Chapter 2. Effectiveness

Contents

Cancer
Diabetes
End Stage Renal Disease (ESRD)
Heart Disease
HIV and AIDS
Maternal and Child Health
Mental Health and Substance Abuse
Respiratory Disease
Nursing Home, Home Health, and Hospice Care

As noted in Chapter 1, Introduction and Methods, effectiveness of care is presented under nine clinical condition/care setting areas: cancer; diabetes; end stage renal disease (ESRD); heart disease; HIV and AIDS; maternal and child health; mental health and substance abuse; respiratory diseases; and nursing home, home health, and hospice care. The nine individual sections of this chapter highlight a small number of core measures; results for all core measures are found in the List of Core Report Measures at the end of this report.

In this chapter, 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 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 particularly difficult to categorize when prevention, treatment, and management all play important roles. Nevertheless, for the purposes of this report, measures are placed into categories that best fit the general descriptions below.

Prevention

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

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 ESRD, are chronic, which means they cannot simply be treated once; they must be managed across a lifetime. 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.

The measures highlighted on the following pages are categorized as follows:

Section	Measure
Prevention:
Cancer	Breast cancer screening (mammography)
Cancer	Breast cancer first diagnosed at advanced stage
Cancer	Breast cancer mortality
Diabetes	Lower extremity amputations
Heart disease	Counseling smokers to quit smoking
Heart disease	Counseling obese adults about being overweight*
Heart disease	Counseling obese adults about exercise
HIV and AIDS	New AIDS cases
HIV and AIDS	HIV testing*
HIV and AIDS	Eligible AIDS patients receiving PCP and MAC prophylaxis*
Maternal and child health	Receipt of prenatal care in the first trimester
Maternal and child health	Receipt of all recommended immunizations by young children
Maternal and child health	Dental visits for children
Maternal and child health	Counseling for children about healthy eating
Maternal and child health	Children told by health provider they were overweight*
Mental health and substance abuse	Suicide deaths
Respiratory diseases	Pneumococcal vaccination
Treatment:
Cancer	Receipt of recommended care for breast and colon cancer*
Heart disease	Receipt of recommended care for heart attack
Heart disease	Inpatient mortality following heart attack
Heart disease	Receipt of recommended care for acute heart failure
Maternal and child health	Hospital admissions for pediatric gastroenteritis
Mental health and substance abuse	Receipt of needed treatment for illicit drug use
Mental health and substance abuse	Receipt of treatment for depression
Respiratory diseases	Receipt of recommended care for pneumonia
Respiratory diseases	Receipt of antibiotics for the common cold
Respiratory diseases	Completion of tuberculosis therapy
Management:
Diabetes	Receipt of three recommended diabetes services
Diabetes	Controlled hemoglobin, cholesterol, and blood pressure
Diabetes	State variation in retinal eye exams*
End stage renal disease	Adequacy of hemodialysis
End stage renal disease	Registration for transplantation
Respiratory diseases	Hospital admissions for pediatric asthma
Nursing home, home health, and hospice care	Use of restraints on long-stay nursing home residents
Nursing home, home health, and hospice care	Presence of pressure ulcers in nursing home residents
Nursing home, home health, and hospice care	Pain management for nursing home residents*
Nursing home, home health, and hospice care	Improvement in ambulation in home health episodes
Nursing home, home health, and hospice care	Acute care hospitalization of home health patients
Nursing home, home health, and hospice care	Receipt of right amount of pain medicine by hospice patients*
Nursing home, home health, and hospice care	Receipt of care consistent with patient's stated end-of-life wishes*

^* Supplemental measure

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Cancer

Importance and Measures

Type of statistic	Number
Mortality
Number of deaths (2007 est.)	559,6501
Cause of death rank (2004)	2nd2
Prevalence
Number of living Americans who have been diagnosed with cancer (2004 est.)	10,762,2143
Incidence
New cases of cancer (2007 est.)	1,444,9201
New cases of breast cancer in women (2007 est.)	178,4801
Cost
Total costi (2006)	$206.3 billion4
Direct costsii(2006)	$78.2 billion4
Cost effectivenessiii of colorectal cancer screening	$0-$14,000/QALY5
Cost effectiveness of breast cancer screening	$35,000-$165,000/QALY5

Note: Statistics may vary from previous years due to revised and updated source statistics or addition of new data sources.

