Effectiveness (continued)

Mental Health and Substance Abuse

Type of statistic	Number
Highest cause of death rank-suicide (2004)	11th4
Alcohol-related motor vehicle deaths (2005)	16,88533
Students grades 9-12 who have seriously considered suicide (2005)	16.9%34
People age 12 and over with alcohol and/or illicit drug dependence or abuse (2005)	22.2 million (9.1%)35
Adults age 18 and over with serious psychological distress (2005)	24.6 million (11.3%)35
Adults with serious psychological distress and substance dependence or abuse (2005)	5.2 million (21.3%)35
Youths ages 12-17 with a major depressive episode during the past year (2005)	2.2 million (8.8%)35
Adults age 18 and over with a major depressive episode during the past year (2005)	15.8 million (7.3%)35
Adults with history of major depressive disorder (2005)	30.8 million (14.2%)35
Adults age 18 and over with any mental disorder or substance abuse disorder in past year (2001-2003)	28.1%36
Adults age 18 and over with substance abuse disorders (2001-2003)	7.2%36
Total medical expenditures for substance abuse and mental disorders (2001 est.)	$104 billion37
Cost effectiveness of problem drinking screening and brief counseling	$ 0-$ 14,000/QALY7

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

Almost one-fourth of all stays in U.S. community hospitals for patients age 18 and over—7.6 million of nearly 32 million stays—involved depression, bipolar disorder, schizophrenia, and other mental health disorders or substance-use-related disorders in 2004.³⁸ In a cross-national survey of adults in 14 countries conducted from 2001 to 2003, the United States had the highest rate with any mental disorders, including substance abuse.^{39, xii} The proportion of people with any mental disorders or substance abuse in the United States during this time period was 28.1%.⁴⁰ The 12-month prevalence of anxiety disorders in the United States in 2004 was 18.7%; mood disorders, 9.7%; impulse-control disorder, 10.4%; and any substance disorder, 7.2%.^{34, 38}

Poverty is a risk factor for poor mental health.⁴¹ Poor people are more likely to be exposed to stressful social environments (e.g., violence and unemployment) and less likely to have social and material resources.^{42, 43} Poverty disproportionately affects racial and ethnic minorities. Culturally appropriate treatment has the potential to decrease the prevalence, incidence, severity, and duration of certain mental disorders, such as depression and substance abuse. However, cost of care, societal stigma, fragmented organization of services, shame, discrimination, racism, and mistrust represent significant barriers to treatment for depression and substance abuse. One way to help meet the needs of racial and ethnic populations is to engage representatives from the community being served in the design, planning, and implementation of services.

Suicide is often the result of untreated depression and may be prevented when its warning signs are detected and treated. However, social stigma and attitudes toward mental illness held by some racial and ethnic groups may prevent acknowledgment of the condition and may hinder seeking care for depression, suicidal ideation, and related conditions.^{44, 45, 46} As a result, suicides are often underreported. Therefore, suicide rates should be used cautiously as a measure of differences in access to quality care for various groups, especially for racial and ethnic groups.^{47, 48}

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^xii Readers should note that, to some extent, this finding may be attributable to different rates of screening and diagnosis for different countries.

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Treatment: Receipt of Needed Treatment for Illicit Drug Use

Illicit drug^xiii use is a medical problem that can have a direct toxic effect on a number of body organs, as well as exacerbate numerous health and mental health conditions. Treatment for illicit drug use at a specialty facility is an effective way to reduce the chances of future illicit drug use.

Figure 2.19. Persons age 12 and over who needed treatment for illicit drug use and received it at a specialty facility in the past year, 2005

Source: Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2005.

Reference population: U.S. population age 12 and over who needed treatment for illicit drug use in the past year.

Note: Estimates by education were available only for persons age 18 and over. Received illicit drug treatment at a specialty facility refers to treatment received at a hospital (inpatient), a rehabilitation facility (inpatient or outpatient), or mental health center in order to reduce or stop the nonmedical use of prescription-type psychotherapeutic drugs or for medical problems associated with drug use. Respondents were classified as needing treatment for an illicit drug problem if they met at least one of these three criteria during the past year: (1) dependent on any illicit drug; (2) abuse of any illicit drug; or (3) received treatment for an illicit drug problem at a specialty facility (drug and alcohol rehabilitation facilities [inpatient or outpatient], hospitals [inpatient only], and mental health centers). Data were insufficient for this analysis for Asians, Native Hawaiians or Other Pacific Islanders, and American Indians and Alaska Natives.

