Chapter 2. Effectiveness (continued)
Respiratory Diseases
Importance
| Mortality |
| Number of deaths due to chronic lower respiratory diseasesxxiv (2007) |
127,9241 |
| Number of deaths, influenza and pneumonia combined (2007) |
52,7171 |
| Cause of death rank, chronic lower respiratory diseases (2007) |
4th1 |
| Cause of death rank for influenza and pneumonia combined (2007) |
8th1 |
| Prevalence |
| Adults age 18 and over with current asthma (2009) |
17.5 million62 |
| Children under age 18 with current asthma (2009) |
7.1 million63 |
| People under age 18 with an asthma attack in last 12 months (2007) |
3.8 million64 |
| Annual number of cases of the common cold |
>1 billion65 |
| Number of discharges attributable to pneumonia (2007) |
1.2 million66 |
| Incidence |
| Annual number of pneumonia cases due to Streptococcus pneumoniae |
500,00067 |
| New cases of tuberculosis (2008) |
12,89868 |
| Cost |
| Total cost of lung diseases (2009 est.) |
$177.4 billion69 |
| Direct medical costs of lung diseases (2009 est.) |
$113.6 billion69 |
| Total cost of upper respiratory infections (annual est.) |
$40 billion70 |
| Total cost of asthma (2007 est.) |
$19.7 billion71 |
| Direct medical costs of asthma (2007 est.) |
$14.7 billion71 |
| Cost-effectiveness of influenza immunization |
$0-$14,000/QALY5 |
Measures
The NHQR tracks several quality measures for prevention and treatment of this broad category of illnesses that includes influenza, pneumonia, asthma, upper respiratory infection, and tuberculosis. The four core report measures highlighted in this section are:
- Pneumococcal vaccination.
- Receipt of recommended care for pneumonia.
- Completion of tuberculosis therapy.
- Daily asthma medication.
Findings
Prevention: Pneumococcal Vaccination
Vaccination is a cost-effective strategy for reducing illness and death associated with pneumonia and influenza.72, 73
Figure 2.27. Adults age 65 and over who reported having ever received pneumococcal vaccination, 2000-2008, and by residence location, 2005-2008
Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2000-2008.
Denominator: Civilian noninstitutionalized population age 65 and over.
Note: Age adjusted to the 2000 U.S. standard population. Data for residence location were not available from 2000-2004. Benchmark is derived from the Behavioral Risk Factor Surveillance System (BRFSS); see Introduction and Methods for details.
- Overall, the percentage of adults age 65 and over who reported having ever received pneumococcal vaccination increased from 53.4% in 2000 to 60.3% in 2008 (Figure 2.27).
- In 2008, among residents of metropolitan areas, adults age 65 and over in large central metropolitan areas (52.3%) were least likely to report having received pneumococcal vaccination while adults age 65 and over in medium metropolitan areas (63.8%) were most likely to have reported having received pneumococcal vaccination. There were no statistically significant differences between nonmetropolitan areas.
- The 2008 top 5 State achievable benchmark was 66.4%.xxv At the current 1.2% annual rate of increase, this benchmark could be attained overall in about 9 years.
Also, in the NHDR:
- In 2008, the percentage of adults age 65 and over who reported having ever received pneumococcal vaccination was significantly lower for Blacks and Asians than for Whites; for Hispanics compared with non-Hispanic Whites; and for poor people compared with high-income people.
- Whites could attain the achievable benchmark in about 6 years, while Blacks and Asians would not attain the benchmark for 14 years and 25 years, respectively. Hispanics would not attain the benchmark for about 54 years.
