Chapter 10. Priority Population (continued)
National Healthcare Disparities Report, 2010
Low-Income Groups
In this report, poor populations are defined as people living in families whose household income falls below specific poverty thresholds. These thresholds vary by family size and composition and are updated annually by the U.S. Bureau of the Census.12 After falling for a decade (1990-2000), the number of poor people in America rose from 31.6 million in 2000 to 36.5 million in 2006, and the rate of poverty increased from 11.3% to 12.3% during the same period.13
Poverty varies by race and ethnicity. In 2006, 24% of Blacks, 21% of Hispanics, 10% of Asians, and 8% of Whites were poor. People with low incomes often experience worse health and are more likely to die prematurely.14 In general, poor populations have reduced access to high-quality care. While people with low incomes are more likely to be uninsured, income-related differences in quality of care that are independent of health insurance coverage have also been demonstrated.15
Previous chapters of this report describe health care differences by income. This section summarizes disparities in quality of and access to health care for poorviii individuals compared with high-incomeix individuals. For each core report measure, poor people can have health care that is worse than, about the same as, or better than health care received by high-income people. Only relative differences of at least 10% that are statistically significant at alpha ≤0.05 are discussed in this report. Access measures focus on facilitators and barriers to health care and exclude health care utilization measures.In addition, changes in differences related to income are examined over time.
Table 10.5. Measures for which poor people were worse than high-income people for most recent year and their trends over time
| Topic | Poor worse than high income and getting better |
|---|---|
| Maternal and child health | Children ages 2-17 who had a dental visit in the calendar year |
| Lifestyle modification | Adults with obesity who ever received advice from a health provider about healthy eating |
| Topic | Poor worse than high income and staying the same |
|---|---|
| Diabetes | Hospital admissions for short-term complications of diabetes per 100,000 population |
| Heart disease | Deaths per 1,000 adult hospital admissions with acute myocardial infarction |
| Maternal and child health | Children ages 2-17 for whom a health provider ever gave advice about exercise |
| Children ages 2-17 for whom a health provider ever gave advice about healthy eating | |
| Children ages 19-35 months who received all recommended vaccines | |
| Mental health and substance abuse | Adults with a major depressive episode in the last 12 months who received treatment for depression in the last 12 months |
| Respiratory diseases | Adults age 65 and over who ever received pneumococcal vaccination |
| People with current asthma who are now taking preventive medicine daily or almost daily | |
| Lifestyle modification | Adults with obesity who ever received advice from a health provider to exercise more |
| Functional status preservation and rehabilitation | Female Medicare beneficiaries age 65 and over who reported ever being screened for osteoporosis with a bone mass or bone density measurement |
| Timeliness | Adults who needed care right away for an illness, injury, or condition in the last 12 months who got care as soon as wanted |
| Patient safety | Adults age 65 and over who received potentially inappropriate prescription medications in the calendar year |
| Patient centeredness | Adults with ambulatory visits who reported poor communication with health providers |
| Children with ambulatory visits whose parents reported poor communication with health providers | |
| Access | People under age 65 with health insurance |
| People under age 65 who were uninsured all year | |
| People with a specific source of ongoing care | |
| People with a usual primary care provider | |
| People unable to get or delayed in getting needed care due to financial or insurance reasons | |
| People who were unable to get or delayed in getting needed medical care, dental care, or prescription medicines in the last 12 months |
| Topic | Poor worse than high income and getting worse |
|---|---|
| Cancer | Women age 40 and over who received a mammogram in the last 2 years |
| Adults age 50 and over who ever received colorectal cancer screening | |
| Diabetes | Adults age 40 and over with diagnosed diabetes who received all three recommended services for diabetes in the calendar year |
Figure 10.8. Change in poor-high-income disparities over time for all core measures
Improving = Poor-high-income difference becoming smaller at an average annual rate greater than 1%.
Same = Poor-high-income difference not changing.
Worsening = Poor-high-income difference becoming larger at an average annual rate greater than 1%.
Note: The time period for this figure is the most recent and oldest years of data used in the NHDR. Only 27 core report measures of quality and access could be tracked over time for poor individuals. No acute care measures reported data for income.
Residents of Rural Areas
About one in five Americans lives in a nonmetropolitan area.16 Compared with their urban counterparts, rural residents are more likely to be older, be poor,17 and be in fair or poor health, and have chronic conditions.16 Rural residents are less likely than their urban counterparts to receive recommended preventive services and on average report fewer visits to health care providers.18
Although 20% of Americans live in rural areas,x only 9% of physicians in America practice in those settings.19 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, Indian Health Service, 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,20 1,500 of which have 50 or fewer beds. Most of these hospitals are critical access hospitals that have 25 or fewer beds. Rural hospitals face unique challenges due to their size and case mix. During the 1980s, many were forced to close due to financia1 losses.21 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"xi in the Nation, most have limited health care services and many do not have any.22
Geographic areas are classified in different ways depending on the data source. Chapter 1, Introduction and Methods, provides more information on the classifications used. In this chapter, we compare residents of noncorexii (rural) areas with residents of large fringe metropolitan (suburban) areas because residents of suburban areas tend to have higher quality health care and better outcomes.
