National Healthcare Quality Report, 2011

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Highlights From the 2011 National Healthcare Quality and Disparities Reports

The U.S. health care system seeks to prevent, diagnose, and treat disease and to improve the physical and mental well-being of all Americans. Across the lifespan, health care helps people stay healthy, recover from illness, live with chronic disease or disability, and cope with death and dying. Quality health care delivers these services in ways that are safe, timely, patient centered, efficient, and equitable.

Unfortunately, Americans too often do not receive care that they need, or they receive care that causes harm. Care can be delivered too late or without full consideration of a patient's preferences and values. Many times, our system of health care distributes services inefficiently and unevenly across populations. Some Americans receive worse care than other Americans. These disparities may be due to differences in access to care, provider biases, poor provider-patient communication, or poor health literacy.

Each year since 2003, the Agency for Healthcare Research and Quality (AHRQ) has reported on progress and opportunities for improving health care quality and reducing health care disparities. As mandated by the U.S. Congress, the National Healthcare Quality Report (NHQR) focuses on "national trends in the quality of health care provided to the American people" (42 U.S.C. 299b-2(b)(2)) while the National Healthcare Disparities Report (NHDR) focuses on "prevailing disparities in health care delivery as it relates to racial factors and socioeconomic factors in priority populations" (42 U.S.C. 299a-1(a)(6)).

As in 2010, we have integrated findings from the 2011 NHQR and NHDR to produce a single summary chapter. This is intended to reinforce the need to consider simultaneously the quality of health care and disparities across populations when assessing our health care system. The National Healthcare Reports Highlights seeks to address three questions critical to guiding Americans toward the optimal health care they need and deserve:

What is the status of health care quality and disparities in the United States?
How have health care quality and disparities changed over time?ⁱ
Where is the need to improve health care quality and reduce disparities greatest?

Table H.1. National Quality Strategy priorities and location in NHQR and NHDR

National Priority Area	NHQR/NHDR Chapter
Making Care Safer	Patient Safety
Ensuring Person- and Family-Centered Care	Patient Centeredness
Promoting Effective Communication and Care Coordination	Care Coordination
Promoting Effective Prevention and Treatment of Leading Causes of Mortality, Starting With Cardiovascular Disease	Effectiveness (Cardiovascular Disease section)
Working with Communities To Promote Wide Use of Best Practices To Enable Healthy Living	Effectiveness (Lifestyle Modification section)
Making Quality Care More Affordable	Access to Health Care, Efficiency

New this year, the Highlights focus on national priorities identified in the National Strategy for Quality Improvement in Health Care (National Quality Strategy or NQS) and HHS Action Plan To Reduce Racial and Ethnic Health Disparities (Disparities Action Plan). Published in March 2011, the NQS identified six national priorities for quality improvement. These priorities were matched with measures in the NHQR/NHDR, and assessments of quality and disparities related to each priority are included in the Highlights (Table H.1). The Highlights also discuss health care strategies identified in the Disparities Action Plan that was released in April 2011.

Consistent with past reports, the 2011 reports emphasize one of AHRQ's priority populations as a theme and present expanded analyses of care received by older Americans. Finally, this document presents novel strategies from AHRQ's Health Care Innovations Exchange (HCIE), as well as examples of Federal and State initiatives for improving quality and reducing disparities.

Four themes from the 2011 NHQR and NHDR emphasize the need to accelerate progress if the Nation is to achieve higher quality and more equitable health care in the near future:

Health care quality and access are suboptimal, especially for minority and low-income groups.
Quality is improving; access and disparities are not improving.
Urgent attention is warranted to ensure continued improvements in quality and progress on reducing disparities with respect to certain services, geographic areas, and populations, including:
- Diabetes care and adverse events.
- Disparities in cancer screening and access to care.
- States in the South.
Progress is uneven with respect to national priorities identified in the National Quality Strategy and the Disparities Action Plan:
- Improving in quality: Ensuring Person- and Family-Centered Care and Promoting Effective Prevention and Treatment of Cardiovascular Disease.
- Lagging: Making Care Safer, Promoting Healthy Living, and Increasing Data on Racial and Ethnic Minority Populations.
- Lacking sufficient data to assess: Promoting More Effective Care Coordination and Making Care More Affordable.
- Disparities related to race, ethnicity, and socioeconomic status present in all priority areas.