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 report. The 2006 NHQR highlighted colon cancer; this year's focus is on breast cancer. The core report measures are:

• Breast cancer screening (mammography).
• Breast cancer first diagnosed at an advanced stage.
• Breast cancer mortality.

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ⁱ 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."⁴

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. For example, the net cost for colorectal cancer screening ranges from $0 to $14,000 for each QALY saved.

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In addition, the 2007 NHQR includes three supplemental cancer care measures—two for breast cancer and one for colon cancer—from the National Cancer Data Base that have been endorsed by the National Quality Forum:

• Recommended care for breast and colon cancer patients:
  1. Administration of radiation therapy within 1 year of diagnosis for women under age 70 receiving breast-conserving surgery.
  2. Women with Stage I-IIb breast cancer who received either axillary node dissection or sentinel lymph node biopsy at the time of surgery (lumpectomy or mastectomy).
  3. Surgical resection of colon cancer that includes at least 12 lymph nodes.

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Findings

Prevention: Breast Cancer Screening (Mammography)

Early detection of cancer increases treatment options and often improves outcomes. Mammography, the most effective method for detecting breast cancer at its early stages,⁶ can identify malignancies before they can be felt and before symptoms develop. The U.S. Preventive Services Task Force recommends mammograms every 1-2 years for women age 40 and over.⁷

Figure 2.1. Women age 40 and over who reported they had a mammogram within the past 2 years, 1999, 2003, and 2005

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 1999, 2003, and 2005.

Reference population: Civilian noninstitutionalized women age 40 and over.

Note: Total rate is adjusted to the 2000 U.S. standard population.

• Between 1999 and 2005, the proportion of women age 40 and over who reported that they had a mammogram in the past 2 years decreased overall by 3.7%; it also decreased for the subgroups of women ages 40-64 and age 65 and over (Figure 2.1).
• The decline in rates of mammography observed in 2005 based on the National Health Interview Survey (NHIS) is not entirely consistent with data available from other U.S. national and State data sources (e.g., the Medical Expenditure Panel Survey), which indicate more stable rates of mammography over the period 2000-2005. The apparent decline in mammography rates between 1999 and 2005 based on the NHIS is due at least in part to a change in the skip pattern for the 2005 NHIS mammography questions in order to obtain more accurate estimates.

Figure 2.2. State variation: Women age 40 and over who reported they had a mammogram within the past 2 years, 2004

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, Behavioral Risk Factor Surveillance System, 2004.

Key: Above average = rate is significantly above the reporting States average in 2004. Below average = rate is significantly below the reporting States average in 2004.

Note: Age adjusted to the 2000 U.S. standard population. The "reporting States average" is the average of all reporting States (50 in this case, including the District of Columbia), which is a separate figure from the national average.

• Variation was seen among States in the rates of receipt of mammograms for women age 40 and over (Figure 2.2). In 2004, the reporting States average was 74.4%, ranging from 63.6% to 82.6%.
• Twelve States^iv were significantly above the reporting States average in 2004, with a combined average rate of 80.3%.
• Seventeen States^v were significantly below the reporting States average in 2004, with a combined average rate of 68.6%.

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^iv The States are Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, Michigan, Minnesota, New Hampshire, North Carolina, Rhode Island, and Tennessee.

^v The States are Alaska, Arkansas, Colorado, Idaho, Indiana, Mississippi, Missouri, Montana, Nevada, New Mexico, Oklahoma, Oregon, South Carolina, Texas, Utah, Washington, and Wyoming.

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Prevention: Advanced Stage Breast 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 cases of cancer that are diagnosed at late or advanced stages is a measure of the effectiveness of cancer screening efforts and of followup care after a positive screening test.

Figure 2.3. Age-adjusted rate of late stage^a breast cancer per 100,000 women age 40 and over, 1992-2004

^a Regional, distant stage, or local stage with tumor greater than 2-cm diameter.

Source: National Cancer Institute, Surveillance, Epidemiology, and End Results Program, 1992-2004.