• The proportion of persons age 12 and over who needed treatment for illicit drug use and received it at a specialty facility in the past year was significantly higher for Blacks than for Whites (24.7% compared with 15.6%) and for persons with less than a high school education than for persons with any college education (22.2% compared with 14.1%; Figure 2.19).
• There were no significant trends between 2002 and 2005 for this measure (data not shown).
• In 2005, as in 2004, only Blacks achieved the Healthy People 2010 target of 24% of persons age 12 and over who needed treatment for illicit drug use actually receiving such treatment.

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^xiii Illicit drugs included in this measure are marijuana/hashish, cocaine (including crack), inhalants, hallucinogens, heroin, and prescription-type psychotherapeutic (nonmedical use) drugs.

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Treatment: Receipt of Treatment for Depression

Treatment for depression is an effective way to reduce the chances of future major depressive episodes. However, cost of care, societal stigma, and fragmented organization of services are some of the significant barriers to treatment for depression.⁴⁹

Figure 2.20. Persons age 18 and over with a major depressive episode in the past year who received treatment for depression in the past year, 2005

Source: Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2005.

Reference population: U.S. population age 18 and over who had a major depressive episode in the past year.

Note: Major depressive episode is defined as a period of at least 2 weeks when a person experienced a depressed mood or loss of interest or pleasure in daily activities and had a majority of the symptoms for depression described in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Treatment for depression is defined as seeing or talking to a medical doctor or other professional or using prescription medication in the past year for depression. Data were insufficient for this analysis for Asians, Native Hawaiians or Other Pacific Islanders, and American Indians and Alaska Natives.

• The proportion of adults with a major depressive episode in the past year who received treatment for depression in the past year was significantly lower for Blacks than for Whites (56.4% compared with 67.2%) and lower for Hispanics than for non-Hispanic Whites (50.2% compared with 69.8%; Figure 2.20).
• The proportion of adults with a major depressive episode in the past year who received treatment for depression in the past year was significantly lower for people with less than a high school education than for people with some college education (59.5% compared with 68.0%).

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Respiratory Diseases

Type of statistic	Number
Number of deaths due to lung diseases (2004)	226,37950
Number of deaths, influenza and pneumonia combined (2004)	59,6644
Cause of death rank, influenza and pneumonia combined (2004)	8th4
People age 18 and over with an asthma attack in past 12 months (2005)	8.4 million51
People under age 18 with an asthma attack in past 12 months (2005)	3.8 million52
Annual number of cases of the common cold (est.)	>1 billion53
Number of discharges attributable to pneumonia (2003 est.)	1.4 million54
Total cost of lung diseases (2006 est.)	$144.2 billion6
Direct medical costs of lung diseases (2006 est.)	$87 billion6
Total approximate cost of upper respiratory infections (annual)	$40 billion55
Total cost of asthma (2004)	$16.1 billion50
Direct medical costs of asthma (2004)	$11.5 billion50
Cost effectiveness of influenza immunization	$0-$ 14,000/QALY7

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

Prevention: Pneumococcal Vaccination

Vaccination is an effective strategy for reducing illness, death, and disparities associated with pneumococcal disease and influenza.^56,57

Figure 2.21. Adults age 65 and over who ever had pneumococcal vaccination, by race, ethnicity, and income, 1999-2005

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

Reference population: Civilian noninstitutionalized population age 65 and over.

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. Age adjusted to the 2000 standard population. Data were insufficient for this analysis for Asians, Native Hawaiians or Other Pacific Islanders, and American Indians and Alaska Natives.

• From 1999 to 2005, the overall proportion of adults age 65 and over who had received pneumococcal vaccine improved significantly, from 49.9% to 56.3% (data not shown). Improvements were observed for Whites, Blacks, and non-Hispanic Whites (Figure 2.21).
• The gap between Blacks and Whites remained the same. In 2005, the proportion of adults age 65 and over who ever had pneumococcal vaccine was significantly lower for Blacks than for Whites (40.4% compared with 58.4%).
• From 1999 to 2005, the gap between Hispanics and non-Hispanic Whites increased. In 2005 the proportion of Hispanic adults age 65 and over who had ever had pneumococcal vaccine was about half that of non-Hispanic Whites (29.0% compared with 60.5%).
• The gap between poor and high income people remained the same. In 2005, the proportion was significantly lower for poor elderly people than for high income elderly (45.8% versus 57.3%).
• In 2005, as in 2004, no group achieved the Healthy People 2010 target of 90% of adults age 65 and over having received pneumococcal vaccination.

