Respiratory Diseases

Importance and Measures

Type of statistic	Number
Mortality
Number of deaths due to lung diseases (2003)	243,00037
Number of deaths, influenza and pneumonia combined (2004)	59,6642
Cause of death rank, influenza and pneumonia combined (2004)	8th2
Prevalence
People 18 and over who have asthma (2005)	15,697,00038
People under 18 who have asthma (2005)	6,531,00039
Incidence
Annual number of cases of the common cold (est.)	>1 billion40
Annual number of pneumonia cases due to Streptococcus pneumoniae	500,00041
New cases of tuberculosis (2006)	13,76742
Cost
Total cost of lung diseases (2006 est.)	$144.2 billion4
Direct medical costs of lung diseases (2006 est.)	$87.0 billion4
Total approximate cost of upper respiratory infections (annual)	$40 billion43
Total cost of asthma (2004)	$16.1 billion37
Direct medical costs of asthma (2004)	$11.5 billion37
Cost effectiveness of influenza immunization	$0-$14,000/QALY5

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

Measures

The NHQR tracks several quality measures for prevention and treatment of this broad category of illnesses that includes influenza, pneumonia, asthma, upper respiratory infection, and tuberculosis. The five core report measures highlighted in this section are:

• Pneumococcal vaccination.
• Receipt of recommended care for pneumonia.
• Receipt of antibiotics for the common cold.
• Completion of tuberculosis therapy.
• Hospital admissions for pediatric asthma.

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Findings

Prevention: Pneumococcal Vaccination

Vaccination is a cost effective strategy for reducing illness and death associated with pneumococcal disease of the lungs (pneumonia) and influenza.

Figure 2.37. Noninstitutionalized adults age 65 and over who ever received pneumococcal vaccination, 1999-2005

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

Reference population: Civilian noninstutionalized population age 65 and over.

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

• The percent of adults age 65 and over who ever received a pneumococcal vaccination increased from 49.9% in 1999 to 56.3% in 2005 (Figure 2.37). The Healthy People 2010 target of 90% is unlikely to be met until after 2020 at this rate of change.

Figure 2.38. State variation: Adults age 65 and over who ever received pneumococcal vaccination, 2005

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

Reference population: Civilian noninstitutionalized population age 65 and over.

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.

Note: Age adjusted to the 2000 U.S. standard population. "Reporting States average" is the average of all reporting States (51 in this case, including the District of Columbia), which is a separate figure from the national average.

• In 2005, the reporting States average of adults 65 and over who had ever received a pneumococcal vaccination was 64.1%, with a range from 51.4% to 71.7% (Figure 2.38).
• Nineteen States^xxi were significantly above the reporting States average in 2005, with a combined average rate of 69.3%.
• Three States^xxii were significantly below the reporting States average in 2005, with a combined average rate of 55.2%.
• Eighteen States showed improvement between 2001 and 2005 in the number of adults age 65 and over who had ever received a pneumococcal vaccination.^xxiii No State showed a significant decrease on this measure over this time period.

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^xxi The States are Colorado, Connecticut, Iowa, Louisiana, Michigan, Minnesota, Montana, Nebraska, Nevada, New Hampshire, North Carolina, North Dakota, Oklahoma, Oregon, Pennsylvania, Rhode Island, Washington, West Virginia, and Wyoming.

^xxii The States are Arkansas, District of Columbia, and Illinois.

^xxiii The States are Connecticut, Indiana, Kentucky, Louisiana, Michigan, Minnesota, Mississippi, Missouri, Nebraska, New Hampshire, New Jersey, North Dakota, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, and West Virginia.

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Treatment: Receipt of Recommended Care for Pneumonia

Recommended care for patients with pneumonia includes receipt of: (1) initial antibiotics within 4 hours of hospital arrival; (2) antibiotics consistent with current recommendations; (3) blood culture before antibiotics are administered; (4) influenza vaccination status assessment/vaccine provision; and (5) pneumonia vaccination status assessment/vaccine provision. The NHQR tracks receipt of this care for each measure and as an overall composite.

