Chapter 2. Effectiveness of Care

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, many Americans do not receive the full benefits of high-quality care.

This chapter is organized around nine clinical areas (cancer, cardiovascular disease, chronic kidney disease, diabetes, HIV disease, maternal and child health, mental health and substance abuse, musculoskeletal disease, 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). Two sections in this chapter focus on national priorities identified in the National Strategy for Quality Improvement in Health Care. The cardiovascular disease section addresses the priority, "promoting the most effective prevention and treatment of the leading causes of mortality, starting with cardiovascular disease." The lifestyle modification section addresses the priority, "working with communities to promote wide use of best practices to enable healthy living."

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 (IOM) 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.

Prevention

Caring for healthy people is an important component of health care. Educating people about health and promoting healthy behaviors can help postpone or prevent 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 end stage renal disease (ESRD), are chronic, which means they cannot simply be treated once; they must be managed over time. 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.

Outcomes

Many 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.

Cancer

Importance

Mortality
Number of deaths (2011 est.)	571,950 (ACS, 2011)
Cause of death rank (2009 prelim.)	2nd (Kochanek, et al., 2011)
Prevalence
Number of living Americans who have been diagnosed with cancer (2008)	11,957,599 (Howlader, et al., 2008)
Incidence
New cases of cancer (2011 est.)	1,596,670 (ACS, 2011)
New cases of breast cancer (2011 est.)	232,620 (ACS, 2011)
New cases of colorectal cancer (2011 est.)	141,210 (ACS, 2011)
Cost
Total costi (2010 est.)	$226.8 billion (NHLBI, 2010)
Direct costsii (2010 est.)	$103.8 billion (NHLBI, 2010)
Indirect costs (2010 est.)	$161.0 billion (NHLBI, 2010)
Cost-effectivenessiii of colorectal cancer screening	$35,000-$165,000/QALY (Maciosek, et al., 2006)

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 National Healthcare Quality Report (NHQR) and National Healthcare Disparities Report (NHDR). In even years, the reports focus on colorectal cancer, and in odd years, the reports focus on breast cancer. This year, the report measures are:

• Breast cancer screening.
• Breast cancer first diagnosed at advanced stage.
• Axillary node dissection or sentinel lymph node biopsy at time of surgery for breast cancer.
• Radiation therapy following breast-conserving surgery.
• Breast cancer deaths.

Findings

New! Prevention: Breast Cancer Screening

Early detection of cancer allows more treatment options and often improves outcomes. Mammography, the most effective method for detecting breast cancer at its early stages, can identify malignancies before they can be felt and before symptoms develop. Previous reports tracked receipt of mammography among women age 50 and over. The breast cancer screening measure used in the 2011 NHQR and NHDR reflects a more recent recommendation of the U.S. Preventive Services Task Force for mammograms every 2 years for women ages 50-74.

Figure 2.1. Women ages 50-74 who reported having a mammogram within the past 2 years, by age and insurance status, 2000, 2003, 2005, and 2008

   

[D] Select for Text Description.

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2000, 2003, 2005, and 2008.
Denominator: Civilian noninstitutionalized women ages 50-74.
Note: Rates are age adjusted to the 2000 U.S. standard population.

• From 2000 to 2008, the percentage of women ages 50-74 who reported they had a mammogram in the past 2 years did not change significantly (data not shown). Rates fell for women ages 50-64 who had private health insurance but did not change for any other age or insurance group (Figure 2.1).
• In all years, among women ages 50-64, uninsured women were less likely to have a mammogram than those with private insurance. Except in 2008, women with public insurance only were also less likely to have a mammogram than women with private insurance.
• In all years, among women ages 65-74, those with Medicare only were less likely to have a mammogram than those with Medicare and any private supplemental insurance. Except in 2003, women with Medicare and other public insurance were also less likely to have a mammogram than those with Medicare and any private supplemental insurance. Medicare does not cover all health care costs. Medicare beneficiaries can purchase private supplemental insurance from insurance companies to help pay for coinsurance, copayments, and deductibles. Low-income beneficiaries may receive assistance from Medicaid and other public insurance programs to help pay for costs not covered by Medicare. Beneficiaries with Medicare only typically must pay out of pocket for costs not covered by Medicare.
• The 2008 top 5 State achievable benchmark was 88%.^iv There is no evidence of progress toward the benchmark by any age or insurance group.

