National Healthcare Quality Report, 2011

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Chapter 4. Timeliness

Timeliness in health care is the system's capacity to provide care quickly after a need is recognized. It is one of the six dimensions of quality the Institute of Medicine established as a priority for improvement in the health care system (IOM, 2001). Measures of timeliness include time spent waiting in doctors' offices and emergency departments (EDs) and the interval between identifying a need for specific tests and treatments and actually receiving services.

Importance

Morbidity and Mortality

Lack of timeliness can result in emotional distress, physical harm, and higher treatment costs for patients (Boudreau, et al., 2004).
Stroke patients' mortality and long-term disability are largely influenced by the timeliness of therapy (Kwan, et al., 2004).
Timely delivery of appropriate care can help reduce mortality and morbidity for chronic conditions, such as kidney disease (Kinchen, et al., 2002).
Timeliness in childhood immunizations helps maximize protection from vaccine-preventable diseases while minimizing risks to the child and reducing the chance of disease outbreaks (Luman, et al., 2005).
Timely antibiotic treatments are associated with improved clinical outcomes (Houck & Bratzler, 2005).

Cost

Early care for comorbid conditions has been shown to reduce hospitalization rates and costs for Medicare beneficiaries (Himelhoch, et al., 2004).
Some research suggests that, over the course of 30 years, the costs of treating diabetic complications can approach $50,000 per patient (Caro, et al., 2002). Early care for complications in patients with diabetes can reduce overall costs of the disease (Ramsey, et al., 1999).
Timely outpatient care can reduce admissions for pediatric asthma, which account for more than $1.25 billion in total hospitalization charges annually (AHRQ, 2009).

Measures

This report includes three measures related to timeliness of primary, emergency, and hospital care: getting care for illness or injury as soon as wanted, ED wait times, and timeliness of cardiac reperfusion for heart attack patients.

Findings

Getting Care for Illness or Injury As Soon As Wanted

A patient's primary care provider should be the first point of contact for most illnesses and injuries. A patient's ability to receive timely treatment for illness and injury is a key element in a patient-centered health care system.

Figure 4.1. 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 age and geographic location, 2002-2008

Figure 4.1. 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 age, 2002-2008. For details, go to [D] Text Description below.

[D] Select for Text Description.

From 2002 to 2008, the percentage of adults ages 45-64 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 increased from 13% to 15%. The percentage of adults who did not receive care as soon as wanted was significantly lower for adults age 65 and over than for adults ages 18-44 and ages 45-64 (Figure 4.1).
During this period, the percentage of adults who sometimes or never got care as soon as wanted was significantly lower for large fringe metropolitan areas than for large central metropolitan areas in 5 of 7 years.

Also, in the NHDR:

From 2002 to 2008, the percentage of 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 was significantly lower for Whites than for Blacks in 6 of 7 years and significantly lower than for Asians in 5 of 7 years.

Figure 4.2. 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 geographic location and insurance status, 2002-2008

Figure 4.2. 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 geographic location, 2002-2008. For details, go to [D] Text Description below.

Key: MSA = Metropolitan statistical area.
Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2008.
Denominator: Civilian noninstitutionalized population age 18 and over.
Note: For this measure, lower rates are better. Data for some geographic areas in some years did not meet criteria for statistical reliability, data quality, or confidentiality.

[D] Select for Text Description.

From 2002 to 2008, there was no statistically significant change in the gap between children living in large central metropolitan areas who did not receive care as soon as wanted and children in all other geographic areas (Figure 4.2).
During this same period, the percentage of 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 was significantly lower for children with private insurance than for children with public insurance in 6 of 7 years.

Also, in the NHDR:

From 2002 to 2008, the percentage of children who did not receive care as soon as wanted was significantly lower for children from high-income families than for children from poor families in 5 of 6 years and for low-income children in 4 of 6 years.

Emergency Department Visit Waiting Times

In 2008, an estimated 123.8 million visits were made to hospital EDs compared with 116.8 million visits in 2007 (NHAMCS: 2008 Emergency Department Tables; Niska, et al., 2010).
The median waiting time for patients to be seen by a physician during an ED visit in the United States was 35 minutes (NHAMCS: 2008 Emergency Department Tables).
Not all patients seeking care in an ED need urgent care, and use of EDs for nonurgent care could lead to longer waiting times.

The National Hospital Ambulatory Medical Care Survey defines five levels of urgency of ED visits:

Immediate, requiring immediate care.
Emergent, requiring care in less than 15 minutes.
Urgent, requiring care within 1 hour.
Semiurgent, requiring care within 2 hours.
Nonurgent, not requiring care within 2 hours.

Figure 4.3. Emergency department visits in which patient had to wait an hour or more by urgency, age, and geographic location, 2008-2009

Figure 4.3. Emergency department visits in which patient had to wait an hour or more by urgency, age, 2008-2009. For details, go to [D] Text Description below.

Key: MSA = metropolitan statistical area.
Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Ambulatory Medical Care Survey, 2008-2009.
Denominator (Immediate or Emergent): Visits to U.S. emergency department with triage assessment of immediate or emergent.
Denominator (Urgent): Visits to U.S. emergency department with triage assessment of urgent. Note: For this measure, lower rates are better.

[D] Select for Text Description.

In 2008-2009, among ED visits for both immediate/emergent and urgent conditions, the percentage of patients who had to wait an hour or more was significantly higher for those ages 18-44 than for those age 65 and over (Figure 4.3).
In 2008-2009, among ED visits for immediate/emergent conditions, there was no statistically significant difference between patients living in metropolitan areas and patients living in nonmetropolitan areas in the percentage who had to wait an hour or more. Among visits for urgent conditions, the percentage who had to wait an hour or more was lower among nonmetropolitan patients compared with metropolitan patients (20% compared with 33%).

