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National Healthcare Disparities Report, 2009 | ||||||||||||||||||
Patient Safety
* For more information, refer to Gurwitz JH, Field TS, Harrold LR, et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA 2003 Mar 5;289:1107-16. In 1999, the IOM published To Err Is Human, which called for a national effort to reduce medical errors and increase patient safety.86 The IOM defines patient safety as freedom from accidental injury due to medical care or medical errors.86 In response to the IOM's report on patient safety, President Bush signed the Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act). The act was designed to spur the development of voluntary, provider-driven initiatives to improve the quality, safety, and outcomes of patient care. The Patient Safety Act addresses many of the current barriers to improving patient care. Several factors limit our current ability to aggregate data in sufficient numbers to rapidly identify the most prevalent risks and hazards in the delivery of patient care, their underlying causes, and the practices that are most effective in mitigating them. These include the reluctance of providers to participate in improvement initiatives, based on fear of increased liability; and difficulty in aggregating and sharing data confidentially across facilities or State lines. To Err Is Human does not mention race or ethnicity when discussing the problem of patient safety. A 2006 review of the literature found that only 9 of 323 articles on pediatric patient safety (2.8%) included race or ethnicity in the analysis. Five of the nine studies from this review used data from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project (HCUP).94 This section highlights five measures of patient safety in three areas:
For findings related to all core measures of patient safety, refer to Table 2.2a. Health Care-Associated InfectionsPostoperative Wound InfectionsInfections acquired during hospital stays (health care-associated or nosocomial infections) are among the most serious safety concerns. A common HAI is a wound infection following surgery. Hospitals can reduce the risk of wound infection after surgery by making sure patients get the right antibiotics at the right time on the day of their surgery. However, taking these antibiotics for more than 24 hours after routine surgery is usually not necessary and can increase the risk of side effects, such as stomachaches, serious types of diarrhea, and antibiotic resistance. Among adult hospital patients having surgery, the NHDR tracks an opportunities model composite of two measures: receipt of antibiotics within 1 hour prior to surgical incision and discontinuation of antibiotics within 24 hours after the end of surgery. Figure 2.34. Composite measure: Adult surgery patients who received appropriate timing of antibiotics, by race/ethnicity, 2005-2007 Key: AI/AN = American Indian or Alaska Native. Source: Centers for Medicare & Medicaid Services, Medicare Quality Improvement Organization Program, 2005-2007. Denominator: Medicare patients age 18 and over having surgery. Note: Whites, Blacks, Asians, and AI/ANs are non-Hispanic groups. Data were insufficient for this analysis for Native Hawaiians and Other Pacific Islanders. Appropriate timing of antibiotics received by adult surgical patients for all payers included in this composite are: (1) antibiotics started within 1 hour of surgery, and (2) antibiotics stopped within 24 hours after surgery.
Other Complications of Hospital CareVarious types of care delivered in hospitals in addition to surgery can place patients at risk for injury or death. Adverse Events Associated With Central Venous CathetersPatients who require a central venous catheter (CVC) to be inserted into the great vessels of their heart tend to be severely ill. However, the procedure itself can result in a number of infectious and noninfectious complications. Figure 2.35. Composite measure: Bloodstream infections or mechanical adverse events associated with central venous catheter placements, Medicare hospital patients, by race, 2004-2007 Source: Centers for Medicare & Medicaid Services, Medicare Patient Safety Monitoring System (MPSMS), 2004-2007. Denominator: Medicare fee-for-service (FFS) discharges from the MPSMS sample with central venous catheter placement, all ages. Note: Central venous catheter complications included in this composite are bloodstream infections and mechanical adverse events. Data were not available for Asians, Native Hawaiians and Other Pacific Islanders, and American Indians and Alaska Natives.
