, and medium metropolitan areas could achieve the benchmark in 5 to 10 years and residents of small metropolitan and micropolitan areas could achieve the benchmark in 10 to 15 years.

Also, in the NHDR:

  • In all years, Blacks had higher colorectal cancer death rates than Whites.
  • In all years, AI/ANs and APIs had lower death rates than Whites and Hispanics had lower death rates than non-Hispanic Whites.

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 Cardiovascular Disease

Importance

Mortality
Number of deaths from major cardiovascular disease (2010 prelim.)777,548 (Murphy, et al., 2012)
Cause of death rank (2010 prelim.)1st (Murphy, et al., 2012)
Prevalence
Number of cases of heart failure (2010 est.)5.1 million (AHA, 2013)
Number of cases of high blood pressure among U.S. adults age 18 years and over (2003-2010 est.)67 million (MMWR, 2012b)
Incidence
Number of heart attacks or cases of fatal coronary heart disease (2010 est.)915,000 (AHA, 2013)
Cost
Total cost of cardiovascular disease (2009 est.)$312.6 billion (AHA, 2013)
Total cost of heart disease (2009 est.)$195.2 billion (AHA, 2013)
Direct costs of cardiovascular disease (2009 est.)$192.1 billion (AHA, 2013)
Cost-effectiveness of hypertension screening$14,000-$35,000/QALY (Maciosek, et al., 2006)

Measures

The NHQR and NHDR track several quality measures for preventing and treating cardiovascular disease. Five measures are highlighted here:

Four measures are highlighted here:

  • Blood pressure monitoring.
  • Blood pressure control.
  • Inpatient deaths following heart attack.
  • Angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) for heart failure.
  • Hospitalization for congestive heart failure.

Several measures related to heart disease are also presented in other chapters of this report. Timeliness of cardiac reperfusion for heart attack patients is tracked in Chapter 4, Timeliness. Receipt of complete written discharge instructions by patients with heart failure is tracked in Chapter 6, Care Coordination.

Findings

Prevention: Blood Pressure Monitoring

National screening guidelines for hypertension are well established (USPSTF, 2007). However, since high blood pressure is asymptomatic in most cases, it is not surprising that many of those affected do not know they have this condition.

 Figure 2.6. Adults who received a blood pressure measurement in the last 2 years and can state whether their blood pressure was normal or high, by gender and insurance (ages 18-64), 1998, 2003, and 2008

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Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 1998, 2003, and 2008.
Denominator: Civilian noninstitutionalized population age 18 and over.
Note: Rates are age adjusted to the 2000 U.S. standard population.

  • In 2008, 92.9% of adults reported they had a blood pressure measurement in the past 2 years (Figure 2.6).
  • In all years, men were less likely to have a blood pressure measurement than women.
  • Among adults ages 18-64, those who were uninsured were less likely to have a blood pressure measurement than those with private health insurance.

Also, in the NHDR:

  • In all years, Hispanics were less likely than Whites and adults with less than a high school education and high school graduates were less likely than adults with any college education to have a blood pressure measurement.

Management: Blood Pressure Control

Although progress has been made in raising awareness of blood pressure screening and monitoring, blood pressure control among people with diagnosed high blood pressure remains a problem.

 Figure 2.7. Adults with hypertension whose blood pressure is under control, by age, 1999-2002, 2003-2006, and 2007-2010, and gender, 1988-1994, 1999-2002, 2003-2006, and 2007-2010

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Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health and Nutrition Examination Survey, 1988-1994, 1999-2002, 2003-2006, and 2007-2010.
Denominator: U.S. civilian noninstitutionalized population age 18 and over.
Note: Rates are age adjusted to the 2000 U.S. standard population. Rates by age are not age adjusted. Blood pressure under control is defined as having a mean systolic blood pressure <140 and mean diastolic blood pressure <90 among all hypertensive patients.