Also, in the NHDR:

• In 3 of 4 years, Asian women were less likely to have a mammogram than White women, and Hispanic women were less likely to have a mammogram than non-Hispanic White women.

New! Outcome: Breast Cancer First Diagnosed at Advanced Stage

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 diagnosed at 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 screening rates.

In past reports, rates of advanced stage cancer from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program were reported. Estimates for the Nation were based on 13 SEER areas encompassing about 26% of the U.S. population. Beginning in the 2011 NHQR and NHDR, data from the SEER program and the National Program on Cancer Registries were combined to calculate national statistics on rates of advanced stage cancer. Together, the SEER program and the National Program on Cancer Registries collect cancer data for the entire U.S. population.

Figure 2.2. Age-adjusted rate of advanced stage breast cancer per 100,000 women age 40 and over, by age, 2000-2007

[D] Select for Text Description.

Source: Centers for Disease Control and Prevention, National Program of Cancer Registries and National Cancer Institute, Surveillance, Epidemiology, and End Results (SEER) Program, 2000-2007. Registries meeting United States Cancer Statistics publication criteria for every year, 2000-2007, are included and cover 89.3% of the total U.S. population. States excluded are Arkansas, DC, Mississippi, Nevada, North Carolina, South Dakota, Tennessee, and Virginia.
Denominator: Women age 40 and over.
Note: For this measure, lower rates are better. 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.

• From 2000 to 2007, the rate of advanced stage breast cancer in women ages 50-64 decreased from 106 to 96 per 100,000 women. Rates among women ages 40-49 and age 65 and over did not change significantly (Figure 2.2).
• In all years, women ages 50-64 and age 65 and over had significantly higher rates of advanced stage breast cancer than women ages 40-49.
• The 2007 top 5 State achievable benchmark was 79 per 100,000 women.^v At the current rate of decrease, women ages 50-64 could achieve the benchmark in 11 years.

Also, in the NHDR:

• From 2000 to 2007, the rate of advanced stage breast cancer rose among Black women.
• In all years, rates were significantly lower among Asians and Pacific Islanders (APIs), American Indians and Alaska Natives (AI/ANs), and Hispanic women compared with White women. Since 2003, rates have been significantly higher among Blacks than Whites.

Treatment: Recommended Care for Breast 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 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 2.3. Women with clinical Stage I-IIb breast cancer who received axillary node dissection or sentinel lymph node biopsy at the time of lumpectomy or mastectomy, by age and insurance status (under age 65), 2004-2008

   

[D] Select for Text Description.

Source: Commission on Cancer, American College of Surgeons and American Cancer Society, National Cancer Data Base, 2004-2008.
Denominator: Women with Stage I-IIb breast cancer undergoing lumpectomy or mastectomy.

• The percentage of women with clinical Stage I-IIb breast cancer who received axillary node dissection or sentinel lymph node biopsy at the time of lumpectomy or mastectomy increased from 85% in 2004 to 94% in 2008 (Figure 2.3). Significant improvement was observed among all age and insurance groups.
• In all years, women ages 70-79 and 80 and over were less likely than women under age 40 to receive axillary node dissection or sentinel lymph node biopsy.
• In all years, women under age 65 with public health insurance only were less likely than those with private insurance to receive axillary node dissection or sentinel lymph node biopsy. In contrast, among women age 65 and over, differences were not observed between women with Medicare and supplemental insurance and women with Medicare only (data not shown).
• The 2008 top 5 State achievable benchmark was 97%.^vi At the current rate of increase, most women could achieve the benchmark in 1 year; women with public insurance only would take 2 years and women age 80 and over would take 5 years.

Also, in the NHDR:

• Between 2004 and 2008, all racial and ethnic groups except AI/ANs showed significant improvement in the percentage of women with clinical Stage I-IIb breast cancer who received axillary node dissection or sentinel lymph node biopsy at the time of surgery.
• In all years, Asian women were more likely than White women to receive axillary node dissection or sentinel lymph node biopsy.