Racial and ethnic minorities are disproportionately of lower socioeconomic status. To distinguish the effects of race, ethnicity, income, and education on pneumococcal vaccination, this measure is stratified by income and education level.

Figure 2.22. Adults age 65 and over who ever had pneumococcal vaccination, by race (left) and ethnicity (right), stratified by income, 2005

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

Reference population: Civilian noninstitutionalized population age 65 and over.

Note: Age adjusted to the 2000 standard population. Data were insufficient for this analysis for Asians, Native Hawaiians or Other Pacific Islanders, and American Indians and Alaska Natives.

Figure 2.23. Adults age 65 and over who ever had pneumococcal vaccination, by race (left) and ethnicity (right), stratified by education, 2005

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

Reference population: Civilian noninstitutionalized population age 65 and over.

Note: Age adjusted to the 2000 standard population. Data were insufficient for this analysis for Asians, Native Hawaiians or Other Pacific Islanders, and American Indians and Alaska Natives.

• There were no statistically significant Black-White differences in pneumococcal vaccination in the poor and high income groups (Figure 2.22).
• With the exception of the middle income group, Hispanics at all income levels were less than half as likely as non-Hispanic Whites of the same income level to have ever had a pneumococcal vaccination.
• Blacks and Hispanics at all education levels were less likely than Whites to have ever had a pneumococcal vaccination (Figure 2.23).

Treatment: Receipt of Recommended Hospital Care for Pneumonia

The elderly are at high risk for pneumonia. The highest rate of hospitalizations for pneumonia occurs in the population 65 and over—220.4 per 10,000 population for this group in 2004, compared with 45.5 per 10,000 for the overall population.⁵⁸ The Centers for Medicare & Medicaid Services tracks a set of measures for quality of pneumonia care for hospitalized patients from the CMS Quality Improvement Organization (QIO) program. This set of measures has been adopted by the Hospital Quality Alliance (HQA).

Figure 2.24. Recommended hospital care received by Medicare patients with pneumonia, by race/ethnicity, 2002-2005

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

Source: Centers for Medicare & Medicaid Services, Quality Improvement Organization program, 2002-2005.

Denominator: Medicare beneficiaries with pneumonia who are hospitalized, all ages.

Note: Whites, Blacks, Asians, and AI/ANs are non-Hispanic groups. Composite includes the following five measures: (1) receipt of antibiotics within 4 hours, (2) receipt of appropriate antibiotics, (3) receipt of blood culture before antibiotics, (4) receipt of influenza screening (i.e., person is assessed as to whether he or she would be a good candidate for vaccination) or vaccination, and (5) receipt of pneumococcal screening or vaccination. Composite is calculated by averaging the percentage of opportunities for care in which the patient received all five incorporated components of care. For further details on composite measures, go to Chapter 1, Introduction and Methods. The denominator used to calculate these measures was refined in 2005 to exclude patients with health-care associated pneumonia. The percent of Medicare beneficiaries with blood cultures within 24 hours of hospital arrival was changed to include in the denominator only patients who were admitted to the intensive care unit within 24 hours of hospital arrival.

• In 2005 the proportion of Medicare patients with pneumonia who received recommended hospital care^xiv was lower for Blacks (69.5%), Asians (68.7%), and Hispanics (66.2%) than for Whites (74.6%).
• From 2002 to 2004, the overall percentage of Medicare patients with pneumonia who received recommended hospital care improved significantly, from 54.3% to 64.4%.
• In all three years, from 2002 to 2004, this percentage was significantly lower for Blacks and Hispanics compared with Whites. In 2004 the percentage was also significantly lower for Asians compared with Whites.
• From 2002 to 2004, the percentage of Medicare patients with pneumonia who received recommended hospital care improved significantly for the total population and for all racial/ethnic groups.

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^xiv "Recommended hospital care" is a composite of five separate measures. (go to Note in Figure 2.24 for a list of these measures.) For further details on composite measures, go to Chapter 1, Introduction and Methods.

