National Healthcare Quality Report, 2008

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Chapter 2. Effectiveness

Cancer
Diabetes
End Stage Renal Disease (ESRD)
Heart Disease
HIV and AIDS
Maternal and Child Health
Mental Health and Substance Abuse
Respiratory Disease
Nursing Home, Home Health, and Hospice Care

As noted in Chapter 1, Introduction and Methods, effectiveness of care is presented under nine clinical condition/care setting areas: cancer; diabetes; end stage renal disease (ESRD); heart disease; HIV and AIDS; maternal and child health; mental health and substance abuse; respiratory diseases; and nursing home, home health, and hospice care. The nine individual sections of this chapter highlight a small number of core measures. Results for all core measures are found in the List of Core Report Measures at the end of this report.

In this chapter, measures are organized into several categories related to the patient's need for preventive care, treatment of acute illness, and chronic disease management. These are derived from the original Institute of Medicine categories: staying healthy, getting better, living with illness or disability, and coping with the end of life. There is sizable overlap among these categories, and some measures may be considered to belong in more than one category. Outcome measures are particularly difficult to categorize when prevention, treatment, and management all play important roles. Nevertheless, for the purposes of this report, measures are placed into categories that best fit the general descriptions below.

Prevention

Caring for healthy people is an important component of health care. Educating people about health and promoting healthy behaviors can help postpone or avoid illness and disease. In addition, detecting health problems at an early stage increases the chances of effectively treating them, often reducing suffering and costs.

Treatment

Even when preventive care is ideally implemented, it cannot entirely avert the need for acute care. Delivering optimal treatments for acute illness can help reduce the consequences of illness and promote the best recovery possible.

Management

Some diseases, such as diabetes and ESRD, are chronic, which means they cannot simply be treated once; they must be managed across a lifetime. Management of chronic disease often involves promotion and maintenance of lifestyle changes and regular contact with a provider to monitor the status of the disease. For patients, effective management of chronic diseases can mean the difference between normal, healthy living and frequent medical problems.

The measures highlighted on the following pages are categorized as follows:

Section	Measure
Prevention:
Cancer	Colorectal cancer screening
Cancer	Advanced stage colorectal cancer
Cancer	Colorectal cancer mortality
Heart disease	Counseling smokers to quit smoking
Heart disease	Counseling obese adults about overweight*
Heart disease	Counseling obese adults about exercise and diet†
Maternal and child health	Prenatal care in the first trimester
Maternal and child health	Receipt of all recommended immunizations by young children
Maternal and child health	Vision checks for children
Maternal and child health	Counseling for children about healthy eating
Maternal and child health	Counseling for children about physical activity
Maternal and child health	Weight monitoring of overweight children*
Respiratory diseases	Pneumococcal vaccination
Treatment:
Cancer	Receipt of recommended care for breast and colon cancer*
Heart disease	Receipt of recommended care for heart attack
Heart disease	Inpatient mortality following heart attack
Heart disease	Receipt of recommended care for heart failure
Mental health and substance abuse	Suicide deaths
Mental health and substance abuse	Receipt of needed treatment for illicit drug use
Mental health and substance abuse	Receipt of minimally adequate treatment for mental disorders*
Respiratory diseases	Receipt of recommended care for pneumonia
Respiratory diseases	Receipt of antibiotics for the common cold
Respiratory diseases	Completion of tuberculosis therapy
Management:
Diabetes	Receipt of three recommended diabetes services
Diabetes	Lower extremity amputations
Diabetes	Controlled hemoglobin, cholesterol, and blood pressure
Diabetes	State variation in influenza immunization*
End stage renal disease	Patients with adequate hemodialysis
End stage renal disease	Registration for transplantation
HIV and AIDS	New AIDS cases
HIV and AIDS	PCP and MAC prophylaxis*
Respiratory diseases	Daily asthma medication
Nursing home, home health, and hospice care	Use of restraints on long-stay nursing home residents
Nursing home, home health, and hospice care	Presence of pressure sores in nursing home residents
Nursing home, home health, and hospice care	Improvement in ambulation in home health care episodes
Nursing home, home health, and hospice care	Acute care hospitalization of home health care patients
Nursing home, home health, and hospice care	Receipt of right amount of pain medicine by hospice patients*
Nursing home, home health, and hospice care	Receipt of care consistent with patient's stated end-of-life wishes*
Nursing home, home health, and hospice care	Referral to hospice at the right time*

^* Supplemental measure
† Counseling about diet is a noncore measure.