Treatment: Receipt of Recommended Care for Pneumonia
Older adults are at high risk for pneumonia. The highest rate of hospitalizations for pneumonia occurs in the population age 65 and over—220.4 per 10,000 population for this group in 2004, compared with 45.5 per 10,000 for the overall population.74
CMS tracks a set of measures for quality of pneumonia care for hospitalized patients from the CMS Quality Improvement Organization Program. This set of measures has been adopted by the Hospital Quality Alliance. Recommended care for patients with pneumonia includes receipt of (1) initial antibiotics within 6 hours of hospital arrival, (2) antibiotics consistent with current recommendations, (3) blood culture before antibiotics are administered, (4) influenza vaccination status assessment/vaccine provision, and (5) pneumococcal vaccination status assessment/vaccine provision. The NHQR tracks receipt of each process measure as well as an overall composite.
Figure 2.28. Hospital patients with pneumonia who received recommended hospital care: Overall composite and five components, 2008
Source: Centers for Medicare & Medicaid Services, Medicare Quality Improvement Organization Program, 2008.
Denominator: Patients hospitalized with a principal discharge diagnosis of pneumonia or a principal discharge diagnosis of either septicemia or respiratory failure and secondary diagnosis of pneumonia.
- Among the five components of the composite measure, patients were most likely to receive antibiotics within 6 hours (93.5%) and least likely to have their influenza vaccination status assessed (84.7%) (Figure 2.28).
- In 2008, the top 5 State achievable benchmark was 93.5%.xxvi The available data were not sufficient to calculate time to benchmark.
Also, in the NHDR:
- In 2008, the percentage of patients with pneumonia who received recommended hospital care was significantly lower for Blacks, Asians, AI/ANs, and Hispanics compared with Whites.
Outcome: Completion of Tuberculosis Therapy
To be effective for individuals as well as the public, tuberculosis therapy must be taken to its completion. Failure to complete tuberculosis therapy puts patients at increased risk for treatment failure and for spreading the disease to others. Even worse, it may result in the development of drug-resistant strains of the disease.75
Figure 2.29. Percentage of patients with tuberculosis who completed a curative course of treatment within 1 year of initiation of treatment, by age and gender, 2000-2006
Source: Centers for Disease Control and Prevention, National Tuberculosis Surveillance System, 1999-2006.
Denominator: U.S. civilian noninstitutionalized population treated for tuberculosis.
- The percentage of adults ages 18-44 who completed tuberculosis therapy within 1 year increased from 78.2% in 2000 to 82.3% in 2006 (Figure 2.29).
- In all years, children ages 0-17 with tuberculosis were more likely than adults age 18 and over to complete a curative course of treatment within 1 year of initiation of treatment.
- The percentage of adults who completed tuberculosis therapy within 1 year improved for both males and females from 1999 to 2006. However, in 2006, females were more likely to complete treatment than males (85.5% compared with 82.2%).
- The 2006 top 5 State achievable benchmark was 91.5%.xxvii At the current 0.7% annual rate of increase, this benchmark could be attained overall in about 14 years.
Also, in the NHDR:
- In the general population, there were no significant differences by race but Hispanics were less likely than non-Hispanic Whites to complete tuberculosis therapy within 1 year.
- Among the foreign-born population, Blacks and Asians were more likely than foreign-born Whites to complete tuberculosis therapy within 1 year.
- Among the foreign born population, Whites would not attain the achievable benchmark for about 31 years, while Blacks and Asians would not attain the benchmark for 13 years and 19 years, respectively. Hispanics would not achieve the benchmark for 28 years.
Management: Daily Asthma Medication
Improving quality of care for people with asthma can reduce the occurrence of asthma attacks and avoidable hospitalizations. The National Asthma Education and Prevention Program, coordinated by the National Heart, Lung, and Blood Institute, develops and disseminates science-based guidelines for asthma diagnosis and management.76 These recommendations are built around four essential components of asthma management critical for effective long-term control of asthma: assessment and monitoring, control of factors contributing to symptom exacerbation, pharmacotherapy, and education for partnership in care.77
Daily long-term controller medication is necessary to prevent exacerbations and chronic symptoms for all patients with persistent asthma. Appropriate controller medications for people with mild persistent asthma78, xxviii include inhaled corticosteroids, cromolyn, nedocromil, theophylline, and leukotriene modifiers.79
Figure 2.30. People with current asthma who are now taking preventive medicine daily or almost daily (either oral or inhaler), by geographic location and age, 2003-2007
Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2003-2007.
