National Healthcare Disparities Report, 2011

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Chapter 10. Priority Populations

To examine the issue of disparities in health care, Congress directed the Agency for Healthcare Research and Quality (AHRQ) to produce an annual report to track disparities related to "racial factors and socioeconomic factors in priority populations" (IOM, 2010). Although the emphasis is on disparities related to race, ethnicity, and socioeconomic status, this directive includes a charge to examine disparities in "priority populations," which are groups with unique health care needs or issues that require special attention.

Integrated throughout the Highlights in both the National Healthcare Disparities Report (NHDR) and the National Healthcare Quality Report (NHQR) and Chapters 2 through 9 of this report are racial, ethnic, socioeconomic, gender, geographic location, and age differences in quality of and access to health care in the general U.S. population. Subpopulation data for Asians and Hispanics are also integrated in these chapters where data are available.

Chapter 10 of the NHDR addresses the congressional directive on priority populations in addition to what is presented throughout the NHDR and in the NHQR this year.ⁱ This chapter summarizes differences for racial, ethnic, and low-income populations, as well as for residents of rural areas and people with disabilities (activity limitations).

New to the NHDR is the focus on health care for transgender individuals. Transgender individuals have been identified as the most vulnerable of the lesbian, gay, bisexual, and transgender (LGBT) populations. This year, new data are featured from the National Transgender Discrimination Survey Report on Health and Health Care. The survey wasconducted by the National Center for Transgender Equality and the National Gay and Lesbian Task Force. This section is intended to be an evolving part of the reports as the Department of Health and Human Services (HHS) and other organizations develop health care measures and data relevant to LGBT populations.

The approach taken in this chapter may help policymakers understand the impact of racial, ethnic, and socioeconomic differences on specific populations and target quality improvement programs toward groups in greatest need. The Data Tables appendix includes detailed tables that allow examination of racial, ethnic, and socioeconomic disparities both in the general population and across priority populations for most measures.

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:

Racial and ethnic minority groups.ⁱⁱ
Low-income groups.ⁱⁱⁱ
Women.
Children (under age 18).
Older adults (age 65 and over).
Residents of rural areas.^iv
Individuals with special health care needs,^v including individuals with disabilities and individuals who need chronic care or end-of-life care.

Other populations, such as LGBT, are also included.

How This Chapter Is Organized

This chapter provides the most recent information available on racial, ethnic, and income differences in quality and access for priority populations. It is presented in the following order:

Racial and ethnic minorities.
Low-income groups.
Residents of rural areas.
Individuals with disabilities or special health care needs.
LGBT individuals.

Measures related to women, children, and older adults are integrated into other chapters of this report and the Data Tables appendix and include comparisons by gender and age.

This chapter does not provide a comprehensive assessment of health care differences in each priority population. In general, most of the measures tracked in the NHQR and NHDR were selected to be applicable across many population groups to fulfill the purpose of these reports, which is to track quality and disparities at the national level.

These general measures overlook some important health care problems specific to particular populations. For example, people with disabilities may face barriers in getting access to care and experience differences in quality of care that are not captured by data because of the limitations in the survey instruments.

Racial and Ethnic Minorities

In 2010, more than one-third of the U.S. population identified themselves as members of racial or ethnic minority groups (U.S. Census Bureau, 2011a). By 2050, it is projected that these groups will account for almost half of the U.S. population. The U.S. Census Bureau estimated that the United States had about 39 million Blacks or African Americans in 2010 (12.6% of the U.S. population) (U.S. Census Bureau, 2011a); more than 47.8 million Hispanics or Latinos (15.5%) (U.S. Census Bureau, 2008); almost 14.8 million Asians (4.8%); about 6.2 million NHOPIs (0.2%); and nearly 3 million AI/ANs (0.9%) (U.S. Census Bureau, 2011a), of whom 57% reside on Federal trust lands (Smedley, et al., 2003).

