Effectiveness (continued)

Heart Disease

Type of statistic	Number
Number of deaths (2004)	654,0924
Cause of death rank (2004)	1st4
Number of cases of coronary heart disease (2005)	14,088,00018
Number of cases of heart failure (2004)	5,200,00019
Number of cases of high blood pressure (2005)	48,759,00018
Number of heart attacks (2004)	7,900,00019
Number of new cases of heart failure (2004)	550,00019
Total cost of cardiovascular disease (2006 est.)	$403.0 billion6
Total cost of congestive heart failure (2006 est.)	$29.6 billion18
Direct medical costs of cardiovascular disease (2006 est.)	$257.6 billion6
Cost effectiveness of hypertension screening	$14,000-$35,000/QALY7
Cost effectiveness of aspirin chemoprophylaxis	cost savings7,viii

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

Prevention: Counseling Obese Adults About Overweight

As in the 2005 report, measures related to overweight and obesity are presented in the NHDR. In this section, measures for counseling obese adults about overweight and exercise are presented. In Chapter 4, Priority Populations, a measure for counseling children about overweight is presented in the section on children.

Over 32% of adults age 20 and over in the United States are obese,^{20, ix} putting them at increased risk for many chronic, deadly conditions, such as hypertension, cancer, diabetes, and coronary heart disease.²¹ Reducing obesity is a major objective in preventing heart disease and stroke.²² Although physician guidelines recommend that health care providers screen all adult patients for obesity,²³ obesity remains underdiagnosed in U.S. adults.²⁴ The health care system has a central role to play in helping people become aware of the risks of obesity when they are overweight and suggesting strategies for reducing these risks.

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^viii Unlike other interventions which often involve greater costs for health benefits, this intervention actually results in net cost savings to society.

^ix Obesity is defined as having a body mass index (BMI) of 30 or higher. It is noteworthy that BMI incorporates both a person's weight and height in determining if he or she is overweight or obese.

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Figure 2.10. Obese adults (body mass index of 30 or higher) age 20 and over who were told by a doctor or health professional that they were overweight, by race/ethnicity, income, and education, 1999-2004

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

Reference population: Civilian noninstitutionalized population age 20 and over.

Note: Whites and Blacks are non-Hispanic populations. "Mexican American" is used in place of "Hispanic" because the NHANES is designed to provide estimates for this group rather than all Hispanics. Education groups are for adults age 25 and over only. Rates other than the total are age adjusted to the 2000 standard population. Data were not available for Asians, Native Hawaiians or Other Pacific Islanders, and American Indians and Alaska Natives.

• About two-thirds (66.2%) of obese adults were told by a doctor or health professional that they were overweight (Figure 2.10).
• The proportion of obese adults told that they were overweight was significantly lower for Blacks (61.1%) and Mexican Americans (56.5%) compared with Whites (68.8%); for middle income people compared with high income people (64.2% compared with 69.8%); and for adults with less than a high school education compared with adults with any college education (62.7% compared with 70.7%).

Prevention: Counseling Obese Adults About Exercise

Exercise counseling within the clinical setting is an important component of effective weight loss interventions.²³ Regular exercise aids in weight loss and blood pressure control efforts, reducing the risk of heart disease, stroke, diabetes, and other diseases.

Figure 2.11. Obese adults (body mass index of 30 or higher) age 18 and over who were given advice by a doctor or health professional about exercise, by race (top left), ethnicity (top right), income (bottom left), and education (bottom right), 2002-2004

Source:Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2004.

Reference population: Civilian noninstitutionalized population age 18 and over.

Note: Data were insufficient for this analysis for Asians, Native Hawaiians or Other Pacific Islanders, and American Indians and Alaska Natives.

• From 2002 to 2004, there were no significant changes in the proportion of obese adults who were given advice about exercise (Figure 2.11).
• During the same time period, there was no significant gap between Blacks and Whites on this measure.
• From 2002 to 2004, the gap between Hispanics and non-Hispanic Whites remained the same. In 2004, this proportion was significantly lower for Hispanics than for non-Hispanic Whites (44.7% compared with 62.6%).
• The gap between poor people and high income people remained the same. In 2004, this proportion was significantly lower for poor people compared with high income people (52.0% compared with 65.0%).
• The gap between people with less than a high school education and people with at least some college education remained the same. In 2004, the proportion of obese adults who were given advice about exercise was significantly lower for people with less than a high school education than for people with at least some college education (52.0% compared with 63.4%).

Each year, multivariate analyses are conducted in support of the NHDR to identify the independent effects of race, ethnicity, and socioeconomic status on quality of health care. Past reports have listed some of these findings. This year, the NHDR presents the results of a multivariate model for one measure: obese adults who were given advice about exercise. Adjusted odds ratios are shown to quantify the relative magnitude of disparities after controlling for a number of confounding factors.

Figure 2.12. Obese adults (body mass index of 30 or higher) who were given advice by a doctor or health professional about exercise: Adjusted odds ratios, 2002, 2003, and 2004

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002, 2003, and 2004.

Reference population: Obese civilian noninstitutionalized population ages 18-64.