Denominator: Civilian noninstitutionalized population with asthma, as defined below.
Note: People with current asthma report that they still have asthma or had an asthma attack in the last 12 months.
- Of those with current asthma in 2007, 29.1% reported taking preventive medicine daily or almost daily (Figure 2.30).
- In 2007, people living in large central metropolitan areas were less likely than people living in large fringe metropolitan areas to take daily preventive medication (24.7% compared with 32.5%).
- There were no statistically significant differences among nonmetropolitan areas. Nor were there any statistically significant differences between metropolitan areas (total) and nonmetropolitan areas (total).
Also, in the NHDR:
- In 2007, poor people with current asthma were less likely than high-income people to take daily preventive medicine for asthma.
- In 2007, there were no statistically significant differences between people who spoke English at home and people who spoke another language at home.
Return to Contents
Lifestyle Modification
Importance
| Mortality |
| Number of deaths per year attributable to smoking (2000-2004) |
443,00080 |
| Prevalence |
| Number of adult current cigarette smokers (2007) |
46.6 million81 |
| Number of obese adults (2005-2006) |
≥72 million82 |
| Number of adults with no leisure-time physical activity (2007) |
84.8 million81 |
| Cost |
| Total cost of smoking (2000-2004 est.) |
$193 billion80 |
| Total health care cost related to obesity (2008 est.) |
$147 billion83 |
Measures
Unhealthy behaviors place many Americans at risk for a variety of diseases. Lifestyle practices account for more than 40% of the differences in health among individuals.84 A recent study examined the effects on incidence of coronary heart disease, stroke, diabetes, and cancer of four healthy lifestyles: never smoking, not being obese, engaging in at least 3.5 hours of physical activity per week, and eating a healthy diet (higher consumption of fruits, vegetables, and whole grain bread and lower consumption of red meat). Engaging in one healthy lifestyle compared with none cut the risk of developing these diseases in half while engaging in all four cut risk by 78%.85 Unfortunately, healthy lifestyle practices have declined over the past two decades.85
Helping patients choose and maintain healthy lifestyles is a critical role of health care. The NHQR tracks several quality measures for modifying unhealthy lifestyles, including the following three core report measures:
- Counseling smokers to quit smoking.
- Counseling obese adults about exercise.
- Counseling obese adults about healthy eating.
In addition, one supporting measure is presented:
- Counseling obese adults about overweight.
Findings
Prevention: Counseling Smokers To Quit Smoking
Smoking harms nearly every organ of the body and causes or exacerbates many diseases. Smoking causes more than 80% of deaths from lung cancer and more than 90% of deaths from chronic obstructive pulmonary disease.86 Heart disease is the leading cause of death in the United States for both men and women,87 with approximately 135,000 deaths due to smoking.88 Cigarette smoking increases the risk of dying from coronary heart disease (CHD) two- to threefold.88
Quitting smoking has immediate and long-term health benefits. The risk of developing CHD attributed to smoking can be decreased by 50% after 1 year of cessation.89 Smoking is a modifiable risk factor, and health care providers can help encourage patients to change their behavior and quit smoking.
Figure 2.31. Adult current smokers with a checkup in the last 12 months who received advice to quit smoking, by geographic location, age, and gender, 2002-2007
Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2007.
Denominator: Civilian noninstitutionalized adult current smokers who had a checkup in the last 12 months.
Note: Data for 2007 for noncore residents did not meet criteria for statistical reliability.
- In 2007, only 66.2% of current adult smokers overall who had a checkup in the last 12 months were advised to quit smoking (data not shown).
- There were no statistically significant differences between adult current smokers living in metropolitan areas and those living in nonmetropolitan areas in the percentage with a checkup in the last 12 months who received advice to quit smoking (Figure 2.31). Among metropolitan areas, residents of small metropolitan areas who were current smokers were least likely to receive advice to quit smoking (57.9%).