Figure 2.39. Patients with pneumonia who received recommended care for pneumonia: Overall composite and five components, 2005

Source: Centers for Medicare & Medicaid Services, Quality Improvement Organization Program, 2005.

Denominator: Patients hospitalized with a principal diagnosis of pneumonia or a principal diagnosis of either septicemia or respiratory failure and secondary diagnosis of pneumonia.

Note: Beginning in 2005, the data collection method changed from the abstraction of randomly selected medical records for Medicare beneficiaries to the receipt of hospital self-reported data for all payer types.

• In 2005, 74.1% of adult patients with pneumonia received the recommended care included in the overall pneumonia treatment composite measure (Figure 2.39).
• Among the five components of the composite measure, patients were most likely to receive blood cultures when clinically appropriate (82.5%) and least likely to have their influenza vaccination status assessed and receive the vaccine if indicated (56.9%).
• Revisions to two component measures related to recommended care for pneumonia should be noted:
  • The individual measure of appropriate antibiotic selection for community-acquired pneumonia was changed to exclude patients with health-care-associated pneumonia from the denominator used in the calculation.
  • The individual measure for the collection of samples for blood culture within 24 hours of hospital arrival was changed so that only those patients who were admitted to the intensive care unit within 24 hours of hospital arrival are included in the denominator.

Treatment: Receipt of Antibiotics for the Common Cold

Taking antibiotics does not treat or relieve symptoms of the common cold and may lead to the development of antibiotic-resistant bacteria. Although antibiotic prescribing patterns are slowly improving, overuse of antibiotics is still a concern.⁴⁴ Children have the highest rates of antibiotic use and the highest rates of infection with antibiotic-resistant bacterial pathogens.⁴⁵

Figure 2.40. Rate of antibiotic drug utilization at ambulatory care visits with a diagnosis of common cold per 10,000 population, overall, for children under age 18, and for adults 65 and over, 1997-2005

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, 1997-1998, 1999-2000, 2001-2002, 2003-2004, and 2004-2005.

Denominator: U.S. noninstitutionalized population.

• In 2004-2005, the overall rate of antibiotics prescribed at visits with a diagnosis of the common cold stood at 137.0 per 10,000, above the Healthy People 2010 target of 126.8 per 10,000 (Figure 2.40). However, if current trends continue, this target will be achieved before the year 2010.
• From 1997-1998 to 2004-2005, the rate of antibiotic prescription at visits with a diagnosis of common cold decreased overall for persons of all ages and for children under age 18. The rate did not change significantly for adults under age 65 (data not shown).

Treatment: Completion of Tuberculosis Therapy

In order to be effective for individuals as well as the public, tuberculosis therapy must be taken to its completion. Failure to complete tuberculosis therapy puts patients at increased risk for treatment failure and for spreading the disease to others. Even worse, it may result in the development of drug-resistant strains of the disease.⁴⁶

Figure 2.41. Completion of tuberculosis therapy within 1 year, by age group, 1998-2003

Source: Centers for Disease Control and Prevention, National TB Surveillance System, 1998-2003.

Reference population: U.S. civilian noninstitutionalized population.

• From 1998 to 2003, the rate of completion of tuberculosis therapy within 1 year rose from 79.1% to 81.5% (Figure 2.41).
• Children under age 18 and adults ages 18-44 showed a significant increase in completion of tuberculosis therapy. The percentages for these groups rose from 87.4 % and 76.6% in 1998 to 91.0% and 80.0% in 2003, respectively.
• In all six data years, children under age 18 were more likely than adults ages 18-44 to complete tuberculosis therapy within 1 year.

Management: Hospital Admissions for Pediatric Asthma

Asthma can be effectively controlled over the long term with recommended medications (depending on the severity of the disease), routine checkups, education of patients, and use of asthma management plans. Preventing hospital admissions for asthma is one measure of successful management of asthma at the population level.