Health Care Quality and Access Are Suboptimal, Especially for Minority and Low-Income Groups

A key function of the reports is to summarize the state of health care quality, access, and disparities for the Nation. This undertaking is difficult, as no single national health care database collects a comprehensive set of data elements that can produce national and State estimates for all population subgroups each year. Rather, data come from more than three dozen databases that provide estimates for different population subgroups and data years. While most data are gathered annually, some data are not collected regularly or are old. Despite the data limitations, our analyses indicate that health care quality in America is suboptimal. The gap between best possible care and that which is routinely delivered remains substantial across the Nation.

On average, people received the preventive services tracked in the reports 60% of the time, appropriate acute care services 80% of the time, and recommended chronic disease management services 70% of the time. Moreover, wide variation was found in receipt of different types of services. For instance, 95% of hospital patients with pneumonia received their initial antibiotic dose within 6 hours of hospital arrival but only 9% of patients who needed treatment for an alcohol problem received treatment at a specialty facility. Access to care is also far from optimal. On average, Americans report barriers to care 20% of the time, ranging from 3% of people saying they were unable to get or had to delay getting prescription medications to 57% of people saying their usual provider did not have office hours on weekends or nights.

All Americans should have equal access to high-quality care. Instead, we find that racial and ethnic minorities and poor people often face more barriers to care and receive poorer quality of care when they can get it. In previous years, we assessed disparities using a set of core measures. This year, we analyze disparities including all measures in the measure set. We observe few differences in results from the core and full measure sets and present findings from the full measure set here.

For each measure, we examine the relative difference between a selected group and its reference group. Differences that are statistically significant, are larger than 10%, and favor the reference group are labeled as indicating poor quality or access for the selected group. Differences that are statistically significant, are larger than 10%, and favor the selected group are labeled as indicating better quality or access for the selected group. Differences that are not statistically significant or are smaller than 10% are labeled as the same for the selected and reference groups.

Figure H.1. Number and proportion of all quality measures for which members of selected groups experienced better, same, or worse quality of care compared with reference group

Key: AI/AN = American Indian or Alaska Native; NHW = non-Hispanic White; n = number of measures.
Better = Population received better quality of care than reference group.
Same = Population and reference group received about the same quality of care.
Worse = Population received worse quality of care than reference group.

Disparities in quality of care are common:
- Adults age 65 and over received worse care than adults ages 18-44 for 39% of quality measures.
- Blacks received worse care than Whites for 41% of quality measures.
- Asians and American Indians and Alaska Natives (AI/ANs) received worse care than Whites for about 30% of quality measures.
- Hispanics received worse care than non-Hispanic Whites for 39% of measures.
- Poor people received worse care than high-income peopleⁱⁱ for 47% of measures.

Figure H.2. Number and proportion of all access measures for which members of selected groups experienced better, same, or worse access to care compared with reference group

Key: AI/AN = American Indian or Alaska Native; NHW = non-Hispanic White; n = number of measures.
Better = Population had better access to care than reference group.
Same = Population and reference group had about the same access to care.
Worse = Population had worse access to care than reference group.

Disparities in access are also common, especially among AI/ANs, Hispanics, and poor people:
- Adults age 65 and over rarely had worse access to care than adults ages 18-44.
- Blacks had worse access to care than Whites for 32% of access measures.
- Asians had worse access to care than Whites for 17% of access measures.
- AI/ANs had worse access to care than Whites for 62% of access measures.
- Hispanics had worse access to care than non-Hispanic Whites for 63% of measures.
- Poor people had worse access to care than high-income people for 89% of measures.

Quality Is Improving; Access and Disparities Are Not Improving

Suboptimal health care is undesirable, but we may be less concerned if we observe evidence of vigorous improvement. Hence, the second key function of the reports is to examine change over time. To track the progress of health care quality and access in this country, the reports present annual rates of change, which represent how quickly quality of and access to services delivered by the health care system are improving or declining. Another way to describe rate of change is the speed of improvement or decline in health care quality and access.

As in past reports, regression analysis is used to estimate annual rate of change for each measure. Annual rate of change is calculated only for measures with at least 4 years of data. For most measures, trends include data points from 2002-2003 to 2007-2008. New this year, we use weighted least squares regression to assess whether trends are statistically significant. Rates that are going in a favorable direction at a rate exceeding 1% per year and statistically significant are considered to be improving. Rates going in an unfavorable direction at a rate exceeding 1% per year and statistically significant are considered to be worsening. Rates that are changing less than 1% per year or that are not statistically significant are considered to be static. Because of the addition of significance testing, this year's results cannot be compared with results in previous reports.

