National Healthcare Quality Report, 2008

You Are Here: AHRQ Home > Quality & Patient Safety > Measuring Healthcare Quality > National Healthcare Quality & Disparities Reports, 2008 > National Healthcare Quality Report, 2008 > Chapter 2 (continued)

End Stage Renal Disease

Importance

Type of statistic	Number
Mortality
Total ESRD deaths (2005)	85,790¹³
Prevalence
Total cases (2005).	485,012¹³
Incidence
Number of new cases (2005)	106,912¹³
Cost
Total ESRD Medicare program expenditures (2005)	$19.3 billion¹³

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

Measures

The NHQR includes six measures of ESRD management to assess the quality of care provided to renal dialysis patients. The two core report measures highlighted here are:

Adequacy of hemodialysis.
Registration for transplantation.

Return to Contents

Findings

Management: Patients With Adequate Hemodialysis

Dialysis removes harmful waste and excess fluid buildup in the blood that occurs when kidneys fail to function. Hemodialysis is the most common method used to treat advanced and permanent kidney failure. The adequacy of dialysis is measured by the percentage of hemodialysis patients with a urea reduction ratio equal to or greater than 65%; this measure indicates how well urea, a waste product, is eliminated by the dialysis machine.

Figure 2.12. Adult hemodialysis patients with adequate dialysis (urea reduction ratio 65% or greater), 2002-2006

Figure 2.12. Adult hemodialysis patients with adequate dialysis (urea reduction ratio 65% or greater) 2002-2006. trend line chart. 2002, 86%, 2003, 87%, 2004, 87%, 2005, 88%, 2006, 87%

Source: Centers for Medicare & Medicaid Services, ESRD Clinical Performance Measures Project, 2002-2006.

Reference population: ESRD hemodialysis patients age 18 and over.

There is no significant difference between the 2002 percentage of all hemodialysis patients with adequate dialysis (86%) and the 2006 percentage (87%) (Figure 2.12). The rates for each age group have remained stable during this period (data not shown)

Figure 2.13. State variation: Adult hemodialysis patients with adequate dialysis (urea reduction ratio 65% or greater), 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 Medicare & Medicaid Services, University of Michigan Kidney Epidemiology and Cost Center, 2006.

Reference population: ESRD hemodialysis patients and peritoneal dialysis patients.

Note: The "reporting States average" is the average of all reporting States (52 in this case, including the District of Columbia and Puerto Rico), which is a separate figure from the national average.

In 2006, the reporting States average for adult patients with adequate dialysis was 94.6%, with all States 90% or above.
Fourteen States^xi and the District of Columbia were significantly above the reporting States average in 2006 (Figure 2.13), with a combined average rate of 96.4%.
Eleven States and Puerto Rico^xii were significantly below the reporting States average in 2006, with a combined average rate of 92.3%.
Thirty-two States showed improvement on this measure from 2005 to 2006, with no States reporting a decline (data not shown).

^xi The States are Colorado, Connecticut, Florida, Hawaii, Indiana, Maine, New Hampshire, New Jersey, New Mexico, North Carolina, Rhode Island, South Carolina, South Dakota, and Texas.
^xii The States are California, Georgia, Illinois, Louisiana, Missouri, Nebraska, Nevada, Tennessee, Utah, West Virginia, and Wisconsin.

Management: Registration for Transplantation

Kidney transplantation is a procedure that replaces a failing kidney with a healthy kidney. If a patient is deemed a good candidate for transplant, he or she is placed on the transplant program's waiting list. Dialysis patients wait for transplant centers to match them with the most suitable donor. Registration for transplantation is an initial step toward patients receiving the option of kidney transplantation. Patients who receive transplants from living donors, about 36% of kidney transplants, do not need to register on a waiting list.

Early transplantation that decreases or eliminates the need for dialysis can also lessen the occurrence of acute rejection and patient mortality. In 2006, 70,778 patients were on the Organ Procurement and Transplantation Network deceased donor kidney transplant waiting list in the United States. Only 10,212 deceased donor kidney transplants were performed.*

Figure 2.14. Dialysis patients under age 70 who were registered on a waiting list for transplantation, by age group, 1999-2004

Source: Centers for Medicare & Medicaid Services, U.S. Renal Data System, 1999-2004.

Reference population: ESRD hemodialysis patients and peritoneal dialysis patients under age 70.

Note: The estimates in this chart differ from those reported in the 2007 NHQR. The 2007 NHQR estimates have been updated.