  • From 1988-1994 to 2007-2010, the percentage of adults with hypertension who had their blood pressure under control increased from 23.1% to 45.9% (Figure 2.7).
  • In all years, adults ages 40-59 and 60 and over were more likely to have their blood pressure under control than adults ages 18-39.
  • In all years, women were more likely to have their blood pressure under control than men.

Also, in the NHDR:

  • In all years, Mexican Americans were less likely than Whites to have their blood pressure under control.

Outcome: Inpatient Deaths Following Heart Attack

Heart attack, or acute myocardial infarction, is a common life-threatening condition that requires rapid recognition and efficient treatment in a hospital to reduce the risk of serious heart damage and death. Measuring processes of heart attack care can provide information about whether a patient received specific needed services, but these processes make up a very small proportion of all the care that a heart attack patient needs. Measuring outcomes of heart attack care, such as mortality, can provide a more global assessment of all the care a patient receives and usually is the aspect of quality that matters most to patients.

Significant improvements in process measures of quality of care for heart attack have occurred in recent years. All process measures tracked in past reports have attained overall performance levels exceeding 95% and have been retired. Therefore, the 2012 NHQR and NHDR focus on outcome measures. Survival following admission for heart attack reflects multiple patient factors, such as a patient's comorbidities, as well as health care system factors, such as the possible need to transfer patients to other hospitals for services. It also may partly reflect receipt of appropriate health services.

 Figure 2.8. Inpatient deaths per 1,000 adult hospital admissions with heart attack, by gender and expected payment source, 2004-2009

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Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample and AHRQ Quality Indicators modified version 4.1, 2004-2009.
Denominator: Adults age 18 and over admitted to a non-Federal community hospital in the United States with acute myocardial infarction as principal discharge diagnosis.
Note: For this measure, lower rates are better. Rates are adjusted by age, major diagnostic category, all payer refined-diagnosis related group risk of mortality score, and transfers into the hospital.

  • From 2004 to 2009, the overall inpatient mortality rate for hospital admissions with heart attack decreased significantly overall and for both genders and all expected payment sources (Figure 2.8).
  • In all years, women had higher rates of inpatient heart attack deaths than men and uninsured patients had higher rates than privately insured patients. Before 2008, Medicaid patients also had higher rates than privately insured patients.
  • The 2008 top 3 State achievable benchmark for inpatient heart attack mortality was 47 per 1,000 admissions.ix At current rates of improvement, men, women, and all patients with insurance could achieve the benchmark within 2 years; uninsured patients would not achieve the benchmark for 7 years.

Also, in the NHDR:

  • Since 2004, Blacks have had lower inpatient mortality rates than Whites.

Treatment: Angiotensin-Converting Enzyme Inhibitor or Angiotensin Receptor Blocker for Heart Failure

Heart failure occurs when the heart muscle is too weak to adequately pump blood for the body's metabolic needs. Such impairment can result in a lack of adequate blood flow to vital organs, including the brain, kidney, and other organs, as well as a backup of fluid into the lungs. Often, heart failure is caused by damage to the heart muscle from a heart attack, which can seriously weaken the left ventricle, the main pumping chamber of the heart.

Congestive heart failure is the most frequent discharge diagnosis for Medicare beneficiaries. ACE inhibitors and ARBs have been found to improve survival and slow or prevent further loss of the heart's pumping ability.

 Figure 2.9. Hospital patients with heart failure and left ventricular systolic dysfunction prescribed ACE inhibitor or ARB at discharge, by age and gender, 2005-2010

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Source: Centers for Medicare & Medicaid Services, Medicare Quality Improvement Organization Program, 2005-2010.
Denominator: Patients hospitalized with a principal diagnosis of acute heart failure and left ventricular systolic dysfunction.

