2014 National Healthcare Quality & Disparities Report

Quality and Quality Disparities

Quality and Quality Disparities

Measures of health care quality tracked in the QDR encompass a broad array of services, including prevention, acute treatment, and chronic disease management, and settings, including doctors' offices, emergency departments, dialysis centers, hospitals, nursing homes, hospices, and home health. Most QDR quality measures quantify processes that make up high-quality health care or outcomes related to receipt of high-quality health care. A few structural measures are included, such as the availability of health information technologies and diverse workforces.

Data used to generate QDR measures include results from more than three dozen datasets that provide estimates for various population subgroups and data years. Sources used to assess health care quality in the reports include:

  • Surveys of patients, patients' families, and providers.
  • Administrative data from health care facilities.
  • Abstracts of clinical charts.
  • Registry data.
  • Vital statistics.

Most data are reported annually and are generally available through 2012.

Historically, quality of health care has varied based on race, ethnicity, socioeconomic status, age, sex, disability status, sexual orientation, and residence location. As specified in the Healthcare Research and Quality Act, this summary focuses on disparities related to race and socioeconomic status.

With the passage of the Affordable Care Act, HHS was charged with identifying national priorities and developing and implementing a National Quality Strategy to improve the delivery of health care services, patient health outcomes, and population health. This section presents summary data across the six priorities. The last section provides more detail about each NQS priority.

QUALITY: Quality of health care improved generally through 2012, but the pace of improvement varied by measure.

Number and percentage of all quality measures that are improving, not changing, or worsening through 2012, overall and by NQS priority

Chart shows number and percentage of all quality measures that are improving, not changing, or worsening through 2012. Go to table below for details.

NQS Priority Improving No Change Worsening
Total (n=168) 102 55 11
Person-Centered Care (n=20) 17 3  
Effective Treatment (n=46) 24 17 5
Healthy Living (n=38) 18 17 3
Patient Safety (n=31) 14 16 1

 

Key: n = number of measures.

Note: For the majority of measures, trend data are available from 2001-2002 to 2012.

For each measure with at least four estimates over time, weighted log-linear regression is used to calculate average annual percentage change and to assess statistical significance. Measures are aligned so that positive change indicates improved access to care.

  • Improving = Rates of change are positive at 1% per year or greater and statistically significant.
  • No Change = Rate of change is less than 1% per year or not statistically significant.
  • Worsening = Rates of change are negative at -1% per year or greater and statistically significant.

Trends:

  • Through 2012, across a broad spectrum of measures of health care quality, 60% showed improvement (black).
  • Almost all measures of Person-Centered Care improved.
  • About half of measures of Effective Treatment, Healthy Living, and Patient Safety improved.
  • There are insufficient numbers of reliable measures of Care Coordination and Care Affordability to summarize in this way.

QUALITY: Through 2012, the pace of improvement varied across NQS priorities.

Average annual rates of change of quality of care measures through 2012, by National Quality Strategy priority

Scatterplot showing average annual percent change in performance of quality measures for NQS priorities. Patient Safety had 31 measures and the highest median change, followed by Person-Centered Care (20 measures), Effective Treatment (46 measures), and Healthy Living (38 measures).

Key: n = number of measures.

Note: Each point represents one measure. Large red diamonds indicate median values. For each measure with at least four estimates over time, weighted log-linear regression is used to calculate average annual percentage change. Measures are aligned so that positive change indicates improved quality of care.

Trends:

  • Through 2012, quality of health care improved steadily but the median pace of change varied across NQS priorities.
  • Median change in quality was 3.6% per year among measures of Patient Safety.
  • Median improvement in quality was 2.9% per year among measures of Person-Centered Care.
  • Median improvement in quality was 1.7% per year among measures of Effective Treatment.
  • Median improvement in quality was 1.1% per year among measures of Healthy Living.
  • There were insufficient data to assess Care Coordination and Care Affordability.

QUALITY: Publicly reported CMS measures were much more likely than measures reported by other sources to achieve high levels of performance.

Achieved Success

Eleven quality measures achieved an overall performance level of 95% or better this year. At this level, additional improvement is limited, so these measures are no longer reported in the QDR. Of measures that achieved an overall performance level of 95% or better this year, seven were publicly reported by CMS on the Hospital Compare Web site (bold).

