2012 National Healthcare Disparities Report

Maternal and Child Health

Importance

Measures

The NHQR and NHDR track several prevention, treatment, and outcome measures related to maternal and child health care. The measures highlighted in this section are:

• Prenatal care.
• Receipt of recommended immunizations by young children.
• Children's vision screening.
• Well visits in the last year.
• Receipt of meningococcal vaccine by adolescents.

Findings

New! Prevention: Early and Adequate Prenatal Care

The timing of initiation and the quality and quantity of prenatal care (PNC) may influence pregnancy outcomes, in particular the occurrence of preterm birth and low birth weight (Anum, et al., 2010; Debiec, et al., 2010; Cox, et al., 2011; AAP, 2007). In the past, the NHQR and NHDR have followed a measure of PNC access in the first trimester as a key maternal and child health preventive measure. Because this measure does not take into account whether women then receive additional PNC throughout the pregnancy, we now report on a measure of early and adequate PNC.

One of the Healthy People 2020 objectives is that 77.6% of pregnant women receive early and adequate PNC, based on the Adequacy of Prenatal Care Utilization Index. This index looks at both initiation of PNC and number of visits; thus, early and adequate PNC is defined as PNC initiated by month 4 of the pregnancy and in which the woman also had at least 80% of the number of expected PNC visits.

The target number of PNC visits is based on when PNC started and on the infant's gestational age at birth. Because of consistency problems between the 1998 and 2003 versions of birth certificates, PNC timing and adequacy were evaluated only for the 28 States using the 2003 standard birth certificate for all of 2009. Because we have data for only 28 States, national estimates were not generated. However, these 28 States accounted for 66% of live births in the United States in 2009.

Given the persistent Black-White disparity in infant mortality and low birth weight, we mapped the absolute percentage point differences between White and Black infants (based on the reported race of the mother) in the proportion whose mothers had obtained early and adequate PNC. The map below shows overall State rankings (by quartiles) for these differences. The first quartile represents States with the smallest differences and the fourth quartile represents States with the largest differences. States ranged from a minimum difference between Whites and Blacks of 2.9% to a maximum difference of 28.7%.^xix

  Figure 2.27. Absolute differences between percentages of White and Black infants born in 2009 whose mothers had obtained early and adequate prenatal care, by State quartiles

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Source: Centers for Disease Control and Prevention, National Center for Health Statistics, Division of Vital Statistics, National Vital Statistics System, 2009.

• Interquartile ranges were as follows:
  • First quartile (best): 2.9%-9.0% (CA, DE, KY, NM, SC, TX, WY).
  • Second quartile (second best): 9.4%-11.86%.
  • Third quartile (second worst): 11.89%-15.7%.
  • Fourth quartile (worst): 16.3%-28.7% (IA, ID, IN, MT, SD, TN, UT).
• There was no clear pattern based on geographic region.
• Only one State (CA) that was in the best quartile for the overall State rates shown in the NHQR was also in the best quartile for the difference between White and Black rates as shown here. Two States in the worst quartile for overall receipt of early and adequate PNC were in the best quartile for differences between Blacks and Whites (NM and TX). This presumably reflects relatively poor performance in both the reference group (Whites) and the comparison group (Blacks).

Also, in the NHQR:

• Overall State rates for obtaining early and adequate PNC ranged from 60.8% to 86.5%. There was no clear pattern based on geographic region.

New! Prevention: Receipt of Recommended Immunizations by Young Children

Immunizations are important in reducing mortality and morbidity. They protect recipients from illness and protect others in the community who are not vaccinated. Beginning in 2007, recommended vaccines for children that should have been completed by ages 19-35 months included diphtheria-tetanus-pertussis vaccine, polio vaccine, measles-mumps-rubella vaccine, Haemophilus influenzae type B vaccine, hepatitis B vaccine, varicella vaccine, and pneumococcal conjugate vaccine. These vaccines constitute the 4:3:1:3:3:1:4 vaccine series tracked in Healthy People 2020. The Healthy People 2020 target is 80% coverage in the population ages 19-35 months.