Figure 2.42. Pediatric hospital admissions for asthma per 100,000 population ages 2-17, 1994, 1997, and 2000-2004

Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project Nationwide Inpatient Sample, 1994, 1997, and 2000-2004.

Denominator: Children ages 2-17.

Note: Rates are adjusted by age and gender, using the total U.S. population for 2000 as the standard population. The estimates in this chart differ from those reported in the 2006 NHQR and have been updated for the 2007 NHQR. The 2006 NHQR estimates included children ages 0-17. Data were analyzed for two selected historical years (1994, 1997) and annually with each NHQR (2000-2004).

• In 2004, there were 155.5 admissions for asthma per 100,000 children ages 2-17. This rate was less than the rate of 193.2 per 100,000 in 1994 but not significantly different from the rates in 2000 to 2003 (Figure 2.42).

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Nursing Home, Home Health, and Hospice Care

Importance and Measures

Type of statistic	Number
Demographics
Number of nursing home residents (2004)	1,442,50347
Number of home health patients (2000)	1,355,29048
Number of current hospice care patients (2000)	105,49649
Discharges from nursing homes (1998-1999)	2,500,00047
Discharges from home health agencies (2000)	7,179,00048
Discharges from hospice care (2000)	621,10049
Cost
Total costs of nursing home services (2005)	$121.9 billion50
Total costs of home health services (2005)	$47.5 billion50
Annual national expenditures for hospice care for decedents (1992-1996)	$1.232 billion51
Percent of health care expenditures for hospice care in last 6 months of life	74%51

Note: Statistics may vary from previous years due to revised and updated source statistics or addition of new data sources. Cost estimates for nursing home and home health services include only costs for freestanding skilled nursing facilities, nursing homes, and home health agencies, and not those that are hospital based.

Measures

The NHQR tracks 14 measures of nursing home care. Care is tracked among both short-stay and long-stay residents. Short-stay residents commonly have a brief stay in a nursing home after a hospitalization which, in turn, is usually followed by return to their home. Care for short-stay residents is often funded by the Medicare Skilled Nursing Facility benefit. Long-stay residents, in contrast, are expected to stay in the nursing home either permanently or for an extended period of time. The NHQR also tracks 12 measures for home health care that reflect improvement or deterioration during the course of care. Two core report measures on nursing home care and two core report measures on home health care are highlighted in this section:

• Use of restraints on long-stay nursing home residents.
• Presence of pressure ulcers in nursing home residents.
• Improvement in ambulation in home health episodes.
• Acute care hospitalization of home health patients.

In addition, this year the NHQR includes a supplemental measure from the 2004 National Nursing Home Survey:

• Pain management for nursing home residents.

Building on last year's first presentation of supplemental measures of quality of hospice care, this year's NHQR extends its analysis of this important area. Hospice care is delivered at the end of life to patients with a terminal illness or condition requiring comprehensive medical care as well as psychosocial and spiritual support for the patient and family. The goal of end-of-life care is to achieve a "good death," defined by the Institute of Medicine as one that is "free from avoidable distress and suffering for patients, families, and caregivers; in general accord with the patients' and families' wishes; and reasonably consistent with clinical, cultural, and ethical standards."⁵²

The National Hospice and Palliative Care Organization's Family Evaluation of Hospice Care survey examines the quality of hospice care for dying patients and their family members. Family respondents report how well hospices respect patient wishes, communicate about illness, control symptoms, support dying on one's own terms, and provide family emotional support.^{53, xxiv}

The two supplemental measures presented here from the National Hospice and Palliative Care Organization's Family Evaluation of Hospice Care are:

• Receipt of right amount of pain medicine.
• Receipt of care consistent with patient's stated end-of-life wishes.

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^xxiv This survey provides unique insight into end-of-life care and captures information about a large proportion of hospice patients but is limited by nonrandom data collection and a response rate of about 40%. Survey questions were answered by family members of patients, who might not be fully aware of the patients' wishes and concerns. These limitations should be considered when interpreting these findings.

