2012 National Healthcare Quality Report

Chronic Kidney Disease

Importance

Measures

The NHQR and NHDR track several measures of management of chronic kidney disease to assess the quality of care provided to renal dialysis patients. A previous core measure, adequacy of dialysis, was retired because it achieved a rate above 95%. Four measures are highlighted here:

• Nephrology care before kidney failure.
• Use of arteriovenous fistula (AVF) at first outpatient dialysis.
• Survival on dialysis.
• Registration for transplantation.

Findings

Management: Nephrology Care Before Kidney Failure

Early referral to a nephrologist is important for patients with progressive chronic kidney disease approaching kidney failure. Mindful management during the transition to ESRD permits informed selection of renal replacement therapy, placement and maturation of vascular access, and workup for kidney transplantation. Patients who begin nephrology care more than a year before kidney failure are less likely to begin dialysis with a catheter, experience infections related to vascular access, or die during the months after dialysis initiation (USRDS, 2010).

 Figure 2.11. New adult end stage renal disease patients beginning nephrology care more than 12 months before start of dialysis, by age and gender, 2008-2009

[D] Select for Text Description

Source: National Institute of Diabetes and Digestive and Kidney Diseases, U.S. Renal Data System, 2008-2009.
Denominator: New end stage renal disease patients age 18 and over.

• In 2009, only 28% of new ESRD patients age 18 and over began nephrology care more than 12 months before start of dialysis (Figure 2.11).
• In both years, patients ages 45-64 and 65 and over were more likely to receive timely nephrology care than patients ages 18-44.

Also, in the NHDR:

• In 2008 and 2009, Blacks were less likely than Whites and Hispanics were less likely than non-Hispanic Whites to begin nephrology care more than 12 months before start of dialysis.

Management: Use of Arteriovenous Fistula at First Outpatient Dialysis

For people with ESRD, dialysis can accommodate for lost kidney function by balancing minerals and water in the blood and removing waste. Vascular access is needed to reach blood vessels so that dialysis can be performed. An AVF is the preferred type of access for most hemodialysis patients for three reasons: It provides adequate blood flow for dialysis, it lasts a long time, and it has a low complication rate compared with other methods.

Although there is consensus that AVF should be the primary method of vascular access, AVF utilization has historically been very low. Therefore, the Centers for Medicare & Medicaid Services (CMS) has sought to increase rates of AVF for primary access by forming a nationwide initiative and collaborative effort to increase overall use of AVF. In 2005, CMS set a national AVF goal of 66% for prevalent hemodialysis patients in the United States.

 Figure 2.12. Incident adult hemodialysis patients who used an arteriovenous fistula at first outpatient dialysis, by age and gender, 2008-2011

[D] Select for Text Description

Source: Centers for Medicare & Medicaid Services, Fistula First Incident AVF Dataset, 2008-2011.
Denominator: New end stage renal disease hemodialysis patients.

• From 2008 to 2011, the percentage of dialysis patients who used an AVF at first dialysis increased from 13.6% to 15.8% (Figure 2.12).
• In all years, patients ages 65-74 had higher rates of AVF at first dialysis than those younger than age 65. Female patients had significantly lower rates of AVF at first dialysis than males.
• The 2008 top 5 State achievable benchmark was 27%.^xii Overall, this benchmark could not be achieved for 15 years. Males and people age 65 and over could attain the benchmark sooner while females and people under age 65 would need between 15 and 20 years.

Also, in the NHDR:

• In all years, Blacks had lower rates of AVF at first dialysis than Whites, and Hispanics had lower rates than non-Hispanic Whites.

Outcome: Survival on Dialysis

Survival on dialysis may be related in part to the quality of care dialysis providers deliver. This measure compares actual patient survival with expected patient survival based on patients' age, race, gender, diabetes status, years on dialysis, and comorbid conditions. Values greater than 1 indicate worse than expected survival; values less than 1 indicate better than expected survival.