Deaths Following Complications of CareMany complications that arise during hospital stays cannot be prevented. However, rapid identification and aggressive treatment of complications may prevent these complications from leading to death. This indicator, also called "failure to rescue," tracks deaths among patients whose hospitalizations are complicated by pneumonia, thromboembolic event, sepsis, acute renal failure, shock, cardiac arrest, gastrointestinal bleeding, or acute ulcer. Figure 2.36. Deaths per 1,000 discharges with complications potentially resulting from care (failure to rescue), adults ages 18-74, by race/ethnicity, 2001-2006 Key: API = Asian or Pacific Islander. Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project (HCUP), State Inpatient Databases (SID) disparities analysis file, 2001-2006. Denominator: Patients ages 18-74 from U.S. community hospitals whose hospitalizations were complicated by pneumonia, thromboembolic event, sepsis, acute renal failure, shock, cardiac arrest, gastrointestinal bleeding, or acute ulcer. Note: White, Black, and API are non-Hispanic. Data were not available for American Indians and Alaska Natives. Data are adjusted for age, gender, and all patient refined-diagnosis related group clusters. The HCUP SID disparities analysis file is designed to provide national estimates using weighted records from a sample of hospitals from 25 States that have 66% of the U.S. resident population.
Figure 2.37. Deaths per 1,000 discharges with complications potentially resulting from care (failure to rescue), adults ages 18-74, by income, 2006 Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project (HCUP), State Inpatient Databases (SID) disparities analysis file, 2006. Denominator: Patients ages 18-74 from U.S. community hospitals whose hospitalization is complicated by pneumonia, thromboembolic event, sepsis, acute renal failure, shock, cardiac arrest, gastrointestinal bleeding, or acute ulcer. Note: Data are adjusted for age, gender, and diagnosis-related group clusters. Quartile income categories are used instead of the NHDR's usual descriptive categories because that is how data are collected for this measure. Quartile 1 corresponds to the lowest income quartile, and Quartile 4 corresponds to the highest income quartile. Income categories are based on the median household income of the ZIP Code of the patient's residence. The HCUP SID disparities analysis file is designed to provide national estimates using weighted records from a sample of hospitals from 25 States that have 66% of the U.S. resident population.
Complications of MedicationsComplications of medications are common safety problems. Some adverse drug events may be related to misuse of medication, but others are not. However, prescribing medications that are inappropriate for a specific population may increase the risk of adverse drug events. Adverse Drug Events in the HospitalSome medications used in hospitals can cause serious complications. The Medicare Patient Safety Monitoring System tracks a number of "high-risk" drugs and the adverse events associated with them. Adverse drug events can include serious bleeding associated with intravenous heparin, subcutaneously administered low-molecular-weight heparin, and oral warfarin, as well as hypoglycemia associated with insulin or oral hypoglycemics. Figure 2.38. Medicare hospital patients with medication-related adverse drug events, by race, 2004-2007 Intravenous heparin Low-molecular-weight heparin Warfarin Insulin Source: Centers for Medicare & Medicaid Services, Medicare Patient Safety Monitoring System (MPSMS), 2004-2007. Denominator: Medicare fee-for-service (FFS) discharges from the MPSMS sample that received the drug, all ages. Note: Data were not collected for Asians, Native Hawaiians and Other Pacific Islanders, American Indians and Alaska Natives, and Hispanics. In 2007, data for adverse drug events for intravenous heparin among Blacks were not statistically reliable.
Potentially Inappropriate Medication Prescriptions for Older PatientsSome drugs that are appropriate for some patients are considered potentially harmful for older patients but are still prescribed to them.95,xvii Inappropriate medication use by older patients includes the use of drugs that should often or always be avoided for these patients. Figure 2.39. Adults age 65 and over who received potentially inappropriate prescription medications in the calendar year, by race, ethnicity, income, education, insurance status, and gender, 2006 Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2006. Denominator: Civilian noninstitutionalized population age 65 and over. Note: Data were insufficient for this analysis for Asians and Other Pacific Islanders and for American Indians and Alaska Natives. This measure includes 33 inappropriate prescription medications. Prescription medications received include all prescribed medications initially purchased or otherwise obtained, as well as any refills.