Racial and ethnic minorities are more likely than non-Hispanic Whites to be poor or near poor (Lillie-Blanton, et al., 2003). In addition, Hispanics, Blacks, and some Asian subgroups are less likely than non-Hispanic Whites to have a high school education (Collins, et al., 2002).

Previous chapters of the NHDR describe health care differences by racial and ethnic categories as defined by the Office of Management and Budget and used by the U.S. Census Bureau (Executive Office of the President, 1997). In this section, quality of and access to health care for each minority group are summarized to the extent that statistically reliable data are available for each group.

Criteria for importance are that the difference is statistically significant at the alpha ≤ 0.05 level (two-tailed test) and that the relative difference from the reference group is at least 10% when framed positively as a favorable outcome or negatively as an adverse outcome. Access measures focus on facilitators and barriers to health care and exclude health care utilization measures.

Changes Over Time

This section also examines changes over time in differences related to race and ethnicity. For each measure, racial, ethnic, and socioeconomic groups are compared with a designated comparison group. The time periods range from 2000-2002 to 2008-2010, depending on the data source. Consistent with Healthy People 2020, disparities are measured in relative terms as the percentage difference between each group and a comparison group. New this year is the use of a linear regression model to estimate the difference in the annual rate of change for the comparison group relative to the reference group.

The difference in annual rate of change for the comparison group relative to the reference group was estimated. Determinations of whether subgroup differences have grown, narrowed, or remained the same were based on estimated differences in annual rate of change as specified below:

Subgroup differences are deemed to be narrowing if the change in disparities is less than -1 and p <0.10.
Subgroup differences are deemed to be growing if the change in disparities is greater than 1 and p <0.10.
Subgroup differences are deemed to have remained the same if the change in disparities is between -1 and 1, or p >0.10.

Only those measures with 4 or more years of data were included in the trending analysis. Due to methodological changes in trending analysis, it is not appropriate to compare the annual change or rates of change for measure groups discussed in this year's report with those from prior years. More information regarding the methodology can be found in Chapter 1, Introduction and Methods.

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. Of all measures of health care quality and access that are tracked in the reports and support trends over time, Blacks had worse care than Whites in the most recent year for 67 measures. Most of these measures showed no significant change in disparities over time.

For 9 measures, the gap between Blacks and Whites grew smaller, indicating improvement:

Prostate cancer deaths per 100,000 male population per year.
Cancer deaths per 100,000 population per year.
Hospital admissions for uncontrolled diabetes per 100,000 population age 18 and over.
Incidence of end stage renal disease (ESRD) due to diabetes per 100,000 population.
Hospital admissions for congestive heart failure per 1,000 population.
New AIDS cases per 100,000 population age 13 and over.
Hospital patients with pneumonia who received influenza screening or vaccination.
Long-stay nursing home residents who were assessed for pneumococcal vaccination.
Short-stay nursing home residents who were assessed for pneumococcal vaccination.

For 2 measures, the gap grew larger, indicating worsening disparities:

Breast cancer diagnosed at advanced stage (regional, distant stage, or local stage with tumor greater than 2 cm) per 100,000 women age 40 and over.
Maternal deaths per 100,000 live births.

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 that the report tracks. Of all measures of health care quality and access that are tracked in the reports and support trends over time, Asians or Asians and Pacific Islanders in aggregate had worse care than Whites in the most recent year for 30 measures. Most of these measures showed no significant change in disparities over time.

For 2 measures, the gap between Asians and Whites grew smaller, indicating improvement:

Hospital patients with pneumonia who received influenza screening or vaccination.
Hospital patients with pneumonia who received pneumococcal screening or vaccination.

For one measure, the gap grew larger, indicating worsening disparities:

Children 0-40 lb for whom a health provider gave advice within the past 2 years about using child safety seats when riding in a car.

Native Hawaiians and Other Pacific Islanders

The ability to assess disparities among NHOPIs for the NHDR has been a challenge for two main reasons. First, the NHOPI racial category is relatively new to Federal data collection. Before 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 (Executive Office of the President, 1997). However, these standards have not yet been incorporated into all databases. Second, when information about this population was collected, databases often included insufficient numbers of NHOPIs to allow reliable estimates to be made.

