2012 National Healthcare Quality Report

Chapter 2. Effectiveness of Care (continued)

Maternal and Child Health

Importance

Mortality
Number of maternal deaths (2007)548 (Xu, et al., 2010)
Number of infant deaths (2010 prelim.)24,548 (Murphy, et al., 2012)
Demographics
Number of childrenxix (2010)73,904,493 (U.S. Census Bureau, 2010)
Number of babies born in United States (2010)4,000,279 (Hamilton, et al., 2011)
Cost
Total cost of health care for children (2009)

$143.3 billion (AHRQ, 2009)

Cost-effectiveness of vision screening for children$0-$14,000/QALY (Maciosek, et al., 2006)
Cost-effectiveness of childhood immunization series (2001)

approx. $16 per $1 spent (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:

  • Prenatal care.
  • Receipt of recommended immunizations by young children.
  • Children's vision screening.
  • Well visits in the last year.
  • Receipt of meningococcal vaccine by adolescents.

Findings

New! Prevention: Early and Adequate Prenatal Care

The timing of initiation and the quality and quantity of prenatal care (PNC) may influence pregnancy outcomes, in particular the occurrence of preterm birth and low birth weight (Anum, et al.; 2010; Debiec, et al., 2010; Cox, et al., 2011; AAP, 2007). In the past, the NHQR and NHDR have followed a measure of PNC access in the first trimester as a key maternal and child health preventive measure. Because this measure does not take into account whether women then receive additional PNC throughout the pregnancy, we now report on a measure of early and adequate PNC.

One of the Healthy People 2020 objectives is that 77.6% of pregnant women receive early and adequate PNC, based on the Adequacy of Prenatal Care Utilization Index. This index looks at both initiation of PNC and number of visits; thus, early and adequate PNC is defined as PNC initiated by month 4 of the pregnancy and in which the woman also had at least 80% of the number of expected PNC visits.

The target number of PNC visits is based on when PNC started and on the infant's gestational age at birth. Because of consistency problems between the 1998 and 2003 versions of birth certificates, PNC timing and adequacy were evaluated only for the 28 States using the 2003 standard birth certificate for all of 2009. Because we have data for only 28 States, national estimates were not generated. However, these 28 States accounted for 66% of live births in the United States in 2009.

The data are shown in the map below. This map shows overall State rankings by quartiles in the percentage of infants born to women who received early and adequate PNC. State values ranged from 60.8% to 86.5%.

Figure 2.22. Infants born in 2009 whose mothers had obtained early and adequate prenatal care, by State quartiles

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Source: Centers for Disease Control and Prevention, National Center for Health Statistics, Division of Vital Statistics, National Vital Statistics System, 2009.

  • Interquartile ranges were as follows:
    • 1st quartile (best): 78.0%-86.5% (CA, IA, KS, MI, NH, UT, VT).
    • 2nd quartile (second best): 73.9%-75.9%.
    • 3rd quartile (second worst): 69.4%-73.2%.
    • 4th quartile (worst): 60.8%-68.0% (CO, NM, OH, PA, SD, TX, WA).
  • There was no clear pattern based on geographic region (Figure 2.22).

Also, in the NHDR:

  • Within the individual States, the NHDR mapped the absolute differences between White and Black infants (based on the reported race of the mother) in the percentage whose mothers had obtained early and adequate PNC in 2009. States ranged from a minimum difference between Whites and Blacks of 2.9% to a maximum difference of 28.7%.

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. These vaccines constitute the 4:3:1:3:3:1:4 vaccine series tracked in Healthy People 2020. The Healthy People 2020 target is 80% coverage in the population ages 19-35 months.

Figure 2.23. Children ages 19-35 months who received the 4:3:1:3:3:1:4 vaccine series, by income, 2009-2010

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Source: Centers for Disease Control and Prevention, National Center for Health Statistics and National Center for Immunization and Respiratory Diseases, National Immunization Survey, 2009-2010.
Denominator: U.S. civilian noninstitutionalized population ages 19-35 months.

  • In 2010, 70.2% of children ages 19-35 months had received all recommended vaccinations (Figure 2.23).
  • In both years, children from high-income households were more likely to receive all the recommended vaccinations than those from poor, low-income, and middle-income households.
  • The 2009 top 6 State achievable benchmark was 72%.xx At the current rate of improvement, most income groups could achieve the benchmark in a year. Children from high-income groups have already achieved the benchmark.