  • Hospital patients with heart attack given percutaneous coronary intervention within 90 minutes.
  • Adults with HIV and CD4 cell count of 350 or less who received highly active antiretroviral therapy during the year.
  • Hospital patients with pneumonia who had blood cultures before antibiotics were administered.
  • Hospital patients age 65+ with pneumonia who received pneumococcal screening or vaccination.
  • Hospital patients age 50+ with pneumonia who received influenza screening or vaccination.
  • Hospital patients with heart failure and left ventricular systolic dysfunction who were prescribed angiotensin-converting enzyme or angiotensin receptor blocker at discharge.
  • Hospital patients with pneumonia who received the initial antibiotic dose consistent with current recommendations.
  • Hospital patients with pneumonia who received the initial antibiotic dose within 6 hours of arrival.
  • Adults with HIV and CD4 cell counts of 200 or less who received Pneumocystis pneumonia prophylaxis during the year.
  • People with a usual source of care for whom health care providers explained and provided all treatment options.
  • Hospice patients who received the right amount of medicine for pain management.

Last year, 14 of 16 quality measures that achieved an overall performance level of 95% or better were publicly reported by CMS. Measures that reach 95% and are no longer reported in the QDR continue to be monitored when data are available to ensure that they do not fall below 95%.

Improving Quickly

Through 2012, a number of measures showed rapid improvement, defined as an average annual rate of change greater than 10% per year. Of these measures that improved quickly, four are adolescent vaccination measures (bold).

  • Adolescents ages 16-17 years who received 1 or more doses of tetanus-diphtheria-acellular pertussis vaccine.
  • Adolescents ages 13-15 years who received 1 or more doses of tetanus-diphtheria-acellular pertussis vaccine.
  • Hospital patients with heart failure who were given complete written discharge instructions.
  • Adolescents ages 16-17 years who received 1 or more doses of meningococcal conjugate vaccine.
  • Adolescents ages 13-15 years who received 1 or more doses of meningococcal conjugate vaccine.
  • Patients with colon cancer who received surgical resection that included 12+ lymph nodes pathologically examined.
  • Central line-associated bloodstream infection per 1,000 medical and surgical discharges, age 18+ or obstetric admissions.
  • Women with Stage I-IIb breast cancer who received axillary node dissection or sentinel lymph node biopsy at time of surgery.

Worsening

Through 2012, a number of measures showed worsening quality. Of these measures that showed declines in quality, three track chronic diseases (bold). Note that these declines occurred prior to implementation of most of the health insurance expansions included in the Affordable Care Act.

  • Maternal deaths per 100,000 live births.
  • Children ages 19-35 months who received 3 or more doses of Haemophilus influenzae type b vaccine.
  • People who indicate a financial or insurance reason for not having a usual source of care.
  • Suicide deaths per 100,000 population.
  • Women ages 21-65 who received a Pap smear in the last 3 years.
  • Admissions with diabetes with short-term complications per 100,000 population, age 18+.
  • Adults age 40+ with diagnosed diabetes who had their feet checked for sores or irritation in the calendar year.
  • Women ages 50-74 who received a mammogram in the last 2 years.
  • Postoperative physiologic and metabolic derangements per 1,000 elective-surgery admissions, age 18+.
  • People with current asthma who are now taking preventive medicine daily or almost daily.
  • People unable to get or delayed in getting needed medical care, dental care, or prescription medicines due to financial or insurance reasons.

QUALITY DISPARITIES: Disparities remained prevalent across a broad spectrum of quality measures. People in poor households experienced the largest number of disparities, followed by Blacks and Hispanics.

Disparities: Number and percentage of quality measures for which members of selected groups experienced better, same, or worse quality of care compared with reference group

Chart shows number and percentage of quality measures for which members of selected groups experienced better, same, or worse quality of care compared with reference group. Go to table below for details.

  Poor vs. High Income (n=109) Black vs. White (n=165) Hispanic vs. White (n=150) Asian vs. White (n=146) AI/AN vs. White (n=85)
Better 6 20 30 36 15
Same 41 85 77 78 50
Worse 62 60 43 32 20

 

Key: AI/AN = American Indian or Alaska Native; n = number of measures.