Focus on U.S. Territories

Few data sources can assess quality of care received by residents of U.S. territories. Available data suggest that care in U.S. territories is suboptimal (Nunez-Smith, et al., 2011). Data collected by CMS on dialysis facilities and compiled by the University of Michigan Kidney Epidemiology and Cost Center are unusual because they include such residents and are valuable for measuring quality received by U.S. citizens residing outside of the United States.

 Figure 2.13. Standardized mortality rates on dialysis, by State or territory, 2009/2010

[D] Select for Text Description

Source: University of Michigan Kidney Epidemiology and Cost Center, 2010 Dialysis Facility Report.
Denominator: End stage renal disease hemodialysis patients age 20 and over.
Note: For this measure, rates for 2009 and 2010 are averaged. Lower rates are better.

• Standardized mortality rates vary widely across U.S. States and territories (Figure 2.13).
• The four jurisdictions with the highest standardized mortality rates are all territories.

Management: Registration for Transplantation

Kidney transplantation is a procedure that replaces a failing kidney with a healthy kidney. Transplantation is not best for all patients. If a patient is deemed a good candidate for transplant, he or she is placed on the transplant program's waiting list. Patients wait for transplant centers to match them with the most suitable donor. Registration for transplantation is an initial step toward kidney transplantation. Early transplantation that decreases or eliminates the need for dialysis can also lessen the occurrence of acute rejection and patient mortality.

 Figure 2.14. Dialysis patients who were registered on a waiting list for transplantation, by age and gender, 2000-2008

[D] Select for Text Description

Source: National Institute of Diabetes and Digestive and Kidney Diseases, U.S. Renal Data System, 2000-2008.
Denominator: End stage renal disease hemodialysis patients and peritoneal dialysis patients under age 70.

• From 2000 to 2008, the percentage of dialysis patients who were registered on a waiting list for transplantation increased from 14.7% to 17% (Figure 2.14).Improvements were observed among all age groups except patients ages 20-39 and among both males and females.
• In all years, patients ages 20-69 were less likely than patients ages 0-19 to be registered on a waiting list. Females were less likely than males to be registered on a waiting list.
• The 2008 top 5 State achievable benchmark was 27%.^xiii Overall, at the current rate of improvement, the benchmark would not be attained for 25 years. Patients ages 40-59 would need 37 years to achieve the benchmark.

Also, in the NHDR:

• In all years, Blacks and AI/ANs were less likely to be registered on a waiting list than Whites. However, APIs were more likely to be registered on a waiting list than Whites.

Return to Contents

 Diabetes

Importance

Measures

Routine monitoring of blood glucose levels with hemoglobin A1c (HbA1c^xiv) tests and foot and dilated eye examinations have been shown to help prevent or mitigate complications of diabetes, such as diabetic neuropathy, retinopathy, and vascular and kidney disease. With more than 600,000 discharges in 2009, diabetes is one of the leading causes of hospitalization in the United States (CDC, 2011a). However, with appropriate and timely ambulatory care, it may be possible to prevent many hospitalizations for diabetes and related complications.

The measures reported in this section examine the extent to which individuals with diabetes receive care needed to prevent complications and the development of kidney failure, a serious complication of diabetes:

• Receipt of four recommended diabetes services.
• Control of HbA1c and blood pressure.
• Hospital admissions for uncontrolled diabetes.
• End stage renal disease due to diabetes.

Findings

Management: Receipt of Four Recommended Diabetes Services

A composite measure is used to track the national rate of receipt of four recommended annual diabetes interventions: at least two HbA1c tests, a foot examination, an eye examination, and a flu shot. These are basic process measures that provide an assessment of the quality of diabetes management. This diabetes composite measure differs from the composite presented in previous years. To be more consistent with current recommendations, the required frequency of HbA1c tests was increased in 2011 to two per year and receipt of a flu shot was added.

 Figure 2.15. Adults age 40 and over with diagnosed diabetes who reported receiving four recommended services for diabetes in the calendar year (2+ hemoglobin A1c tests, foot exam, dilated eye exam, and flu shot), by age and residence location, 2008-2009

[D] Select for Text Description

Key: MSA = metropolitan statistical area.
Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2008-2009.
Denominator: Civilian noninstitutionalized population with diagnosed diabetes, age 40 and over.
Note: Data include people with both type 1 and type 2 diabetes. Rates are age adjusted to the 2000 U.S. standard population. The noncore sample size in 2008 did not meet requirements for statistical reliability, data quality, or confidentiality.