  • From 2005 to 2010, the overall percentage of patients with heart failure and left ventricular systolic dysfunction prescribed ACE inhibitor or ARB at discharge increased from 82.6% to 94.9% (Figure 2.9). Improvements were observed among all age groups and both genders.
  • In all years, patients age 65 and over were less likely to receive ACE inhibitors or ARBs for heart failure than patients under age 65.
  • The 2008 top 5 State achievable benchmark for patients with heart failure and left ventricular systolic dysfunction prescribed ACE inhibitor or ARB at discharge was 95%.x At current rates, all age and gender groups could attain the benchmark within a year.

Also, in the NHDR:

  • In all years, Blacks were more likely than Whites to receive ACE inhibitors or ARBs at discharge for heart failure.

Outcome: Hospitalization for Congestive Heart Failure

Some hospitalizations for heart failure are unavoidable, but rates of hospitalization can be influenced by the quality of outpatient care.

 Figure 2.10. Adult admissions for congestive heart failure per 100,000 population, by age and gender, 2004-2009

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Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample and AHRQ Quality Indicators modified version 4.1, 2004-2009.
Denominator: U.S. resident population age 18 and over.
Note: For this measure, lower rates are better. Age rates are adjusted by gender; gender rates are adjusted by age.

  • From 2004 to 2009, the overall hospitalization rate for congestive heart failure decreased significantly overall and for each age group and both genders (Figure 2.10).
  • In all years, patients ages 45-64 and 65 and over had higher rates than patients ages 18-44, and men had higher rates than women.
  • The 2008 top 4 State achievable benchmark for heart failure admissions was 195 per 100,000 population.xi Overall, this benchmark could not be achieved for 10 years.
  • At current rates of improvement, patients ages 45-64 could achieve this benchmark in 6 years while patients age 65 and over would take 21 years. Women could achieve the benchmark in 7 years while men would take 15 years.

Also, in the NHDR:

  • In all years, Blacks had higher rates of admission for congestive heart failure compared with Whites while APIs had lower rates.
  • In all years, residents of the highest area income quartile had lower rates than residents of the two lower area income quartiles.

i. Throughout this report, total cost equals cost of medical care (direct cost) and economic costs of morbidity and mortality (indirect cost).
ii. Direct costs are defined as "personal health care expenditures for hospital and nursing home care, drugs, home care, and physician and other professional services."
iii. Cost-effectiveness is measured here by the average net cost of each quality-adjusted life year (QALY) that is saved by the provision of a particular health intervention. QALYs are a measure of survival adjusted for its value: 1 year in perfect health is equal to 1.0 QALY, while a year in poor health would be something less than 1.0. A lower cost per QALY saved indicates a greater degree of cost-effectiveness.
iv. Medicare does not cover all health care costs. Medicare beneficiaries can purchase private supplemental insurance from insurance companies to help pay for coinsurance, copayments, and deductibles. Low-income beneficiaries may receive assistance from Medicaid and other public insurance programs to help pay for costs not covered by Medicare. Beneficiaries with Medicare only typically must pay out of pocket for costs not covered by Medicare.
v. The top 5 States that contributed to the achievable benchmark are Connecticut, Maine, Massachusetts, New Hampshire, and Rhode Island.
vi. The top 5 States that contributed to the achievable benchmark are Arizona, Colorado, District of Columbia, Vermont, and Virginia.
vii. The top 5 States that contributed to the achievable benchmark are Delaware, Missouri, Utah, Vermont, and Wisconsin.
viii. The top 5 States that contributed to the achievable benchmark are Arizona, Hawaii, Idaho, Montana, and Utah.
ix. The top 3 States that contributed to the achievable benchmark are Arizona, Michigan, and Ohio.
x. The top 5 States that contributed to the achievable benchmark are Alaska, Maine, New Hampshire, South Carolina, and Virginia.
xi. The top 4 States that contributed to the achievable benchmark are Colorado, Oregon, Utah, and Vermont.

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Current as of May 2013
Internet Citation: 2012 National Healthcare Quality Report: Chapter 2. Effectiveness of Care. May 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/nhqrdr/nhqr12/chap2.html