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National Healthcare Quality Report, 2009 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Chapter 2. EffectivenessContentsCancer As better understanding of health and sickness has led to superior ways of preventing, diagnosing, and treating diseases, the health of most Americans has improved dramatically. However, ample evidence indicates that some Americans do not receive the full benefits of high-quality care. As noted in Chapter 1, Introduction and Methods, this year's findings include an assessment of the effects of health insurance on quality of care. When possible, findings in this chapter show measures of effectiveness of care for individuals with different types of insurance. For those under age 65, individuals with any private insurance, public insurance only, and no insurance are typically compared. For those age 65 and over, individuals with Medicare and private insurance, Medicare and other public insurance, and Medicare only are typically compared. Differences in care according to insurance status may reflect the direct impact of insurance coverage on access to and quality of services. But other factors may play a part, such as differences in personal decisions, social norms, and communication styles across groups with differing levels of insurance. In addition, this year's sections on effectiveness of care have been reorganized. This chapter is organized around eight clinical areas (cancer, diabetes, end stage renal disease, heart disease, HIV and AIDS, maternal and child health, mental health and substance abuse, and respiratory diseases) and three types of health care services that typically cut across clinical conditions (lifestyle modification, functional status preservation and rehabilitation, and supportive and palliative care). The 11 sections of this chapter highlight a small number of core measures. In this chapter, process 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 organized separately because prevention, treatment, and management can all play important roles in affecting outcomes. PreventionCaring 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. TreatmentEven 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. ManagementSome diseases, such as diabetes and end stage renal disease, 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. OutcomesMany factors other than health care influence health outcomes, including a person's genes, lifestyle, and social and physical environment. However, for many individuals, appropriate preventive services, timely treatment of acute illness and injury, and meticulous management of chronic disease can positively affect mortality, morbidity, and quality of life. The measures highlighted in this chapter are categorized as follows:
CancerImportance
MeasuresEvidence-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 2008 National Healthcare Quality Report (NHQR) highlighted colorectal cancer; this year's focus is on breast cancer. The core report measures are:
As in previous reports, the 2009 NHQR includes two noncore measures for breast cancer care from the National Cancer Data Base that have been endorsed by the National Quality Forum:
FindingsPrevention: Breast Cancer Screening (Mammography)Early detection of cancer increases treatment options and often improves outcomes. Mammography, the most effective method for detecting breast cancer at its early stages,6 can identify malignancies before they can be felt and before symptoms develop. For available data years, the U.S. Preventive Services Task Force recommended mammograms every 1 to 2 years for women age 40 and over.7 Figure 2.1. Women age 40 and over who reported they had a mammogram within the past 2 years, by insurance status, 2000, 2003, and 2005
Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2000, 2003, and 2005. Denominator: Civilian noninstitutionalized women age 40 and over. Note: Insurance-specific rates are age adjusted to the 2000 U.S. standard population.
Figure 2.2. State variation: Women age 40 and over who reported they had a mammogram within the past 2 years, 2006 Key: Best quartile indicates States with highest rates of mammography; worst quartile indicates States with lowest rates. Source: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System, 2006.
Outcome: Advanced Stage Breast CancerCancers 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 adherence to followup care after a positive screening test. Because many cancers often take years to develop, changes in rates of late-stage cancer may lag behind changes in rates of screening. Figure 2.3. Age-adjusted rate of advanced stage breast cancer per 100,000 women age 40 and over, by age, 2000-2006 Source: National Cancer Institute, Surveillance, Epidemiology, and End Results Program, 2000-2006. Denominator: Women age 40 and over. Note: Age adjusted to the 2000 U.S. standard population. Advanced stage breast cancer is defined as local stage with tumor size greater than 2 cm diameter, regional stage, or distant stage.