Table 10.6. Measures for which residents of noncore areas were worse than residents of large fringe metropolitan areas for most recent year onlyxiii
| Topic | Measure |
|---|---|
| Cancer | Adults age 50 and over who ever received colorectal cancer screening |
| Colorectal cancer deaths per 100,000 population per year | |
| Cancer deaths per 100,000 population per year | |
| Lung cancer deaths per 100,000 population per year | |
| Diabetes | Hospital admissions for short-term complications of diabetes per 100,000 population |
| Adults age 40 and over with diagnosed diabetes who received an influenza vaccination in the last 12 months | |
| Hospital admissions for uncontrolled diabetes per 100,000 population age 18 and over | |
| Heart disease | Adults who received a blood cholesterol measurement in the last 5 years |
| Deaths per 1,000 adult hospital admissions with acute myocardial infarction | |
| Deaths per 1,000 adult hospital admissions with congestive heart failure | |
| Deaths per 1,000 hospital admissions with coronary artery bypass surgery, age 40 and over | |
| Maternal and child health | Women who completed a pregnancy in the last 12 months who received prenatal care in the first trimester |
| Children ages 2-17 for whom a health provider ever gave advice about the amount and kind of exercise, sports, or physically active hobbies they should have | |
| Children ages 2-17 for whom a health provider ever gave advice about healthy eating | |
| Children who ever had their height and weight measured by a health provider | |
| Children 41-80 lb for whom a health provider ever gave advice about using booster seats | |
| Children ages 2-17 for whom a health provider ever gave advice about using a helmet when riding a bicycle or motorcycle | |
| Mental health and substance abuse | Suicide deaths per 100,000 population |
| Respiratory diseases | Hospital admissions for immunization-preventable influenza per 100,000 population age 65 and over |
| Deaths per 1,000 adult hospital admissions with pneumonia | |
| Lifestyle modification | Adults with obesity who ever received advice from a health provider to exercise more |
| Efficiency | Avoidable admissions for angina per 100,000 population age 18 and over |
| Avoidable admissions for chronic obstructive pulmonary disease per 100,000 population age 18 and over | |
| Avoidable admissions for bacterial pneumonia per 100,000 population age 18 and over | |
| Perforated appendixes per 1,000 admissions with appendicitis | |
| Access | People under age 65 who were uninsured all year |
| People under age 65 whose family's health insurance premium and out-of-pocket medical expenditures were more than 10% of total family income | |
| People under age 65 with health insurance | |
| People under age 65 with any private health insurance | |
| People with a usual source of care who has office hours nights or weekends |
Figure 10.9. Distribution of measures for residents of noncore areas compared with residents of large fringe metropolitan areas for most recent yearxiv
Better = Noncore area is better than large fringe metropolitan area at a relative rate greater than 10%.
Same = No difference between noncore area and large fringe metropolitan area.
Worse = Noncore area is worse than large fringe metropolitan area at a relative rate greater than 10%.
Note: All measures with data for metropolitan areas are included (core and supporting measures).
Individuals With Disabilities or Special Health Care Needs
Individuals with disabilities or special health care needs include individuals with disabilities, individuals who use nursing home and home health care or end-of-life health care, and children with special heath care needs. The NHDR tracks many measures of relevance to individuals with special health care needs.
Again this year, the NHQR and NHDR aim to include more information about individuals with disabilities. To reach this goal, AHRQ convened a disabilities subgroup of the NHQR/NHDR Interagency Work Group. This subgroup received assistance from the Interagency Subcommittee on Disability Statistics of the Interagency Committee on Disability Research. The charge to the disabilities subgroup was to advise AHRQ on measures of disabilities from existing data that could track disparities for disabled individuals in quality of and access to care for the NHDR and that would be comparable across national surveys. For this initial effort, the subgroup focused on measures for adults, a population for which the most survey data are available.
For the 2010 NHDR, AHRQ is again using a broad, inclusive measure of disability. This measure is intended to be consistent with statutory definitions of disability, such as the first criterion of the 1990 Americans With Disabilities Act (ADA) (i.e., having a physical or mental impairment that substantially limits one or more major life activities23,24) and Federal program definitions of disability based on the ADA. For the purpose of the NHDR, adults with disabilities are those with physical, sensory, and/or mental health conditions that can be associated with a decrease in functioning in such day-to-day activities as bathing, walking, doing everyday chores, and engaging in work or social activities.
In displaying the data on disability, paired measures are shown to preserve the qualitative aspects of the data:
- Limitations in basic activities represent problems with mobility and other basic functioning at the person level.
- Limitations in complex activities represent limitations encountered when the person, in interaction with the environment, attempts to participate in community life.
Limitations in basic activities include problems with mobility, self-care (activities of daily living), domestic life (instrumental activities of daily living), and activities that depend on sensory functioning (limited to people who are blind or deaf). Limitations in complex activities include limitations experienced in work and in community, social, and civic life. The use of the subgroup's recommendation of these paired measures of basic and complex activity limitations is conceptually similar to the way others have divided disability25 and is consistent with the International Classification of Functioning, Disability, and Health separation of activities and participation domains.26 These two categories are not mutually exclusive; people may have limitations in basic activities and complex activities. The residual category Neither includes adults with neither basic nor complex activity limitations.