  Figure 2.28. Children ages 19-35 months who received the 4:3:1:3:3:1:4 vaccine series, by race/ethnicity, 2009-2010

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Source: Centers for Disease Control and Prevention, National Center for Health Statistics and National Center for Immunization and Respiratory Diseases, National Immunization Survey, 2009-2010.
Denominator: U.S. civilian noninstitutionalized population ages 19-35 months.
Note: White, Black, Asian, and more than one race are non-Hispanic; Hispanic includes all races.

• In 2010, 70.2% of children ages 19-35 months had received all recommended vaccinations (Figure 2.28).
• In both years, Black children were less likely than White children to receive all recommended vaccinations.
• The 2009 top 6 State achievable benchmark was 72%.^xx Hispanics have achieved the benchmark. At the current rate of improvement, most other racial/ethnic groups could achieve the benchmark in a year.

Also, in the NHQR:

• In both years, children from high-income households were more likely to receive all the recommended vaccinations than those from poor, low-income, and middle-income households.

Prevention: Children's Vision Screening

Vision checks for children may detect problems of which children and their parents were previously unaware. Early detection also improves the chances that corrective treatments will be successful.

  Figure 2.29. Children ages 3-6 who ever had their vision checked by a health provider, by race/ethnicity and income, United States, 2002-2009

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Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2009.
Denominator: U.S. civilian noninstitutionalized population ages 3-6.
Note: White and Black are non-Hispanic; Hispanic includes all races.

• In 2009, 64.2% of children ages 3-6 had their vision checked by a health provider (Figure 2.29). Improvements were observed in Hispanic and White children and poor and low-income groups.
• In 3 of the 8 years from 2002 to 2009, Hispanic children were less likely to have their vision checked than non-Hispanic White children.
• In 4 of the 8 years from 2002 to 2009, children from poor, low-income, and middle-income households were less likely to have their vision checked than children from high-income households.

Also, in the NHQR:

• In all years, children ages 3-5 were less likely to have their vision checked than those age 6 years.
• In 5 of the 8 years from 2002 to 2009, children without special health care needs were less likely to have their vision checked than those with such needs.

Prevention: Well Visits by Children in the Last Year

The American Academy of Pediatrics recommends annual preventive health care visits for all children (AAP, 2008). The AAP recommends regular preventive health care visits for children of all ages. Current recommendations are for 7 well child visits prior to 12 months of age; 5 well child visits between 12 and 30 months of age, inclusive; and one well child visit per year from 3 years of age on.

  Figure 2.30. Children ages 0-17 years with a well visit in the last 12 months, by race/ethnicity and income, 2009-2010

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Source: Children ages 0-17 years with a well visit in the last 12 months, by race/ethnicity and income, 2009-2010
Denominator: U.S. civilian noninstitutionalized population ages 0-17.
Note: White and Black are non-Hispanic; Hispanic includes all races.

• In 2010, 79.9% of children ages 0-17 had a wellness checkup in the last 12 months (Figure 2.30).
• In 2009 and 2010, Black children had higher rates of well visits compared with their White counterparts, while Hispanic children had lower rates than White children.
• In both years, children from high-income households were more likely to have well visits than those from poor, low-income, and middle-income households.

Also, in the NHQR:

• In both years, children ages 0-5 were more likely to have a well visit than those ages 6-11 and 12-17.
• In both years, children with private insurance were more likely to have a well visit than uninsured children.

Prevention: Receipt of Meningococcal Vaccine by Adolescents

According to the 2010 Census, individuals ages 10-14 years made up 6.7% of the U.S. population while those ages 15-19 years made up 7.1% of the population (U.S. Census Bureau, 2010). Youth in these age groups are at risk of contracting meningitis.