Treatment: Receipt of Recommended Care for Breast CancerDifferent 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 adequate examination of lymph nodes when surgery is performed. Figure 2.4. Women with clinical Stage I-IIb breast cancer who received axillary node dissection or sentinel lymph node biopsy at the time of surgery (lumpectomy or mastectomy), by insurance status, 2000-2006
Source: Commission on Cancer, American College of Surgeons and American Cancer Society, National Cancer Data Base, 2000-2006. Denominator: U.S. population, women with Stage I-IIb breast cancer.
Figure 2.5. Women under age 70 treated for breast cancer with breast-conserving surgery who received radiation therapy to the breast within 1 year of diagnosis, by insurance status, 2000-2006
Source: Commission on Cancer, American College of Surgeons and American Cancer Society, National Cancer Data Base, 2000-2006. Denominator: U.S. population, women under age 70 treated for breast cancer (American Joint Committee on Cancer Stage I, II, or III primary invasive epithelial breast cancer) with breast-conserving surgery.
Outcome: Breast Cancer DeathsThe death rate from a disease is a function of many factors, including the causes of the disease; social forces; and the effectiveness of the health care system in providing prevention, treatment, and management of the disease. Breast cancer deaths reflect the impact of breast cancer screening, diagnosis, and treatment. Mortality is measured as the number of deaths per 100,000 women. Declines in breast cancer deaths can be attributed, in part, to improvements in early detection and treatment. Figure 2.6. Age-adjusted breast cancer deaths per 100,000 women, by age, 2000-2006 Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System-Mortality, 2000-2006. Denominator: U.S. population, women. Note: Total rate is age adjusted to the 2000 U.S. standard population.
DiabetesImportance
MeasuresEffective management of diabetes includes appropriate receipt of recommended processes, such as hemoglobin A1c (HbA1c)vi 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 levels. The core report measure highlighted in this section is:
In addition, three noncore measures are presented:
FindingsManagement: Receipt of Three Recommended Diabetes ServicesThe NHQR uses a composite measure to track the national rate of the receipt of all three recommended annual diabetes interventions: an HbA1c test, an eye examination, and a foot examination. These are basic process measures that provide an assessment of the quality of diabetes management. Figure 2.7. Composite measure: Adults age 40 and over with diagnosed diabetes who received three recommended services for diabetes in the calendar year (hemoglobin A1c measurement, dilated eye examination, and foot examination), by insurance status, 2002-2006
Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2006. Denominator: Civilian noninstitutionalized population with diagnosed diabetes, age 40 and over. Note: Data include people with both type 1 and type 2 diabetes.
Management and Outcome: Receipt of HbA1c Measurement and Admissions for Short-Term Diabetes ComplicationsThis year, the NHQR introduces a new type of State variation map. Rather than focus on a single process or outcome measure, these maps seek to identify States that perform poorly on both a process measure and a related outcome measure. These maps do not imply causality; improvements in processes of care typically affect outcomes many years in the future. Rather, these maps are intended to help identify those States that may have the greatest opportunity to improve performance in this area. For diabetes, HbA1c measurement is critical for guiding treatment and achieving good control of glucose. Individuals who do not achieve good control are more prone to develop diabetic ketoacidosis and other short-term complications requiring hospitalization. Figure 2.8. State variation: Adults age 40 and over with diagnosed diabetes who received a hemoglobin A1c measurement (2006) and admissions for diabetes with short-term complications per 100,000 population age 18 and over (2006) Key: Process measure in worst quartile indicates States with the lowest rates of HbA1c measurement; outcome measure in worst quartile indicates States with the highest rates of admission for short-term complications of diabetes. Source: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System, 2006 (HbA1c measurement); Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, 2006 (admissions for diabetes with short-term complications).
Outcome: Controlled Hemoglobin, Cholesterol, and Blood PressurePeople diagnosed with diabetes 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 Hgx can decrease these risks. Figure 2.9. Adults age 40 and over with diagnosed diabetes with hemoglobin A1c, total cholesterol, and blood pressure under control, by age, 2003-2006 Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health and Nutrition Examination Survey, 2003-2006. Denominator: 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?"
i Throughout this report, total cost equals cost of medical care (direct cost) and economic costs of morbidity and mortality (indirect cost). 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 Return to Contents
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