AHRQ's Priority Populations

AHRQ's priority populations, specified by Congress in the Healthcare Research and Quality Act of 1999 (Public Law 106-129), are:

• Minority groups.
• Low income groups.
• Women.
• Children.
• Elderly.
• Individuals with special health care needs, including individuals with disabilities and individuals who need chronic care or end-of-life health care.

In addition, this legislation directs AHRQ to examine health care delivery in rural areas. Hence, this chapter addresses each of these priority populations as well as residents of rural areas.

How This Chapter Is Organized

This chapter presents new information about disparities in quality of and access to health care in priority populations. It is presented in the following order:

• Racial and ethnic minorities.
• Low income groups.
• Women.
• Children.
• Elderly.
• Residents of rural areas.
• Individuals with special health care needs.

To avoid repetition of findings from previous chapters on race, ethnicity, and socioeconomic status, the first two sections summarize quality of and access to health care for racial and ethnic minorities and low income groups.

Subsequent sections focus on the remaining priority populations and examine disparities in care within each population group and changes in disparities over time. To present this greater detail, these sections highlight a small number of measures. Measures for each priority population were selected with the assistance of members of the Interagency Work Group and AHRQ experts for particular populations. For smaller priority populations, measure selection was often driven by available sample sizes. When possible, measures were selected to encompass multiple components of health care need, such as preventive services, treatment of acute illness, management of chronic disease, and access to health care. Results for all measures are found in the detailed appendix tables.

It should be noted that this chapter does not provide a comprehensive assessment of health care differences in each priority population. Most of the measures tracked in the NHDR were selected to be applicable across many population groups; only a few, such as immunizations among children and screening for breast cancer among women, were specific to particular groups. For some groups, these general measures overlook important health care problems specific to particular populations. In addition, national data may not address key health issues for specific population groups and are often unable to generate reliable estimates for many smaller groups. Instead, this chapter should be seen as a starting point, identifying some problem areas and indicating gaps in current data and understanding.

Racial and Ethnic Minorities

Blacks or African Americans

Previous NHDRs showed that Blacks had poorer quality of care and worse access to care than Whites for many measures tracked in the reports. Findings based on 43 core report measures of quality and 8 core report measures of facilitators and barriers to health care are shown below.

Figure 4.1. Blacks compared with Whites on measures of quality and access

Better = Blacks receive better quality of care or have better access to care than Whites.

Same = Blacks and Whites receive about the same quality of care or access to care.

Worse = Blacks receive poorer quality of care or have worse access to care than Whites.

CRM = core report measures.

Note: Data presented are the most recent available.

• For 22 of the 43 core report measures of quality, Blacks had poorer quality of care than Whites (Figure 4.1). Black-White differences ranged from Blacks being over 10 times as likely as Whites to be diagnosed with AIDSⁱⁱⁱ to Blacks being 56% less likely than Whites to commit suicide. The median difference over all 43 core report measures was 16% (Blacks 16% more likely to receive poorer quality care than Whites).
• For 3 of the 8 core report measures of access, Blacks had significantly worse access to care than Whites. Differences ranged from Blacks being 35% more likely than Whites to have communication problems with their children's providers to Blacks being 4% less likely than Whites to have a specific source of ongoing care. The median difference over all 8 core report measures was 15% (Blacks 15% more likely to have worse access to care than Whites).

ⁱⁱⁱ Although differences in developing AIDS do not necessarily translate into differences in quality of care, early and appropriate treatment of HIV disease can delay progression to AIDS.

Figure 4.2. Change in Black-White disparities over time

Improving >5% = Black-White difference becoming smaller at rate greater than 5% per year.

Improving 1-5% = Black-White difference becoming smaller at rate between 1% and 5% per year.

Same = Black-White difference not changing.

Worsening 1-5% = Black-White difference becoming larger at rate between 1% and 5% per year.

Worsening >5% = Black-White difference becoming larger at rate greater than 5% per year.

CRM = core report measures.

Note: The most recent and oldest years of data available are compared. Only 41 core report measures of quality could be tracked over time for Blacks and Whites.

• Of core report measures of quality that could be tracked over time for Blacks and Whites, Black-White differences became smaller for 11 measures and larger for 16 measures (Figure 4.2). For 14 measures, Black-White differences did not change over time.
• Of core report measures of access that could be tracked over time for Blacks and Whites, Black-White differences became smaller for 3 measures and larger for 4 measures. For 1 measure, the Black-White difference did not change over time.

Asians

Previous NHDRs showed that Asians had similar or better quality of care than Whites but worse access to care than Whites for many measures tracked in the reports. Findings based on 29 core report measures of quality and 7 core report measures of facilitators and barriers to health care that support estimates for either Asians or Asians and Pacific Islanders in aggregate are shown below.

Figure 4.3. Asians compared with Whites on measures of quality and access

Better = Asians receive better quality of care or have better access to care than Whites.

Same = Asians and Whites receive about the same quality of care or access to care.

Worse = Asians receive poorer quality of care or have worse access to care than Whites.

CRM = core report measures.

Note: Data presented are the most recent available.

• For 11 of the 29 core report measures of quality, Asians had significantly poorer quality of care than Whites, while for 8 measures, Asians had significantly better quality of care than Whites (Figure 4.3). The median difference over all 29 core report measures was -2% (Asians 2% less likely to receive poorer quality care than Whites).
• For 3 of the 7 core report measures of access, Asians had significantly worse access to care than Whites. Asian-White differences ranged from Asian parents being 2.3 times as likely as Whites to report communication problems with their child's providers to Asians being 32% less likely to report difficulties or delays getting care. The median difference over all 7 core report measures was 8% (Asians 8% more likely to have worse access to care than Whites).

Figure 4.4. Change in Asian-White disparities over time

Improving >5% = Asian-White difference becoming smaller at rate greater than 5% per year.

Improving 1-5% = Asian-White difference becoming smaller at rate between 1% and 5% per year.

Same = Asian-White difference not changing.

Worsening 1-5% = Asian-White difference becoming larger at rate between 1% and 5% per year.