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Nursing Home, Home Health, and Hospice Care

Type of statistic	Number
Number of nursing home residents (2004)	1,442,50359
Number of home health patients (2000)	1,355,29060
Number of current hospice care patients (2000)	105,49661
Discharges from nursing homes (1998-1999)	2,500,00059
Discharges from home health agencies (2000)	7,179,00062
Discharges from hospice care (2000)	621,00061
Total cost of nursing home services (2005)	121.9 billion63
Total cost of home health services (2005)	$47.5 billion61
Annual national expenditures for hospice care for decedents (1992-1996)	$1.232 billion64
Percent of health care expenditures for hospice care in last 6 months of life	74%64

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 costs only for free-standing skilled nursing facilities, nursing homes, and home health agencies, and not those that are hospital based.

This section highlights two core measures of nursing home quality of care—use of physical restraints and presence of pressure sores—and two measures of home health care quality—improvement in walking or moving around and episodes with acute care hospitalization. In addition, this section includes supplemental measures on management of pain in hospice care and a supplemental measure of the quality of end-of-life care.

Management: Use of Physical Restraints on Nursing Home Residents

Although restraining nursing home residents is sometimes a component of keeping residents safe and well cared for, residents who are restrained daily can become weak, lose their ability to go to the bathroom by themselves, and develop pressure sores or other medical complications. Restraints should be used only when they are necessary as part of the medical treatment.

Figure 2.25. Long-stay nursing home residents who were physically restrained, by race/ethnicity, 1999-2005

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

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

Denominator: Long-stay nursing home residents, all ages.

Note: White, Black, API, and AI/AN are non-Hispanic groups. Long-stay residents are persons in an extended/permanent nursing home stay.

• From 1999 to 2005, the proportion of residents who were physically restrained decreased from 10.7% to 6.6% (Figure 2.25).
• From 1999 to 2005, the gap between APIs and Whites in the proportion of residents who were physically restrained decreased. However, in 2005 the proportion of residents who were physically restrained was higher for APIs than for Whites (9.8% compared with 6.6%).
• From 1999 to 2005, the gap between Hispanics and non-Hispanic Whites decreased. However, in 2005, the proportion of residents who were physically restrained was still higher for Hispanics than for Whites (8.7% compared with 6.6%).

Management: Presence of Pressure Sores 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. Residents should be assessed by nursing home staff for presence or risk of developing pressure sores. Nursing homes can help to prevent or heal pressure sores by keeping residents clean and dry and by changing their position frequently or helping them move around, making sure residents get proper nutrition, and using soft padding to reduce pressure on the skin. However, some residents may get pressure sores even when a nursing home provides good preventive care.

Figure 2.26. Long-stay high-risk nursing home residents (left) and short-stay all-risk residents (right) who developed pressure sores, by race/ethnicity, 1999-2005

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

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

Denominator: Long-stay nursing home residents (left), and short-stay nursing home residents (right).

Note: White, Black, API, and AI/AN are non-Hispanic groups. Long-stay residents are persons in an extended/permanent nursing home stay. Short-stay residents are persons needing skilled nursing care or rehabilitation services following a hospital stay but expected to return home.

• From 1999 to 2005, the proportion of long-stay high-risk^xv residents who developed pressure sores decreased from 14.3% to 13.1% (Figure 2.26). Significant improvements were observed for AI/ANs (16.1% to 13.4%) and Hispanics (15.6% to 14.2%).
• In 2005, the proportion of long-stay high-risk residents who developed pressure sores was significantly higher for Blacks (16.7%), AI/ANs (13.4%), and Hispanics (14.2%) than for Whites (12.5%).
• From 1999 to 2005, the proportion of short-stay residents who had pressure sores improved significantly for all groups.
• There were no significant differences among short-stay patients.

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^xvHigh-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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Treatment: Improvement by Home Health Patients in Walking or Moving Around

How well a patient improves in ability level while getting home health care is a reflection of the provider's quality of service; patient level factors such as fear of falling, mobility, etc.; and the patient's available support system. Improved ambulation, i.e., getting better at walking or using a wheelchair, is a measure of improved outcomes.^xvi

Figure 2.27. Home health care episodes with patients who get better at walking or moving around, by race (left) and ethnicity (right), 2002-2005

Key: NHOPI=Native Hawaiian or Other Pacific Islander; AI/AN=American Indian or Alaska Native.

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.

Note: An episode is a 60-day time period 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 from home health care or transferred to an inpatient facility. Some patients have multiple episodes in a year. Data are reported only for those patients who were not already performing at the highest level of ambulation.

