2012 National Healthcare Quality Report

In its 2010 report Future Directions for the National Healthcare Quality and Disparities Reports, the Institute of Medicine (IOM, 2010) recommended that future editions of the National Healthcare Quality Report (NHQR) and National Healthcare Disparities Report (NHDR) include data on the health care system’s infrastructure capabilities. According to the IOM:

These components are not necessarily health care aims/attributes in themselves, but are a means to those aims since they are elements of the health care system that better enable the provision of quality care….and health systems infrastructure are of interest to the extent that they improve effectiveness, safety, timeliness, patient-centeredness, access, or efficiency.

Acknowledging that the measures and data required to assess the strength and capabilities of the health care infrastructure have not been well developed, the IOM identified structural elements that may affect quality improvement. Key elements include:

• Information systems for data collection, quality improvement analysis, and clinical communication support.
• An adequate and well-distributed workforce.
• Organizational capacity to support emerging models of care, cultural competence services, and ongoing improvement efforts.

Of significance, inadequacies in health system infrastructure may limit access and contribute to poor quality of care and outcomes, particularly among vulnerable population groups that include racial and ethnic minority groups and people residing in areas with health professional shortages.

This chapter presents data to illustrate the strength of the U.S. health system infrastructure and how this infrastructure may influence quality of care. The chapter is divided into three sections, each addressing a unique aspect of the health care system:

• Health information technology (IT).
• Workforce distribution.
• Health care safety net.

The chapter begins with data to describe the adoption and use of health IT. Use of health IT can be an effective way to manage health care costs and improve the quality of care.

Since the publication of the IOM report Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare,ⁱ which emphasized the need for standardized collection and reporting of racial and ethnic data, the need for more granular detail on racial and ethnic subgroups has become apparent. This is an area where the adoption and use of health IT can be beneficial.

Another area of patient care that could be improved with the adoption and use of health IT is care coordination. A Commonwealth Fund study found that health IT can facilitate care coordination within a practice, but a lack of interoperability makes exchange of information between health care facilities difficult (Shih, et al., 2008).

Evidence has also shown that the adoption and effective use of health IT can help reduce medical errors and adverse events, enable better documentation and file organization, provide patients with information that assists their adherence to medication regimens and scheduled appointments, and assist doctors in tracking their treatment protocols (IOM, 2010).

Following presentation of measures of the use of health IT, data on health care workforce diversity are presented. An adequate supply of health care providers is an important indicator of health care quality. Aside from a provider-to-population ratio that effectively meets demand for care, it is important that the workforce be appropriately distributed.

In previous quality and disparities reports, data have been presented on diversity in the nursing, dental, pharmacy, and allied health professional workforce. This year, the NHQR and NHDR present data on the geographic and racial/ethnic distribution of primary care physicians and primary care specialists.

The distribution and availability of a culturally competent health care workforce has significant repercussions for access to care, particularly among the Nation’s most vulnerable populations—racial and ethnic minorities, low-income populations, and uninsured or underinsured people. People who cannot access health care services, either because of financial considerations or inadequacy in the local health care infrastructure, often rely on safety net providers for essential health care services. The final section presents measures related to the performance of safety net providers, including people served, characteristics of selected safety net providers, and patient outcomes.

Measures

The IOM acknowledges that health system infrastructure measures such as adoption and effective use of health IT are likely to be in the developmental stage, and evidence of the impact on quality improvement has not yet been strongly established. The IOM highlighted three infrastructure capabilities that should be further evaluated for reporting. These capabilities include adoption and use of health IT, workforce distribution and its relevance to minority and other underserved populations, and care management processes.

Findings

Health Information Technology: Focus on Electronic Health Records

According to the Office of the National Coordinator for Health IT, an electronic health record (EHR) is a real-time patient health record with access to evidence-based decision support tools that can be used to aid clinicians in decisionmaking. The EHR can automate and streamline a clinician’s workflow, ensuring that all clinical information is communicated. The EHR can also support the collection of data for uses other than clinical care, such as billing, quality management, outcome reporting, and disease surveillance and reporting for public health purposes.

The IOM report Future Directions for the National Healthcare Quality and Disparities Reports highlights the adoption and use of health IT as a tool to manage cost and improve the quality of care delivered (IOM, 2010). Meaningful use of an EHR, for instance, is increasingly viewed as essential to improving both the efficiency of service delivery and health care quality (Resnick & Alwan, 2010).

Health providers using EHRs have reported improvement in clinical decisionmaking and communication with other providers and patients, as well as faster and more accurate access to medical records and avoidance of medical errors (Romano & Stafford, 2011). Components of EHRs, such as computerized provider order entry (CPOE) and clinical decision support (CDS), have been found to be associated with significant reductions in medication errors (Devine, et al., 2010).

CPOE systems are computer applications that allow direct electronic entry of orders for medications, laboratory tests, radiology services, referrals, and procedures. CDS encompasses a wide range of computerized tools directed at improving patient care, including alerts, reminders, order sets, drug dose calculations that automatically remind the clinician of a specific action, or care summary dashboards that provide feedback on quality indicators (Bright, et al., 2012).

Electronic Health Records in Hospitals

The 2012 Commonwealth Fund report Using Electronic Health Records To Improve Quality and Efficiency: The Experience of Leading Hospitals found that successful implementation of EHRs depends on strong leadership, full involvement of clinical staff in design and implementation, and mandatory staff training. EHRs can improve health care quality and patient safety through the use of checklists and alerts and by promoting evidence-based practices. EHRs can increase efficiency by alerting physicians to duplicate orders and enabling faster prescribing and test ordering while reducing errors and redundancy. This year’s NHQR tracks overall EHR use in hospitals.