Figure H.3. Number and proportion of all quality measures that are improving, not changing, or worsening, overall and for select populations

Key: AI/AN = American Indian or Alaska Native; n = number of measures.
Improving = Quality is going in a positive direction at an average annual rate greater than 1% per year.
No Change = Quality is not changing or is changing at an average annual rate less than 1% per year.
Worsening = Quality is going in a negative direction at an average annual rate greater than 1% per year.

Quality is improving slowly for all groups:
- Across all measures of health care quality tracked in the reports, almost 60% showed improvement. However, median rate of change was only 2.5% per year.
- Improvement included all groups defined by age, race, ethnicity, and income

Figure H.4. Number and proportion of all access measures that are improving, not changing, or worsening, overall and for select populations

Key: AI/AN = American Indian or Alaska Native; n = number of measures.
Improving = Access is going in a positive direction at an average annual rate greater than 1% per year.
No Change = Access is not changing or is changing at an average annual rate less than 1% per year.
Worsening = Access is going in a negative direction at an average annual rate greater than 1% per year.

Access is not improving for most groups:
- Across the measures of health care access tracked in the reports, about 50% did not show improvement and 40% were headed in the wrong direction. Median rate of change was -0.8% per year, indicating no change over time.
- Adults age 65 and over improved on about one-quarter of access measures. No group defined by race, ethnicity, or income showed significant improvement.

A similar method for assessing change in disparities using weighted least squares regression results is used. When a selected group's rate of change is at least 1% higher than the reference group's rate of change and this difference in rates of change is statistically significant, we label the disparity as improving. When a selected group's rate of change is at least 1% lower than the reference group's rate of change and this difference in rates of change is statistically significant, we label the disparity as worsening. When the difference is less than 1% or not statistically significant, we label the disparity as static. As with trends, because of the addition of significance testing, this year's results cannot be compared with results in previous reports.

Figure H.5 Number and proportion of all quality measures for which disparities related to age, race, ethnicity, and income are improving, not changing, or worsening

Key: AI/AN = American Indian or Alaska Native; NHW = non-Hispanic White; n = number of measures.
Improving = Disparity is getting smaller at a rate greater than 1% per year.
No Change = Disparity is not changing or is changing at a rate less than 1% per year.
Worsening = Disparity is getting larger at a rate greater than 1% per year.

Few disparities in quality of care are getting smaller:
- The gap in quality between adults age 65 and over and adults ages 18-44 improved (grew smaller) for about one-quarter of measures.
- Few disparities in quality of care related to race, ethnicity, or income showed significant improvement although the number of disparities that were getting smaller exceeded the number of disparities that were getting larger.

Figure H.6 Number and proportion of all access measures for which disparities related to age, race, ethnicity, and income are improving, not changing, or worsening

Almost no disparities in access to care are getting smaller:
- The gap in access between Asians and Whites improved (grew smaller) for one-quarter of measures. Few other disparities in access to care showed improvement.

Urgent Attention Is Warranted To Ensure Improvements in Quality and Progress on Reducing Disparities

The third key function of the reports is to identify areas in greatest need of improvement. Potential problem areas can be defined by types of services and populations at risk. Pace of improvement varies across preventive care, acute treatment, and chronic disease management.

Figure H.7. Number and proportion of measure that are improving, not changing, or worsening, by type of quality measure

Key: n = number of measures.
Improving = Quality is going in a positive direction at an average annual rate greater than 1% per year.
No Change = Quality is not changing or is changing at an average annual rate less than 1% per year.
Worsening = Quality is going in a negative direction at an average annual rate greater than 1% per year.
Note: Preventive care includes screening, counseling, and vaccinations; acute treatment includes hospital care for cancer, heart attack, and pneumonia; chronic disease management includes ambulatory care for diabetes, arthritis, and asthma and nursing home care for pressure sores and pain.

Measures of acute treatment are improving; other measures are lagging:
- About 60% of process measures and half of outcome measures showed improvement.
- Of the quality measures related to treatment of acute illness or injury, 77% showed improvement. In contrast, only about half of quality measures related to preventive care and chronic disease management showed improvement. Acute treatment includes a high proportion of hospital measures, many of which are tracked by the Centers for Medicare & Medicaid Services (CMS) and publicly reported. Hospitals often have more infrastructure to improve quality and to respond to performance measurement compared with providers in other settings.