In 2004, 15.4% of dialysis patients were registered on a waiting list for transplantation. This rate did not improve from 1999 for the total population or for almost any age group (Figure 2.14).
From 1999 to 2004, the likelihood of being on a transplant waiting list did increase significantly for adults ages 60-69 (6.4% to 9.0%).
During the same period, the likelihood of being on a transplant waiting list decreased significantly for the 20-39 age group.
From 1999 to 2004, the likelihood of being on a transplant waiting list stayed the same for patients under age 20 and ages 40-59.

*Go to Health Resources and Services Administration. 2007 annual report of the U.S. Organ Procurement and Transplantation Network and Scientific Registry of Transplant Recipients: transplant data 1997-2006. Available at: http://www.optn.org/AR2007/chapterindex.htm.

Return to Contents

Heart Disease

Importance

Type of statistic	Number
Mortality
Number of deaths (2005)	652,091²
Cause of death rank (2005)	1st²
Prevalence
Number of cases of coronary heart disease (2005)	16.0 million⁵^,14
Number of cases of heart failure (2005)	5.3 million¹⁴
Number of cases of high blood pressure (2005)	73.0 million¹⁴
Number of heart attacks (2005)	8.1 million¹⁴
Incidence
Number of new cases of congestive heart failure (2005)	336,815¹⁴
Cost
Total cost of cardiovascular disease (2008 est.)	$448.5 billion¹⁴
Total cost of congestive heart failure (2008 est.)	$34.8 billion¹⁴
Direct medical costs of cardiovascular disease (2008 est.)	$296.4 billion¹⁴
Cost effectiveness of hypertension screening	$14,000-$35,000/QALY⁶

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

Measures

The NHQR tracks several quality measures for preventing and treating heart disease, including the following five core report measures:

Counseling smokers to quit smoking.
Counseling obese adults about exercise.
Receipt of recommended care for heart attack.
Inpatient mortality following heart attack.
Receipt of recommended care for acute heart failure.

In addition, two noncore measures are presented:

Counseling obese adults about overweight.
Counseling obese adults about healthy eating.

Return to Contents

Findings

Prevention: Counseling Smokers To Quit Smoking

Heart disease is the leading cause of death in the United States for both men and women,² with approximately 135,000 deaths due to smoking.¹⁵ Cigarette smoking increases the risk of dying from coronary heart disease (CHD) two-to threefold.¹⁵ The risk of developing CHD attributed to smoking can be decreased by 50% after one year of cessation.¹⁶ Smoking is a modifiable risk factor, and health care providers can help encourage patients to change their behavior and quit smoking.

Figure 2.15. Adult current smokers with a checkup in the last 12 months who received advice to quit smoking, 2000-2005

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2000-2005.

Reference population: Civilian noninstitutionalized population age 18 and over.

In 2005, 64.5% of adult smokers with a doctor visit in the last 12 months reported that their providers had advised them to quit. There was no significant difference between 2000 and 2005 in the percentage of adult smokers during the preceding year who reported that their providers had advised them to quit (Figure 2.15).
In all 6 data years, adult smokers ages 18-44 were less likely than the other age groups 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 body mass index of 30 or higher),¹⁷ putting them at increased risk for many chronic, often deadly conditions, such as hypertension, cancer, diabetes, and CHD.¹⁸ Although physician guidelines recommend that health care providers screen all adult patients for obesity,¹⁹ obesity remains underdiagnosed among U.S. adults.²⁰

Figure 2.16. Adults with obesity who were told by a doctor they were overweight, 2003-2006

Figure 2.16. Adults with obesity who were told by a doctor they were overweight, 2003-2006. bar chart. percent. total, 64.8, 20-44, 58.9,45-64, 69.7, 65 and over, 73.0

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

Reference population: Civilian noninstitutionalized adults age 20 and over.

In 2003-2006, 64.8% of obese adults were told they were overweight by a doctor or health professional (Figure 2.16).
In 2003-2006, obese adults ages 20-44 (58.9%) were less likely than those ages 45-64 (69.7%) and 65 and over (73.0%) to be told by a doctor or health professional they were overweight.

Prevention: Counseling Obese Adults About Exercise and Diet

Physician-based exercise and diet counseling is an important component of effective weight loss interventions,¹⁹ and it has been shown to produce increased levels of physical activity among sedentary patients.²¹ While not every obese person needs 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 loss, and blood pressure control efforts, reducing the risk of heart disease, stroke, diabetes, and other comorbidities of obesity.