Reference population: Women age 40 and over.

Note: Age adjusted to the 2000 U.S. standard population.

• Between 1992 and 2004, the overall rate of late stage breast cancer in women age 40 and over decreased from 95.7 to 92.8 per 100,000 women (Figure 2.3). This change was not statistically significant. However, both the increase in late stage disease observed between 1992 and the peak in 2001 (103.5 per 100,000), as well as the subsequent decrease (improvement) between 2001 and 2004, were statistically significant.

Prevention: Breast Cancer Mortality

The death rate from a disease is a function of many determinants, including the causes of the disease, social forces, and how well the health care system performs in providing effective prevention, treatment, and management of the disease. Breast cancer mortality reflects the impact of breast cancer screening, diagnosis, and treatment and is measured as the number of deaths per 100,000 women. Declines in breast cancer mortality can be attributed, in part, to improvements in early detection and treatment.

Figure 2.4. Age-adjusted breast cancer deaths per 100,000 women per year, all ages, 1999-2004

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System—Mortality.

Reference population: U.S. population, women.

Note: Age adjusted to the 2000 U.S. standard population.

• Between 1999 and 2004, the rate of breast cancer deaths decreased from 26.6 to 24.4 per 100,000 female population (Figure 2.4).
• At 24.4 deaths per 100,000 females, the overall breast cancer death rate in 2004 was higher than the Healthy People 2010 target of 22.3. At the present rate of change, this target could be met by 2010.

Treatment: Recommended Care for Breast and Colon Cancer Patients

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 the adequate examination of lymph nodes when surgery is performed (e.g., to remove colon cancer).

Figure 2.5. Patients with breast cancer^a who received recommended care: Radiation therapy to the breast within 1 year of diagnosis for women under age 70 receiving breast-conserving surgery, 1999 and 2004

^a American Joint Committee on Cancer Stage I, II, or III, primary invasive epithelial breast cancer.

Source: American Cancer Society and American College of Surgeons, National Cancer Data Base, 1999 and 2004.

Reference population: U.S. population, women.

Note: Age adjusted to the 2000 U.S. standard population.

• Between 1999 and 2004, the rates of women under age 70 with breast cancer and receiving breast-conserving surgery who received the recommended treatment of radiation therapy to the breast within 1 year of diagnosis remained stable overall at 73.7%. It also remained stable for all age groups except women under 40, for whom the rate decreased from 68.3% in 1999 to 65.4% in 2004 (Figure 2.5).
• In both 1999 and 2004, the rates of radiation therapy were highest for women ages 60-69 (75.6% and 75.9%) and lowest for women under 40 (68.3% and 65.4%).

Figure 2.6. Patients with breast cancer who received recommended care: Axillary node dissection or sentinel lymph node biopsy at the time of surgery (lumpectomy or mastectomy) for women with Stage I-IIb breast cancer, 1999 and 2004

Source: American Cancer Society and American College of Surgeons, National Cancer Data Base, 1999 and 2004.

Reference population: U.S. population, women.

Note: Age adjusted to the 2000 U.S. standard population.

• Between 1999 and 2004, rates of patients with breast cancer who received recommended care of axillary node dissection or sentinel lymph node biopsy at the time of surgery (lumpectomy or mastectomy) for women with Stage I-IIb breast cancer increased overall (83.1% in 1999 to 90.3% in 2004), as well as for all age groups (Figure 2.6).
• In 2004, women ages 50-59 had the highest rate of receipt of this care for breast cancer (93.1%). Women 80 years and over had the lowest rates in both data years but also showed the highest relative increase from 1999 to 2004 (56.6% to 71.7%).

Figure 2.7. Patients with colon cancer who received recommended care: Surgical resection of colon cancer that included at least 12 lymph nodes, 1999 and 2004

Source: American Cancer Society and American College of Surgeons, National Cancer Data Base, 1999 and 2004.

Reference population: U.S. population.

Note: Age adjusted to the 2000 U.S. standard population.