Note: Poor indicates family income less than the federal poverty level; High Income indicates family income four times the federal poverty level or greater. Numbers of measures differ across groups because of sample size limitations. For the majority of measures, data from 2012 are shown. Measures that achieve an overall performance level of 95% or better are not reported in the QDR and are not included in these analyses. Because disparities are typically eliminated when overall performance reaches 95%, our analyses may overstate the percentage of measures exhibiting disparities.

The relative difference between a selected group and its reference group is used to assess disparities.

  • Better = Population received better quality of care than reference group. Differences are statistically significant, are equal to or larger than 10%, and favor the selected group.
  • Same = Population and reference group received about the same quality of care. Differences are not statistically significant or are smaller than 10%.
  • Worse = Population received worse quality of care than reference group. Differences are statistically significant, equal to or larger than 10%, and favor the reference group.

Disparities:

  • People in poor households received worse care than people in high-income households on more than half of quality measures (green).
  • Blacks received worse care than Whites for about one-third of quality measures.
  • Hispanics, American Indians and Alaska Natives, and Asians received worse care than Whites for some quality measures and better care for some measures.
  • For each group, disparities in quality of care are similar to disparities in access to care, although access problems are more common than quality problems (select for disparities in access).

QUALITY DISPARITIES: Through 2012, some disparities were getting smaller but most were not improving across a broad spectrum of quality measures.

Change in Disparities: Number and percentage of quality measures for which disparities related to race, ethnicity, and income were improving, not changing, or worsening through 2012

Chart shows number and percentage of quality measures for which disparities related to race, ethnicity, and income were improving, not changing, or worsening through 2012. Go to table below for details.

  Poor vs. High Income (n=98) Black vs. White (n=148) Hispanic vs. White (n=130) Asian vs. White (n=123) AI/AN vs. White (n=64)
Worsening 13 9 5 9 5
No Change 76 126 109 97 55
Improving 9 13 16 17 4

 

Key: AI/AN = American Indian or Alaska Native; n = number of measures.

Note: Poor indicates family income less than the federal poverty level; High Income indicates family income four times the federal poverty level or greater. Numbers of measures differ across groups because of sample size limitations. For the majority of measures, trend data are available from 2001-2002 to 2012.

For each measure, average annual percentage changes were calculated for select populations and reference groups. Measures are aligned so that positive rates indicate improvement in access to care. Differences in rates between groups were used to assess trends in disparities.

  • Worsening = Disparities are getting larger. Differences in rates between groups are statistically significant and reference group rates exceed population rates by at least 1% per year.
  • No Change = Disparities are not changing. Differences in rates between groups are not statistically significant or differ by less than 1% per year.
  • Improving = Disparities are getting smaller. Differences in rates between groups are statistically significant and population rates exceed reference group rates by at least 1% per year.

Disparity Trends

  • Through 2012, most disparities in quality of care related to race, ethnicity, or income showed no significant change (blue), neither getting smaller nor larger.
  • When changes in disparities occurred, measures of disparities were more likely to show improvement (black) than decline (green). However, for people in poor households, more measures showed worsening disparities than improvement.

QUALITY DISPARITIES: Through 2012, few disparities in quality of care were eliminated while a small number became larger.

Table 1. Disparities in health care quality that were eliminated or worsened over time

Groups Disparities Eliminated Disparities Worsened
Black compared with White Mechanical adverse events in patients receiving central venous catheter placement, age 18+a Adult current smokers with a checkup in the past year who received advice in the last 12 months to quit smoking
Hospital patients with an anticoagulant-related adverse drug event to low-molecular-weight heparin and factor Xa, age 18+a Breast cancer diagnosed at advanced stage per 100,000 women age 40+
Children ages 19-35 months who received 1+ doses of measles-mumps-rubella vaccineb People age 12+ who needed treatment for illicit drug use and who received treatment at a specialty facility in the last 12 months
Deaths per 1,000 hospital admissions with abdominal aortic aneurysm repair, age 18+ Family caregivers who did not want more information about what to expect while the patient was dyinge
Postoperative respiratory failure per 1,000 elective-surgery admissions, age 18+a  
Admissions with iatrogenic pneumothorax per 1,000 admissions, age 18+a  
Asian compared with White Adults age 40+ with diagnosed diabetes who had their feet checked in the calendar yearc Admissions with iatrogenic pneumothorax per 1,000 admissions, age 18+a
Adults age 40+ with diagnosed diabetes who received a dilated eye examination in the calendar yearc  
Adults age 65+ who received an influenza vaccination in the last 12 monthsb  
Adult hospital patients who sometimes or never had good communication with doctorsd  
Patients under age 70 with treated chronic kidney failure who received a transplant within 3 years of date of renal failurec  
Adults who had a visit in the last 12 months whose health providers sometimes or never listened carefully to themd  
AI/AN compared with White Children ages 19-35 months who received 3 or more doses of hepatitis B vaccineb Hospice patient caregivers who perceived patient was referred to hospice at right timee
Hispanic compared with Non-Hispanic White Adults with obesity who ever received advice from a health professional about eating fewer high-fat foods Hospice patients who received care consistent with their stated end-of-life wishese
  Hospice patients who received the right amount of medicine for pain managemente
Poor compared with High Income Adolescent females ages 13-15 years who received 3+ doses of human papillomavirus vaccineb Adults age 40+ with diagnosed diabetes who received 2+ hemoglobin A1c measurements in the calendar yearc
  Adults with chronic joint symptoms who have ever seen a doctor or other health professional for joint symptomsc