Figure 2.17. Adults with obesity who ever received advice from a health provider to exercise more, 2002-2005

Figure 2.17. Adults with obesity who ever received advice from a health provider to exercise more, 2002-2005. bar chart. percent. 2002, Total, 56.8, 18-44, 46.5, 45-64, 66.8, 65 and over, 64.6, 2003, Total, 58.2, 18-44, 48.8, 45-64, 67.1, 65 and over, 64.9, 2004, Total, 58.8, 18-44, 47.4, 45-64, 68.6, 65 and over, 67.7, 2005, Total, 58.3, 18-44, 47.4, 45-64, 67.8, 65 and over, 66

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

Reference population: Civilian noninstitutionalized adults age 18 and over.

In 2005, 58.3% of obese adults were ever given advice from a health provider to exercise more. This figure did not improve from 2002, nor did it improve for any age group (Figure 2.17).
In all 4 data years, obese adults ages 45 and over were more likely than those ages 18-44 to ever receive advice from a health provider about exercising more.

Figure 2.18. Adults with obesity who ever received advice from a health provider about eating fewer high-fat or high-cholesterol foods, 2002-2005

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

Reference population: Civilian noninstitutionalized adults age 18 and over.

In 2005, 49.7% of obese adults were ever given advice from a health provider about eating fewer high-fat or high-cholesterol foods. This figure did not significantly improve from 2002, nor did it improve for any age group (Figure 2.18).
In all 4 years, obese adults ages 45-64 and 65 and over were more likely than those ages 18-44 to ever receive advice about eating fewer high-fat or high-cholesterol foods.

Treatment: Receipt of Recommended Care for Heart Attack

There is consensus that recommended care for patients with a heart attack includes administration of aspirin within 24 hours of heart attack and at discharge, administration of beta blocker within 24 hours of attack and at discharge, angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) treatment among patients with left ventricular systolic dysfunction, and, among smokers, counseling to quit smoking. The NHQR reports on these measures, as well as a composite of these measures that addresses the proportion of all opportunities in which heart attack patients receive recommended care.

Figure 2.19. Hospital patients with heart attack who received recommended hospital care: Overall composite and six components, 2002-2004 (Medicare) and 2005-2006 (all payers)

Key: ACE = angiotensin-converting enzyme; ARB = angiotensin receptor blocker.

Source: Centers for Medicare & Medicaid Services, Medicare Quality Improvement Organization Program, 2002-2006.

Denominator: Patients hospitalized with a principal diagnosis of acute myocardial infarction.

Note: Beginning in 2005, the data collection method changed from the abstraction of randomly selected medical records for Medicare beneficiaries to the receipt of hospital self-reported data for all payer types. The ACE inhibitor measure was changed in 2005 to include angiotensin receptor blockers as an acceptable alternative to ACE inhibitors.

From 2002 to 2004, the overall heart attack composite shows significant improvement in the provision of recommended care for Medicare patients with heart attacks.
From 2005 to 2006, among all payers, there was no significant improvement in the provision of recommended care for heart attacks (Figure 2.19).
From 2002 to 2004, five of the six individual component measures of recommended care for heart attack significantly increased (aspirin within 24 hours of admission, from 85.3% to 88.5%; aspirin prescribed at discharge, from 87.4% to 91.0%; beta blocker administered within 24 hours, from 76.3% to 82.5%; beta blocker prescribed at discharge, from 81.5% to 89.0%; and smoking cessation counseling, from 49.5% to 68.1%).
From 2005 to 2006, four of the six individual component measures for recommended care for heart attack significantly increased (aspirin within 24 hours of admission, from 95.3% to 96.5%; ACE inhibitor or ARB prescribed at discharge, from 83.7% to 86.9%; beta blocker administered within 24 hours, from 91.5% to 93.2%; and smoking cessation counseling, from 90.9% to 95.9%).

Treatment: Inpatient Mortality Following Heart Attack

Acute myocardial infarction (AMI) is a common, life-threatening condition that requires rapid recognition and efficient treatment in a hospital to reduce the risk of serious damage to the heart and death. Measuring processes of AMI care can provide information about whether a patient received specific needed services, but these processes make up a very small proportion of all the care that an AMI patient needs. Measuring outcomes of AMI care, such as mortality, can provide a more global assessment of all the care a patient receives and usually is the aspect of quality that matters most to patients.

Survival following admission for AMI reflects multiple patient factors, such as a patient's comorbidities, as well as health care system factors, such as the possible need to transfer hospitals in order to receive services. Also, it may partly reflect receipt of appropriate health services.