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Findings

Management: Use of Restraints on Long-Stay Nursing Home Residents

A physical restraint is any device, material, or equipment that keeps a resident from moving freely. A resident who is restrained daily can become weak and develop other medical complications. The use of physical and pharmacological restraints can result in a variety of emotional, mental, and physical problems. According to regulations for the nursing home industry, restraints should be used only to ensure the physical safety of a nursing home resident.

Figure 2.43. Long-stay nursing home residents with physical restraints, 1999-2005

Source: Centers for Medicare & Medicaid Services, Minimum Data Set, 1999-2005. Data are from the third quarter of each calendar year.

Denominator: All long-stay residents in Medicare or Medicaid certified nursing home facilities.

Note: Restraint use was determined based on a 7-day assessment period.

• The overall proportion of long-stay nursing home residents who are physically restrained decreased from 10.7% in 1999 to 6.6% in 2005 (Figure 2.43).
• Decreases in the use of physical restraints were also observed for all age groups (data not shown).

Figure 2.44. State variation: Long-stay nursing home residents with physical restraints, 2006

Source: Centers for Medicare & Medicaid Services, Minimum Data Set, Nursing Home Compare, 2006.

Denominator: All long-stay residents in Medicare or Medicaid certified nursing and long-term care facilities.

Key: Higher rate = State has rate in use of restraints higher than the reporting States average in 2006. Lower rate = State has rate in use of restraints lower than the reporting States average in 2006.

Note: The "reporting States average" is the average of all reporting States (51 in this case, including the District of Columbia), which is a separate figure from the national average.

• The reporting States average on this measure improved between 2002 and 2006, dropping from 9.7% to 5.9% during this time period. There was considerable variation in this measure among States in 2006. States ranged from a low of 1.3% to a high of 13.4% in 2006 (Figure 2.44).
• Twenty-six States^xxv outperformed the reporting States average (i.e., less use of physical restraints on long-stay nursing home residents), with a combined average rate of 3.0% in 2006.
• Thirteen States^xxvi had rates higher than the reporting States average (i.e., greater use of restraints), with a combined average rate of 9.5% in 2006.
• In seven States,^xxvii the rate of long-stay nursing home residents with physical restraints did not improve from 2002 to 2006 (data not shown).

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^xxv The States are Alabama, Connecticut, Delaware, District of Columbia, Hawaii, Illinois, Iowa, Kansas, Maine, Maryland, Minnesota, Montana, Nebraska, New Hampshire, New Jersey, New York, North Dakota, Pennsylvania, Rhode Island, South Dakota, Texas, Vermont, Virginia, Washington, West Virginia, and Wisconsin.

^xxvi The States are Arkansas, California, Florida, Georgia, Louisiana, Mississippi, Nevada, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, and Utah.

^xxvii The States are Alaska, Delaware, Florida, New Jersey, New Mexico, Oklahoma, and Utah.

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Management: Presence of Pressure Ulcers in Nursing Home Residents

A pressure ulcer, or pressure sore, is an area of broken down skin caused by sitting or lying in one position for an extended period of time. Pressure sores can be painful, take a long time to heal, and cause other complications such as skin or bone infections. Pressure sores are classified into four stages (stages 1 through 4, with stage 4 being the most severe) according to the depth or type of tissue damage. The measures presented here include all four stages.

Figure 2.45. Short-stay and long-stay nursing home residents with pressure ulcers, by type of resident, 1999-2005

Source: Centers for Medicare & Medicaid Services, Minimum Data Set, 1999-2005.

Denominator: All residents in Medicare or Medicaid certified nursing and long-term care facilities.

• There were only minor improvements in pressure sore measures for all three types of nursing home residents between 1999 and 2005.
• From 1999 to 2005, the rate of short-stay residents with pressure ulcers fell from 22.4% to 20.7% (Figure 2.45).^xxviii For high-risk, long-stay residents, the rate fell from 14.3% to 13.1%, and for low-risk, long-stay residents, the rate fell from 2.8% to 2.5%.^xxix
• High-risk, long-stay residents have a fivefold greater risk of having pressure sores than low-risk, long-stay residents.