• Among adults age 40 and over with diagnosed diabetes, only 23% received all four recommended services in 2009 (Figure 2.15).
• In both years, adults ages 40-59 were less likely to receive recommended care for diabetes than adults age 60 and over.
• In 2009, residents of micropolitan and noncore areas were less likely to receive recommended care for diabetes than residents of large fringe metropolitan areas.

Also, in the NHDR:

• In 2008 and 2009, poor, low-income, and middle-income adults were less likely to receive recommended care for diabetes than high-income adults.

Outcome: Control of Hemoglobin A1c and Blood Pressure

People diagnosed with diabetes are often at higher risk for other cardiovascular risk factors, such as high blood pressure and high cholesterol. Having these conditions in combination with diagnosed diabetes increases the likelihood of complications, such as heart and kidney diseases, blindness, nerve damage, and stroke. Patients who manage their diagnosed diabetes and maintain an HbA1c level <7%, total cholesterol <200 mg/dL, and blood pressure <140/80 mm Hg can decrease these risks.

 Figure 2.16. Adults age 40 and over with diagnosed diabetes with hemoglobin A1c and blood pressure under control, by age, 1988-1994, 1999-2002, 2003-2006, and 2007-2010

[D] Select for Text Description

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health and Nutrition Examination Survey, 1988-1994, 1999-2002, 2003-2006, and 2007-2010.
Denominator: Civilian noninstitutionalized population with diagnosed diabetes, age 40 and over.
Note: Age adjusted to the 2000 U.S. standard population using two age groups: 40-59 and 60 and over.

• Among adults age 40 and over with diagnosed diabetes, only 52% achieved HbA1c less than 7% and about 65% achieved blood pressure less than 140/80 mm Hg in 2007-2010 (Figure 2.16). Improvements were observed among all age groups.

Also, in the NHDR:

• In most years, Mexican Americans were less likely to achieve HbA1c control than non-Hispanic Whites. Non-Hispanic Blacks were less likely to achieve blood pressure control than non-Hispanic Whites.

Outcome: Admissions for Uncontrolled Diabetes

Individuals who do not achieve good control of their diabetes may develop symptoms that require hospitalization to correct. Admission rates for uncontrolled diabetes may be reduced by better outpatient treatment and tighter adherence to diet and medications for diabetes.

 Figure 2.17. Hospital admissions for uncontrolled diabetes per 100,000 population, age 18 and over, by age and residence location, 2004-2009

[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 version 4.1, 2004-2009.
Denominator: U.S. resident population age 18 and over.
Note: For this measure, lower rates are better. Data are adjusted for age and gender. Rates by age are not age adjusted.

• Between 2004 and 2009, the overall adult admission rate for uncontrolled diabetes did not change significantly (Figure 2.17). Rates increased among patients ages 45-64 and residents of large central, large fringe, and medium metropolitan areas. Only residents of micropolitan and noncore areas experienced declines.
• In all years, adults ages 45-64 and 65 and over had higher admission rates for uncontrolled diabetes than adults ages 18-44.
• In all years, residents of large central metropolitan areas and noncore areas had higher rates than residents of large fringe metropolitan areas.
• The 2008 top 4 State achievable benchmark was 5 per 100,000 population.^xv Only residents of micropolitan and noncore areas show progress toward the benchmark but still could not achieve it for about 16 years.

Also, in the NHDR:

• In all years, the rate of hospital admissions for uncontrolled diabetes was higher for Blacks and Hispanics compared with Whites.
• In all years, the rate of hospital admissions for uncontrolled diabetes was higher for adults living in communities with median household incomes in the first, second, and third quartiles than for people living in communities in the fourth quartile.