Meningitis is an infection of the membranes that cover the brain and spinal cord. If meningitis is caused by bacteria, it is often life threatening. Meningococcal diseases are infections caused by the bacteria Neisseria meningitidis. Although Neisseria meningitidis can cause various types of infections, it is most important as a potential cause of meningitis. It can also cause meningococcemia, a serious bloodstream infection. The meningococcal vaccine can prevent most cases of meningitis caused by Neisseria meningitidis and is recommended for all children ages 11-12 years. Effective in January 2011, a second dose is recommended at age 16.

Figure 2.31. Adolescents ages 13-15 who ever received at least 1 dose of the meningococcal vaccine, by race/ethnicity and income, 2008-2010

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Source: Centers for Disease Control and Prevention, National Center for Health Statistics and National Center for Immunization and Respiratory Diseases, National Immunization Survey, 2008-2010.
Note: White, Black, and Asian are non-Hispanic; Hispanic includes all races.

• In 2010, 64.8% of adolescents ages 13-15 had ever received at least 1 dose of the meningococcal vaccine (Figure 2.31).
• In 2008 and 2010, Hispanic adolescents were more likely to receive the meningococcal vaccine than White adolescents.
• In all years, adolescents from high-income households were more likely to receive the meningococcal vaccine than those from poor, low-income, and middle-income households.
• The 2009 top 5 State achievable benchmark was 75%.^xxi At the current rate, most racial/ethnic and income groups could achieve the benchmark in a year.

Also, in the NHQR:

• From 2008 to 2010, there were no statistically significant gender differences among adolescents ages 13-15 who received the meningococcal vaccine.
• In all years, residents of nonmetropolitan areas were less likely to receive the meningococcal vaccine than those living in metropolitan areas.

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 Mental Health and Substance Abuse

Importance

Measures

The NHQR and NHDR track measures of the quality of treatment for major depression and substance abuse. Mental health treatment includes counseling, inpatient care, outpatient care, and prescription medications. This section highlights four measures of mental health and substance abuse treatment:

• Receipt of treatment for depression.
• Suicide deaths.
• Receipt of treatment for illicit drug use or alcohol problem.
• Completion of substance abuse treatment.

Findings

Treatment: Receipt of Treatment for Depression

Treatment for depression can be very effective in reducing symptoms and associated illnesses and returning individuals to a productive lifestyle. The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study, funded by the National Institute of Mental Health, was the largest clinical trial ever conducted to help determine the most effective treatment strategies for major depressive disorder. It involved both primary care and specialty care settings. Participants included people with complex health conditions, such as multiple concurrent medical and psychiatric conditions.

This study found that between 28% and 33% of participants achieved a symptom-free state after the first round of medication, and nearly 70% achieved remission after 12 months (Insel & Wang, 2009). Strategies for treating depression in primary care settings, such as the collaborative care model, have also been shown to generate positive net social benefits in cost-benefit analyses compared with usual care (Glied, et al., 2010).

Barriers to high-quality mental health care include cost of care, lack of sufficient insurance for mental health services, social stigma, fragmented organization of services, and mistrust of providers. In rural and remote areas, limited availability of skilled care providers is also a major problem. For racial and ethnic populations, these problems are compounded by the lack of culturally and linguistically competent providers.

Barriers can exist for patients across the lifespan. The National Survey of Children's Health (HRSA, 2010) showed that among children with emotional, developmental, or behavioral conditions, 45.6% were receiving needed mental health services, and about half were taking medications. Recent data indicate, however, that service use for mental health is increasing among children (Pfuntner, et al., 2013).

  Figure 2.32. Adults (top) and adolescents (bottom) with a major depressive episode in the past year who received treatment for depression in the past year, by age and race/ethnicity, 2008-2010

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Source: Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2008-2010.
Denominator: Adults age 18 and over and adolescents ages 12-17 with a major depressive episode in the past year.
Note: Major depressive episode is defined as a period of at least 2 weeks when a person experienced a depressed mood or loss of interest or pleasure in daily activities and had a majority of the symptoms of depression described in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders. Treatment for depression is defined as seeing or talking to a medical doctor or other professional or using prescription medication in the past year for depression. White and Black are non-Hispanic; Hispanic includes all races.