Worsening >5% = Asian-White difference becoming larger at rate greater than 5% per year.

CRM = core report measures.

Note: The most recent and oldest years of data available are compared. Only 28 core report measures of quality could be tracked over time for Asians and Whites.

• Of core report measures of quality that could be tracked over time for Asians and Whites, Asian-White differences became smaller for 8 measures but larger for 11 measures (Figure 4.4). For 9 measures, Asian-White differences did not change over time.
• Of core report measures of access that could be tracked over time for Asians and Whites, Asian-White differences became smaller for 4 measures but larger for 2 measures. For 1 measure, the Asian-White difference did not change over time.

American Indians and Alaska Natives

Previous NHDRs showed that American Indians and Alaska Natives (AI/ANs) had poorer quality of care and worse access to care than Whites for many measures tracked in the reports. Findings based on 23 core report measures of quality and 6 core report measures of access are shown below.

Figure 4.5. AI/ANs compared with Whites on measures of quality and access

Better = AI/ANs receive better quality of care or have better access to care than Whites.

Same = AI/ANs and Whites receive about the same quality of care or access to care.

Worse = AI/ANs receive poorer quality of care or have worse access to care than Whites.

CRM = core report measures.

Note: Data presented are the most recent available.

• Only about half of the core report measures supported estimates of quality for AI/ANs.
• For 10 of the 23 core report measures of quality, AI/ANs had significantly poorer quality of care than Whites (Figure 4.5). AI/AN-White differences ranged from AI/ANs being twice as likely as Whites to lack early prenatal care to AI/ANs being 37% less likely to die from colorectal cancer. The median difference over all 23 core report measures was 12% (AI/ANs 12% more likely to receive poorer quality care than Whites).
• For 1 of the 6 core report measures of access, AI/ANs had significantly worse access to care than Whites. AI/AN-White differences ranged from AI/ANs under age 65 being over twice as likely as Whites to lack health insurance to AI/ANs being 12% less likely than Whites to report communication problems. The median difference over all 6 core report measures was 40% (AI/ANs 40% more likely to have worse access than Whites).

Figure 4.6. Change in AI/AN-White disparities over time

Improving >5% = AI/AN-White difference becoming smaller at rate greater than 5% per year.

Improving 1-5% = AI/AN-White difference becoming smaller at rate between 1% and 5% per year.

Same = AI/AN-White difference not changing.

Worsening 1-5% = AI/AN-White difference becoming larger at rate between 1% and 5% per year.

Worsening >5% = AI/AN-White difference becoming larger at rate greater than 5% per year.

CRM = core report measures.

Note: The most recent and oldest years of data available are compared. Only 20 core report measures of quality and 5 core report measures of access could be tracked over time for AI/ANs and Whites.

• Less than half of the core report measures supported estimates for changing disparities for AI/ANs.
• Of core report measures of quality that could be tracked over time for AI/ANs and Whites, AI/AN-White differences became smaller for 5 measures but larger for 8 measures (Figure 4.6). For 7 measures, AI/AN-White differences did not change over time.
• Of core report measures of access that could be tracked over time for AI/ANs and Whites, AI/AN-White differences became smaller for 4 measures. For 1 measure, the AI/AN-White difference did not change over time.

Native Hawaiians and Other Pacific Islanders

The ability to assess disparities among Native Hawaiians and Other Pacific Islanders (NHOPIs) for the NHDR has been hampered by two main issues. First, the NHOPI racial category is relatively new to Federal data collection. Prior to 1997, NHOPIs were classified as part of the Asian and Pacific Islander racial category and could not be identified separately in most Federal data. In 1997, the Office of Management and Budget promulgated new standards for Federal data on race and ethnicity and mandated that information about NHOPIs be collected separately from information about Asians.⁸ Federal agencies had until 2003 to be fully compliant with these standards. Because earlier NHDRs report predominantly on data collected before 2003, many of the databases used had not fully transitioned to the new standards. Hence, few databases could provide any estimates for the NHOPI population. Second, when information about this population was collected, databases often included insufficient numbers of NHOPIs to allow reliable estimates.

Consequently, in previous NHDRs, estimates for the NHOPI population could be generated for only about 5 NHDR core measures. However, problems persist. In this NHDR, of the 42 core report measures of quality, estimates for NHOPIs could be made for only 3—1 measure from the National Health Interview Survey and 2 measures from the CMS Home Health Care Outcome and Assessment Information Set. Of the 8 core report measures of access, estimates for NHOPIs could be made for only 3—persons with health insurance and persons with a source of ongoing care from the National Health Interview Survey and persons with a primary care provider from the Medical Expenditure Panel Survey. A lack of quality data on this population prohibits the NHDR from detailing disparities for this group. As more data become available, this information will be included in future reports.

Hispanics or Latinos

Focus on Hispanic Subpopulations

The Hispanic population in the United States is highly heterogeneous. Almost 60% are of Mexican origin, making it the largest Hispanic subpopulation in the country. People originating from Puerto Rico, Central America, and South America are the next largest subgroups. Among Hispanics, variation in access to and quality of health care has been observed related to country of origin. Findings are presented below on differences among different Hispanic subpopulations in three quality measures focusing on prevention, timeliness, and patient centeredness—advice to quit smoking, care for illness or injury as soon as wanted, and the patient experience of care, respectively—and one access measure—uninsurance.

Figure 4.11. Adult smokers receiving advice to quit smoking, by ethnicity and country of origin, 2003

Source: Medical Expenditure Panel Survey, 2003.

Reference population: Civilian noninstitutionalized smokers age 18 and over.

• The percentage of adult smokers receiving advice to quit smoking is significantly lower among all Hispanics compared with non-Hispanic Whites (Figure 4.11).
• Among Hispanic subpopulations, Mexicans have the lowest rates of advice to quit smoking, and their rate is significantly lower compared with non-Hispanic Whites.

Figure 4.12. Adults who sometimes or never get care for illness or injury as soon as wanted, by ethnicity and country of origin, 2003

Source: Medical Expenditure Panel Survey, 2003.

Reference population: Civilian noninstitutionalized population age 18 and over.