 

Note: a = hospital adverse events; b = vaccinations; c = chronic disease measures; d = communication measures; e = hospice measures. Disparities Eliminated indicates measures with significant population differences in the past that have been reduced to zero. Disparities Worsened indicates measures for which the population rate decreased as the reference group rate increased. For the majority of measures, trend data are available from 2001-2002 to 2012.

Disparities Trends (Table 1):

  • Through 2012, several disparities were eliminated.
    • One disparity in vaccination rates was eliminated for Blacks (measles-mumps-rubella), Asians (influenza), American Indians and Alaska Natives (hepatitis B), and people in poor households (human papillomavirus).
    • Four disparities related to hospital adverse events were eliminated for Blacks.
    • Three disparities related to chronic diseases and two disparities related to communication with providers were eliminated for Asians.
  • On the other hand, a few disparities grew larger because improvements in quality for Whites did not extend uniformly to other groups.
    • At least one disparity related to hospice care grew larger for Blacks, American Indians and Alaska Natives, and Hispanics.
    • People in poor households experienced worsening disparities related to chronic diseases.

QUALITY DISPARITIES: Overall quality and racial/ethnic disparities varied widely across states and often not in the same direction.

States sorted by overall quality (top) and average differences between Blacks, Hispanics, and Asians compared with Whites (bottom).

Map of United States showing States in each quartile based on overall quality score, from lowest to highest.

Map of United States showing States in each quartile based on disparities, from quartile with the fewest disparities to quartile with the most disparities.

Source: Agency for Healthcare Research and Quality, 2013 State Snapshots.

Note: An overall quality score is computed for each state based on the number of quality measures that are above, at, or below the average across all states; states are ranked and quartiles are shown in the top map. To assess disparities, separate quality scores are computed for Whites, Blacks, Hispanics, and Asians. For each state, the average of the Black, Hispanic, and Asian scores is divided by the White score; states are ranked on this ratio and quartiles are shown in the bottom map. See State Snapshots at http://nhqrnet.ahrq.gov/inhqrdr/state/select for more detailed methods.

Geographic Disparities

  • There was significant variation in quality among states. There was also significant variation in disparities.
  • States in the New England, Middle Atlantic, West North Central, and Mountain census divisions tended to have higher overall quality (blue and green) while states in the South census region tended to have lower quality (yellow and red).
  • States in the South Atlantic, West South Central, and Mountain census divisions tended to have fewer racial/ethnic disparities (blue and green) while states in the Middle Atlantic, West North Central, and Pacific census divisions tended to have more disparities (yellow and red).
  • The variation in state performance on quality and disparities may point to differential strategies for improvement.

The State Snapshots tool (http://nhqrnet.ahrq.gov/inhqrdr/state/select), part of the QDR Web site, focuses on variation across states and helps state health leaders, researchers, and consumers understand the status of health care in individual states and the District of Columbia. It is based on more than 100 QDR measures for which state estimates are possible. Data from the 2013 State Snapshots were used to rank each state by overall quality and by the average difference between Blacks, Hispanics, and Asians compared with Whites.

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Page last reviewed April 2015
Page originally created April 2015
Internet Citation: Quality and Quality Disparities. Content last reviewed April 2015. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/nhqrdr/nhqdr14/key2.html