• In 2010, only 68% of adults and 38% of adolescents with a major depressive episode received treatment for depression (Figure 2.32).
• In all years, Black adults and adolescents were less likely to receive treatment for depression than White adults and adolescents.

Also, in the NHQR:

• In all years, adult males were less likely than adult females to receive treatment for depression. In 2009 and 2010, adolescent males were less likely than adolescent females to receive treatment for depression.

New! Outcome: Suicide Deaths

Most individuals who die by suicide have mental illnesses, such as depression or schizophrenia, or have substance abuse problems (Moscicki, 2001). Suicide may be prevented when its warning signs are detected and treated. A previous suicide attempt is among the strongest predictors of subsequent suicide. Cognitive-behavioral therapy can significantly help those who have attempted suicide consider alternative actions when thoughts of self-harm arise and may reduce suicide attempts (Tarrier, et al., 2008).

Previous reports tracked suicide death for all ages. Beginning with 2008 and 2009 data shown in the 2011 reports, we track suicide death among people age 12 and over.

  Figure 2.33. Suicide deaths per 100,000 population, by race and ethnicity, 2008-2009

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Key: API = Asian and Pacific Islander; AI/AN = American Indian or Alaska Native.
Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System—Mortality, 2008-2009.
Denominator: U.S. population age 12 and over.
Note: For this measure, lower rates are better. Estimates are age adjusted to the 2000 U.S. standard population.

• In 2009, the overall suicide death rate was 14.2 per 100,000 population age 12 and over (Figure 2.33).
• In both years, Blacks, APIs, and AI/ANs had lower suicide death rates than Whites, and Hispanics had lower suicide death rates than non-Hispanic Whites.
• The 2008 top 5 State achievable benchmark was 9 suicide deaths per 100,000 population.^xxii Data are insufficient to assess progress toward the benchmark.

Also, in the NHQR:

• In 2008 and 2009, adolescents ages 12-17 had lower suicide death rates than adults ages 18-44 and adults ages 45-64 had higher suicide death rates than adults ages 18-44.
• In both years, residents of medium and small metropolitan areas, micropolitan areas, and noncore areas had higher suicide death rates than residents of large fringe metropolitan areas (suburbs).

Treatment: Receipt of Treatment for Illicit Drug Use or Alcohol Problem

Illicit drug^xxiii use is a medical problem that can have a direct toxic effect on a number of bodily organs and exacerbate numerous health and mental health conditions. Alcohol problems also can lead to serious health risks. Heavy drinking can increase the risk of certain cancers and cause damage to the liver, brain, and other organs. In addition, alcohol can cause birth defects, including fetal alcohol spectrum disorders. Alcoholism and illicit drug use increase the risk of death from car crashes and other injuries (Ringold, et al., 2006). Illicit drug use and alcohol problems can be effectively treated at specialty facilities.

  Figure 2.34. People age 12 and over who needed treatment for illicit drug use or an alcohol problem and who received such treatment at a specialty facility in the last 12 months, by race/ethnicity and gender, 2002-2010

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Source: Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2002-2010.
Denominator: Civilian noninstitutionalized population age 12 and over who needed treatment for illicit drug use or an alcohol problem.
Note: Treatment refers to treatment at a specialty facility, such as a drug and alcohol inpatient and/or outpatient rehabilitation facility, inpatient hospital setting, or a mental health center. White and Black are non-Hispanic; Hispanic includes all races.