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^xxviii Short-stay refers to residents who are admitted to a facility and stay fewer than 30 days; these admissions, also referred to as "post-acute," typically follow an acute care hospitalization and involve high-intensity rehabilitation or clinically complex care.

^xxix Long- stay (also know as "chronic care") refers to residents who enter a nursing facility typically because they are no longer able to care for themselves at home; they tend to remain in the facility from several months to several years. High-risk residents are those who are in a coma, who do not get or absorb the nutrients they need, or who cannot move or change position on their own. Conversely, low-risk residents can be active, can change positions, and are getting and absorbing the nutrients they need.

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Management: Pain Management for Nursing Home Residents

Adequate pain management is an important indicator of quality of care and quality of life. Untreated and under-treated pain are common problems among the elderly living in the community⁵⁴ as well as in nursing homes.⁵⁵ Assessment and management of pain in this population is complex and is made more difficult with high prevalence of multiple chronic conditions, dementia, and other impairments.^{54, 56}

The percentage of residents with moderate or severe pain has been reported as a quality measure in the Centers for Medicare & Medicaid Services (CMS) Nursing Home Compare Web site and in data tables for previous NHQRs. However, corresponding national information about how pain is managed was not previously available. The 2004 National Nursing Home Survey, a national probability survey of 1,174 nursing facilities, collected information from patient records and other sources used to document the occurrence, intensity, and management^xxx of pain over the past week. For this analysis, residents were divided into groups according to length of stay in order to approximate pain measures from Nursing Home Compare (which uses CMS Minimum Data Set data). Short stay was defined as less than 100 days and long stay as 100 days or more.

Among residents with moderate, severe, or excruciating pain, the use of an as-needed (pro re nata [PRN]) pain management strategy varies by sex, age, and condition. Regardless of these demographic or clinical differences, medication only as needed is a common management strategy for intense pain. Use of a PRN-only pain management strategy, although appropriate in some cases, should largely be viewed as less than optimal care, particularly for those reporting higher levels of pain. For these patients, pain management strategies that include treatment according to a regular schedule (i.e., standing order or special pain management program) are more likely to be appropriate care.

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^xxx Administration of medication only as needed, by standing order, or by use of nonpharmacologic strategies.

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Figure 2.46. Pain management for nursing home residents with moderate, severe, or excruciating pain, by type of resident, 2004

* Standing order plus PRN and other nonpharmacologic methods.

** PRN = pro re nata and refers to the administration of medication only as needed.

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Nursing Home Survey, 2004

• Despite reporting similar levels of pain, a greater percentage of short- stay than long-stay residents with moderate, severe, or excruciating pain had a PRN-only strategy (59.0% versus 42.6; Figure 2.46).
• Overall, 23% of residents reported having some level of pain (data not shown). A significantly higher percentage of short-stay residents than long-stay residents reported having pain (35% versus 19%) and having moderate, severe, or excruciating pain (26% versus 13%).
• More men than women (53% versus 47%) and more people under age 65 than age 65 and over (58% versus 47%) with moderate, severe, or excruciating pain had a PRN-only management strategy (data not shown).
• A large percentage of residents (43%-58%) with diagnoses or conditions strongly associated with pain—cancer, musculoskeletal disorders, fractures, and posthospital care—had a PRN-only pain management strategy (data not shown).

Management: Improvement in Ambulation in Home Health Episodes

Improvement in ambulation/locomotion is demonstrated by an increase in the percentage of patients who improve walking or mobility with a wheelchair. Many patients receiving home health care may need help to walk safely. This assistance can come from another person or from equipment, such as a cane. Patients who use a wheelchair may have difficulty moving around safely, but if they can perform this activity with little assistance, they are more independent, self-confident, and active. In cases of patients with some neurological conditions, such as progressive multiple sclerosis or Parkinson's disease, ambulation may not improve even when the nursing home or home health service provides good care.