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Cancer

Importance

Type of statistic	Number
Mortality
Number of deaths (2008 est.)	565,650¹
Cause of death rank (2005)	2nd²
Prevalence
Number of living Americans who have been diagnosed with cancer (2005 est.)	11,098,450³
Incidence
New cases of cancer (2008 est.)	1,437,180¹
New cases of colorectal cancer (2008 est.)	148,810⁴
Cost
Total costⁱ (2007)	$219.2 billion⁵
Indirect costs (2007)	$130.2 billion⁵
Direct costsⁱⁱ (2007)	$89.0 billion⁵
Cost-effectivenessⁱⁱⁱ of colorectal cancer screening	$0-$14,000/QALY⁶
Cost-effectiveness of breast cancer screening	$35,000-$165,000/QALY⁶

Note: Statistics may vary from previous years due to revised and updated source statistics or addition of new data sources.

ⁱ Total cost equals cost of medical care (direct cost) and economic costs of morbidity and mortality (indirect cost).
ⁱⁱ Direct costs are defined as "personal health care expenditures for hospital and nursing home care, drugs, home care, and physician and other professional services."⁴
ⁱⁱⁱ Cost-effectiveness is measured here by the average net cost of each quality-adjusted life year (QALY) that is saved by the provision of a particular health intervention. QALYs are a measure of survival adjusted for its value: 1 year in perfect health is equal to 1.0 QALY, while a year in poor health would be something less than 1.0. A lower cost per QALY saved indicates a greater degree of cost-effectiveness. For example, the net cost for colorectal cancer screening ranges from $0 to $14,000 for each QALY saved.

Measures

Evidence-based consensus defining good quality care and how to measure it currently exists for only a few cancers and a few aspects of care. Breast and colorectal cancers have high incidence rates and are highlighted in alternate years of the report. The 2007 NHQR highlighted breast cancer; this year's focus is on colorectal cancer. The core report measures are:

Colorectal cancer screening.
Advanced stage colorectal cancer.
Colorectal cancer mortality.

The 2008 NHQR continues to include three noncore cancer care measures—two for breast cancer and one for colon cancer—from the National Cancer Data Base that have been endorsed by the National Quality Forum.

Recommended care for breast and colon cancer patients:

Administration of radiation therapy within 1 year of diagnosis for women under age 70 receiving breast-conserving surgery.
Axillary node dissection or sentinel lymph node biopsy at the time of surgery (lumpectomy or mastectomy) for women with Stage I-IIb breast cancer.
Surgical resection of colon cancer that includes at least 12 lymph nodes.

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Findings

Prevention: Colorectal Cancer Screening

Colorectal cancer is the third most common cancer in adults.¹ Prevention of colorectal cancer includes modifying risk factors such as weight, physical activity, smoking, and alcohol use, as well as screening for early disease. Screening is important because early stages of colorectal cancer may not present any symptoms, and it also can detect abnormal growths before they develop into cancer.¹^,7 Early detection increases treatment options and the chances for survival.⁸ The U.S. Preventive Services Task Force recommends colorectal cancer screening for men and women age 50 and over.⁹ The screening tests include fecal occult blood test FOBT), flexible sigmoidoscopy, colonoscopy, proctoscopy, and barium enema.

Figure 2.1. Adults age 50 and over who ever received colorectal cancer screening (colonoscopy, sigmoidoscopy, proctoscopy, or fecal occult blood test [FOBT]), 2000, 2003, and 2005

Figure 2.1. Adults age 50 and over who ever received colorectal cancer screening (colonoscopy, sigmoidoscopy, proctoscopy, or fecal occult blood test [FOBT]), 2000, 2003, and 2005. bar chart. percent. 2000, total, 49.8, 50-64, 43.8, 65 and over, 56.8, 2003, total, 51.7, 50-64, 45.4, 65 and over, 59.2, 2005, total, 55.5, 50-64, 49.2, 65 and over, 63.1

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2000, 2003, and 2005.

Reference population: Civilian noninstitutionalized population age 50 and over.

Note: Total rate is adjusted to the 2000 U.S. standard population.