• From 2002 to 2005, the proportion of home health care patients who got better at walking and moving around improved for Whites (from 33.8% to 38.9%), NHOPIs (from 39.2% to 42.5%), AI/ANs (from 35.4% to 38.5%), multiple race persons (from 33.8% to 39.3%), and the total population (from 33.9% to 38.8%; data not shown).
• In 2005, there were no significant differences between minority groups and Whites (Figure 2.27).

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^xvi In cases of patients with some neurological conditions, such as progressive multiple sclerosis or Parkinson's disease, ambulation may not improve even when the home health service provides good care.

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Treatment: Acute Care Hospitalization of Home Health Patients

Improvement in the acute care hospitalization outcome is demonstrated by a decrease in the percentage of patients who had to be admitted to the hospital; lower percentages are the desirable outcome. Acute care hospitalization may be avoided if the home health staff adequately checks the patient's health condition at each visit to detect problems early. However, patients may need to go into the hospital while they are getting care, and, in some instances, this may not be avoidable even with good home health care.

Figure 2.28. Home health care episodes with patients who were admitted to the hospital, by race (left) and ethnicity (right), 2002-2005

Key: NHOPI=Native Hawaiian or Other Pacific Islander; AI/AN=American Indian or Alaska Native.

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.

Note: 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 from home health care or transferred to an inpatient facility. Some patients have multiple episodes in a year.

• From 2002 to 2005, the gap between Blacks and Whites in the proportion of home health care patients who were admitted to the hospital remained the same. In 2005, the proportion was higher for Blacks than for Whites (33.9% compared with 26.9%; Figure 2.28).
• The gap between AI/ANs and Whites in the proportion of home health care patients who were admitted to the hospital increased. In 2005, the proportion was higher for AI/ANs than for Whites (33.6% compared with 26.9%).
• The gap between Asians and Whites in the proportion of home health care patients who were admitted to the hospital decreased. In 2005 the proportion was lower for Asians than for Whites (23.0% compared with 26.9%).
• Over the same period, the gap between Hispanics and non-Hispanic Whites in the proportion of home health care patients who were admitted to the hospital remained the same. In 2005, the proportion was higher for Hispanics than for non-Hispanic Whites (31.0% compared with 26.9%).

Treatment: Hospice Care

Hospice care is generally delivered at the end of life to patients with a terminal illness or condition who desire palliative medical care; it also includes 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 patient's and families' wishes; and reasonably consistent with clinical, cultural, and ethical standards."⁶⁵ The National Hospice and Palliative Care Organization's Family Evaluation of Hospice Care examines the quality of hospice care for patients and their family members.^xvii 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.⁶⁶

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

Figure 2.29. Hospice patients who did not receive the right amount of medicine for pain, by race, ethnicity, and education, 2006

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

Source: National Hospice and Palliative Care Organization Family Evaluation of Hospice Care, 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 2.29).
• The percentage of hospice patients whose families reported that they did not receive the right amount of medicine for pain was significantly higher for Blacks (7.6%), AI/ANs (10.5%), and APIs (11.5%) than for Whites (5.6%).
• The percentage of hospice patients whose families reported that they did not receive the right amount of medicine for pain was also higher for Hispanics than for non-Hispanic Whites (8.9% compared with 5.6%).

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^xvii This annual 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%. In addition, race and ethnicity were not reported by large numbers of respondents. These limitations should be considered when interpreting these findings.

^xviii This measure is based on responses from a family member of the deceased. 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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End-of-life care. End-of-life care should respect a patient's stated end-of-life wishes. This includes shared communication and decision-making between providers, patients, and family members and respect for cultural beliefs.

Figure 2.30. Hospice patients who received care inconsistent with their wishes, by race, ethnicity, and education, 2006

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

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

Denominator: Adult hospice patients.

• The overall proportion of hospice patients whose families reported that they did not receive end-of-life care consistent with their wishes was 5.5% in 2006 (Figure 2.30).
• The percentage whose families reported that they did not receive care consistent with their wishes was almost two times higher for Blacks (10.6%), more than three times higher for APIs (18.3%), and more than two times higher for AI/ANs (12.9%) compared with Whites (5.5%).
• This percentage was more than two times higher for Hispanics than for non-Hispanic Whites (11.1% compared with 4.9%).
• The percentage of patients whose families reported that they did not receive care consistent with their wishes was almost three times higher for hospice patients with less than a high school education compared with those who had any college education (11.4% compared with 4.6%).

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