TimelinessTimeliness is the health care system's capacity to provide care quickly after a need is recognized. For patients, lack of timeliness can result in emotional distress, physical harm, and financial consequences.96,97 For example, stroke patients' mortality and long-term disability are largely influenced by the timeliness of therapy.98,99 Timely delivery of appropriate care can also help reduce mortality and morbidity for chronic conditions such as chronic kidney disease,100 and timely antibiotic treatments are associated with improved clinical outcomes.101 Timely delivery of childhood immunizations helps maximize protection from vaccine-preventable diseases while minimizing risks to the child and reducing the chance of disease outbreaks.102 Early care for comorbid conditions has been shown to reduce hospitalization rates and costs for Medicare beneficiaries.103 Some research suggests that, over the course of 30 years, the costs of treating diabetic complications can approach $50,000 per patient.104 Timely outpatient care also can reduce admissions for pediatric asthma, which account for $1.25 billion in total hospitalization charges annually.105 The measures of timeliness highlighted in this section are getting care for illness or injury as soon as wanted and timeliness of cardiac reperfusion for heart attack patients. (For findings related to all core measures of timeliness, refer to Tables 2.3a and 2.3b.) Getting Care for Illness or Injury As Soon As WantedThe ability of patients to receive illness and injury care in a timely fashion is a key element in a patient-centered health care system. Figure 2.40. Adults who needed care right away for an illness, injury, or condition in the last 12 months who sometimes or never got care as soon as wanted, by race, ethnicity, and income, 2002-2006
Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2006. Denominator: Civilian noninstitutionalized population age 18 and over. Note: Data were insufficient for this analysis for Native Hawaiians and Other Pacific Islanders and for American Indians and Alaska Natives.
Socioeconomic factors may explain at least some of the racial and ethnic differences in timeliness. To distinguish the effects of race, ethnicity, income, and education on timeliness of primary care, this measure is stratified by income and education. Figure 2.41. Adults who needed care right away for an illness, injury, or condition in the last 12 months who sometimes or never got care as soon as wanted, by race and ethnicity, stratified by income, 2006
Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2006. Denominator: Civilian noninstitutionalized population age 18 and over. Note: Data were insufficient for this analysis for Asians, Native Hawaiians and Other Pacific Islanders, and American Indians and Alaska Natives. Figure 2.42. Adults who needed care right away for an illness, injury, or condition in the last 12 months who sometimes or never got care as soon as wanted, by race and ethnicity, stratified by education, 2006
Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2006. Denominator: Civilian noninstitutionalized population age 18 and over. Note: Data were insufficient for this analysis for Asians, Native Hawaiians and Other Pacific Islanders, and American Indians and Alaska Natives.
Figure 2.43. Children who needed care right away for an illness, injury, or condition in the last 12 months who sometimes or never got care as soon as wanted, by race, ethnicity, and income, 2002-2006
Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2006. Denominator: Civilian noninstitutionalized population under age 18.
Emergency Department Visits in Which Patients Left Without Being SeenIn 2006, almost a quarter (24.8%) of patients who had an emergency department (ED) visit in the United States spent 4 hours or more in the ED, with the same percentage of patients waiting 1 hour or more to be seen by a physician.106 This finding may reflect the population-based 18% per person increase in ED visit volumes from 1996 to 2006.106,107 Although there are many reasons that a patient seeking care in an ED may leave without being seen, long waits tend to explain many departures. Figure 2.44. Emergency department visits in which patients left without being seen, by race and payment source, 2000-2007
Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Ambulatory Medical Care Survey, 2000-2001, 2001-2002, 2003-2004, 2005-2006, and 2006-2007. Denominator: Visits by patients (of all ages) to the EDs of non-Federal, short-stay, and general hospitals. Note: Data were insufficient for this analysis for Asians, Native Hawaiians and Other Pacific Islanders, and American Indians and Alaska Natives.
Timeliness of Cardiac Reperfusion for Heart Attack PatientsThe capacity to treat hospital patients in a timely manner is especially important for emergency situations such as heart attacks. Some heart attacks are caused by blood clots. Early actions, such as percutaneous coronary intervention (PCI) or fibrinolytic medication, may open blockages caused by blood clots by restoring blood flow to the heart, thus reducing heart muscle damage and saving lives.108 To be effective, these actions need to be performed quickly after the start of a heart attack. In the NHDR, we examine a new measure of timeliness of cardiac reperfusion: receipt of PCI within 90 minutes among appropriate patients. Figure 2.45. Hospital patients with heart attack who received percutaneous coronary intervention within 90 minutes, by race/ethnicity, 2005-2007 Key: AI/AN = American Indian or Alaska Native. Source: Centers for Medicare & Medicaid Services, Medicare Quality Improvement Organization Program, 2005-2007. Denominator: Patients hospitalized with a principal diagnosis of acute myocardial infarction who were appropriate candidates for percutaneous coronary intervention.