Also, in the NHDR:

  • In both years, Black children were less likely than White children to receive all recommended vaccinations.

Prevention: Children's Vision Screening

Vision checks for children may detect problems of which children and their parents were previously unaware. Early detection also improves the chances that corrective treatments will be successful.

Figure 2.24. Children ages 3-6 who ever had their vision checked by a health provider, by age and special health care needs status, United States, 2002-2009

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Key: CSHCN = Children with special health care needs.
Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2009.
Denominator: U.S. civilian noninstitutionalized population ages 3-6.
Note: For details on CSHCN, see the MEPS entry in the Detailed Methods appendix.

  • In 2009, 64.2% of children ages 3-6 had their vision checked by a health provider (Figure 2.24). Improvements were observed in both age groups and special health care needs status groups.
  • In all years, children ages 3-5 years were less likely to have their vision checked than those age 6 years.
  • In 5 of the 8 years from 2002 to 2009, children without special health care needs were less likely to have their vision checked than those with such needs.

Also, in the NHDR:

  • In 3 of the 8 years from 2002 to 2009, Hispanic children were less likely to have their vision checked than non-Hispanic White children.
  • In 4 of the 8 years from 2002 to 2009, children from poor, low-income, and middle-income households were less likely to have their vision checked than children from high-income households.

Prevention: Well Visits by Children in the Last Year

The American Academy of Pediatrics recommends annual preventive health care visits for all children (AAP, 2008). The AAP recommends regular preventive health care visits for children of all ages. Current recommendations are for 7 well child visits prior to 12 months of age; 5 well child visits between 12 and 30 months of age, inclusive; and one well child visit per year from 3 years of age on.

Figure 2.25. Children ages 0-17 with a well visit in the last 12 months, by age and insurance, 2009-2010

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Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2009-2010.
Denominator: Civilian noninstitutionalized population ages 0-17.

  • In 2010, 79.9% of children ages 0-17 had a wellness checkup in the last 12 months (Figure 2.25).
  • In both years, children ages 0-5 were more likely to have a well visit than those ages 6-11 and 12-17.
  • In both years, children with private insurance were more likely to have a well visit than uninsured children.

Also, in the NHDR:

  • In 2009 and 2010, non-Hispanic Black children had higher rates of well visits compared with their White counterparts, while Hispanic children had lower rates than non-Hispanic White children.
  • In both years, children from high-income households were more likely to have well visits than those from poor, low-income, and middle-income households.

Prevention: Receipt of Meningococcal Vaccine by Adolescents

According to the 2010 Census, individuals ages 10-14 years made up 6.7% of the U.S. population while those ages 15-19 years made up 7.1% of the population (U.S. Census Bureau, 2010). Youth in these age groups are at risk of contracting meningitis. 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. It can also cause meningococcemia, a serious bloodstream infection. 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 is recommended at age 16.

Figure 2.26. Adolescents ages 13-15 who ever received at least 1 dose of the meningococcal vaccine, by gender and residence location, 2008-2010

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Source:Centers for Disease Control and Prevention, National Center for Health Statistics and National Center for Immunization and Respiratory Diseases, National Immunization Survey, 2008-2010.

  • In 2010, 64.8% of adolescents ages 13-15 had ever received at least 1 dose of the meningococcal vaccine (Figure 2.26).
  • From 2008 to 2010, there were no statistically significant gender differences among adolescents ages 13-15 who received the meningococcal vaccine.
  • In all years, residents of nonmetropolitan areas were less likely to receive the meningococcal vaccine than those living in metropolitan areas.
  • The 2009 top 5 State achievable benchmark was 75%.xxi At the current rate, most groups could achieve the benchmark in a year.

Also, in the NHDR:

  • In 2008 and 2010, Hispanic adolescents were more likely to receive the meningococcal vaccine than non-Hispanic White adolescents.
  • In all years, adolescents from high-income households were more likely to receive the meningococcal vaccine than those from poor, low-income, and middle-income households.