• The percentage of adults who sometimes or never get care for illness or injury as soon as wanted is significantly higher among all Hispanics compared with non-Hispanic Whites (Figure 4.12).
• Among Hispanic subpopulations, Mexicans have the highest rates, and their rate is significantly higher compared with non-Hispanic Whites.

Figure 4.13. Adults whose providers sometimes or never listened carefully, explained things clearly, showed respect for what they had to say, and spent enough time with them, by ethnicity and country of origin, 2003

Source: Medical Expenditure Panel Survey, 2003.

Reference population: Civilian noninstitutionalized population age 18 and over.

• The percentage of adults whose providers sometimes or never listened carefully, explained things clearly, showed respect for what they had to say, and spent enough time with them is significantly higher among all Hispanics compared with non-Hispanic Whites (Figure 4.13).
• Among Hispanic subpopulations, Central or South Americans have the highest rates of poor communication, and their rate and the rate among Mexicans are significantly higher compared with non-Hispanic Whites.

Figure 4.14. People under age 65 uninsured all year, by ethnicity and country of origin, 2003

Source: Medical Expenditure Panel Survey, 2003.

Reference population: Civilian noninstitutionalized population under age 65.

• The percentage of people under age 65 uninsured all year is significantly higher among all Hispanics compared with non-Hispanic Whites (Figure 4.14).
• Among Hispanic subpopulations, Mexicans have the highest rates of uninsurance. The rates for Mexicans, Central or South Americans, and Cubans are significantly higher compared with rates for non-Hispanic Whites.

Focus on Recent Immigrants and Limited English-Proficient Populations

Recent Immigrants

Immigrants often encounter barriers to high quality health care. About 30 million persons living in the United States in 2000 were born outside the United States, up from 20 million in 1990. Asians and Hispanics are much more likely to be foreign-born. About 70% of Asians and 40% of Hispanics in the United States are foreign-born compared with 6% of Whites and Blacks.¹¹ This section identifies differences in one quality measure focusing on treatment—completion of tuberculosis therapy—and one measure of access to care—persons with a usual source of care—for Americans born outside of the United States.

Treatment: completion of tuberculosis therapy. Certain diseases are concentrated among Americans born in other countries. For example, more than half of tuberculosis cases in the Nation are among foreign-born individuals, and the case rate among foreign-born individuals is more than 8 times higher than among individuals born in the United States. The percentage of cases of tuberculosis among U.S.-born individuals is decreasing while the percentage of cases among foreign-born individuals is increasing.¹² Adherence to recommended treatments is important for reducing drug resistant tuberculosis and leads to completion of therapy within 12 months of diagnosis.

Figure 4.15. Completion of therapy for tuberculosis within 12 months of being diagnosed among persons born outside the United States, by race and ethnicity, 1999-2002

Key: API=Asian or Pacific Islander.

Source: Centers for Disease Control and Prevention, National Tuberculosis Surveillance System, 1999-2002.

Reference population: Foreign-born U.S. resident population with verified tuberculosis, all ages.

• In 1999 and 2002, the proportion of persons who completed therapy for tuberculosis within 12 months of being diagnosed was significantly lower among foreign-born Hispanics compared with foreign-born non-Hispanic Whites (Figure 4.15).
• In 2001, the proportion was significantly higher among foreign-born Blacks compared with foreign-born Whites, but in 2002 this disparity was eliminated.
• From 1999 to 2002, the proportion of persons who completed therapy for tuberculosis within 12 months of being diagnosed increased significantly for the overall foreign-born U.S. population and for foreign-born APIs but did not change significantly for any other group.

Access to care: usual source of care. The patient-primary care provider relationship is built upon mutual respect, trust, and understanding. Being born outside the United States may influence whether patients are able to build such relationships due to cultural, language, or other factors.

Figure 4.16. Persons who have a usual primary care provider, by race and ethnicity, stratified by place of birth, 2003

Source: Medical Expenditure Panel Survey, 2003.

Reference population: Civilian noninstitutionalized population age 18 and over.

• The overall proportion of adults with a usual source of care was significantly lower among foreign-born persons compared with individuals born in the United States (Figure 4.16).
• Compared with U.S.-born Whites, the proportion of adults with a usual source of care was significantly lower among Whites, Blacks, and Asians born outside the United States as well as Blacks born in the United States.
• Compared with U.S.-born non-Hispanic Whites, the proportion of adults with a usual source of care was significantly lower among Hispanics born outside the United States as well as Hispanics born in the United States.

Language Spoken at Home

Quality health care requires that patients and providers communicate effectively. The ability of providers and patients to communicate clearly with one another can be compromised if they do not speak the same language. Quality may suffer if patients with limited English proficiency are unable to express their care needs to providers who speak English only or who do not have an interpreter's assistance.

Limited English proficiency is a barrier to quality health care for many Americans. About 47 million Americans, or 18% of the population, spoke a language other than English at home in 2000, up from 32 million in 1990. Of these individuals, 28 million (about 11% of the population) spoke Spanish, 10 million (about 4% of the population) spoke another Indo-European language, and 7 million (about 3% of the population) spoke an Asian or Pacific Islander language at home. Almost half of persons who spoke a foreign language at home reported not speaking English very well.¹³ A study of health plan members and use of interpreters showed that the use of interpreters reduced disparities for Hispanic and API members (28% and 21%, respectively).¹⁴ Findings are presented below on differences in one quality measure focusing on patient centeredness—the patient experience of care—and one access measure—uninsurance—between persons who speak English at home and those who speak some other language at home.

Patient centeredness: patient experience of care. Communication problems between the patient and provider can lead to lower patient adherence to medications and decreased participation in medical decisionmaking. Language problems can also exacerbate cultural differences that impair the delivery of quality health care.

Figure 4.17. Adults whose health providers sometimes or never listened carefully, explained things, showed respect, and spent enough time with them, by race and ethnicity, stratified by language spoken at home, 2003

Source: Medical Expenditure Panel Survey, 2003.

Denominator: Civilian noninstitutionalized population age 18 and over.