Figure 2.4. 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 age and insurance status (ages 65-69), 2004-2008

   

[D] Select for Text Description.

Source: Commission on Cancer, American College of Surgeons and American Cancer Society, National Cancer Data Base, 2004-2008.
Denominator: Women under age 70 undergoing breast-conserving surgery.

• Between 2004 and 2008, the percentage of women under age 70 treated for breast cancer with breast-conserving surgery who received radiation therapy to the breast within 1 year of diagnosis did not change overall or for any age or insurance group (Figure 2.4).
• In all years, women ages 40-49, 50-59, and 60-69 were more likely than women under age 40 to receive radiation therapy. In all years, women ages 65-69 with Medicare only were less likely than those with Medicare and supplemental insurance to receive radiation therapy.
• The 2008 top 5 State achievable benchmark was 93%.^vii No insurance or age group showed progress toward the benchmark.

Also, in the NHDR:

• In all years, Black, Asian, and Hispanic women were less likely than White women to receive radiation therapy.

Outcome: Breast Cancer Deaths

The 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 cancer screening, diagnosis, and treatment. Mortality is measured as the number of deaths per 100,000 population. Declines in breast cancer deaths can be attributed, in part, to improvements in early detection and treatment.

Figure 2.5. Age-adjusted breast cancer deaths per 100,000 women, by age, 2000-2007, and residence location, 2004-2007

     

[D] Select for Text Description.

Key: MSA = metropolitan statistical area.
Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System—Mortality, 2000-2007.
Denominator: U.S. female population.
Note: For this measure, lower rates are better. Total rate is age adjusted to the 2000 U.S. standard population.

• Between 2000 and 2007, the rate of breast cancer deaths significantly decreased, from 27 to 23 per 100,000 women (Figure 2.5). Improvements were observed among all age groups and residence locations except micropolitan and noncore areas.
• In all years, women ages 45-64 and 65 and over had higher rates of breast cancer death compared with women ages 18-44. No statistically significant differences by residence location were noted.
• The 2006 top 5 State achievable benchmark was 20 per 100,000 women.^viii Women ages 18-44 were under the benchmark. At the current rate of improvement, women ages 45-64 would not achieve the benchmark for 20 years and women age 65 and over would not achieve the benchmark for 50 years. Women in large metropolitan statistical areas (MSAs) could achieve the benchmark in 7 years but women in small MSAs, micropolitan, and noncore areas would need 10 to 11 years.

Also, in the NHDR:

• In all years, Black women had higher rates than White women, while API, AI/AN, and Hispanic women had lower rates.

Return to Contents

Cardiovascular Disease

Importance

Mortality
Number of deaths from major cardiovascular disease (2009 prelim.)	779,367 (Kochanek, et al., 2011)
Cause of death rank (2009 prelim.)	1st (Kochanek, et al., 2011)
Prevalence
Number of cases of heart failure (2008)	5.7 million (AHA, 2011)
Number of cases of high blood pressure (2005-2008)	68.0 million (MMWR, 2011c)
Incidence
Number of heart attacks or fatal coronary heart disease (2008)	1.3 million (AHA, 2011)
Cost
Total cost of cardiovascular disease (2011 est.)	$444.2 billion (AHA, 2011)
Total cost of heart failure (2010 est.)	$34.4 billion (AHA, 2011)
Direct costs of cardiovascular disease (2010 est.)	$272.5 billion (AHA, 2011)
Cost-effectiveness of hypertension screening	$14,000-$35,000/QALY (Maciosek, et al., 2006)

Measures

The NHQR and NHDR track several quality measures for preventing and treating cardiovascular disease. Several changes in measures from last year have been made. First, the measure receipt of angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) for heart attack was retired because it achieved a rate above 95%. Second, the measure evaluation of left ventricular ejection fraction for heart failure was also retired because it achieved a rate above 95%. Because of these retirements, ACE/ARB for heart failure is now presented instead.

Four measures are highlighted here:

• Cholesterol screening.
• Inpatient deaths following heart attack.
• ACE inhibitor or ARB for heart failure.
• Hospitalization for congestive heart failure.