Outcome: End Stage Renal Disease Due to Diabetes

Diabetes is the most common cause of kidney failure. Keeping blood sugar levels under control can prevent or slow the progression of kidney disease due to diabetes. In addition, when kidney disease is detected early, medication can slow the disease's progress. If it is detected late, progression to ESRD requiring dialysis is common. While some cases of kidney failure due to diabetes cannot be avoided, other cases reflect inadequate control of blood sugar or delayed detection and treatment of early kidney disease due to diabetes.

 Figure 2.18. End stage renal disease due to diabetes per million population, by age and gender, 2000-2009

[D] Select for Text Description

Source: National Institute of Diabetes and Digestive and Kidney Diseases, U.S. Renal Data System, 2000-2009.
Denominator: U.S. resident population.
Note: For this measure, lower rates are better. Rates are age adjusted.

• Between 2000 and 2009, the overall incidence of ESRD due to diabetes did not change (Figure 2.18). The rate increased among people ages 20-44 and age 75 and over. It also increased among males and fell among females.
• In all years, people age 45 and over had higher rates of ESRD due to diabetes than people ages 20-44. Males had higher rates than females.
• The 2008 top 5 State achievable benchmark was 93 per million population.^xvi People ages 20-44 have achieved the benchmark. Of the other age groups and genders, only women are moving toward the benchmark but still will not achieve it for 21 years.

Also, in the NHDR:

• In all years, AI/ANs, APIs, and Blacks had higher rates of ESRD due to diabetes than Whites and Hispanics had higher rates than non-Hispanic Whites.

Return to Contents

 HIV and AIDS

Importance

HIV is a virus that kills or damages cells of the body's immune system. AIDS is the most advanced stage of HIV infection. HIV can be spread through unprotected sex with an infected person, sharing of drug needles, or contact with the blood of an infected person. In addition, women with HIV can pass the virus to their babies during pregnancy, childbirth, or breastfeeding.

The impact of HIV infection and AIDS is disproportionately higher for racial and ethnic minorities and people of lower income and education levels. Although access to care has improved, research shows that Blacks, Hispanics, women, and uninsured people with HIV remain less likely to have access to care and less likely to have optimal patterns of care (Tobias, et al., 2007)

The spread of HIV is linked to complex social and economic factors, including:

• Poverty.
• Concentration of the virus in specific geographic areas and smaller sexual networks.
• Sexually transmitted co-infections.
• Stigma (negative attitudes, beliefs, and actions directed at people living with HIV/AIDS or directed at people who engage in behaviors that might put them at risk for HIV), and
• Injection and noninjection drug use and associated behaviors (CDC, 2010).

According to the Centers for Disease Control and Prevention (CDC), HIV and AIDS disproportionately affect Blacks in the United States. In 2009, Blacks represented 14% of the U.S. population but accounted for 44% of all diagnoses of new HIV infections (CDC, 2012). The HIV/AIDS epidemic is also a serious threat to the Hispanic community. An estimated 20% of new HIV infections occurred among Hispanics in 2009, which is three times the rate of Whites (CDC, 2012). In addition to being seriously affected by HIV, Hispanics continue to face challenges in accessing health care, especially preventive services and HIV treatment.

Undocumented immigrants face an even greater challenge in accessing care and information regarding HIV and AIDS, but data are limited on HIV infection rates of undocumented immigrants (Carrillo & DeCarlo, 2003). In 2007, HIV/AIDS was the fourth leading cause of death among Hispanic men and women ages 35-44 (CDC, 2011a). Having Medicaid and a usual source of care decreased the likelihood of delaying care for HIV, but research shows that delay in care is still greater for Hispanics and Blacks (Cunningham, et al., 2006).

Another group that is severely affected by HIV includes gay, bisexual, and other men who have sex with men (MSM). MSM represent 2% of the U.S. population and is the only risk group in which new HIV infections have been gradually increasing since the 1990s. MSM have constantly represented the largest percentage of people diagnosed with AIDS and people with an AIDS diagnosis who have died. In 2009, MSM accounted for more than half (61%) of all new HIV infections in the United States (CDC, 2012).