• The overall proportion of adults whose health providers sometimes or never listened carefully, explained things clearly, respected what they had to say, or spent enough time with them was significantly higher among individuals who speak a foreign language at home compared with individuals who speak English at home (Figure 4.17).
• Compared with Whites who speak English at home, the proportion of adults with communication problems was significantly higher among Whites and Asians who speak some other language at home.
• Compared with non-Hispanic Whites who speak English at home, the proportion of adults with communication problems was significantly higher among Hispanics who speak some other language at home as well as Hispanics who speak English at home.

Access to care: uninsurance. Persons who speak a language other than English at home may have less access to resources, such as health insurance, that facilitate getting needed health care.

Figure 4.18. Adults under age 65 uninsured all year, by race and ethnicity, stratified by language spoken at home, 2003

Source: Medical Expenditure Panel Survey, 2003.

Reference population: Civilian noninstitutionalized population ages 18-64.

• The overall proportion of adults under age 65 uninsured all year was significantly higher among individuals who speak a foreign language at home compared with individuals who speak English at home (Figure 4.18).
• Compared with Whites who speak English at home, the proportion of persons uninsured all year was significantly higher among Whites, Blacks, and Asians who speak some other language at home as well as Blacks who speak English at home.
• Compared with non-Hispanic Whites who speak English at home, the proportion of persons uninsured all year was significantly higher among Hispanics who speak some other language at home as well as Hispanics who speak English at home.

Language Assistance

Clear communication is an important component of effective health care delivery. It is vital for providers to understand patients' health care needs and for patients to understand providers' diagnoses and treatment recommendations. Communication barriers can relate to language, culture, and health literacy.

For persons with limited English proficiency, having language assistance is of particular importance. Persons with limited English proficiency may choose a usual source of care in part based on language concordance; thus, not having a language-concordant provider may limit or discourage some patients from establishing a usual source of care

This year's NHDR includes a supplemental measure of access: provision of language assistance by the usual source of care. Language assistance includes bilingual clinicians, trained medical interpreters, and bilingual receptionists and other informal interpreters.

Figure 4.19. Adults with limited English proficiency with and without a usual source of care who offers language assistance, 2003

Key: USC = usual source of care.

Source: Medical Expenditure Panel Survey, 2003.

Reference population: Civilian noninstitutionalized population age 18 and over.

Note: Language assistance includes bilingual clinicians, trained medical interpreters, and informal interpreters (e.g., bilingual receptionists).

• A large proportion of individuals with limited English proficiency do not have a usual source of care—47% (Figure 4.19).
• Another 47% of individuals with limited English proficiency have a usual source of care that offers language assistance.
• Only 6% of individuals with limited English proficiency have a usual source of care that does not offer language assistance.

Low Income Groups

Focus on Uninsurance

Quality of Health Care

Prevention: screening for colorectal cancer. Screening for colorectal cancer with fecal occult blood testing or sigmoidoscopy is an effective way of reducing new cases of late stage disease and mortality caused by this cancer.

Figure 4.22. Adults age 50 and over who received recommended colorectal screening by income, stratified by insurance status, 2003

Source: National Health Interview Survey, 2003.

Reference population: Adults age 50 and over in the civilian noninstitutionalized population.

Note: Fecal occult blood testing is recommended every 2 years for adults age 50 and over; sigmoidoscopy is recommended as a one-time screening for adults age 50 and over.

• The proportion of adults age 50 and over who had received recommended colorectal cancer screening was significantly lower for uninsured compared with privately insured persons for the total population and for every income group (Figure 4.22). The proportion was also significantly lower for the total population of publicly insured compared with privately insured persons.
• Compared with privately insured high income persons, the proportion of adults age 50 and over who had received recommended colorectal cancer screening was significantly lower among uninsured poor, near poor, and middle income persons; among publicly insured poor and near poor persons; and among privately insured near poor and middle income persons.

Prevention: counseling obese adults about exercise. Regular exercise aids in weight loss and blood pressure control, reducing the risk of heart disease, stroke, diabetes, and other diseases.

Figure 4.23. Obese adults given advice about exercise by their doctor or other health provider, by insurance status, 2002 and 2003

Source: Medical Expenditure Panel Survey, 2002 and 2003.

Reference population: Civilian noninstitutionalized population age 18 and over.

• In both years, the proportion of obese adults who were given advice about exercise was significantly lower among uninsured compared with privately insured persons (Figure 4.23).
• From 2002 to 2003, no significant trends were observed.

Prevention: counseling overweight children about healthy eating. Counseling about healthy eating can play an important role in helping children to loose excess weight and establish healthy lifestyle behaviors.

Figure 4.24. Overweight children ages 2-19 whose parents/guardians reported advice from a doctor or other health provider about healthy eating, by insurance status, 2002 and 2003

Source: Medical Expenditure Panel Survey, 2002 and 2003.

Reference population: Civilian noninstitutionalized population ages 2-19.

• In both years, the proportion of children ages 2-19 whose parents/guardians reported advice from a doctor or other health provider about healthy eating was significantly lower among uninsured and publicly insured compared with privately insured persons (Figure 4.24).
• From 2002 to 2003, no significant trends were observed.

Access to Health Care

Dental care. Regular dental visits promote prevention, early diagnosis, and optimal treatment of oral diseases and conditions.

Figure 4.25. Persons with a dental visit in the past year, by income, stratified by insurance status, 2003

Source: Medical Expenditure Panel Survey, 2003.

Reference population: Civilian noninstitutionalized population, all ages.

• The proportion of persons with a dental visit in the past year was significantly lower among uninsured compared with privately insured persons in the total population and in every income group (Figure 4.25).
• For the total population and for near poor and middle income persons, the proportion was also significantly lower among publicly insured compared with privately insured persons.
• For persons of every insurance status, the proportion with a dental visit in the past year was significantly lower among poor, near poor, and middle income compared with high income persons.
• Only high income persons with private health insurance met the Healthy People 2010 target of 56% of persons with a dental visit in the past year.

Focus on Care of Children Served by School-Based Health Centers

Access to Health Care

Dental care. Regular dental care, especially good oral habits formed early in life, can promote good health over a lifetime and help prevent other diseases.