The percentage of adults who reported ever having received a sigmoidoscopy, colonoscopy, or proctoscopy or an FOBT increased from 49.8% in 2000 to 55.5% in 2005.(Figure 2.1).
From 2000 to 2005, the percentage of adults who report ever receiving a sigmoidoscopy, colonoscopy, or proctoscopy or an FOBT increased from 43.8% to 49.2% for adults ages 50-64 and from 56.8% to 63.1% for adults age 65 and over.
In all 3 data years, adults age 65 and over were more likely than adults ages 50-64 to report ever having received a sigmoidoscopy, colonoscopy, or proctoscopy or an FOBT.

Figure 2.2. State variation: Adults age 50 and over who ever received a colonoscopy or sigmoidoscopy, 2006

Key: Above average = rate is significantly above the reporting States average in 2006. Below average = rate is significantly below the reporting States average in 2006.

Source: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System, 2006.

Note: Age adjusted to the 2000 U.S. standard population. The "reporting States average" is the average of all reporting States (51 in this case, including the District of Columbia), which is a separate figure from the national average. Data source differs from national estimates in Figure 2.1. Figure does not include proctoscopy or fecal occult blood test.

Variation was seen among States in the rates of receipt of a colonoscopy or sigmoidoscopy. In 2006, the all-States average improved to 59.5%, ranging from 50.7% to 69.4%.
Seventeen States^iv and the District of Columbia were significantly above the reporting States average in 2006, with a combined average rate of 65.8% (Figure 2.2).
Twenty States^v were significantly below the reporting States average in 2006, with a combined average rate of 54.5%.

^iv The States are Connecticut, Delaware, Maine, Maryland, Massachusetts, Michigan, Minnesota, New Hampshire, New York, North Carolina, Oregon, Rhode Island, Utah, Vermont, Virginia, Washington, and Wisconsin.
^v The States are Alabama, Arkansas, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Louisiana, Mississippi, Montana, Nebraska, Nevada, New Mexico, North Dakota, Oklahoma, South Dakota, Tennessee, West Virginia, and Wyoming.

Prevention: Advanced Stage Colorectal Cancer

Cancers can be diagnosed at different stages of development. Cancers diagnosed early before spread has occurred are generally more amenable to treatment and cure. Cancers diagnosed late with extensive spread often have poor prognoses. The rate of cancer cases that are diagnosed at late or advanced stages is a measure of the effectiveness of cancer screening efforts and of cancer diagnosis following a positive screening test.

Figure 2.3. Colorectal cancer diagnosed at advanced stage (tumors diagnosed at regional or distant stage) per 100,000 population age 50 and over, 2000-2005

Colorectal cancer diagnosed at advanced stage per 100,000 population age 50 and over, 2000-2005. trend line chart. Rate per 100,000 population (50+). 2000, 95.2, 2001, 94.5, 2002, 91.6, 2003, 88.5, 2004, 84.3, 2005, 80.8

Source: National Cancer Institute, Surveillance, Epidemiology, and End Results Program, 2000-2005.

Reference population: U.S. population age 50 and over.

Note: Data from the SEER 17 registries are used to expand the sample size. The earliest data year available is 2000.

Between 2000 and 2005, the rate of colorectal cancer diagnosed at advanced stage decreased from 95.2 to 80.8 per 100,000 population age 50 and over (Figure 2.3).

Prevention: Colorectal Cancer Mortality

The death rate from a disease is a function of many determinants, including causes of the disease, social forces, and health care system quality in providing prevention, treatment, and management of the disease. Colorectal cancer mortality reflects the impact of colorectal cancer screening, diagnosis, and treatment and is measured as the number of deaths per 100,000 population. Declines in colorectal cancer mortality can be attributed, in part, to improvements in early detection and treatment.

Figure 2.4. Colorectal cancer deaths per 100,000 population per year, United States, 1999-2005

Colorectal cancer deaths per 100,000 population per year, United States, 1999-2005. trend line chart. HP 2010 Target: 13.7. Rate per 100,000 population. 1999, 20.9, 2000, 20.9, 2001, 20.1, 2002, 19.7, 2003, 19.1, 2004, 18, 2005, 17.5

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System-Mortality, 1999-2005.

Reference population: U.S. population.

Note: Age adjusted to the 2000 U.S. standard population. Healthy People 2010 target is revised. Please go to Chapter 1, Introduction and Methods, for details.