Also, in the NHDR:

In 2008-2009, among ED visits for immediate/emergent conditions, there was no statistically significant difference between Blacks and Whites in the percentage who had to wait an hour or more. There were also no statistically significant differences between uninsured patients and patients with private insurance.
Among visits for urgent conditions, the percentage of patients who had to wait an hour or more was higher for Blacks compared with Whites and for uninsured patients under age 65 compared with privately insured patients under age 65.

Timeliness of Cardiac Reperfusion for Heart Attack Patients

The 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, reduce heart muscle damage, and save lives (Kloner & Rezkalla, 2004). To be effective, these actions need to be performed quickly after the start of a heart attack.

In this report, we present two measures of timeliness of cardiac reperfusion:

PCI within 90 minutes among appropriate patients.
Fibrinolytic medication within 30 minutes among appropriate patients.

Figure 4.4. Hospital patients with heart attack who received percutaneous coronary intervention within 90 minutes, by age, 2005-2009

For details, go to [D] Text Description below.

Key: PCI = percutaneous coronary intervention.
Source: Centers for Medicare & Medicaid Services, Medicare Quality Improvement Organization Program, 2005-2009.
Denominator: Patients hospitalized with a principal diagnosis of acute myocardial infarction who were appropriate candidates for PCI medication.

[D] Select for Text Description.

From 2005 to 2009, among heart attack patients, the percentage of patients receiving PCI within 90 minutes improved from 42% to 88% (data not shown).
During this same period, the percentage of patients receiving PCI within 90 minutes improved for all age groups (Figure 4.4). In all years, a significantly higher percentage of patients under age 65 received PCI than patients of all other age groups.
In 2008, the top 5 State PCI achievable benchmark was 91%.ⁱ At the current rate of improvement, the achievable benchmark could be attained in less than 1 year.
All ages and both genders are expected to reach the PCI achievable benchmark in less than 1 year.

Figure 4.5. Hospital patients with heart attack who received fibrinolytic medication within 30 minutes, by age, 2005-2009

Source: Centers for Medicare & Medicaid Services, Medicare Quality Improvement Organization Program, 2005-2009.
Denominator: Patients hospitalized with a principal diagnosis of acute myocardial infarction who were appropriate candidates for fibrinolytic medication.

[D] Select for Text Description.

From 2005 to 2009, the percentage of heart attack patients receiving fibrinolytic medication within 30 minutes improved from 38% to 54% (data not shown).
In 4 of 5 years, a significantly higher percentage of patients under age 65 received fibrinolytic medication than patients age 75 and over (Figure 4.5).
In 2008, the top 5 State fibrinolytic medication achievable benchmark was 61%.ⁱⁱ At the current rate of improvement, the achievable benchmark could be attained in about 1.5 years.

References

Boudreau RM, McNally C, Rensing EM, et al. Improving the timeliness of written patient notification of mammography results by mammography centers. Breast J 2004 Jan-Feb;10(1):10-19.

Calculated from Web site: Agency for Healthcare Research and Quality. Healthcare Cost and Utilization Project. Kids' Inpatient Database. Rockville, MD. Available at: http://hcupnet.ahrq.gov. Accessed April 24, 2009.

Caro JJ, Ward AJ, O'Brien JA. Lifetime costs of complications resulting from type 2 diabetes in the U.S. Diabetes Care 2002 Mar;25(3):476-81.

Centers for Disease Control and Prevention. National Hospital Ambulatory Medical Care Survey: 2008 emergency department summary tables. Available at http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/nhamcsed2008.pdf [Plugin Software Help]. Accessed May 9, 2011.

Himelhoch S, Weller WE, Wu AW, et al. Chronic medical illness, depression, and use of acute medical services among Medicare beneficiaries. Med Care 2004 Jun;42(6):512-21.

Houck PM, Bratzler DW. Administration of first hospital antibiotics for community-acquired pneumonia: does timeliness affect outcomes? Curr Opin Infect Dis 2005 Apr;18(2):151-6.

Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academies Press; 2001.

Kinchen KS, Sadler J, Fink N, et al. The timing of specialist evaluation in chronic kidney disease and mortality. Ann Intern Med 2002 Sep 17;137(6):479-86.

Kloner RA, Rezkalla SH. Cardiac protection during acute myocardial infarction: where do we stand in 2004? J Am Coll Cardiol 2004 Jul 21;44(2):276-86.

Kwan J, Hand P, Sandercock P. Improving the efficiency of delivery of thrombolysis for acute stroke: a systematic review. QJM 2004 May;97(5):273-9.

Luman ET, Barker LE, Shaw KM, et al. Timeliness of childhood vaccinations in the United States: days undervaccinated and number of vaccines delayed. JAMA 2005 Mar 9;293(10):1204-11.

Niska R, Bhuiya F, Xu J, et al. National Hospital Ambulatory Medical Care Survey: 2007 emergency department summary. Natl Hlth Stat Rep 2010 Aug 6;26. Available at: http://www.cdc.gov/nchs/data/nhsr/nhsr026.pdf [Plugin Software Help]. Accessed February 1, 2012.

Ramsey SD, Newton K, Blough D, et al. Patient-level estimates of the cost of complications in diabetes in a managed-care population. Pharmacoecon 1999 Sep;16(3):285-95.

^i. The top 5 States that contributed to the achievable benchmark are Massachusetts, Minnesota, North Carolina, Rhode Island, and South Carolina.
^ii. The top 5 States that contributed to the achievable benchmark are Arkansas, California, Georgia, Kentucky, and Tennessee.

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