Figure 2.47. Home health episodes showing ambulation/locomotion improvement, by age group, 2002-2005

Source: Centers for Medicare & Medicaid Services, Outcome and Assessment Information Set (OASIS), 2002-2005.

Denominator: Episodes for adult nonmaternity patients receiving at least some skilled home health care and not already performing at the highest level according to the OASIS question on ambulation.

• From 2002 to 2005, the proportion of home health episodes^xxxi showing improvement in ambulation/locomotion increased (Figure 2.47) from 33.9% to 38.8%.
• The proportion of home health episodes showing ambulation/locomotion improvement also increased for every age group.

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^xxxi An "episode" is the time during which a patient is under the direct care of a home health agency. It starts with the beginning/resumption of care and finishes when the patient is discharged or transferred to an inpatient facility. The same patient may be involved in multiple episodes. An episode is a 60-day time period.

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Management: Acute Care Hospitalization of Home Health Patients

Improvement in acute care hospitalization of home health patients is demonstrated by a decrease in the percentage of patients who had to be admitted to the hospital. Patients may need to go into the hospital while they are getting home health care. Depending on the severity of the patient's condition, this may not be avoidable even with good home health care.

Figure 2.48. Home health episodes with acute care hospitalization, by age group, 2002-2005

Source: Centers for Medicare & Medicaid Services, Outcome and Assessment Information Set, 2002-2005.

Denominator: Episodes for adult nonmaternity patients receiving at least some skilled home health care.

• In 2005, 28.0% of home health episodes ended in hospitalization (Figure 2.48).
• Between 2002 and 2005, the rate did not improve for the entire population or for any age group.
• In all four data years, home health patients under 65 years of age were more likely than patients ages 65-74 to require hospitalization. This may be related to the fact that home health patients under age 65 tend to have different characteristics, such as greater degrees of disability and illness.

Management: Receipt of Right Amount of Pain Medicine by Hospice Patients

Addressing the comfort aspects of care, such as relief from pain, fatigue, and nausea, is an important component of hospice care.^xxxii

Figure 2.49. Hospice patients age 18 and over who did not receive the right amount of medicine for pain, by age group, 2005 and 2006

Source: National Hospice and Palliative Care Organization, Family Evaluation of Hospice Care, 2005 and 2006.

Denominator: Adult hospice patients.

• The proportion of hospice patients whose families reported that they did not receive the right amount of medicine for pain was 5.8% in 2006 (Figure 2.49).
• Families of hospice patients ages 18-44 and ages 45-64 were more likely to report the patient did not receive the right amount of pain medicine (7.8% and 6.2%, respectively) in 2006 compared with families of patients age 65 and over (5.0%).
• Between 2005 and 2006, the proportion of hospice patients whose families reported that they did not receive the right amount of medicine for pain did not improve significantly overall or for any adult age groups (18-44, 45-64, 65 and over).

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^xxxii This measure is based on responses from a family member of the deceased. In interpreting it, it should be noted that family members may or may not be able to determine whether the right amount of medicine for pain was administered.

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Management: Receipt of Care Consistent With Patient's Stated End-of-Life Wishes

End-of-life care should respect a patient's stated end-of-life wishes. This includes shared communication and decision-making between providers and hospice patients and their family members and respect for cultural beliefs.

Figure 2.50. Hospice patients age 18 and over who did not receive care consistent with their stated end-of-life wishes, by age group, 2005 and 2006

Source: National Hospice and Palliative Care Organization, Family Evaluation of Hospice Care, 2005 and 2006.

Denominator: Adult hospice patients.

• The proportion of hospice patients whose families reported that they did not receive end-of-life care consistent with their stated wishes was 5.5% in 2006 (Figure 2.50).
• In 2006, hospice patients ages 18-44 were less likely than patients ages 45-64 and 65 and over to receive end-of-life care consistent with their wishes.
• Between 2005 and 2006, the proportion of hospice patients whose families reported that they did not receive end-of-life care consistent with their stated wishes did not improve significantly overall or for any adult age groups (18-44, 45-64, 65 and over).

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