Between 1999 and 2005, the age-adjusted rate of colorectal cancer deaths decreased from 20.9 to 17.5 per 100,000 population (Figure 2.4).
At 17.5 deaths per 100,000 population, the overall colorectal cancer age-adjusted death rate in 2005 was higher than the Healthy People 2010 target of 13.7. At the present rate of change from 1999 to 2005, this target will not be met by 2010.

Treatment: Receipt of Recommended Care for Breast and Colon Cancer

Different diagnostic and treatment options exist for various types of cancer. Some aspects of cancer care are well established as beneficial and are commonly recommended. The appropriateness of recommended care depends on different factors, such as the stage or the extent of the cancer within the body (especially whether the disease has spread from the original site to other parts of the body). Other types of care are important for accurate diagnosis, such as ensuring the adequate examination of lymph nodes when surgery is performed (e.g., to remove colon cancer).

Figure 2.5. Women under age 70 treated for breast cancer^a with breast-conserving surgery who received radiation therapy to the breast within 1 year of diagnosis, 1999 and 2005

Women under age 70 treated for breast cancer with breast-conserving surgery who received radiation therapy to the breast within 1 year of diagnosis, 1999 and 2005. bar chart. percent. total, 1999, 73.7, 2005, 74, less than 40,1999, 68.2, 2005, 66.4, 40-49, 1999, 71.7, 2005, 72.1, 50-59, 1999, 74.4, 2005, 75, 60-69, 1999, 75.6, 2005, 75.9.

^a American Joint Committee on Cancer Stage I, II, or III, primary invasive epithelial breast cancer.

Source: Commission on Cancer, American College of Surgeons and American Cancer Society, National Cancer Data Base, 1999 and 2005.

Reference population: U.S. population, women.

Between 1999 and 2005, the rates of women under age 70 treated for breast cancer with breast-conserving surgery who received the recommended treatment of radiation therapy to the breast within 1 year of diagnosis remained stable overall at 74.0% with no significant changes (Figure 2.5).
In both 1999 and 2005, the rates of radiation therapy were highest for women ages 60-69 (75.6% and 75.9%) and lowest for women under age 40 (68.2% and 66.4%).

Figure 2.6. Women with Stage I-IIb breast cancer who received axillary node dissection or sentinel lymph node biopsy (SLNB) at the time of surgery (lumpectomy or mastectomy), 1999 and 2005

Source: Commission on Cancer, American College of Surgeons and American Cancer Society, National Cancer Data Base, 1999-2005.

Reference population: U.S. population, women.

Between 1999 and 2005, rates of patients with breast cancer who received recommended care of axillary node dissection or sentinel lymph node biopsy at the time of surgery (lumpectomy or mastectomy) for women with Stage I-IIb breast cancer increased overall (75.3% in 1999 to 86.5% in 2005) (Figure 2.6).
In 2005, women ages 50-59 had the highest rate of receipt of this care for breast cancer (90.9%). Women age 80 years and over had the lowest rates in both data years but also showed the highest relative increase from 1999 to 2005 (37.2% to 59.4%).

Figure 2.7. Patients with colon cancer who received surgical resection of colon cancer that included at least 12 lymph nodes pathologically examined, 2003-2005

Source: Commission on Cancer, American College of Surgeons and American Cancer Society, National Cancer Data Base, 2003-2005.

Reference population: U.S. population.

Between 2003 and 2005, rates of patients with colon cancer who received the recommended care, in which the surgical resection of colon cancer included at least 12 lymph nodes, increased overall (from 51.5% in 2003 to 59.9% in 2005), as well as for each age group (Figure 2.7).
In all 3 data years, patients under age 40 had the highest rates of receipt of this care, and patients age 80 and over had the lowest rates.
For patients with colon cancer, the median number of regional lymph nodes examined in resected colon specimens in 2005 was 13 overall. Patients under age 40 had the highest (19) and patients age 60 and over had the lowest (13) median number of regional lymph nodes examined (data not shown).