Several measures related to heart disease are also presented in other chapters of this report. Timeliness of cardiac reperfusion for heart attack patients is tracked in Chapter 4, Timeliness. Receipt of complete written discharge instructions by patients with heart failure is tracked in Chapter 6, Care Coordination.

Findings

Prevention: Cholesterol Screening

High blood cholesterol is one of the major risk factors for heart disease. The major culprit is low-density lipoprotein cholesterol, which normally makes up 60% to 70% of total cholesterol. When levels are elevated, cholesterol, a fatlike substance, builds up in the walls of the arteries and causes them to narrow, slowing down or blocking the flow of blood and oxygen to the heart.

Figure 2.6. Adults who reported they had a blood cholesterol measurement in the past 5 years, by age and insurance status, 1998, 2003, and 2008

   

[D] Select for Text Description.

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 1998, 2003, and 2008.
Denominator: Civilian noninstitutionalized people age 18 and over.
Note: Rates are age adjusted to the 2000 U.S. standard population. Rates by age are not age adjusted. Insurance status refers to adults ages 18-64.

• In 2008, only 75% of adults reported they had a blood cholesterol measurement in the past 5 years (Figure 2.6).
• In all years, adults ages 45-64 and 65 and over were more likely to have a blood cholesterol measurement than adults ages 18-44. Among adults under age 65, those who had public insurance or who were uninsured were less likely to have a blood cholesterol measurement than those with private health insurance.

Also, in the NHDR:

• In all years, poor, low-income, and middle-income adults were less likely to have a blood cholesterol measurement than high-income adults.

New! Outcome: Inpatient Deaths Following Heart Attack

Heart attack, or acute myocardial infarction, is a common life-threatening condition that requires rapid recognition and efficient treatment in a hospital to reduce the risk of serious heart damage and death. Measuring processes of heart attack 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 a heart attack patient needs. Measuring outcomes of heart attack 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.

Significant improvements in process measures of quality of care for heart attack have occurred in recent years. All process measures tracked in past reports have attained overall performance levels exceeding 95% and have been retired. Therefore, the 2011 NHQR and NHDR focus on outcome measures. Survival following admission for heart attack reflects multiple patient factors, such as a patient's comorbidities, as well as health care system factors, such as the possible need to transfer patients to other hospitals for services. It also may partly reflect receipt of appropriate health services.

Previous reports used AHRQ Quality Indicators version 3.1 to generate death rates for heart attack. The 2011 reports use a modified version 4.1 of the software. While the effects of version change are extremely small, these estimates should not be compared with estimates in previous reports.

Figure 2.7. Inpatient deaths per 1,000 adult hospital admissions with heart attack, by age and geographic location, 2004-2008

   

[D] Select for Text Description.

Key: MSA = metropolitan statistical area.
Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample and AHRQ Quality Indicators modified version 4.1, 2004-2008.
Denominator: Adults age 18 and over admitted to a non-Federal community hospital in the United States with acute myocardial infarction as principal discharge diagnosis.
Note: For this measure, lower rates are better. Rates are adjusted by age and all payer refined-diagnosis related group scoring of risk of mortality. Rates by age are not age adjusted. Rates for 2006 were not available.

• From 2004 to 2008, the overall inpatient mortality rate for hospital admissions with heart attack decreased significantly overall and for each age group and geographic location (Figure 2.7).
• In all years, patients ages 45-64 and age 65 and over had higher rates of inpatient heart attack deaths than patients ages 18-44. Residents of small metropolitan, micropolitan, and noncore areas had higher rates of inpatient heart attack mortality than residents of large fringe metropolitan areas.
• The 2008 top 3 State achievable benchmark for inpatient heart attack mortality was 47 per 1,000 admissions.^ix At current rates of improvement, all age and geographic location groups would attain the benchmark within 4 years.

Also, in the NHDR:

• In all years, Blacks had lower rates of inpatient heart attack mortality than Whites, and residents of lower income areas had higher rates than residents of the highest income area.