• In 2010, only 11% of people age 12 and over who needed treatment for illicit drug use or an alcohol problem received such treatment at a specialty facility in the last 12 months (Figure 2.34).
• From 2002 to 2007, Blacks were more likely to receive needed treatment for illicit drug use or an alcohol problem than Whites.
• Since 2007, Hispanics have been less likely to receive treatment than Whites.

Also, in the NHQR:

• In all years, people with any college education were less likely to receive needed treatment for illicit drug use or an alcohol problem than high school graduates and people with less than a high school education.

Treatment: Completion of Substance Abuse Treatment

Completion of substance abuse treatment is strongly associated with improved outcomes, such as long-term abstinence from substance use. Dropout from treatment often leads to relapse and return to substance use.

  Figure 2.35. People age 12 and over treated for substance abuse who completed treatment course, by race/ethnicity and education, 2005-2009

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Source: Substance Abuse and Mental Health Services Administration, Treatment Episode Data Set, Discharge Data Set, 2005-2009.
Denominator: Discharges age 12 and over from publicly funded substance abuse treatment facilities.
Note: White and Black are non-Hispanic; Hispanic includes all races.

• From 2005 to 2009, there were no statistically significant changes in the overall percentage of people age 12 and over treated for substance abuse who completed the treatment course (Figure 2.35).
• Except in 2009, Blacks who were treated for substance abuse were significantly less likely than Whites to complete treatment.
• In all years, people with less than a high school education treated for substance abuse were less likely than people with any college education to complete treatment.
• The 2008 top 5 State achievable benchmark was 74%.^xxiv Only Blacks showed progress toward the benchmark but would not reach it for more than 50 years.

Also, in the NHQR:

• In all years, people ages 12-19 and 20-39 were less likely than those age 40 and over and females were less likely than males to complete substance abuse treatment.

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 Musculoskeletal Diseases

Importance

Measures

This section tracks several quality measures for prevention and management of musculoskeletal diseases. The arthritis measures are part of the Arthritis Foundation's Quality Indicator Set for Osteoarthritis. A multidisciplinary panel of experts on arthritis and pain reviewed scientific evidence to help develop the Quality Indicator Set (Pencharz & MacLean, 2004). The measures were tracked as part of Healthy People 2010 and continue to be tracked in Healthy People 2020. Osteoporosis measures are usually tracked in this section, but no new data are available for this year's reports.

This section highlights three measures related to quality of care for arthritis:

• Arthritis education for adults with arthritis.
• Counseling about physical activity for adults with arthritis.
• Counseling about weight reduction for overweight adults with arthritis.

Findings

Management: Arthritis Education for Adults With Arthritis

Osteoarthritis is the most common form of arthritis, affecting about 12% of the general population. Patients with symptomatic osteoarthritis who receive education about the natural history, treatment, and self-management of the disease have better knowledge and self-efficacy and experience less pain and functional impairment (Pencharz & MacLean, 2004).

  Figure 2.36. Adults with doctor-diagnosed arthritis who reported they had effective, evidence-based arthritis education as an integral part of the management of their condition, by race, ethnicity, income, education, and activity limitation, 2009

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Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2009.
Denominator: Civilian noninstitutionalized adults with doctor-diagnosed arthritis.
Note: Estimates are age adjusted to the 2000 U.S. standard population. Hispanic includes all races. People were considered to have doctor-diagnosed arthritis if they answered yes to "Have you ever been told by a doctor or other health professional that you have some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?"

• In 2009, only 11% of adults with doctor-diagnosed arthritis received effective, evidence-based arthritis education (Figure 2.36).
• High school graduates were less likely than adults with any college education to receive arthritis education.
• Adults with basic or complex activity limitations were more likely than adults without such limitations to receive arthritis education.

Also, in the NHQR:

• Adults age 65 and over were less likely to receive arthritis education than adults ages 45-64, and men were less likely to receive arthritis education than women.

Management: Counseling About Physical Activity for Adults With Arthritis

Patients with symptomatic osteoarthritis should also receive counseling about muscle strengthening and aerobic exercise programs. Such programs can reduce pain and improve functional ability (Pencharz & MacLean, 2004).