- From 2002 to 2007, female current adult smokers continued to be more likely than males to receive advice to quit smoking.
Also, in the NHDR:
- There was improvement for poor patients from 2002 to 2007 (from 57.9% to 67.9%). However, in 2007 near-poor current adult smokers were significantly less likely than high-income current adult smokers to receive advice to quit smoking.
Prevention: Counseling Obese Adults About Overweight
More than 34% of adults age 20 and over in the United States are obese (defined as having a BMI of 30 or higher),82 putting them at increased risk for many chronic, often deadly conditions, such as hypertension, cancer, diabetes, and CHD.90 Although physician guidelines recommend that health care providers screen all adult patients for obesity,91 obesity remains underdiagnosed among U.S. adults.92
Figure 2.32. Adults with obesity who reported being told by a doctor they were overweight, by age and gender, 2005-2008
Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health and Nutrition Examination Survey, 2005-2008.
Denominator: Civilian noninstitutionalized obese adults age 20 and over.
Note: Estimates are age adjusted to the 2000 standard population for total and gender using three age groups: 20-44, 45-64, and 65 and over.
- Overall in 2005-2008, 65.9% of obese adults age 20 and over reported being told by a doctor or health professional that they were overweight (Figure 2.32).
- Obese adults ages 45-64 and age 65 and over were more likely than obese adults ages 20-44 to report being told by a doctor that they were overweight (73.4% and 69.9%, respectively, compared with 59.9%).
- Female obese adults age 20 and over were more likely than males to report being told by a doctor that they were overweight (70.6% compared with 60.7%).
Also, in the NHDR:
- Black and Mexican-American obese adults were more likely than non-Hispanic White obese adults to report being told by a doctor that they were overweight.
- Poor, near-poor, and middle-income obese adults were less likely than high-income obese adults to report being told by a doctor they were overweight.
- Obese adults with less than a high school education and those with a high school education were less likely than obese adults with at least some college education to report being told by a doctor they were overweight.
Prevention: Counseling Obese Adults About Exercise and Diet
Counseling Obese Adults About Exercise
Physician-based exercise and diet counseling is an important component of effective weight loss interventions,91 and it has been shown to produce increased levels of physical activity among sedentary patients.93 Although every obese person may not need counseling about exercise and diet, many would likely benefit from improvements in these activities. Regular exercise and a healthy diet aid in maintaining normal blood cholesterol levels, weight, and blood pressure, reducing the risk of heart disease, stroke, diabetes, and other comorbidities of obesity.
Figure 2.33. Adults with obesity who ever received advice from a health provider to exercise more, by residence location, age, and gender, 2002-2007
Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2007.
Denominator: Civilian noninstitutionalized adults age 18 and over with obesity.
Note: Obesity is defined as a body mass index of 30 or higher.
- Overall, in 2007, 59.2% of adults with obesity had ever received advice from a health provider to exercise more (Figure 2.33).
- In 2007, adults with obesity who resided in nonmetropolitan areas were less likely to receive advice to exercise than those who resided in metropolitan areas (54.1% compared with 60.5%).
- In 2007, adults with obesity ages 18-44 were least likely to ever receive advice to exercise more.
- In 2007, female adults with obesity were more likely than males to ever receive advice to exercise more (63.3% compared with 54.9%).
Also, in the NHDR:
- From 2002 to 2007, the percentage of Hispanic adults with obesity who ever received advice to exercise more increased, but Hispanics were less likely than non-Hispanic Whites to ever receive advice to exercise more.
- In 2007, the percentage of obese adults who had ever received advice to exercise more was lower for poor people, low-income people, and middle-income people than for high-income people.
- In 2007, the percentage of obese adults who had ever received advice to exercise more was lower for people with less than a high school education and people with a high school education than for people with at least some college.
- In 2007, adults with obesity who spoke a language other than English at home were less likely to ever receive advice from a health provider about exercise than adults with obesity who spoke English at home.