Patient CenterednessThe IOM identifies patient centeredness as a core component of quality health care.2 Patient centeredness is defined as: [H]ealth care that establishes a partnership among practitioners, patients, and their families (when appropriate) to ensure that decisions respect patients' wants, needs, and preferences and that patients have the education and support they need to make decisions and participate in their own care.109 Patient centeredness "encompasses qualities of compassion, empathy, and responsiveness to the needs, values, and expressed preferences of the individual patient."2 In addition, effective communication between the provider and the patient is often a legal requirement.* Patient-centered care is supported by good provider-patient communication so that patients' needs and wants are understood and addressed, and patients understand and participate in their own care.109-112 This style of care has been shown to improve patients' health and health care.110,111,113-115 Unfortunately, many barriers exist to good communication. About one-third of Americans are not "health literate,"116,117 which means they lack the "capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions."118 They experience many difficulties, including:
Individuals with inadequate health literacy incur higher medical costs and are more likely to have an inefficient mix of service use compared with those with adequate health literacy.125 Providers also differ in communication proficiency, including varied listening skills and different views from their patients' of symptoms and treatment effectiveness.126 Additional factors influencing patient centeredness and provider-patient communication include:
When health care is patient centered, both underuse and overuse of medical services are reduced.127 Fewer diagnostic tests and referrals reduce strains on system resources and costs.113 Efforts to remove these possible impediments to patient centeredness are underway within the Department of Health and Human Services (HHS). For example, the Office of Minority Health has developed a set of Cultural Competency Curriculum Modules that aim to equip providers with cultural and linguistic competencies to help promote patient-centered care.128,xviii These modules are based on the National Standards on Culturally and Linguistically Appropriate Services. The standards are directed at health care organizations and aim to improve the patient centeredness of care for people with limited English proficiency (LEP). Another example, which is being administered by the Health Resources and Services Administration, is Unified Health Communication, a new Web-based course for providers that integrates concepts related to health literacy with cultural competency and LEP.xix In addition, the HHS Office for Civil Rights has issued Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons. This guidance explains that recipients of Federal financial assistance must take reasonable steps to provide LEP people with a meaningful opportunity to participate in HHS-funded programs. Failure to do so may violate the prohibition under Title VI of the Civil Rights Act of 1964, 42 U.S.C. 2000d, against national origin discrimination.129 The NHDR includes one core measure of patient centeredness—a composite measure on the patient experience of care. In addition, this year's report includes a new supplemental measure of workforce diversity—race/ethnicity of the Nation's dental workforce. Having a diverse workforce of health care providers may be an important component of patient-centered health care for many patients. * For example, Title VI of the Civil Rights Act of 1964, 42 U.S.C. 2000d, may require the practitioner or hospital to provide language interpreters and translate vital documents for limited-English-proficient persons. Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. 794, may require the practitioner or hospital to provide sign language interpreters, materials in Braille, and/or accessible electronic formats for individuals with disabilities. xvii Eleven drugs that should always be avoided for older patients include barbiturates, flurazepam, meprobamate, chlorpropamide, meperidine, pentazocine, trimethobenzamide, belladonna alkaloids, dicyclomine, hyoscyamine, and propantheline. Twenty-two drugs that should often be avoided for older patients include carisoprodol, chlorzoxazone, cyclobenzaprine, metaxalone, methocarbamol, amitriptyline, chlordiazepoxide, diazepam, doxepin, indomethacin, dipyridamole, ticlopidine, methyldopa, reserpine, disopyramide, oxybutynin, chlorpheniramine, cyproheptadine, diphenhydramine, hydroxyzine, promethazine, and propoxyphene.
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