Note: Adjusted odds ratios are calculated from logistic regression models controlling for race, ethnicity, income, education, insurance, age, gender, and residence location. White, non-Hispanic White, high income, some college, and private insurance are reference groups with odds ratio=1; odds ratios <1 indicate a group is less likely to receive a service than the reference group. For example, compared with obese adults with private insurance, the odds that obese adults with no insurance were given advice about exercise is 0.54 after controlling for other factors.

• In multivariate models controlling for race, ethnicity, income, education, insurance, age, gender, and residence location, obese Hispanics had 0.70 times the odds of receiving advice about exercise compared with non-Hispanic Whites, poor individuals had 0.77 times the odds compared with high income individuals, individuals with less than a high school education had 0.84 times the odds compared with individuals with some college education, and individuals with no health insurance had 0.54 times the odds compared with individuals with private insurance to receive advice about exercise when obese (Figure 2.12).

Treatment: Receipt of Recommended Hospital Care for Heart Failure

Recommended hospital care for heart failure includes evaluation of the left ventricular ejection fraction and receipt of an Angiotensin Converting Enzyme (ACE) inhibitor for left ventricular systolic dysfunction. In 2005, the ACE inhibitor measure was modified to include receipt of angiotensin receptor blockers (ARBs) as an alternative to ACE inhibitor receipt.

Figure 2.13. Recommended hospital care received by Medicare patients with heart failure, by race/ethnicity, 2002-2004 and 2005

Key: AI/AN=American Indian or Alaska Native.

Source: Centers for Medicare & Medicaid Services, Medicare Quality Improvement Organization program, 2002-2004.

Denominator: Medicare beneficiaries hospitalized for heart failure, all ages.

Note: Whites, Blacks, AI/ANs, and Asians are non-Hispanic groups. Composite incorporates the following measures: (1) receipt of evaluation of left ventricular ejection fraction and (2) receipt of Angiotensin Converting Enzyme (ACE) inhibitor for left ventricular systolic dysfunction. Composite is calculated by averaging the percentage of the population that received each of the two incorporated components of care. For further details on composite measures, go to Chapter 1, Introduction and Methods. Discontinuity of the trend line between 2004 and 2005 reflects the modification of the ACE inhibitor measure in 2005 to include receipt of angiotensin receptor blockers as an acceptable alternative to ACE inhibitors and the data collection method change made in 2005 from the abstraction of randomly selected medical records for Medicare beneficiaries to the receipt of hospital self-reported data for all payer types. Data were not available for Native Hawaiians or Other Pacific Islanders.

• In 2005, the proportion of Medicare patients with heart failure who received recommended hospital care was higher for Blacks than for Whites (89.1% compared with 87.4%).
• In 2005, the proportion of Medicare patients with heart failure who received recommended hospital care was lower for AI/ANs (85.9%) and Hispanics (86.7%) compared with Whites (87.4%).
• From 2002 to 2004, the overall percentage of Medicare patients with heart failure who received recommended hospital care improved from 73.4% to 77.7% (2005 data not comparable to this time period).
• During the same time period, this percentage was significantly lower for Hispanics compared with Whites. In 2004, the percentage was also significantly lower for AI/ANs compared with Whites.
• From 2002 to 2004, the percentage of Medicare patients with heart failure who received recommended hospital care improved significantly for the total population and for Whites, Blacks, and Hispanics (Figure 2.13).

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HIV and AIDS

Type of statistic	Number
Number of AIDS deaths (2005)	17,01125
Number of persons living with HIV/AIDS (2005)x	475,87125
Number of HIV/AIDS cases (2005)	37,36725
Number of AIDS cases (2005)	41,99325
Federal spending on HIV/AIDS care (fiscal year 2006)	$17.9 billion26

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

Prevention: HIV Testing

HIV infection is a serious health disorder that can be diagnosed before symptoms develop. HIV can be detected by reliable, inexpensive, and noninvasive screening tests. Although blood donations are routinely screened for HIV, tracking HIV testing in a health care setting helps to determine the impact of preventive care for the population. HIV-infected patients have years of life to gain if treatment is initiated early, before symptoms develop. The Centers for Disease Control and Prevention recommend routine voluntary HIV testing as part of normal medical practice in all health care settings.²⁷ HIV testing is recommended for all pregnant women during prenatal care and for people with high-risk behaviors for developing HIV. (Go to Priority Populations chapter on women.)

Figure 2.14. People ages 15-44 who ever had an HIV test outside of blood donations, by race/ethnicity, gender, and education, 2002

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Survey of Family Growth, 2002.

Notes: Whites and Blacks are non-Hispanic populations. Data were not available for Asians, Native Hawaiians or Other Pacific Islanders, and American Indians and Alaska Natives.

• In 2002, the proportion of people ages 15-44 who ever had an HIV test outside of blood donation was higher for Blacks than Whites (61.4% compared to 49.2%; Figure 2.14).
• The proportion of people ages 15-44 who ever had an HIV test outside of blood donations was lower for females than for males (46.6% compared to 54.9%).