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Diabetes

Importance

Type of statistic	Number
Mortality
Number of deaths (2005)	75,119²
Cause of death rank (2005)	6th²
Prevalence
Total number of Americans with diabetes (2007)	23.6 million¹⁰
Number of Americans diagnosed with diabetes (2007)	17.9 million¹⁰
Number of Americans with undiagnosed diabetes (2007)	5.7 million¹⁰
Incidence
New cases (age 20 and over, 2007)	1.6 million¹⁰
Cost
Total cost (2007)	$174 billion¹¹
Direct medical costs (2007)	$116 billion¹¹

Note: Statistics may vary from previous years due to revised and updated source statistics or addition of data sources.

Measures

Effective management of diabetes includes appropriate receipt of recommended processes, such as hemoglobin A1c (HbA1c) tests, eye examinations, and foot examinations. Effective management also promotes outcomes expected to correlate positively with these processes, such as control of cholesterol, blood pressure, and HbA1c^vi levels. In addition, hospital admission rates among patients with diabetes for amputations of a leg or foot can be an indicator of appropriate care for this condition.

The two core report measures highlighted in this section are:

Receipt of three recommended diabetes services.
Lower extremity amputations.

In addition, two noncore measures are presented:

Controlled HbA1c, cholesterol, and blood pressure.
State variation in influenza immunization for adults with diabetes.

^vi HbA1c is glycosylated hemoglobin—the higher the level of glucose in the blood, the higher the HbA1c level.

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Findings

Management: Receipt of Three Recommended Diabetes Services

The NHQR uses a composite measure to track the national rate of the receipt of all three recommended annual diabetes interventions: a hemoglobin A1c test, an eye examination, and a foot examination. These provide an assessment of the management of diabetes and the presence of possible complications that can occur. They are basic process measures for the quality of care for diabetes. They do not include outcomes, such as the hemoglobin A1c value, an indicator of whether diabetes is adequately controlled.

Figure 2.8. Composite measure: Adults age 40 and over with diagnosed diabetes who received all three recommended services for diabetes in the calendar year (hemoglobin A1c measurement, dilated eye examination, and foot examination), 2002-2005

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2005.

Reference population: Civilian noninstitutionalized population with diagnosed diabetes, age 40 and over.

Note: Rates are age adjusted. Data include people with both type 1 and type 2 diabetes. For this report, the time period for the retinal eye examination measure was changed to include only the calendar year. For previous reports, in addition to the calendar year, the early part of the subsequent year was included in the data collection period. This change also affects the composite measure. All data years shown in Figure 2.8 were calculated according to this revised specification.

In 2005, of adults age 40 and over with diagnosed diabetes, 40.1% received all three recommended services for diabetes, including an HbA1c measurement, a dilated eye examination, and a foot examination, compared with 43.2% in 2002. There was no significant change in rate between 2002 and 2005 (Figure 2.8).
From 2002 to 2005, the rate of receipt of HbA1c tests, dilated eye examinations, and foot examinations remained stable.

Management: Lower Extremity Amputations

Although diabetes is the leading cause of lower extremity amputations, amputations can be avoided through proper care on the part of patients and providers. Hospital admissions for lower extremity amputations for patients with diagnosed diabetes reflect poorly controlled diabetes. Better management of diabetes would prevent the need for many lower extremity amputations.

Figure 2.9. Hospital admissions for lower extremity amputations per 1,000 population age 18 and over with diabetes, 1998-2000, 2001-2003, and 2004-2006

Hospital admissions for lower extremity amputations per 1,000 adults 18 and over with diabetes, 1998-2000, 2001-2003, and 2004-2006. HP 2010 Target: 2.9. bar chart. 1998-2000, total, 6.0, 18-44, 3.5, 45-64, 6.3, 65 and over, 9.7, 2001-2003, total, 4.8, 18-44, 2.5, 45-64, 5.0, 65 and over, 7.9, 2004-2006, total, 3.8, 18-44, 2.5, 45-64, 4.1, 65 and over, 5.2

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Discharge Survey, 1998-2000, 2001-2003, and 2004-2006.

Reference population: Civilian noninstitutionalized adults age 18 and over with diagnosed diabetes, from the National Health Interview Survey, 1998-2000, 2001-2003, and 2004-2006.

Note: Total rate is age adjusted to the 2000 U.S. standard population. Healthy People 2010 target is revised. Please go to Chapter 1, Introduction and Methods, for details.