Due to these challenges, in previous NHDRs, estimates for the NHOPI population could be generated for only a handful of measures. A lack of quality data on this population prevents the NHDR from detailing disparities for this group. HHS is working to implement new data standards for analyzing data for minority populations, including NHOPIs.

The Affordable Care Act invests in the improvement of health data collection and analysis. Section 4302 of the Affordable Care Act contains provisions to strengthen Federal data collection efforts by requiring that all national Federal data collection efforts include information on race, ethnicity, sex, primary language, and disability status.

Currently in the NHDR, some data on NHOPIs are available for some measures throughout the report, such as in cancer treatment, heart disease, home health care, access to care, workforce diversity, patient centeredness, and timeliness. Data sources such as the Medical Expenditure Panel Survey, National Health Interview Survey, and Behavioral Risk Factor Surveillance Survey may have larger samples of NHOPIs due to efforts to improve sample sizes. However, these data are not necessarily a comprehensive survey of health and health care. Other surveys and data collection efforts, such as vital statistics and hospital administrative data, include more topics but do not identify NHOPIs or have large enough sample sizes to provide data for these populations.

For all national data sources, the relatively small population sizes of many Pacific Islander groups can cause these populations to be overlooked when categorized as NHOPIs. In addition, identifying individuals with chronic conditions or other health conditions within such small populations further reduces the sample sizes. However, as data become available, this information will be included in future reports.

American Indians and Alaska Natives

Previous NHDRs showed that AI/ANs had poorer quality of care and worse access to care than Whites for many measures tracked in the reports. Of all measures of health care quality and access that are tracked in the reports and support trends over time, AI/ANs had worse care than Whites in the most recent year for 28 measures. Most of these measures showed no significant change in disparities over time.

For one measure, the gap between AI/ANs and Whites grew smaller, indicating improvement:

Incidence of ESRD due to diabetes per 100,000 population.

For 2 measures, the gap grew larger, indicating worsening disparities:

Adults age 50 and over who ever received a colonoscopy, sigmoidoscopy, or proctoscopy.
People with difficulty contacting their usual source of care over the telephone.

Hispanics or Latinos

Previous NHDRs showed that Hispanics had poorer quality of care and worse access to care than non-Hispanic Whites for many measures that the reports track. Of all measures of health care quality and access that are tracked in the reports and support trends over time, Hispanics had worse care than non-Hispanic Whites in the most recent year for 63 measures. Most of these measures showed no significant change in disparities over time. No measure showed worsening disparities.

For 6 measures, the gap between Hispanics and non-Hispanic Whites grew smaller, indicating improvement:

Hospital admissions for uncontrolled diabetes per 100,000 population age 18 and over.
Children ages 2-17 who had a dental visit in the calendar year.
Hospital patients with pneumonia who had blood cultures collected before antibiotics were administered.
Hospital patients with pneumonia who received influenza screening or vaccination.
Hospital patients with pneumonia who received pneumococcal screening or vaccination.
Adult surgery patients who received prophylactic antibiotics within 1 hour prior to surgical incision.

^i. Populations of inner-city areas are also identified as one of AHRQ's priority populations pursuant to 42 U.S.C. 299(c)(1)(A). However, no data are available to support findings for this population.
^ii. Racial groups are White, Black, Asian, Native Hawaiian or Other Pacific Islander, American Indian and Alaska Native, and more than one race. Ethnic groups are Hispanic or Latino, non-Hispanic White, and non-Hispanic Black
^iii. Thresholds for income categories—poor, low income, middle income, and high income—vary by family size and composition and are updated annually by the U.S. Bureau of the Census. For example, in 2011, the Federal poverty threshold for a family of two adults and two children was $22,350.
^iv. Rural areas can be defined differently depending on the data source. The NHDR uses Office of Management and Budget revised definitions of metropolitan and micropolitan statistical areas. Noncore areas are rural areas.
^v. Individuals with special health care needs include children who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.

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