  Figure 2.37. Adults with doctor-diagnosed arthritis who reported they received health care provider counseling about physical activity or exercise, by race, ethnicity, income, education, and activity limitation, 2009

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Key: AI/AN = American Indian or Alaska Native.
Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2009.
Denominator: Civilian noninstitutionalized adults with doctor-diagnosed arthritis.
Note: Estimates are age adjusted to the 2000 U.S. standard population. Hispanic includes all races. People were considered to have doctor-diagnosed arthritis if they answered yes to "Have you ever been told by a doctor or other health professional that you have some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?"

• In 2009, 57.2% of adults with doctor-diagnosed arthritis received health care provider counseling about physical activity or exercise (Figure 2.37).
• Hispanics were more likely than non-Hispanic Whites to receive exercise counseling.
• Low-income adults were less likely to receive exercise counseling than high-income adults.
• Adults with less than a high school education and high school graduates were less likely to receive exercise counseling than adults with any college education.
• Adults with basic or complex activity limitations were more likely than adults without such limitations to receive exercise counseling.

Also, in the NHQR:

• Men were less likely to receive exercise counseling than women and residents of noncore areas were less likely to receive exercise counseling than residents of large fringe metropolitan areas (suburbs).

Management: Counseling About Weight Reduction for Overweight Adults With Arthritis

Weight is a risk factor for osteoarthritis, and weight reduction can be used to prevent the development of osteoarthritis among overweight people. Moreover, overweight people with osteoarthritis who lose weight experience less joint pain and improved function (Pencharz & MacLean, 2004).

  Figure 2.38. Overweight adults with doctor-diagnosed arthritis who reported they received health care provider counseling about weight reduction, by race, ethnicity, income, education, and activity limitation, 2009

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Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2009.
Denominator: Civilian noninstitutionalized overweight adults with doctor-diagnosed arthritis.
Note: Estimates are age adjusted to the 2000 U.S. standard population. Hispanic includes all races. People were considered to have doctor-diagnosed arthritis if they answered yes to "Have you ever been told by a doctor or other health professional that you have some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?"

• In 2009, only 42% of overweight adults with doctor-diagnosed arthritis received health care provider counseling about weight reduction (Figure 2.38).
• Overweight Blacks were more likely than Whites and overweight Hispanics were more likely than non-Hispanic Whites to receive weight reduction counseling.
• High school graduates were less likely to receive weight reduction counseling than adults with any college education.
• Overweight adults with basic or complex activity limitations were more likely than adults without such limitations to receive weight reduction counseling.

Also, in the NHQR:

• Overweight adults age 65 and over were less likely to receive weight reduction counseling than adults ages 45-64, and overweight men were less likely than overweight women to receive weight reduction counseling.

^xviii. In this report, children are defined as individuals under age 18, unless otherwise specified.
^xix. In States with small numbers of births to Black women, caution should be used in interpreting the White-Black differences in adequacy of prenatal care.
^xx. The top 6 States that contributed to the achievable benchmark are California (tie), Louisiana, Maryland, Massachusetts, New Hampshire, and Ohio (tie).
^xxi. The top 5 States that contributed to the achievable benchmark are the District of Columbia, Massachusetts, New Jersey, North Dakota, and Rhode Island.
^xxii. The top 5 States that contributed to the achievable benchmark are Connecticut, District of Columbia, Massachusetts, New Jersey, and New York.
^xxiii. Illicit drugs included in this measure are marijuana/hashish, cocaine (including crack), inhalants (e.g., inhalation of various substances other than for intended use, such as toluene), hallucinogens, heroin, and prescription-type psychotherapeutic drugs (nonmedical use).
^xxiv. The top 5 States that contributed to the achievable benchmark are Colorado, Connecticut, District of Columbia, Mississippi, and Texas.

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