Table H.2. Quality measures with the most rapid pace of improvement and deterioration

Quality Improving	Quality Worsening
Adult surgery patients who received prophylactic antibiotics within 1 hour prior to surgical incision (HC)	Children ages 19-35 months who received 3 doses of Haemophilus influenzae type B vaccine
Adult surgery patients who had prophylactic antibiotics discontinued within 24 hours after surgery end time (HC)	Maternal deaths per 100,000 live births
Hospital patients with heart attack who received percutaneous coronary intervention within 90 minutes of arrival (HC)	Postoperative pulmonary embolism or deep vein thrombosis per 1,000 surgical hospital discharges, adults age 18 and over (AE)
Hospital patients with pneumonia who received pneumococcal screening or vaccination (HC)	Adults age 40 and over with diagnosed diabetes who had their feet checked for sores or irritation in the calendar year (DC)
Hospital patients with pneumonia who received influenza screening or vaccination (HC)	Adults age 40 and over with diagnosed diabetes who received a hemoglobin A1c measurement in the calendar year (DC)
Hospital patients with pneumonia who had blood cultures collected before antibiotics were administered (HC)	Decubitus ulcers per 1,000 selected stays of 5 or more days, adults age 18 and over (AE)
Hospital patients with heart failure discharged home with written instructions or educational material (HC)	Hospital admissions for short-term complications of diabetes per 100,000 population (ages 6-17, 18 and over) (DC)
Hospital patients with heart failure and left ventricular systolic dysfunction who were prescribed ACE inhibitor or ARB at discharge (HC)	Long-stay nursing home residents with a urinary tract infection (AE)
Long-stay nursing home residents who were assessed for pneumococcal vaccination (NHC)	Adults age 50 and over with fecal occult blood test in the past 2 years
Short-stay nursing home residents who were assessed for pneumococcal vaccination (NHC)	Low-risk long-stay nursing home residents with loss of control of bowels or bladder (AE)

Key: HC = Hospital Compare; NHC = Nursing Home Compare; DC = diabetes care; AE = adverse events.

Quality changes unevenly across measures:
- Of the 10 quality measures that are improving at the fastest pace, 8 are CMS measures reported on Hospital Compare (HC) and 2 are CMS adult vaccination measures reported on Nursing Home Compare (NHC).
- Of the 10 quality measures that are worsening at the fastest pace, 3 relate to diabetes care (DC) and 4 relate to adverse events in health care facilities (AE).

The NHDR focuses on disparities related to race, ethnicity, and socioeconomic status. Table H.3 summarizes the disparities for each of these major groups tracked in the reports and for adults age 65 and over. For each group, it shows the measures where disparities are improving at the fastest rate and the measures where disparities favor the comparison group and are worsening.

Table H.3. Disparities that are changing over time

Groups	Disparities Improving	Disparities Worsening
65+ compared with 18-44	Cancer deaths per 100,000 population per year (CC)
	Deaths per 1,000 adult hospital admissions with acute myocardial infarction (HD)
	Prostate cancer deaths per 100,000 male population per year (CC)
Black compared with White	Hospital admissions for congestive heart failure per 100,000 population (HD)	Maternal deaths per 100,000 live births
	Incidence of end stage renal disease due to diabetes per 100,000 population (DC)	Breast cancer diagnosed at advanced stage per 100,000 women age 40 and over
	Long-stay nursing home residents who were assessed for pneumococcal vaccination (CMS)
Asian compared with White	Hospital patients with pneumonia who received pneumococcal screening or vaccination (CMS)	Children 0-40 lb for whom a health provider gave advice about using car safety seats
	Hospital patients with heart failure discharged home with written instructions (CMS)
	Hospital patients with pneumonia who received influenza screening or vaccination (CMS)
American Indian/ Alaska Native compared with White	Incidence of end stage renal disease (ESRD) due to diabetes per 100,000 population (DC)	Adults age 50 and over who ever received a colonoscopy, sigmoidoscopy, or proctoscopy
	Infant deaths per 1,000 live births, birth weight <1,500 grams	People with difficulty contacting their usual source of care over the telephone (AC)
	Patients who received surgical resection of colon cancer that included at least 12 lymph nodes pathologically examined
Hispanic compared with Non-Hispanic White	Hospital admissions for congestive heart failure per 100,000 population (HD)
	Hospital patients with pneumonia who received pneumococcal screening or vaccination (CMS)
	Hospital patients with pneumonia who received influenza screening or vaccination (CMS)
Poor compared with High Income	Hospital admissions for asthma per 100,000 population (2-17, 18-64, 65 and over)	Adults age 50 and over who ever received a colonoscopy, sigmoidoscopy, or proctoscopy
	Hospital admissions for long-term complications of diabetes per 100,000 population age 18+ (DC)	Adults who did not have problems seeing a specialist they needed to see in the last year (AC)
	Patients who received surgical resection of colon cancer that included at least 12 lymph nodes pathologically examined	People without a usual source of care who indicated a financial or insurance reason for not having a source of care (AC)

Key: CMS = CMS publicly reported measures; CC = cancer care; DC = diabetes care; HD = heart disease; AC = access.