• Between 1999 and 2004, rates of patients with colon cancer who received the recommended care, in which the surgical resection of colon cancer includes at least 12 lymph nodes, increased overall (from 43.1% in 1999 to 54.9% in 2004), as well as for each age group (Figure 2.7).
• In 1999 and in 2004, patients under age 40 had the highest rates of receipt of this care (70.4% and 72.8%), and patients age 80 and over had the lowest rates (40.1% and 51.4%).
• For patients with colon cancer, the median number of regional lymph nodes examined in resected colon specimens was 12 overall. Patients under age 40 had the highest (18) and patients age 70 and over had the lowest (12) median number of regional lymph nodes examined (data not shown).

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Diabetes

Importance and Measures

Type of statistic	Number
Mortality
Number of deaths (2004)	72,8152
Cause of death rank (2004)	6th2
Prevalence
Total number of Americans with diabetes (2005)	20,800,0008
Number of Americans diagnosed with diabetes (2005)	14,600,0008
Number of Americans with undiagnosed diabetes (2005)	6,200,0008
Incidence
New cases (age 20 and over, 2005)	1,500,0008
Cost
Total cost (2002)	$132 billion9
Direct medical costs (2002)	$92 billion9

Note: Statistics may vary from previous years due to revised and updated source statistics or addition of new data sources.

Measures

Effective management of diabetes includes appropriate receipt of recommended processes, such as hemoglobin A1c tests, eye exams, and foot exams, as well as outcome measures expected to correlate positively with these processes, such as control of cholesterol, blood pressure, and HbA1c^vi levels. In addition, hospital admission rates among patients with diabetes for amputations of a leg or foot can be an indicator of appropriate care for this condition.

The three core report measures highlighted in this section are:

• Receipt of three recommended diabetes services.
• Lower extremity amputations.
• Controlled hemoglobin, cholesterol, and blood pressure.

In addition, a supplemental measure is presented:

• State variation in retinal eye exams.

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^vi HbA1c is glycosylated hemoglobin—the higher the level of glucose in the blood, the higher the HbA1c level.

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Findings

Management: Receipt of Three Recommended Diabetes Services

The NHQR uses a composite measure to track the national rate of the receipt of all three recommended diabetes interventions: an annual hemoglobin A1c test, an eye examination, and a foot examination. These provide an assessment of the management of diabetes and the presence of possible complications that can occur. They are basic process measures for the quality of care for diabetes. They do not include outcomes, such as the hemoglobin A1c value, an indicator of whether or not diabetes is adequately controlled.

Figure 2.8. Adults age 40 and over with diagnosed diabetes who received at least one HbA1c test, retinal exam, and foot exam in the past year, 2000-2004

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2000-2004.

Reference population: Civilian noninstitutionalized population with diagnosed diabetes age 40 and over.

Note: Rates are age adjusted. Data include persons with both type 1 and type 2 diabetes.

• Of adults age 40 and over diagnosed with diabetes, 46.7% received an HbA1c test, a retinal exam, and a foot exam in 2004 compared with 41.2% in 2000. The rate was statistically unchanged between 2000 and 2004 (Figure 2.8).
• From 2000 to 2004, the rate of receipt of foot exams for adults age 40 and over diagnosed with diabetes increased from 65.4% to 71.5%, while the rates for HbA1c tests and retinal exams remained stable.

Prevention: Lower Extremity Amputations

Although diabetes is the leading cause of lower extremity amputations, amputations can be avoided through proper care on the part of patients and providers. Hospital admissions for lower extremity amputations for patients with diagnosed diabetes reflect poorly controlled diabetes. Better management of diabetes would prevent the need for lower extremity amputations.

Figure 2.9. Hospital admissions for lower extremity amputations per 1,000 adult patients with diagnosed diabetes, 1999-2001 and 2003-2005

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Discharge Survey.

Reference population: Civilian noninstitutionalized adults age 18 and over with diagnosed diabetes, from the National Health Interview Survey, 1999-2001 and 2003-2005.

Note: Total rate is age adjusted to the 2000 U.S. standard population.