Figure 4.26. Children ages 4-17 who saw or talked with a dentist in the past year, by race/ethnicity, 2003

Source: Health Resources and Services Administration, Healthy Schools Healthy Communities User Visit Survey, 2003.

Reference population: Children ages 4-17 years served by a school-based health center.

Note: Whites and Blacks are non-Hispanic groups.

• For both age groups, Hispanic children served by a school-based health center were significantly less likely than White children to have seen or talked with a dentist in the past year (Figure 4.26). Other disparities by race/ethnicity were not observed.
• Among Black children, those ages 4-11 were significantly more likely than those ages 12-17 to have seen or talked with a dentist in the past year. Other disparities by age group were not observed.

Figure 4.27. Children ages 4-17 who were recommended or referred by a school-based health center to another place for dental care, by race/ethnicity and insurance status, 2003

Source: Health Resources and Services Administration, Healthy Schools Healthy Communities User Visit Survey, 2003.

Reference population: Children ages 4-17 years served by a school-based health center.

Note: Whites and Blacks are non-Hispanic groups.

• About 12% of children served by a school-based health center were recommended or referred to another place for dental care (Figure 4.27).
• Disparities by race/ethnicity and by insurance status were not observed.

Figure 4.28. Children ages 4-17 who needed but could not access dental care in the past 6 months, by race/ethnicity and insurance status, 2003

Source: Health Resources and Services Administration, Healthy Schools Healthy Communities User Visit Survey, 2003.

Reference population: Children ages 4-17 served by a school-based health center.

Note: Whites and Blacks are non-Hispanic groups.

• About 10% of children served by a school-based health center who needed dental care in the past 6 months did not receive it (Figure 4.28).
• Disparities by race/ethnicity were not observed.

Women

Quality of Health Care

Prevention: Screening for Colorectal Cancer

Ensuring that all populations have access to appropriate cancer screening services is a core element of reducing cancer health disparities.³¹ Screening for colorectal cancer with fecal occult blood testing or sigmoidoscopy is an effective way of reducing new cases of late stage disease and mortality caused by this cancer.

Figure 4.29. Adults age 50 and over who received recommended colorectal screening, by race, ethnicity, income, and gender, 2003

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

Source: National Health Interview Survey, 2003.

Reference population: Adults age 50 and over in the civilian noninstitutionalized population.

Note: Fecal occult blood testing is recommended every 2 years for adults age 50 and over; sigmoidoscopy is recommended as a one-time screening for adults age 50 and over.

• For the total population, females were significantly less likely to have received a recommended colorectal cancer screening compared with males (Figure 4.29).
• Black and Asian females were significantly less likely than White females; Hispanic females were significantly less likely than non-Hispanic White females; and poor, near poor, and middle income females were significantly less likely than high income females to have received a recommended colorectal cancer screening.
• Within racial, ethnic, and income groups, White, Black, non-Hispanic White, and high income females were significantly less likely than respective males to have received a recommended colorectal cancer screening.

Prevention: Prenatal Care/Maternal Health

Childbirth and reproductive care are the most common reasons for women of childbearing age to use health care; and with more than 11,000 births each day in the United States, childbirth is the most common reason for hospital admission.³² Given that birth outcomes may have lifetime effects, good prenatal care has the potential to affect the future health and health care needs of the Nation.³³ It is recommended that women begin receiving prenatal care in the first trimester of pregnancy.

Figure 4.30. Mothers with prenatal care in the first trimester by race, ethnicity, and education, 1998-2003

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

Source: National Vital Statistics System - Natality, 1998-2003.

Reference population: Women with live births.

• In all 6 years, the proportion of women who initiated prenatal care in the first trimester was significantly lower among Black and AI/AN women compared with White women; among Hispanic compared with non-Hispanic White women; and among women with a high school education or less compared with women with any college education (Figure 4.30). In 1998 the proportion was also significantly lower among API compared with White women; but in all other years, this disparity was not observed.
• Between 1998 and 2003, rates of mothers initiating prenatal care in the first trimester did not change significantly for any group.
• Only persons with any college education achieved the Healthy People 2010 target of 90% of pregnant women receiving prenatal care in the first trimester.

Information about income is not typically collected on birth certificates, so education is commonly used as a proxy for socioeconomic status. Racial and ethnic minorities are disproportionately of lower socioeconomic status than Whites.³⁴ To distinguish the effects of race, ethnicity, and education on quality of health care, this measure is stratified by level of education.

Figure 4.31. Mothers with prenatal care in the first trimester by race and ethnicity, stratified by education, 2001

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

Source: National Vital Statistics System - Natality, 2001.

Reference population: Women with live births.

• Education explains some but not all of the differences in health care among women by race and ethnicity. Racial and ethnic differences in mothers who initiate prenatal care in the first trimester tended to persist among women with similar education (Figure 4.31).
• Only college educated Whites and non-Hispanic Whites achieved the Healthy People 2010 target of 90% of mothers receiving prenatal care in the first trimester.

Treatment: Recommended Hospital Care for Heart Attack

Each year, about half a million women die of cardiovascular disease. Among these, 250,000 die of heart attacks.³⁵ Although heart disease is the leading cause of death among both women and men, sex differences in cardiovascular care have been demonstrated and may relate to sex differences in disease presentation. Moreover, although major risk factors for cardiovascular disease can often be prevented or controlled through lifestyle changes, physicians are less likely to counsel women than men about diet, exercise, and substance abuse.³⁶ After a first heart attack, women are less likely than men to receive cardiac rehabilitation³⁷ and are more likely to die.³⁸

Figure 4.32. Recommended hospital care received by Medicare patients with heart attack by gender, 2002-2003

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

Denominator: Medicare beneficiaries hospitalized for heart attack.

Note: Composite is calculated by averaging the percentage of the population that received each of the six incorporated components of care. See Chapter 1, Introduction and Methods, for composite details.