Disparities also change unevenly across measures:
- Of the disparities that are improving, 6 are CMS publicly reported measures (CMS), 4 relate to cancer care (CC), 3 relate to diabetes care (DC), and 3 relate to heart disease (HD).
- Of the disparities that favor the comparison group and are worsening, 3 relate to cancer care (CC) and 3 relate to access to care (AC). Poor people experience the most disparities that are deteriorating, while no disparities affecting older adults or Hispanics are getting larger.

Quality of care varies not only across types of care but also across parts of the country. Knowing where to focus efforts improves the efficiency of interventions. Delivering data that can be used for local benchmarking and improvement is a key step in raising awareness and driving quality improvement. Since 2005, AHRQ has used the State Snapshots tool (statesnapshots.ahrq.gov) to examine variation across States. This Web site helps State health leaders, researchers, consumers, and others understand the status of health care quality in individual States and the District of Columbia. The State Snapshots are based on more than 100 NHQR measures, each of which evaluates a different aspect of health care performance and shows each State's strengths and weaknesses. Here, we use data from the 2010 State Snapshots to examine variation in quality and disparities across the States (Figure H.8 and Table H.4).

Figure H.8. Overall quality of care by State

Source: 2010 State Snapshots.
Note: States are divided into quartiles based on overall health care score.

Overall quality of care differs across geographic regions:
- States in the New England (CT, MA, ME, NH, RI, VT) and Middle Atlantic (NJ, NY, PA) census divisions were most often in the top quartile (quartile 4).
- States in the East South Central (AL, KY, MS, TN) and West South Central (AR, LA, OK, TX) divisions were most often in the bottom quartile (quartile 1).
- Northeastern States (MA, ME, NH, NY) made up the majority of the best performers in preventive care while Midwestern States (IA, MN, WI) made up the majority of the best performers in chronic disease management.
- Western States (MT, NM, NV, WY) made up the majority of the worst performers in preventive care while Southern States made up the majority of the worst performers in acute treatment (LA, MS) and chronic disease management (KY, OK, TN, WV).

Table H.4. Top and bottom 5 States by type of care

Top / Bottom States	Preventive Care	Acute Treatment	Chronic Disease Management
Top 5 States	Delaware	Florida	Iowa
	Maine	Michigan	Minnesota
	Massachusetts	Minnesota	New Hampshire
	New Hampshire	Pennsylvania	Vermont
	New York	South Carolina	Wisconsin
Bottom 5 States	Indiana	Alaska	Kentucky
	Montana	District of Columbia	Ohio
	Nevada	Louisiana	Oklahoma
	New Mexico	Mississippi	Tennessee
	Wyoming	New Mexico	West Virginia

Source: 2010 State Snapshots

The 2010 State Snapshots also examined disparities in health care related to race, ethnicity, and area income. Information about disparities at the State level is not available for many measures tracked in the reports and State Snapshots. For 29 AHRQ Quality Indicators, data on income-related disparities are available for 34 States and are shown below.

Figure H.9. Income-related disparities in quality of health care by State

Source: 2010 State Snapshots.
Note: States are divided into quartiles based on the quality of care received by residents of low-income neighborhoods relative to care received by residents of high-income neighborhoods. States shown in white have no data.

Income-related disparities also differ across geographic regions:
- In the West South Central census division, two of three States with data (AR, OK) were in the top quartile for income-related disparities (quartile 4, fewest disparities). Two of four States with data (HI, OR) in the Pacific division were in the top quartile.
- In the South Atlantic division, four of six States with data (GA, MD, SC, VA) were in the bottom quartile for income-related disparities (quartile 1). Two of three States with data (IL, OH) in the East North Central division were in the bottom quartile.
- At the State level, there is little relationship between overall quality of care and income-related disparities.

^i. Data years vary across measures. For most measures, trends include data points from 2001-2002 to 2007-2008.
^ii. Throughout the Highlights, poor indicates individuals whose household income is below the Federal poverty level and high income indicates individuals whose household income is at least four times the Federal poverty level.

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