The White House Office of National AIDS Policy launched the National HIV/AIDS Strategy (NHAS) in July 2010. The NHAS is a comprehensive plan focused on: (1) reducing the number of people who become infected with HIV, (2) increasing access to care and optimizing health outcomes for people living with HIV, and (3) reducing HIV-related health disparities. The plan serves as a roadmap for policymakers, partners in prevention, and the public on steps the United States must take to lower HIV incidence, get people living with HIV into care, and reduce HIV-related health disparities.

Measures

This year, one measure is presented focusing on the quality of preventive care for HIV-infected individuals:

• New AIDS cases.

Five measures are presented on access to care, retention in care and treatment, and prevention of opportunistic infections in HIV patients:

• Adult HIV patients who had at least two outpatient visits during the year.
• Adult HIV patients who received two or more CD4 tests during the year.
• Adult HIV patients who received highly active antiretroviral therapy (HAART).
• Eligible patients receiving prophylaxis for Pneumocystis pneumonia (PCP).
• Eligible patients receiving prophylaxis for Mycobacterium avium complex (MAC).

In addition, one measure is presented on HIV infection deaths.

Findings

Management: HIV Patients Receiving Care

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.

HIV/AIDS core clinical performance measures are indicators for use in monitoring the quality of care provided to adults and adolescents living with HIV. Based on the set of quality measures developed by the HIV/AIDS Bureau of the Health Resources and Services Administration (HRSA), performance can be measured for various HIV prevention and treatment services. Services needed by patients with HIV include:

• Two or more medical visits in an HIV care setting in the measurement year.
• Two or more CD4 cell counts performed in the measurement year.
• HAART for patients with AIDS.
• PCP prophylaxis for patients with CD4 cell count below 200 and MAC prophylaxis for patients with CD4 cell count below 50.

Outcome: 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, screening and early detection of HIV disease, and availability of appropriate treatments for HIV-infected individuals.

 Figure 2.19. New AIDS cases per 100,000 population age 13 and over, by age and gender, 2000-2009

[D] Select for Text Description

Source: Centers for Disease Control and Prevention, National Center for HIV, STD, and TB Prevention, HIV/AIDS Surveillance System, 2000-2009.
Denominator: U.S. population age 13 and over.

• Overall, in 2009, the total rate of new AIDS cases was 13.5 per 100,000 population (Figure 2.19).
• From 2000 to 2009, rates of new AIDS cases decreased overall and for almost all age groups and both genders. There were no statistically significant changes in rates for ages 13-17 and age 65+.
• In 2009, people ages 18-44 had a higher rate of new AIDS cases than other age groups and males had a higher rate than females.
• The 2009 top 4 State achievable benchmark for new AIDS cases was 4 per 100,000 population.^xvii People ages 13-17 and 65 and over have achieved the benchmark, but there is no progress toward the benchmark for other age groups. At the current rate, it would take females 13 years to reach the benchmark and males more than 20 years.

Also, in the NHDR:

• In 2009, non-Hispanic Blacks and Hispanics had higher rates of new AIDS cases than non-Hispanic Whites.

Management: Recommended Care for HIV

Currently, national data on HIV care are not routinely collected. HIV measures tracked in the NHQR are from the HIV Research Network, which consists of 18 medical practices across the United States that treat large numbers of patients living with HIV. Data from the voluntary HIV Research Network are not nationally representative of the level of care received by everyone in the United States living with HIV.

HIV Research Network data represent only patients with HIV who are actually receiving care (about 14,000 patients per year) and do not represent patients who do not receive care. Furthermore, data shown below are not representative of the HIV Research Network as a whole because they represent only a subset of network sites that have the most complete data.

Below are data from the HIV Research Network that capture four of the HRSA quality measures. In addition, when CD4 cell counts fall below 50, medicine to prevent development of disseminated MAC infection is routinely recommended (Yeargin, et al., 2003), which is also tracked in the reports.

 Figure 2.20. HIV patients who received recommended care, by age and expected payment source, 2009

[D] Select for Text Description

Key: HAART = highly active antriretroviral therapy; PCP = Pneumocystis pneumonia; MAC = Mycobacterium avium complex.
Source: Agency for Healthcare Research and Quality, HIV Research Network, 2009.
Note: For HAART measure, adult HIV patients had to be enrolled in an HIV Network clinic, receive at least one CD4 test, and have at least one outpatient visit in addition to having at least one CD4 test result of 350 or less.