Treatment: Angiotensin-Converting Enzyme Inhibitor or Angiotensin Receptor Blocker for Heart Failure

Heart failure occurs when the heart muscle is too weak to adequately pump blood for the body's metabolic needs. Such impairment can result in a lack of adequate blood flow to vital organs, including the brain, kidney, and other organs, as well as a backup of fluid into the lungs. Often, heart failure is caused by damage to the heart muscle from a heart attack, which can seriously weaken the left ventricle, the main pumping chamber of the heart. Congestive heart failure is the most frequent discharge diagnosis for Medicare beneficiaries. ACE inhibitors and ARBs have been found to improve survival and slow or prevent further loss of the heart's pumping ability.

Figure 2.8. Hospital patients with heart failure and left ventricular systolic dysfunction prescribed ACE inhibitor or ARB at discharge, by age and gender, 2005-2009

   

[D] Select for Text Description.

Source: Centers for Medicare & Medicaid Services, Medicare Quality Improvement Organization Program, 2005-2009.
Denominator: Patients hospitalized with a principal diagnosis of acute heart failure and left ventricular systolic dysfunction.

• From 2005 to 2009, the overall percentage of patients with heart failure and left ventricular systolic dysfunction prescribed ACE inhibitor or ARB at discharge increased from 83% to 94% (Figure 2.8). Improvements were observed among all age and gender groups.
• In all years, patients ages 65-74, 75-84, and 85 and over were less likely to receive ACE inhibitors or ARBs for heart failure than patients under age 65.
• The 2009 top 5 State achievable benchmark for patients with heart failure and left ventricular systolic dysfunction prescribed ACE inhibitor or ARB at discharge was 96%.^x At current rates, all age and gender groups could attain the benchmark within 2 years.

Also, in the NHDR:

• In all years, Blacks were more likely to receive ACE inhibitor or ARB at discharge for heart failure than Whites.

Outcome: Hospitalization for Congestive Heart Failure

Congestive heart failure is the most frequent discharge diagnosis for Medicare beneficiaries. Some hospitalizations for heart failure are unavoidable, but rates of hospitalization can be influenced by the quality of outpatient care.

Figure 2.9. Admissions for congestive heart failure per 100,000 population, age 18 and over, by age and gender, 2004-2008

   

[D] Select for Text Description.

Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample and AHRQ Quality Indicators modified version 4.1, 2004-2008.
Denominator: U.S. resident population age 18 and over.
Note: For this measure, lower rates are better. Age rates are adjusted by gender; gender rates are adjusted by age. Rates for 2006 were not available.

• From 2004 to 2008, the overall hospitalization rate for congestive heart failure decreased significantly overall and for each age and gender group (Figure 2.9).
• In all years, patients ages 45-64 and age 65 and over had higher rates than patients ages 18-44 and men had higher rates than women.
• The 2008 top 4 State achievable benchmark for heart failure admissions was 195 per 100,000 population.^xi Overall, this benchmark could be achieved in 10 years.
• At current rates of improvement, patients ages 45-64 could achieve this benchmark in 4 years while patients age 65 and over would take 20 years. Women could achieve the benchmark in 7 years while men would take 14 years.

Also, in the NHDR:

• At current rates of improvement, patients ages 45-64 could achieve this benchmark in 4 years while patients age 65 and over would take 20 years. Women could achieve the benchmark in 7 years while men would take 14 years.

---

^i. Throughout this report, 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."
^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.
^iv. The top 5 States contributing to the achievable benchmark are Connecticut, Delaware, Massachusetts, New Hampshire, and Rhode Island.
^v. The top 5 States that contributed to the achievable benchmark are Arizona, Florida, New Hampshire, West Virginia, and Wyoming.
^vi. The top 5 States that contributed to the achievable benchmark are Minnesota, Mississippi, Nevada, Oklahoma, and South Dakota.
^vii. The top 5 States that contributed to the achievable benchmark are New Hampshire, North Dakota, Oregon, South Dakota, and Wisconsin.
^viii. The top 5 States that contributed to the achievable benchmark are Hawaii, Montana, Nebraska, Nevada, and South Dakota.
^ix. The top 3 States that contributed to the achievable benchmark are Arizona, Michigan, and Ohio.
^x. The top 5 States that contributed to the achievable benchmark are Alaska, Idaho, Maine, New Hampshire, and Nevada.
^xi. The top 4 States that contributed to the achievable benchmark are Colorado, Oregon, Utah, and Vermont.

---

Return to Contents
Proceed to Next Section