In this year�s reports, analyses by activity limitations for adults are presented in the Patient Centeredness chapter of both the NHQR and NHDR. In addition, the appendix tables include activity limitations as a stub variable for all National Health Interview Survey and Medical Expenditure Panel Survey tables.
In summarizing disparities for individuals with disabilities, we present comparisons between adults with basic or complex activity limitations and adults with neither basic nor complex activity limitations.
Table 10.7. Measures for which adults with basic activity limitations were worse than adults with neither basic nor complex activity limitations for most recent year and their trends over time
| Topic | Adults with basic activity limitations worse than adults with neither basic nor complex activity limitations and staying the same |
|---|---|
| Lifestyle modification | Adults with obesity who spend half an hour or more in moderate or vigorous physical activity at least three times a week |
| Patient safety | Adults age 65 and over who received potentially inappropriate prescription medications in the calendar year |
| Patient centeredness | Adults who had a doctor's office or clinic visit in the last 12 months whose health providers explained things in a way they could understand |
| Adults who had a doctor's office or clinic visit in the last 12 months whose health providers showed respect for what they had to say | |
| Rating of health care by adults who had a doctor's office or clinic visit in the last 12 months | |
| People with a usual source of care for whom health care providers explained and provided all treatment options | |
| Access | People without a usual source of care who indicated a financial or insurance reason for not having a source of care |
| People who were unable to get or delayed in getting needed medical care in the last 12 months | |
| People who were unable to get or delayed in getting needed dental care in the last 12 months | |
| People who were unable to get or delayed in getting needed prescription medicines in the last 12 months | |
| People with a usual source of care, excluding hospital emergency rooms, who has office hours nights or weekends | |
| People with difficulty contacting their usual source of care over the telephone |
Table 10.8. Measures for which adults with complex activity limitations were worse than adults with neither basic nor complex activity limitations for most recent year and their trends over time
| Topic | Adults with complex activity limitations worse than adults with neither basic nor complex activity limitations and getting worse |
|---|---|
| Access | People without a usual source of care who indicated a financial or insurance reason for not having a source of care |
| Topic | Adults with complex activity limitations worse than adults with neither basic nor complex activity limitations and staying the same |
|---|---|
| Lifestyle modification | Adults with obesity who spend half an hour or more in moderate or vigorous physical activity at least three times a week |
| Patient safety | Adults age 65 and over who received potentially inappropriate prescription medications in the calendar year |
| Patient centeredness | Adults who had a doctor's office or clinic visit in the last 12 months whose health providers listened carefully to them |
| Adults who had a doctor's office or clinic visit in the last 12 months whose health providers explained things in a way they could understand | |
| Adults who had a doctor's office or clinic visit in the last 12 months whose health providers showed respect for what they had to say | |
| Adults who had a doctor's office or clinic visit in the last 12 months whose health providers spent enough time with them | |
| Rating of health care by adults who had a doctor's office or clinic visit in the last 12 months | |
| People with a usual source of care for whom health care providers explained and provided all treatment options | |
| Access | People who were unable to get or delayed in getting needed medical care in the last 12 months |
| People who were unable to get or delayed in getting needed dental care in the last 12 months | |
| People who were unable to get or delayed in getting needed prescription medicines in the last 12 months | |
| People with a usual source of care, excluding hospital emergency rooms, who has office hours nights or weekends | |
| People with difficulty contacting their usual source of care over the telephone | |
| Adults who did not have problems seeing a specialist they needed to see in the last 12 months |
Figure 10.10. Change in complex versus neither disability-related disparities over time for all measures
Improving = Difference between complex activity limitations and neither basic nor complex activity limitations becoming smaller at an average annual rate greater than 1%.
Same = Difference between complex activity limitations and neither basic nor complex activity limitations not changing.
Worsening = Difference between complex activity limitations and neither basic nor complex activity limitations becoming larger at an average annual rate greater than 1%.
Note: The time period for this figure is the most recent and oldest years of data used in the NHDR. Measures include supporting measures. Only 37 measures of quality and access could be tracked over time for individuals with activity limitations.
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viii Household income less than Federal poverty thresholds.
ix Household income 400% of Federal poverty thresholds and higher.
x Many terms are used to refer to the continuum of geographic areas. For Census 2000, the U.S. Census Bureau's classification of "rural" consists of all territory, population, and housing units located outside of urban areas and urban clusters. The Census Bureau classified as "urban" all territory, population, and housing units located within (1) core census block groups or blocks that have a population density of at least 1,000 people per square mile and (2) surrounding census blocks that have an overall density of at least 500 people per square mile.
xi "Frontier counties" have a population density of less than 7 people per square mile; thus, residents may have to travel long distances for care.
xii Noncore areas are outside of metropolitan or micropolitan statistical areas. Micropolitan and noncore areas are typically regarded as "rural."
xiii Data were insufficient to assess change over time.
xiv Data were insufficient to assess change over time.
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