• Overall, in 2009, 88.9% of people with HIV had two or more outpatient visits during the year, and 82.8% of people with HIV had two or more CD4 tests during the year (Figure 2.20). In addition, 93.0% of people with HIV received HAART. A slightly higher percentage (93.3%) of people with HIV who had a CD4 count less than 200 received PCP prophylaxis and 88.3% of people with HIV received MAC prophylaxis.
• In 2009, there were no statistically significant differences by age or insurance type in the percentage of people with HIV receiving recommended services.

Also, in the NHDR:

• In 2009, there were no statistically significant differences by race/ethnicity or gender in the percentage of people with HIV receiving recommended services.

Outcome: Deaths of People With HIV Infection

Improved management of HIV infection has contributed to declines in the number of new AIDS cases in the United States since the 1990s (CDC, 2005). HIV infection deaths reflect a number of factors, including underlying rates of HIV risk behaviors, prevention of HIV transmission, early detection and treatment of HIV disease, and management of AIDS and its complications.

 Figure 2.21. HIV infection deaths per 100,000 population, by age and residence location, 2004-2009

[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, 2004-2009.
Denominator: U.S. population.
Note: For this measure, lower rates are better. Rates are age adjusted to the 2000 U.S. standard population. Age data are unadjusted. Respondents for which age is not reported are not included in the age adjustment calculations and are excluded from numerators.

• Overall, in 2009, the total rate of HIV infection deaths was 3 per 100,000 population (Figure 2.21).
• From 2004 to 2009, the rate of HIV infection deaths decreased for adults ages 18-44 and 45-64, but it increased for those age 65 and over.
• In 2009, the rate of HIV infection deaths for adults ages 45-64 (6.6 per 100,000 population) was higher than for adults ages 18-44 (3 per 100,000 population), but those age 65 and over (1.8 per 100,000) had a lower rate than those ages 18-44.
• From 2004 to 2009, the rate of HIV infection deaths decreased for adults living in large central, large fringe, medium, and small metropolitan areas.
• In 2009, the rate of HIV infection deaths for people living in medium metropolitan (2.5 per 100,000 population) and large central metropolitan (5.2 per 100,000 population) areas was higher compared with those living in large fringe areas (2.1 per 100,000 population). However, it was lower for those living in micropolitan (1.8 per 100, 000 population) and noncore (1.7 per 100, 000 population) areas compared with those in large fringe areas.
• The 2008 top 4 State achievable benchmark for HIV deaths was 0.9 per 100,000 population.^xviii At the current rate, adults ages 18-44 would reach the benchmark in 5 years, while adults ages 45-64 would take 39 years. Adults age 65 and over are moving away from the benchmark. Residents of large fringe metropolitan areas could reach the benchmark in 5 years, while those living in noncore areas would take 24 years.

Also, in the NHDR:

• HIV infection death rates are decreasing for all racial/ethnic groups and both genders.
• In 2009, the HIV infection death rate was higher for males than for females.

^xii. The top 5 States that contributed to the achievable benchmark are Hawaii, Maine, Montana, New Hampshire, and Oregon.
^xiii. The top 5 States that contributed to the achievable benchmark are Delaware, Iowa, Minnesota, Montana, and Vermont.
^xiv. HbA1c, or glycosylated hemoglobin, is a measure of average levels of glucose in the blood.
^xv. The top 4 States that contributed to the achievable benchmark are Colorado, Hawaii, Utah, and Vermont.
^xvi. The top 5 States that contributed to the achievable benchmark are Alaska, Montana, New Hampshire, Oregon, and Wyoming.
^xvii. The top 4 States that contributed to the achievable benchmark are Iowa, New Hampshire, Utah, and Wisconsin.
^xviii. The top 4 States that contributed to the achievable benchmark are Minnesota, Oregon, Utah, and Wisconsin.

Return to Contents