The overall rate of lower extremity amputations in adults with diagnosed diabetes fell from 6.0 per 1,000 population in 1998-2000 to 3.8 per 1,000 population in 2004-2006 (Figure 2.9).
During the same period, lower extremity amputation rates fell from 6.3 to 4.1 per 1,000 population for adults ages 45-64 and from 9.7 to 5.2 per 1,000 population for adults age 65 and over.
The Healthy People 2010 target rate of 2.9 lower extremity amputations in adults with diagnosed diabetes per 1,000 population has not been met by the total population age 18 and over. If current trends continue, the target will not be met by 2010.

Management: Controlled Hemoglobin, Cholesterol, and Blood Pressure

Persons diagnosed with diabetes^vii are often at higher risk for other cardiovascular risk factors, such as high blood pressure and high cholesterol. Having these conditions in combination with diagnosed diabetes increases the likelihood of complications, such as heart and kidney diseases, blindness, nerve damage, and stroke. Patients who manage their diagnosed diabetes and maintain an HbA1c level of <7%, total cholesterol of <200 mg/dL, and blood pressure of <140/80 mm Hg^viii can decrease these risks.

Figure 2.10. Adults age 40 and over with diagnosed diabetes with HbA1c, total cholesterol, and blood pressure under control, 1988-1994, 1999-2002, and 2003-2006

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health and Nutrition Examination Survey, 1988-1994, 1999-2002, and 2003-2006.

Reference population: Civilian noninstitutionalized population with diagnosed diabetes, age 40 and over.

Note: Age adjusted to the 2000 U.S. standard population. Survey respondents were classified as having diabetes only if they had a previous diagnosis of diabetes from a doctor other than during a period of pregnancy (i.e., gestational diabetes was excluded). This is determined by a "Yes" response to the question: "Other than during pregnancy, have you ever been told by a doctor or health professional that you have diabetes or sugar diabetes?"

In 2003-2006, 54.6% of adults age 40 and over diagnosed with diabetes had their HbA1c level under optimal control (<7%) (Figure 2.10). This percentage is significantly higher than the 41.2% reported for the 1988-1994 period.
In 2003-2006, 54.9% of those age 40 and over diagnosed with diabetes had their total cholesterol under control (<200 mg/dL). This is an improvement over the 1988-1994 rate of 29.9% for this measure.
In 2003-2006, 58.5% of this population had their blood pressure under control (<140/80 mm Hg), which is not significantly different from the 1988-1994 period.
Despite significant progress seen with the HbA1c and cholesterol control, fewer than 60% of all adults age 40 and over with diagnosed diabetes have their blood sugar, cholesterol, or blood pressure under optimal control.

^vii In 1997, the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus issued revised guidelines for the diagnosis of diabetes. Included among these was a change of the threshold for fasting plasma glucose level for the diagnosis of diabetes, which was lowered from 140 mg/dL to 126 mg/dL.
^viii Blood pressure control guidelines were updated in 2005. Previously, having a blood pressure reading of <140/90 mm Hg was considered under control. For this measure, the new threshold of <140/80 mm Hg has been applied to historical data for the sake of consistency and comparability.

Management: State Variation in Influenza Immunization

People with diagnosed diabetes are six times more likely to be hospitalized with flu complications. During flu epidemics, deaths among people with diabetes increase 5 to 15%.¹² Therefore, influenza immunization is an important aspect of diabetes management.

Figure 2.11. State variation: High-risk adults ages 18-64 with diagnosed diabetes who received an influenza vaccine in the last 12 months, by State, 2006

Key: Above average = rate is significantly above the reporting States average in 2006. Below average = rate is significantly below the reporting States average in 2006.

Source: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System, 2006.

Reference population: Civilian noninstitutionalized population ages 18-64.

In 2006, State rates of receipt of influenza immunization by noninstitutionalized high-risk adults ages 18-64 with diabetes ranged from 23.9% to 66.4%, with a reporting States average of 40.0%. This is a significant improvement over the 33.7% reported for 2005 (data not shown).
Ten States^ix were significantly above the reporting States average in 2006 (Figure 2.11), with a combined average rate of 56.0% in 2006.
Only eight of these States have influenza immunization above 50% for noninstitutionalized high-risk adults with diabetes.
Two States^x were significantly below the reporting States average in 2006, each with rates under 25%.

^ix The States are Colorado, Hawaii, Massachusetts, Montana, Nebraska, New Hampshire, Rhode Island, South Dakota, Washington, and Wisconsin.
^x The States are Arizona and Florida.

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