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Mental Health and Substance Abuse

Importance

Mortality
Number of deaths due to suicide (2010 prelim.)37,793 (Murphy, et al., 2012)
Rank among causes of death in the United States—suicide (2010 prelim.)10th (Murphy, et al., 2012)
Alcohol-impaired driving fatalities (2010)10,228 (NHTSA, 2010)
Prevalence
People age 12 and over with alcohol and/or illicit drug dependence or abuse in the past year (2010)23.1 million (9.1%) (CBHSQ, 2010)
Children ages 6-17 who had depression or anxiety in their lifetime (2007-2008 est. based on parent report)3.8 million (7.8%) (Ghandour, 2011)
Youths ages 12-17 with a major depressive episode during the past year (2010)1.9 million (8.0%) (CBHSQ, 2010)
Adults age 18 and over with a major depressive episode during the past year (2010)15.5 million (6.8%) (CBHSQ, 2010)
Adults with at least one major depressive episode in their lifetime (2006)30.4 million (13.9%) (CBHSQ, 2007)
Cost
National expenditures for treatment of mental health and substance abuse disorders (2014 est.)$239 billion (CBHSQ, 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 four 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.

Findings

Treatment: Receipt of Treatment for Depression

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 (STAR*D) 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.

Barriers can exist for patients across the lifespan. The National Survey of Children's Health (HRSA, 2010) showed that among children with emotional, developmental, or behavioral conditions, 45.6% were receiving needed mental health services, and about half were taking medications. Recent data indicate, however, that service use for mental health is increasing among children (Pfuntner, et al., 2013).

 Figure 2.27. Adults (top) and adolescents (bottom) with a major depressive episode in the past year who received treatment for depression in the past year, by age and gender, 2008-2010

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Source: Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2008-2010.
Denominator: Adults age 18 and over and adolescents ages 12-17 with a major depressive episode in the past year.
Note: 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 2010, only 68% of adults and 38% of adolescents with a major depressive episode received treatment for depression (Figure 2.27).
  • In all years, adult males were less likely than adult females to receive treatment for depression. In 2009 and 2010, adolescent males were less likely than adolescent females to receive treatment for depression; in 2008 this difference was not statistically significant.

Also, in the NHDR:

  • In all years, Black adults and adolescents were less likely to receive treatment for depression than White adults and adolescents.

New! 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). Previous reports tracked suicide death for all ages. Beginning with 2008 and 2009 data shown in the 2011 reports, we track suicide death among people age 12 and over.

Figure 2.28. Suicide deaths per 100,000 population, by age and residence location, 2008-2009

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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, 2008-2009.
Denominator: U.S. population age 12 and over.
Note:For this measure, lower rates are better. Estimates are age adjusted to the 2000 U.S. standard population.

  • In 2009, the overall suicide death rate was 14.2 per 100,000 population age 12 and over (Figure 2.28).
  • In both years, adolescents ages 12-17 had lower suicide death rates than adults ages 18-44 and adults ages 45-64 had higher suicide death rates than adults ages 18-44.
  • In both years, residents of medium and small metropolitan areas, micropolitan areas, and noncore areas had higher suicide death rates than residents of large fringe metropolitan areas (suburbs).
  • The 2008 top 5 State achievable benchmark was 9 suicide deaths per 100,000 population.xxii Data are insufficient to assess progress toward the benchmark.

Also, in the NHDR:

  • In 2008 and 2009, Blacks, APIs, and AI/ANs 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 drugxxiii 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 spectrum disorders. 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 2.29. 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, 2008-2010

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Source: Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2008-2010.
Denominator: People age 12 and over who needed treatment for any illicit drug use or an 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 2010, 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 (Figure 2.29).
  • In all years, people with any college education were less likely to receive needed treatment for illicit drug use or an alcohol problem than high school graduates and 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 2010, adolescents ages 12-17 were less likely to receive treatment than adults ages 18-44 and adults ages 45-64 were more likely to receive treatment than adults ages 18-44.

Also, in the NHDR:

  • From 2002 to 2007, non-Hispanic Blacks were more likely to receive needed treatment for illicit drug use or an alcohol problem than non-Hispanic Whites.

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 2.30. People age 12 and over treated for substance abuse who completed treatment course, by age and gender, 2005-2009

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Source: Substance Abuse and Mental Health Services Administration, Treatment Episode Data Set, Discharge Data Set, 2005-2009.
Denominator: Discharges age 12 and over from publicly funded substance abuse treatment facilities.

  • From 2005 to 2009, 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 2.30).
  • 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.
  • The 2008 top 5 State achievable benchmark was 74%.xxiv No group showed progress toward the benchmark.

Also, in the NHDR:

  • In all years, people with less than a high school education who were treated for substance abuse were significantly less likely than people with any college education to complete treatment.