Counseling Obese Adults About Healthy Eating
Figure 2.34. Adults with obesity who ever received advice from a health provider about eating fewer high-fat or high-cholesterol foods, by residence location, age, and gender, 2002-2007
Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2007.
Denominator: Civilian noninstitutionalized population age 18 and over.
Note: Obesity is defined as a body mass index of 30 or higher.
- Overall, in 2007, about 51.6% of adults with obesity received advice from a health provider about healthy eating (Figure 2.34). This improved from 2002 when 48.9% said they received this advice.
- In 2007, the percentage of adults with obesity who received advice from a health provider about healthy eating was lower for people who lived in nonmetropolitan areas than for people who lived in metropolitan areas (47.9% compared with 60.5%). There were no significant differences within metropolitan areas or nonmetropolitan areas.
- Adults with obesity ages 18-44 were least likely to receive advice about healthy eating.
- From 2002 to 2007, the percentage of adults with obesity who received advice about healthy eating improved for females. In 2007, there was no significant difference between males and females.
Also, in the NHDR:
- From 2002 to 2007, the percentage of Hispanic adults with obesity who received advice from a health provider about healthy eating decreased, and Hispanics were less likely to receive this advice than non-Hispanic Whites.
- In 2007, the percentage of obese adults who received advice about eating fewer high-fat or high-cholesterol foods was significantly lower for poor, near-poor, and middle-income adults than for high-income adults.
- In 2007, the percentage of obese adults who were given advice about eating fewer high-fat or high-cholesterol foods was significantly lower for people with less than a high school education and people with a high school education than for people with some college education.
- In 2007, the percentage of adults with obesity who spoke another language at home who received advice about healthy eating was lower than it was for adults with obesity who spoke English at home.
Outcome: Obese Adults Who Exercise
Figure 2.35. Adults with obesity who spend half an hour or more in moderate or vigorous physical activity at least 3 times a week, by geographic location, age, and gender, 2002-2007
Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2007.
Denominator: Civilian noninstitutionalized population age 18 and over.
Note: Obesity is defined as a body mass index of 30 or higher.
- Overall, about 46.3% of adults with obesity spent half an hour or more in moderate or vigorous activity at least 3 times a week (data not shown).
- In 2007, there were no statistically significant differences between adults with obesity living in metropolitan areas and nonmetropolitan areas overall in the percentage who exercised (Figure 2.35). However, adults with obesity in large central metropolitan areas and small metropolitan areas were less likely to exercise at least 3 times a week compared with adults with obesity in large fringe metropolitan areas (45.4% and 39.3%, respectively, compared with 50.0%).
- From 2002 to 2007, adults age 65 and over with obesity were least likely to exercise at least 3 times a week; next lowest were adults ages 45-64 with obesity (for 2007, 36.9% and 44.1%, respectively).
- From 2002 to 2007, female adults with obesity were less likely than males to exercise at least 3 times a week (for 2007, 41.5% compared with 51.4%).
Also, in the NHDR:
- From 2002 to 2007, the percentage of adults with obesity who exercised at least 3 times a week improved for non-Hispanic Blacks and Hispanics.
- Poor adults, low-income adults, and adults with less than a high school education with obesity were less likely than high-income adults to exercise as least 3 times a week.
- Adults with obesity who spoke a language other than English at home were less likely than adults who spoke English at home to exercise at least 3 times a week.
xxiv Chronic lower respiratory diseases include emphysema and chronic bronchitis.
xxv The top 5 States that contributed to the achievable benchmark are Colorado, Delaware, Maine, New Hampshire, and Oklahoma.
xxvi The top 5 States contributing to the achievable benchmark are Iowa, Maine, New Hampshire, New Jersey, and Vermont.
xxvii The top 5 States contributing to the achievable benchmark are Alaska (tied), Indiana (tied), Kansas, Maryland, and Oregon.
xxviii "Mild persistent asthma" refers to cases in which people experience asthma symptoms more than 2 days per week and more than 2 nights per month, as well as other clinical indicators.
Return to Contents
Proceed to Next Section
540 Gaither Road Rockville, MD 20850 