• In 2002 and 2003, the percentage of Medicare patients with heart attack receiving recommended hospital care was significantly lower among females compared with males (Figure 4.32). In 2004, this disparity was eliminated.
• From 2002 to 2004, the percentage of Medicare patients with heart attack receiving recommended hospital care increased significantly for both females and males.

Management: New AIDS Cases

Although differences in developing AIDS does not necessarily translate into differences in quality of care, 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.

Figure 4.33. Number of new AIDS cases per 100,000 population age 13 and over, by race/ethnicity, stratified by gender, 2004

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

Source: HIV/AIDS Reporting System, 2004.

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.

• For all populations, the rate of new AIDS cases for males is more than double that for females (Figure 4.33).
• Among males, the rate of new AIDS cases for Hispanics is more than triple that for Whites, and the rate for Blacks is more than 8 times that for Whites.
• Among females, the rate of new AIDS cases for Hispanics is more than 5 times that for Whites, the rate for AI/ANs is more than triple that for Whites, and the rate for Blacks is more than 22 times that for Whites.
• No group has accomplished the Healthy People 2010 target of 1.0 new AIDS case per 100,000 population.

Access to Health Care

Usual Source of Care

Higher costs, poorer outcomes, and greater disparities are observed among individuals without a usual source of care.³⁹

Figure 4.34. Persons with a specific source of ongoing care by race, ethnicity, and income, stratified by gender, 2004

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

Source: National Health Interview Survey, 2004.

Reference population: Civilian noninstitutionalized population, all ages.

Note: Measure is age adjusted to the 2000 standard population.

• The proportion of females with a specific source of ongoing care was significantly higher than the proportion of males for the total U.S. population; it was also significantly higher for White, Black, non-Hispanic White, and Hispanic females and females of all income levels (Figure 4.34) compared with their male counterparts.
• For both males and females, the proportion of persons with a source of ongoing care was significantly lower among Hispanics compared with non-Hispanic Whites and among poor, near poor, and middle income persons compared with high income persons.
• For females, the proportion with a source of ongoing care was significantly lower among Asians and AI/ANs compared with Whites, and among Hispanics compared with non-Hispanic Whites. Significant differences by race were not observed among males.

Children

Quality of Health Care

Prevention: Vaccinations

Childhood vaccinations protect recipients from illness and disability and protect others in the community who cannot be vaccinated, such as people who are immunosuppressed. They are important for reducing mortality and morbidity in populations.

Figure 4.35. Children age 19-35 months who received all recommended vaccines by race, ethnicity, and income, 2000-2004

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

Source: National Immunization Survey, 2000-2004.

Reference population: Civilian noninstitutionalized population ages 19-35 months.

Note: Recommended vaccines for children 19-35 months include 4 doses of diphtheria, tetanus, and pertussis vaccine; 3 doses of polio vaccine; 1 dose of measles, mumps and rubella vaccine; 3 doses of H. influenzae type B vaccine; and 3 doses of hepatitis B vaccine.

• In all 5 years, the proportion of children who received all recommended vaccines was significantly lower among Black compared with White children; Hispanic compared with non-Hispanic White children; and poor, near poor, and middle income compared with high income children (Figure 4.35).
• Between 2000 and 2004, receipt of all recommended vaccines improved significantly among White, Black, Asian, and Hispanic children and among children from every income level.
• Only White, Asian, non-Hispanic White, middle income, and high income children achieved the Healthy People 2010 goal of 80% of children receiving all recommended vaccines (Figure 4.35).

Prevention: Counseling About Overweight

Childhood overweight poses a risk for other health problems and influences adult obesity. Lack of awareness is a key problem. Addressing childhood overweight begins with measuring the height and weight of all children and counseling those who are overweight.

Figure 4.36. Overweight children and adolescents ages 2-19 that were told by a doctor or health professional that they were overweight, 1999-2002

Source: National Health and Nutrition Examination Survey, 1999-2002.

Reference population: Overweight civilian noninstitutionalized population ages 2-19.

Note: "Mexican Americans" are shown in place of Hispanics because this is how data are collected by the data source.

• In sum, 37.0% of children ages 2 to 19 that are overweight have been told by a health care provider that they are overweight (Figure 4.36).
• No statistically significant differences between populations are observed, although this may be due to small sample size.

Prevention: Counseling About Healthy Eating

Unhealthy eating and lack of physical activity contribute to overweight in children. Routine promotion of healthy eating among children is widely recommended and may help to form eating habits that will last into adulthood, thereby influencing better long-term health.

Figure 4.37. Children ages 2-17 whose parents/guardians reported advice from a doctor or other health provider about healthy eating by race, ethnicity, and income, 2001-2003

Source: Medical Expenditure Panel Survey, 2001-2003.

Reference population: Civilian noninstitutionalized population ages 2-17.

• In all 3 years, the proportion of children whose parents/guardians reported advice from a health provider about healthy eating was significantly lower among children from poor, near poor, and middle income families compared with children from high income families (Figure 4.37). Black-White disparities were not observed.
• In 2002 the proportion was also significantly lower among Hispanics compared with non-Hispanic Whites, but in 2003 this disparity was eliminated.
• From 2001 to 2003, the proportion of children getting advice about healthy eating increased significantly for the total population (data not shown) and among Whites, Hispanics, and the poor.

Prevention: Vision Care

Vision checks for children can help to detect eye problems early and, in some cases, improve the chances that corrective treatments will be prescribed and successful.

Figure 4.38. Children ages 3-6 with a vision check, by race, ethnicity, and family income, 2001-2003

Source: Medical Expenditure Panel Survey, 2001-2003.

Reference population: Civilian noninstitutionalized population ages 3-6.

• In 2001 and 2002, the proportion of children with a vision check was significantly higher among Black compared with White children; the proportion was significantly lower among Hispanic compared with non-Hispanic White children, and among children from poor and middle income families compared with children from high income families (Figure 4.38). In 2003 these disparities were no longer statistically significant.
• From 2001 to 2003, the rate among Black children appeared to decline. However, changes in the proportion of children with a vision check were not statistically significant for any group due to small sample sizes.
• In all 3 years, the proportion of children with a vision check was significantly lower among children from near poor compared with high income families.