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Musculoskeletal Diseases

Importance

Prevalence
People who have arthritis, gout, lupus, or fibromyalgia (2007-2009)50 million (22% of U.S. adults) (MMWR, 2010a)
Number of people with low bone density52 million (Crandall, et al., 2012)
Morbidity
Activity limitations attributable to arthritis, gout, lupus, or fibromyalgia (2007-2009)21 million (MMWR, 2010a)
Lifetime osteoporosis-related fractures among women over age 50approx. 50% (NOF)
Lifetime osteoporosis-related fractures among men over age 50approx. 25% (NOF)
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)

Measures

This section tracks several quality measures for prevention and management of musculoskeletal diseases. The arthritis 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. Osteoporosis measures are usually tracked in this section, but no new data are available for this year's reports.

This section highlights three measures related to quality of care for arthritis:

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

Findings

Management: Arthritis Education for 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 2.31. 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, gender, insurance, and residence location, 2009

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Key: MSA = metropolitan statistical area.
Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2009.
Denominator: Civilian noninstitutionalized adults with doctor-diagnosed arthritis.
Note: Estimates are age adjusted to the 2000 U.S. standard population.

  • In 2009, only 11% of adults with doctor-diagnosed arthritis received effective, evidence-based arthritis education (Figure 2.31).
  • Adults age 65 and over were less likely to receive arthritis education than adults ages 45-64.
  • Men were less likely to receive arthritis education than women.

Also, in the NHDR:

  • High school graduates were less likely than adults with any college education to receive arthritis education.
  • Adults with basic or complex activity limitations were more likely than adults without such limitations to receive arthritis education.

Management: Counseling About Physical Activity for 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 2.32. Adults with doctor-diagnosed arthritis who reported they received health care provider counseling about physical activity or exercise, by age, gender, insurance, and residence location, 2009

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Key: MSA = metropolitan statistical area.
Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2009.
Denominator: Civilian noninstitutionalized adults with doctor-diagnosed arthritis.
Note: Estimates are age adjusted to the 2000 U.S. standard population.

  • In 2009, 57.2% of adults with doctor-diagnosed arthritis received health care provider counseling about physical activity or exercise (Figure 2.32).
  • Men were less likely to receive exercise counseling than women.
  • Residents of noncore areas were less likely to receive exercise counseling than residents of large fringe metropolitan areas (suburbs).

Also, in the NHDR:

  • Hispanics were more likely than non-Hispanic Whites to receive exercise counseling.
  • Adults with less than a high school education and high school graduates were less likely to receive exercise counseling than adults with any college education.
  • Adults with basic or complex activity limitations were more likely than adults without such limitations to receive exercise counseling.

Management: Counseling About Weight Reduction for 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 2.33. Overweight adults with doctor-diagnosed arthritis who reported they received health care provider counseling about weight reduction, by age, gender, insurance, and residence location, 2009

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Key: MSA = metropolitan statistical area.
Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2009.
Denominator: Civilian noninstitutionalized overweight adults with doctor-diagnosed arthritis.
Note: Estimates are age adjusted to the 2000 U.S. 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 2.33).
  • Overweight adults age 65 and over were less likely to receive weight reduction counseling than adults ages 45-64.
  • Overweight men were less likely than overweight women to receive weight reduction counseling.

Also, in the NHDR:

  • Overweight Blacks were more likely than Whites and overweight Hispanics were more likely than non-Hispanic Whites to receive weight reduction counseling.
  • Overweight adults with basic or complex activity limitations were more likely than adults without such limitations to receive weight reduction counseling.

xix. In this report, children are defined as individuals under age 18, unless otherwise specified.
xx. The top 6 States that contributed to the achievable benchmark are California (tie), Louisiana, Maryland, Massachusetts, New Hampshire, and Ohio (tie).
xxi. The top 5 States that contributed to the achievable benchmark are the District of Columbia, Massachusetts, New Jersey, North Dakota, and Rhode Island.
xxii. The top 5 States that contributed to the achievable benchmark are Connecticut, District of Columbia, Massachusetts, New Jersey, and New York.
xxiii. 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).
xxiv. The top 5 States that contributed to the achievable benchmark are Colorado, Connecticut, District of Columbia, Mississippi, and Texas.

Page last reviewed May 2013
Internet Citation: 2012 National Healthcare Quality Report: Chapter 2. Effectiveness of Care (continued). May 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/nhqrdr/nhqr12/chap2b.html