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National Healthcare Quality Report, 2009 | ||||||||||
Access to CareDelayed Care Due to CostTimely delivery of appropriate health care has been shown to improve health care outcomes and reduce health care costs. Timely receipt of care is especially important for the older population due to their often increased medical needs. Delayed health care can lead to diagnosis at a more advanced disease stage and can reduce opportunities for optimal treatment.xv Figure 4.48. Medicare beneficiaries age 65 and over with delayed care due to cost, by race, ethnicity, and income, 2002-2006
Source: Centers for Medicare & Medicaid Services, Medicare Current Beneficiary Survey, 2002-2006. Denominator: Medicare beneficiaries age 65 and over living in the community.
Residents of Rural AreasAbout one in five Americans lives in a nonmetropolitan area.62 Compared with their urban counterparts, rural residents are more likely to be older, poor,63 and in fair or poor health and to have chronic conditions.62 Rural residents are less likely than their urban counterparts to receive recommended preventive services and on average report fewer visits to health care providers.64 Although 20% of Americans live in rural areasxvi, only 9% of physicians in America practice in those settings.65 Other important providers of health care in those settings include nurse practitioners, nurse midwives, and physician assistants. A variety of programs deliver needed services in rural areas, such as the National Health Service Corps Scholarship Program, IHS, State offices of rural health, rural health clinics, and community health centers. Cost-based Medicare reimbursement incentives are also available for rural health clinics, critical access hospitals, sole community hospitals, and Medicare-dependent hospitals and physicians in health professional shortage areas. Many rural residents depend on small rural hospitals for their care. There are approximately 2,000 rural hospitals throughout the country,66 1,500 of which have 50 or fewer beds. Most of these hospitals are critical access hospitals that have 25 or fewer beds. They face unique challenges due to their size and case mix. During the 1980s, many were forced to close because of financial losses.67 Yet, more recently, finances of small rural hospitals have improved and few closures have occurred since 2003. Transportation needs are pronounced among rural residents, who must travel longer distances to reach health care delivery sites. Of the nearly 1,000 "frontier counties"xvii in the Nation, most have limited health care services and many do not have any.68 The NHDR tracks many measures of relevance to residents of rural areas. Findings presented here highlight three quality measures and one access measure of particular importance to residents of rural areas, with additional geographic data from metropolitan areas:
In previous NHDRs, detailed geographic typologies were applied to two AHRQ databases-MEPS and HCUP-to define variations in health care quality and access for a range of rural and urban locations. This year, data from MEPS and HCUP are again presented. Federal definitions of micropolitan and noncore statistical areas (not metropolitan or micropolitan areas) published in June 2003 are used.69 In addition, Urban Influence Codes use a methodology developed by the National Center for Health Statistics to subdivide metropolitan areas into large central and large fringe metropolitan areas.70 Thus, categories used in this section of the NHDR may be defined as follows:
Urban-rural contrasts for measures from MEPS and HCUP compare residents of rural statistical areas (including both micropolitan and noncore statistical areas) with residents of urban statistical areas (including large central, large fringe, medium, and small metropolitan statistical areas). Sample sizes are often too small to provide reliable estimates for noncore statistical areas, limiting the ability to assess disparities among residents of these areas. Quality of Health CareOutcome: Heart Attack MortalityHeart disease is the leading cause of death for both men and women in the United States, responsible for nearly 632,000 deaths in 2006.71 About 1.2 million heart attacks occur each year.72 Data on inpatient hospital deaths for patients who are admitted for a heart attack (AMI) are presented. To distinguish the effects of race/ethnicity on the AMI in-hospital mortality rate within urban and rural areas, race/ethnicity data are stratified by urban and rural location of patient residence. Figure 4.49. Deaths per 1,000 adult admissions with acute myocardial infarction as principal diagnosis, by race/ethnicity and geographic location, 2006 Large Central Metropolitan = central counties in metropolitan areas ≥ 1 million inhabitants. Large Fringe Metropolitan = outlying (suburban) counties in metropolitan areas ≥ 1 million inhabitants. Medium Metropolitan = counties in metropolitan areas of 250,000-999,999 inhabitants. Small Metropolitan = counties in metropolitan areas of 50,000-249,999 inhabitants. Micropolitan = counties in an area with an urban cluster of 10,000-49,999 inhabitants. Noncore = < 10,000 inhabitants. Key: API = Asian or Pacific Islander. Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID) disparities analysis file, 2006. Denominator: Adults age 18 and over hospitalized for heart attack in community hospitals. Note: White, Black, and API are non-Hispanic groups. These data are adjusted for age, gender, and all patient refined-diagnosis related group. Data for APIs in small metropolitan areas did not meet criteria for statistical reliability, data quality, or confidentiality. The HCUP SID disparities analysis file is designed to provide national estimates using weighted records from a sample of hospitals from 25 States that have 66% of the U.S. resident population.