Figure 2.20. Deaths per 1,000 adult hospital admissions with acute myocardial infarction (AMI), 1994, 1997, and 2000-2005

Figure 2.20. Deaths per 1,000 adult hospital admissions with acute myocardial infarction (AMI), 1994, 1997, and 2000-2005. trend line chart. Deaths per 1,000 admissions, Total, 1994, 127.7, 1997, 114.5; 2000, 106.4; 2001, 102.0; 2002, 95.1; 2003, 87.8; 2004, 83.0; 2005, 77.5.

Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project Nationwide Inpatient Sample, 1994, 1997, 2000-2005.

Denominator: Any person age 18 and over, U.S. citizen or foreign, using non-Federal, community hospitals in the United States, with a heart attack as principal discharge diagnosis.

Note: Rates are adjusted by age, gender, age-gender interactions, and all-payer refined diagnosis-related group scoring of risk of mortality. Data were analyzed for two selected historic years (1994 and 1997) and annually with each NHQR (2000-2005).

Between 1994 and 2005, the overall inpatient mortality rate declined from 127.7 to 77.5 deaths per 1,000 admissions with heart attack (Figure 2.20).
The rate of overall inpatient mortality for admissions with heart attack as the principal discharge diagnosis decreased significantly from 2000 to 2005 (106.4 to 77.5 deaths per 1,000 admissions with heart attack) (Figure 2.20).

Treatment: Receipt of Recommended Care for Heart Failure

The NHQR tracks the national rates of receipt of the following services:

Recommended test for heart functioning (heart failure patients having evaluation of left ventricular ejection fraction [LVEF]).
Recommended medication treatment (patients with left ventricular systolic dysfunction prescribed ACE inhibitor or ARB at discharge).

In addition, an overall composite measure describes the proportion of all episodes in which heart failure patients receive recommended care.

Figure 2.21. Hospital patients with heart failure who received recommended hospital care: Overall composite and two components, 2002-2004 (Medicare) and 2005-2006 (all payers)

Key: LVEF = left ventricular ejection fraction; ACE = angiotensin-converting enzyme; ARB = angiotensin receptor blocker.

Source: Centers for Medicare & Medicaid Services, Medicare Quality Improvement Organization Program, 2002-2006.

Denominator: Patients hospitalized with a principal diagnosis of acute heart failure.

Note: Beginning in 2005, the data collection method changed from the abstraction of randomly selected medical records for Medicare beneficiaries to the receipt of hospital self-reported data for all payer types. The ACE inhibitor measure was changed in 2005 to include ARBs as an acceptable alternative to ACE inhibitors.

From 2002 to 2004, the overall composite showed improvement in the provision of recommended care for Medicare patients with heart failure, from 73.4% of the opportunities to provide recommended care in 2002 to 77.7% in 2004 (Figure 2.21).
For all payers from 2005 to 2006, the LVEF measure and ACE inhibitors for treatment of acute heart failure showed improvement, from 88.4% to 90.7% and from 82.9% to 85.2%, respectively.

Figure 2.22. State variation: Hospital patients with heart failure who received recommended hospital care, 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 Medicare & Medicaid Services, Medicare Quality Improvement Organization Program, 2006.

Denominator:Patients hospitalized with a principal diagnosis of acute heart failure.

In 2006, the reporting States average for receipt of recommended hospital care for acute heart failure was 89.2%, with States ranging from a low of 74.3% to a high of 94.5%.
Twenty-seven States^xiii were significantly above the reporting States average in 2006 (Figure 2.22), with a combined average rate of 91.7%.
Sixteen States,^xiv the District of Columbia, and Puerto Rico were significantly below the reporting States average in 2006, with a combined average rate of 85.4%.

^xiii The States are Alaska, Arizona, California, Colorado, Connecticut, Florida, Illinois, Iowa, Maine, Maryland, Massachusetts, Michigan, Missouri, Nebraska, New Hampshire, New Jersey, New York, North Carolina, Ohio, Pennsylvania, Rhode Island, South Carolina, Vermont, Virginia, Washington, West Virginia, and Wisconsin.
^xiv The States are Alabama, Arkansas, Georgia, Hawaii, Kansas, Kentucky, Louisiana, Mississippi, Montana, New Mexico, North Dakota, Oklahoma, South Dakota, Tennessee, Texas, and Wyoming.