Treatment: Hospital Admissions for Pediatric Gastroenteritis

Pediatric gastroenteritis can develop into a life-threatening condition due to dehydration, especially among infants. Proper outpatient treatment of gastroenteritis may prevent hospitalization, and lower hospitalization rates may reflect access to better quality care.

Figure 4.39. Hospital admissions for gastroenteritis per 100,000 population age 0-17 by race/ethnicity, 2001-2003

Key: API=Asian or Pacific Islander.

Source: HCUP State Inpatient Databases disparities analysis file, 2001-2003.

Denominator: Children ages 0-17.

Note: White, Black, and API are non-Hispanic groups.

• In both 2001 and 2002, admissions for pediatric gastroenteritis were significantly lower among API children compared with White children; by 2003, this difference was no longer statistically significant (Figure 4.39).
• In 2003, admissions were significantly higher among Hispanic children compared with White children.
• From 2001 to 2003, admissions for pediatric gastroenteritis declined significantly for the total population and Whites and did not change significantly for any other group.

Management: Hospital Admissions for Pediatric Asthma

A disproportionate number of children have asthma. The prevalence rate for children age 0-17 is 83 per 1,000 while the prevalence rate for adults age 18 and older is 68 per 1,000.⁴³ Emergency room visit rates for asthma are highest among children age 0-4 (62 per 10,000 population). Proper outpatient treatment of asthma may prevent hospitalization, and lower hospitalization rates may reflect access to better quality care.^x

^x It should be noted that higher rates of pediatric asthma hospital admissions among Blacks compared with Whites may be partially attributable to higher asthma prevalence in Blacks.

Figure 4.40. Pediatric asthma admission rate per 100,000 population, by race/ethnicity, 2001-2003

Key: API=Asian or Pacific Islander.

Source: HCUP State Inpatient Databases disparities analysis file, 2001-2003.

Denominator: Children ages 0-17.

Note: White, Black, and API are non-Hispanic groups.

• In 2001 and 2002 the rate of asthma admissions was significantly higher among Black children and significantly lower among API children compared with White children (Figure 4.40).
• In 2003 the rate was significantly higher among Black and Hispanic children compared with White children, but the difference between API and White children had been eliminated.
• From 2001 to 2003, the rate of pediatric asthma admissions did not change significantly for any group.
• No population achieved the Healthy People 2010 target of 17.3 pediatric asthma admissions per 10,000 population ages 0-17.

Timeliness: Care for Illness or Injury As Soon As Wanted

Children often need care for illness or injury. Timely receipt of health care can prevent disease complications, alleviate discomfort, and reduce child and parental anxiety.

Figure 4.41. Children whose parents or guardians reported that their child sometimes or never got care for illness or injury as soon as wanted in the past year, by race, ethnicity, and income, 2001-2003

Source: Medical Expenditure Panel Survey, 2001-2003.

Reference population: Civilian noninstitutionalized population ages 0-17.

• In all 3 years, the proportion of children who sometimes or never got care for illness or injury as soon as wanted was significantly higher among Hispanics compared with non-Hispanic Whites and among children from poor and near poor families compared with children from high income families (Figure 4.41).
• In 2002 and 2003 the proportion was also significantly higher among children from middle income families compared with children from high income families.
• From 2001 to 2003, the proportion of children who sometimes or never got care for illness or injury as soon as wanted increased significantly for Whites and children from middle income families and did not change significantly for any other group.

Patient Centeredness: Patient Experience of Care

Patient centeredness "encompasses qualities of compassion, empathy, and responsiveness to the needs, values, and expressed preferences of the individual patient."⁴⁴ Patient centered care is supported by good patient-provider communication so that patients' needs and wants are understood and addressed and patients understand and participate in their own care.^{45, 46, 47, 48} Childhood presents a unique opportunity to promote health through preventive and routine care, identify health problems early, and establish healthy lifestyle behaviors. Communication in children's health care can pose a particular challenge as children are often less able to express their health care needs and preferences, and a third party (i.e., a parent or guardian) is involved in communication and decisionmaking. Optimal communication in children's health care can therefore have a significant impact on receipt of high quality care and subsequent health status. This is especially true for children with special health care needs (CSHCN).

Figure 4.42. Children less than 18 years of age whose parents or guardians reported that their child's health providers sometimes or never listened carefully, explained things clearly, respected what they had to say, and spent enough time with them, by race, ethnicity, income, and special health care needs, 2002 and 2003

Key: CSHCN = children with special health care needs.

Source: Medical Expenditure Panel Survey, 2002 and 2003.

Denominator: Civilian noninstitutionalized population ages 0-17.

• In both years, the proportion of children whose parents or guardians reported that their child's health providers sometimes or never listened carefully, explained things clearly, respected what they had to say, or spent enough time with them was significantly higher among Hispanics compared with non-Hispanic Whites and among poor, near poor, and middle income persons compared with high income persons (Figure 4.42).
• In 2002 the proportion of children whose parents or guardians reported poor communication was significantly higher among children with special health care needs compared with children without special health care needs; in 2003, this difference was eliminated.
• From 2002 to 2003, the proportion of children whose parents or guardians reported poor communication decreased significantly among Whites and non-Hispanic Whites.

Racial and ethnic minorities are disproportionately of lower socioeconomic status.³⁴ To distinguish the effects of race, ethnicity, and income on patient-provider communication in children's care, this measure is stratified by income.

Figure 4.43. Children less than 18 years of age whose parents or guardians reported that their child's health providers sometimes or never listened carefully, explained things clearly, respected what they had to say, and spent enough time with them by race and ethnicity, stratified by income, 2003

Source: Medical Expenditure Panel Survey, 2003.

Denominator: Civilian noninstitutionalized population ages 0-17.

Note: Sample sizes were too small to provide estimates for Blacks and Hispanics with high incomes.

• Income explains some but not all of the differences in patient-provider communication among different ethnicities.
• Parents or guardians of middle income Hispanic children were significantly more likely than parents or guardians of middle income non-Hispanic White children to report poor patient-provider communication (Figure 4.43).