• The overall rate of lower extremity amputations in adults with diagnosed diabetes fell from 5.5 per 1,000 population in 1999-2001 to 4.1 per 1,000 population in 2003-2005 (Figure 2.9).
• During the same period, lower extremity amputation rates fell from 6.1 to 4.4 per 1,000 population for adults ages 45-64 and from 9.2 to 6.0 per 1,000 population for adults age 65 and over.
• The Healthy People 2010 target rate of 1.8 lower extremity amputations in adults with diagnosed diabetes per 1,000 population has not been met by any age group or by the total population age 18 and over.

Management: Controlled Hemoglobin, Cholesterol, and Blood Pressure

Persons diagnosed with diabetes^vii are often at higher risk for other cardiovascular risk factors, such as high blood pressure and high cholesterol. Having these conditions in combination with diagnosed diabetes increases the likelihood of complications, such as heart and kidney diseases, blindness, nerve damage, and stroke. Patients who manage their diagnosed diabetes and maintain an HbA1c level of <7%, total cholesterol of <200 mg/dL, and blood pressure of <140/80 mm Hg^viii can decrease these risks.

Figure 2.10. Adults age 40 and over with diagnosed diabetes with HbA1c, total cholesterol, and blood pressure under control, 1988-1994 and 1999-2004

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health and Nutrition Examination Survey, 1988-1994 and 1999-2004.

Reference population: Civilian noninstitutionalized population with diagnosed diabetes age 40 and over.

Note: Age adjusted to the 2000 U.S. standard population. Survey respondents were classified as having diabetes only if they had a previous diagnosis of diabetes from a doctor other than during a period of pregnancy (i.e., gestational diabetes was excluded). This is determined by a "Yes" response to the question: "Other than during pregnancy, have you ever been told by a doctor or health professional that you have diabetes or sugar diabetes?"

• In 1999-2004, 48.7% of adults age 40 and over diagnosed with diabetes had their HbA1c level under optimal control (<7%) (Figure 2.10). This percentage is statistically unchanged from the 1988-1994 time period.
• In 1999-2004, 48.2% of those age 40 and over diagnosed with diabetes had their total cholesterol under control (<200 mg/dL). This is an improvement over the 1988-1994 rate of 29.9% for this measure.
• In 1999-2004, 56.6% of this population had their blood pressure under control (<140/80 mm Hg), which is not significantly different from the 1988-1994 time period.
• Despite some progress, however, less than 60% of all adults age 40 and over with diagnosed diabetes have their blood sugar, cholesterol, and blood pressure under optimal control.

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^vii In 1997, the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus issued revised guidelines for the diagnosis of diabetes. Included among these was a change of the threshold for fasting plasma glucose level for the diagnosis of diabetes, which was lowered from 140 mg per dL to 126 mg per dL.

^viii Blood pressure control guidelines were updated in 2005. Previously, having a blood pressure reading of <140/90 mm Hg was considered under control. For this measure, the new threshold of <140/80 mm Hg has been applied to historical data for the sake of consistency and comparability.

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Management: State Variation in Retinal Eye Exams

Because persons with diagnosed diabetes are at an increased risk of vision loss due to complications such as diabetic retinopathy, cataracts, and glaucoma, effective management of diabetes includes yearly retinal eye exams.

Figure 2.11. State variation: Rates of receipt of annual retinal eye exam among adults age 40 and over with diagnosed diabetes, by State, 2005

Source: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System, 2005.

Key: Above average = rate is significantly above the reporting States average in 2005. Below average = rate is significantly below the reporting States average in 2005.

Reference population: Civilian noninstitutionalized population age 40 and over.

Note: Age adjusted to the 2000 U.S. standard population. The "reporting States average" is the average of all reporting States (39 in this case, including the District of Columbia), which is a separate figure from the national average.

• In 2005, State rates of receipt of retinal eye exams by adults age 40 and over with diagnosed diabetes ranged from 51% to 78.9%, with a reporting States average of 69.3%.
• Six States^ix were significantly above the reporting States average in 2005 (Figure 2.11), with a combined average rate of 77.9% in 2005.
• Seven States^x were significantly below the reporting States average in 2005, with a combined average rate of 59.8%.

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^ix The States are Connecticut, Delaware, Florida, Iowa, Minnesota, and New Hampshire.

^x The States are Arkansas, Idaho, Indiana, Missouri, Nevada, South Carolina, and Utah.

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