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^x This is the estimated number of persons living with HIV/AIDS in the 33 States and dependent areas with confidential name-based HIV/AIDS infection reporting.

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Figure 2.15. People ages 15-44 with any HIV risk behaviors in the last 12 months who had an HIV test outside of blood donations in the last 12 months, 2002

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Survey of Family Growth, 2002.

Note: This table is based on a composite measure of HIV risk as defined in the Centers for Disease Control and Prevention's Advance Data.^{28, 29} A survey respondent was defined as having any HIV risk behavior if she/he reported any of the following in the 12 months before interview: crack cocaine or illicit intravenous drug use, five or more opposite-sex sexual partners, any same-sex partners (if male), a partner with intravenous drug use, a male partner who has had sex with males (if female), an HIV-positive partner, sex exchanged for money or drugs, or treatment for sexually transmitted disease. Whites and Blacks are non-Hispanic populations. Sample size was insufficient to calculate reliable estimates for Asians, Native Hawaiians or Other Pacific Islanders, and American Indians and Alaska Natives.

• There were no significant differences by race/ethnicity, income, or education in the proportion of people at risk for HIV who reported getting an HIV test during the past 12 months (Figure 2.15).

Management: PCP and MAC Prophylaxis

Management of chronic HIV disease includes outpatient and inpatient services. Because national data on HIV care are not routinely collected,^xi HIV measures tracked in the NHDR come from the HIV Research Network, which consists of 18 medical practices across the United States that treat large numbers of HIV patients.

Without adequate treatment, as HIV disease progresses, CD4 cell counts fall and patients become increasingly susceptible to opportunistic infections. When CD4 cell counts fall below 200, medicine to prevent development of Pneumocystis pneumonia (PCP) is routinely recommended; when CD4 cell counts fall below 50, medicine to prevent development of disseminated Mycobacterium avium complex (MAC) infection is routinely recommended.³⁰

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^xi Although program data are collected from all Ryan White CARE Act grantees, the aggregate nature of the data make it difficult to assess the quality of care provided by the Ryan White HIV/AIDS Program.

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Figure 2.16. HIV patients age 18 and over with CD4 cell count <200 who received PCP prophylaxis in the past year, by race/ethnicity, 2004

Source: HIV Research Network, 2004.

Reference population: HIV patients age 18 and over receiving care from HIV Research Network providers.

Note: Whites and Blacks are non-Hispanic populations. Data were not available for Asians, Native Hawaiians or Other Pacific Islanders, and American Indians and Alaska Natives.

• The proportion of HIV patients with CD4 cell count <200 who received PCP prophylaxis did not differ significantly by race/ethnicity (Figure 2.16).

Figure 2.17. HIV patients age 18 and over with CD4 cell count <50 who received MAC prophylaxis in the past year, by race/ethnicity, 2004

Source: HIV Research Network, 2004.

Reference population: HIV patients age 18 and over receiving care from HIV Research Network providers.

Note: Whites and Blacks are non-Hispanic populations. Data were not available for Asians, Native Hawaiians or Other Pacific Islanders, and American Indians and Alaska Natives.

• The proportion of HIV patients with CD4 cell count <50 who received MAC prophylaxis did not differ significantly by race/ethnicity (Figure 2.17).

Management: New AIDS Cases

Currently, comprehensive data on HIV infection rates across the Nation are lacking; however, early and appropriate treatment of HIV disease can delay progression to AIDS. Improved management of chronic HIV disease has likely contributed to declines in new AIDS cases. For example, as the use of highly active antiretroviral therapy (HAART) to treat HIV infection became widespread in the mid-1990s, rates of new AIDS cases declined.^{31, 32}

Figure 2.18. New AIDS cases per 100,000 population age 13 and over, by race/ethnicity, 1998-2005

Key: API=Asian or Pacific Islander; AI/AN=American Indian or Alaska Native.

Source: Centers for Disease Control and Prevention, National Center for HIV, STD, and TB Prevention, HIV/AIDS Surveillance System, 1998-2005.

Reference population: U.S. population age 13 and over.

Note: The source categorizes race/ethnicity as a single item. White=non-Hispanic White; Black=non-Hispanic Black.

• From 1998 to 2005, the overall rate of new AIDS cases remained about 18 cases per 100,000 persons (Figure 2.18).
• From 1998 to 2005, the rate of new AIDS cases decreased for Blacks (from 80.7 to 75.0 per 100,000), Hispanics (from 31.3 to 26.4 per 100,000), and Whites (from 8.2 to 7.5 per 100,000).
• In this time period, the gap between Blacks and Whites remained the same. In 2003, the rate of new AIDS cases was 10 times higher (75.0 per 100,000 compared with 7.5 per 100,000) for Blacks than for Whites.
• From 1998 to 2005, the gap between Hispanics and non-Hispanic Whites remained the same. In 2003, the rate of new AIDS cases was over 3 times higher for Hispanics than for Whites (26.4 per 100,000 compared with 7.5 per 100,000).
• There was no significant difference between AI/ANs and Whites in the proportion of new AIDS cases.
• No group has reached the Healthy People 2010 target of 1.0 new AIDS case per 100,000 population.

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