Access to Health Care

Health Insurance

Insurance coverage is among the most important factors in access to health care. Special efforts have been made to provide insurance coverage to children.⁴⁹

Figure 4.44. Children age 0-17 with health insurance, by race, ethnicity, and family income, 1999-2004

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

Source: National Health Interview Survey, 1999-2004.

Reference population: Civilian noninstitutionalized population ages 0-17.

Note: Insurance status is determined at the time of interview. Children are considered uninsured if they lack private health insurance, public assistance (including the State Children's Health Insurance Program), Medicare, Medicaid, a State-sponsored health plan, other government-sponsored programs, a military health plan, or if their only coverage is through the Indian Health Service.

• In all 6 years, the proportion of children with health insurance was significantly lower among AI/AN children compared with White children; among Hispanic children compared with non-Hispanic White children; and among poor, near poor, and middle income children compared with high income children (Figure 4.44). In 2004 the proportion of children with health insurance was significantly higher among Black children and children of multiple races compared with White children.
• From 1999 to 2004, the overall rate of health insurance among children improved from 88.1% to 90.8%. Significant improvements were observed among White, Black, multiple race, non-Hispanic White, and Hispanic children, and among children from poor and near poor families. This may reflect the implementation of the State Children's Health Insurance Program (SCHIP) in 1998.

Mental Health Care

The prevalence of mental disorders for racial and ethnic minorities in the United States is similar to that for Whites,⁵⁰ but minorities have less access to mental health care and are less likely to receive needed services.⁵¹ These differences may reflect, in part, variation in preferences and cultural attitudes toward mental health and mental health care.

Figure 4.45. Children ages 12-17 with a major depressive episode in the past year who received treatment in the past year by race, ethnicity, and family income, 2004

Source: SAMHSA National Survey on Drug Use and Health, 2004.

Reference population: U.S. population ages 12-17 with a major depressive episode in the past year.

• The proportion of children ages 12-17 with a major depressive episode who received treatment for depression in the past year was significantly lower among Blacks compared with Whites; among Hispanics compared with non-Hispanic Whites; and among children from poor families compared with children from high income families (Figure 4.45).

Elderly

Quality of Health Care

Prevention: Influenza Vaccination

Influenza is responsible for significant morbidity and decreased productivity during outbreaks. Elderly persons are at increased risk for complications from influenza infections. Vaccination is an effective strategy to reduce illness and deaths due to influenza, and annual influenza vaccination of all elderly individuals is recommended by the U.S. Preventive Services Task Force and the Centers for Disease Control and Prevention.

Figure 4.46. Elderly Medicare beneficiaries with influenza vaccination in the past year by race, ethnicity, and income, 1998, 2000, and 2002

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

Source: Medicare Current Beneficiary Survey, 1998, 2000, 2002.

Reference population: Medicare beneficiaries age 65 or over living in the community.

• In all 3 years, the percentage of elderly Medicare beneficiaries with influenza vaccination in the past year was significantly lower among Blacks compared with Whites; among Hispanics compared with non-Hispanic Whites; and among poor, near poor, and middle income beneficiaries compared with high income beneficiaries (Figure 4.46). In 1998, the percentage was also significantly lower among APIs compared with Whites.
• From 1998 to 2002, the percentage improved among Blacks but did not change significantly for any other population group.
• In 2002, the Healthy People 2010 target of 90% of elderly Americans with influenza vaccination was not achieved by any population group.

Prevention: Vision Care

Visual impairment is a common and potentially serious problem among older people. Personal safety may be compromised as risks of falls and car accidents are increased. Because eye problems are often not recognized by the elderly, the U.S. Preventive Services Task Force recommends routine vision screening.

Figure 4.47. Elderly Medicare beneficiaries with an eye exam in the past year by race, ethnicity, and income, 1998, 2000, 2002

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

Source: Medicare Current Beneficiary Survey, 1998, 2000, 2002.

Reference population: Medicare beneficiaries age 65 or over living in the community.

• In all 3 years, the percentage of elderly Medicare beneficiaries with an eye exam in the past year was significantly lower among Blacks compared with Whites and among poor and near poor beneficiaries compared with high income beneficiaries (Figure 4.47).
• In 2 of the 3 years, the percentage with an eye exam was also significantly lower among Hispanics compared with non-Hispanic Whites and among middle income beneficiaries compared with high income beneficiaries.
• From 1998 to 2002, the percentage of elderly Medicare beneficiaries with an eye exam within the previous year improved significantly overall and among Whites, non-Hispanic Whites, and the poor.

Access to Health Care

Delayed Care Due to Cost

Timely delivery of appropriate care has been shown to improve health care outcomes and reduce health care costs. Timely receipt of care is especially important for the elderly due to the often increased medical needs of this population. Delayed health care can lead to diagnosis at more advance disease stage and reduce opportunities for optimal treatment.^xi

^xiIn this measure, delayed care due to cost is self-reported by patients.

Figure 4.48. Elderly Medicare beneficiaries who delayed health care due to cost by race, ethnicity, and income, 1998, 2000, and 2002

Source: Medicare Current Beneficiary Survey, 1998, 2000, 2002.

Reference population: Medicare beneficiaries age 65 or over living in the community.

• In all 3 years, the percentage of elderly Medicare beneficiaries who delayed care due to cost was significantly higher among poor, near poor, and middle income beneficiaries compared with high income beneficiaries (Figure 4.48).
• In 1998, the percentage was also significantly higher among Blacks compared with Whites.
• From 1998 to 2002, the percentage of elderly Medicare beneficiaries who delayed care due to cost rose significantly among middle income beneficiaries but did not change significantly for any other population.

Residents of Rural Areas

Quality of Health Care

Access to Health Care

Individuals with special health care needs include individuals with disabilities, individuals who utilize nursing home and home health care or end-of-life health care, and children with special heath care needs (CSHCN).

Many measures of relevance to individuals with special health care needs are tracked in the NHDR. As in the 2005 report, data on quality and access are presented for younger and elderly Medicare beneficiaries with disabilities and for CSHCN, as follows:

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