Return to Contents

HIV and AIDS

Importance

Type of statistic	Number
Mortality
Number of deaths among persons with AIDS (2006)	14,627²²
Prevalence
Number of persons in the United States living with HIV (2006)	226,477²²
Number of persons in the United States living with AIDS (2006)	436,693²²
Incidence
New AIDS cases (2006)	37,852²²
New AIDS infection (2006)	56,300²³
Cost
Federal spending on domestic HIV/AIDS care, cash and housing assistance, and prevention and research (FY 2008 est.)	$18.2 billion²⁴

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

Measures

This section highlights one core report measure focusing on quality of preventive care for HIV-infected individuals:

New AIDS cases.

In addition, a noncore measure from the HIV Research Network is presented on the prevention of opportunistic infections in HIV patients:

Eligible AIDS patients receiving prophylaxis for Pneumocystis pneumonia (PCP) and Mycobacterium avium complex (MAC).

Return to Contents

Findings

Management: New AIDS Cases

Changes in HIV infection rates reflect changes in behavior by at-risk individuals that may only partly be influenced by the health care system. However, individual and community programs have shown progress in influencing behavior change. Changes in the incidence of new AIDS cases are affected by changes in HIV infection rates and by the availability of appropriate treatments for HIV-infected individuals. Improved treatments that extend life for those with the disease are reflected in the fact that the number of deaths due to AIDS fell from about 18,000 to 14,600 between 2003 and 2006, after showing no change for the previous 3 years.²²

Figure 2.23. New AIDS cases per 100,000 population age 13 and over, 1998-2006

Source: Centers for Disease Control and Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, HIV/AIDS Surveillance System, 1998-2006.

Reference population: U.S. population age 13 and over.

The overall rate of new AIDS cases per 100,000 decreased significantly between 1998 and 2006 (17.9% to 14.9%; Figure 2.23).
From 1998 to 2006, the rate of new AIDS cases also significantly decreased for people ages 18-44 (26.6% to 20.6%).
The 2006 national rate of 14.9 new AIDS cases per 100,000 population age 13 and over is well above the Healthy People 2010 target of 1.0 new case per 100,000 population age 13 and over. If current trends continue, this target will not be met.

Management: PCP and MAC Prophylaxis

Management of chronic HIV disease includes outpatient and inpatient services. Without adequate treatment, as HIV disease progresses, CD4 cell counts fall and patients become increasingly susceptible to opportunistic infections. When CD4 cell counts fall below 200, medicine to prevent development of PCP is routinely recommended. When CD4 cell counts fall below 50, medicine to prevent development of disseminated MAC infection is routinely recommended.²⁵ Because national data on HIV care are not routinely collected, HIV measures tracked in the NHQR come from the HIV Research Network, which consists of 18 medical practices across the United States that treat large numbers of HIV patients.^xv

Figure 2.24. Eligible AIDS patients age 18 and over receiving PCP and MAC prophylaxis in the calendar year, 2003-2005

Figure 2.24. Eligible AIDS patients age 18 and over receiving PCP and MAC prophylaxis in the calendar year, 2003-2005. bar chart. Percent of those eligible receiving treatment. 2003, PCP prophylaxis, 83.9; MAC prophylaxis, 84.3; 2004, PCP prophylaxis, 86.6; MAC prophylaxis, 81.8; 2005, PCP prophylaxis, 90.6; MAC prophylaxis, 87.1.

Key: PCP = Pneumocystis pneumonia; MAC = Mycobacterium avium complex.

Source: Agency for Healthcare Research and Quality, Center for Delivery, Organization, and Markets, HIV Research Network, 2003-2005.

Reference population: Adult patients with AIDS with CD4 cell counts below 200 (PCP) or CD4 cell counts below 50 (MAC).

Note: Data from the HIV Research Network are not nationally representative of the level of care received by all Americans living with HIV. Participation in this network is voluntary, and network data represent only patients who are actually receiving care. Furthermore, data shown above are not representative of the HIV Research Network as a whole because they represent only a subset of network sites that have the best quality data.

Of eligible patients (3,080 AIDS patients with at least two CD4 cell counts below 200), 90.6% received PCP prophylaxis in 2005 (Figure 2.24), which is a significant increase compared with 2003 and 2004.
Of eligible patients (915 AIDS patients with at least two CD4 cell counts below 50), 87.1% received MAC prophylaxis in 2005, which is not significantly different from 2003 but is a significant increase from 2004.

^xv Although program data are collected from all Ryan White HIV/AIDS Program grantees, the aggregate nature of the data makes it difficult to assess the quality of care provided by Ryan White HIV/AIDS Program providers.

Return to Contents