Management: Recommended Services for DiabetesThe NHDR presents a composite measurexviii that tracks receipt of three recommended services for effective management of diabetes: hemoglobin A1c testing, eye examination, and foot examination in the past year. Figure 4.50. Composite measure: Adults age 40 and over with diagnosed diabetes who received three recommended services for diabetes in the calendar year (hemoglobin A1c measurement, eye examination, and foot examination), by geographic location, stratified by race, ethnicity, income, and education, 2006
Large Central Metropolitan = central counties in metropolitan areas ≥ 1 million inhabitants. Large Fringe Metropolitan = outlying (suburban) counties in metropolitan areas ≥ 1 million inhabitants. Medium Metropolitan = counties in metropolitan areas of 250,000-999,999 inhabitants. Small Metropolitan = counties in metropolitan areas of 50,000-249,999 inhabitants. Micropolitan = counties in an area with an urban cluster of 10,000-49,999 inhabitants. Noncore = < 10,000 inhabitants. Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2006. Denominator: Civilian noninstitutionalized population age 40 and over. Note: Recommended services for diabetes are (1) hemoglobin A1c testing, (2) dilated eye examination, and (3) foot examination. Due to small sample sizes, estimates by race, ethnicity, income, or education could not be provided in all areas; these data were only available for metropolitan (total) and large central metropolitan.
Timeliness: Care for Illness or Injury as Soon as WantedTimely delivery of appropriate care has been shown to improve health care outcomes and reduce health care costs. In addition, when patients need or want care, having access to that care improves their health care experience, which may further promote health. Figure 4.51. 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 geographic location, stratified by income and education, 2006
Large Central Metropolitan = central counties in metropolitan areas ≥ 1 million inhabitants. Large Fringe Metropolitan = outlying (suburban) counties in metropolitan areas ≥ 1 million inhabitants. Medium Metropolitan = counties in metropolitan areas of 250,000-999,999 inhabitants. Small Metropolitan = counties in metropolitan areas of 50,000-249,999 inhabitants. Micropolitan = counties in an area with an urban cluster of 10,000-49,999 inhabitants. Noncore = < 10,000 inhabitants. Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2006. Denominator: Civilian noninstitutionalized population age 18 and over. Note: Data are not available for poor, middle-, and high-income groups in noncore areas or in small metropolitan areas. Data are not available for the high-income group in micropolitan areas.
Access to Health CareHealth InsuranceAccess to health care services is a prerequisite to receipt of care, yet many Americans still face barriers to care. It has been observed that compared with urban residents, residents of rural areas are more likely to be uninsured, and those who are insured are more likely to be individually insured.73 Furthermore, rural residents with group insurance are more likely to have fewer benefits and higher out-of-pocket expenses, suggesting a higher rate of underinsurance. Data for prolonged periods of uninsurance (no insurance coverage for a full year) are presented. Figure 4.52. Adults under age 65 who were uninsured all year, by geographic location, stratified by race, ethnicity, income, and education, 2006
Large Central Metropolitan = central counties in metropolitan areas ≥ 1 million inhabitants. Large Fringe Metropolitan = outlying (suburban) counties in metropolitan areas ≥ 1 million inhabitants. Medium Metropolitan = counties in metropolitan areas of 250,000-999,999 inhabitants. Small Metropolitan = counties in metropolitan areas of 50,000-249,999 inhabitants. Micropolitan = counties in an area with an urban cluster of 10,000-49,999 inhabitants. Noncore = < 10,000 inhabitants. Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2006. Denominator: Civilian noninstitutionalized population age 18 and over. Note: Estimates for Asians in medium metropolitan, small metropolitan, nonmetropolitan, micropolitan, and noncore areas did not meet criteria for statistical reliability and are not reported here. Nonmetropolitan Areas
Metropolitan Areas
xv In this measure, delayed care due to cost is self-reported by patients. Return to Contents
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