EHRs can improve the quality and safety of care in all types of hospitals and in departments within hospitals. In emergency departments, for instance, electronic clinical documentation and decision support can help mitigate problems of treating new patients with complicated medical histories and gaps in their medical records. EHRs can also provide effective decision support and clinical reminders to facilitate a seamless transition of care by reducing communication breakdown between different providers.

  Figure 8.1. Electronic medical record use in hospitals, by geographic region and hospital size, 2010

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Source: American Hospital Association Annual Survey 2010 Information Technology Supplement.
Note: Data were obtained from an average of 3,131 hospitals.

Patient Demographics

• In 2010, 82.5% of hospitals with an EHR system had a component for patient demographics. The percentage of hospitals with EHR systems that had a component for patient demographics was higher for hospitals with 400 beds or more (95.2%) compared with hospitals with 100-399 beds (89.3%) and hospitals with fewer than 100 beds (73.9%; Figure 8.1).
• Hospitals in the Northeast had the highest rate of EHR systems with a component for patient demographics (89.6%). In the Midwest and the South, 83.4% and 80.3% of hospitals, respectively, had an EHR system with a patient demographics component. In the West, 78.5% of hospitals had an EHR system with a patient demographics component.
• More than 86% of urban hospitals and 78.1% of rural hospitals had an EHR system with a component for patient demographics (data not shown).

Physician Notes and Nursing Assessments

• In hospitals with an EHR system, 25.0% support physician notes and 53.0% support nursing assessments.
• The percentage of hospitals with electronic systems that support both physician notes and nursing assessments was higher for hospitals with 400 beds or more than for hospitals with fewer than 400 beds.
• More than 28% of hospitals in the Midwest, 24.7% of hospitals in the West, 22.5% of hospitals in the South, and 22.4% of hospitals in the Northeast had electronic systems that support physician notes. More than 54% of hospitals in the Northeast, 53.8% of hospitals in the South, 53.7% of hospitals in the Midwest, and 48.1% of hospitals in the West had electronic systems that support nursing assessments.
• Nearly 27% of urban hospitals and 23.0% of rural hospitals had an EHR system with a component for physician notes. More than 57% of urban hospitals and 48.0% of rural hospitals had an EHR system with a component for nursing assessments (data not shown).

Problem Lists and Medication Lists

• In 2010, 39.6% of hospitals with an EHR system had a component for problem lists and 58.2% had a component for medication lists.
• The percentage of hospitals with electronic systems that support both problem lists and medication lists was higher for hospitals with 400 beds or more than for hospitals with fewer than 400 beds.
• Forty-one percent of hospitals in the Northeast, 40.7% of hospitals in the Midwest, 39.2% of hospitals in the South, and 36.7% of hospitals in the West had electronic systems that support problem lists. Nearly 65% of hospitals in the Northeast, 57.9% of hospitals in the Midwest, 57.0% of hospitals in the South and 54.8% of hospitals in the West had electronic systems that support medication lists.

Discharge Summaries and Advance Directives

• In 2010, 53.0% of hospitals with an EHR system had a component for discharge summaries and advance directives.
• The percentage of hospitals with electronic systems that support both discharge summaries and advance directives was higher for hospitals with 400 beds or more than for hospitals with fewer than 400 beds.
• Nearly 55% of hospitals in the Northeast, 53.8% of hospitals in the South, 52.9% of hospitals in the Midwest, and 50.2% of hospitals in the West had electronic systems that support discharge summaries. More than 56% of hospitals in the Northeast, 54.8% of hospitals in the Midwest, 52.7% of hospitals in the South, and 46.4% of hospitals in the West had electronic systems that support advance directives.

Also, in the NHDR:

• In 2010, the percentage of Federal Government hospitals with electronic systems that support patient demographics, physician notes, nursing assessments, problem lists, medication lists, discharge summaries, and advance directives was much higher than the percentage for not-for-profit, non-Federal, and investor-owned hospitals.

Electronic Health Records in Physician Practices

In addition to alerts, guidelines, and electronic ordering, the ability to exchange health information efficiently between providers leads to better access to quality care and improved patient safety. Many factors outside of the physician’s control may help determine his or her ability to adopt an EHR system. Unfortunately, practice size and availability of resources affect EHR adoption rates. Thus, the potential quality and efficiency benefits of an EHR system may be unavailable to resource-constrained organizations that are constantly challenged to "do more with less" (McAlearney, et al., 2010).

The most frequent reason cited for not adopting health IT is cost and potential loss of productivity. EHRs cost almost $44,000 per full-time-equivalent provider, with ongoing costs of $8,400 annually (Samantaray, et al., 2011).

  Figure 8.2. Electronic health record use overall and by age and practice size, 2011

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Source: Jamoom E, Beatty P, Bercovitz, et al. Physician adoption of electronic health record systems: United States, 2011. NCHS data brief, no 98. Hyattsville, MD: National Center for Health Statistics; 2012.

Overall Electronic Health Record System Adoption

• In 2011, 54% of physicians had adopted an EHR (Figure 8.2).
• In 2011, 64% of physicians under age 50 had an EHR system but only 49% of physicians age 50 and over had an EHR system.
• In 2011, the percentage of physicians working in practices of 11 or more who had an EHR system was nearly three times as high as the percentage of physicians in solo practices who had an EHR system.

Also, in the NHDR:

• In 2011, nearly all physicians in health maintenance organizations (HMOs), 73% of physicians in community health centers, and 69% of physicians in academic health centers had adopted an EHR system. Only 49% of providers in physician-owned practices had adopted EHRs.
• In 2011, 58% of primary care specialists, 54% of medical subspecialists, and 48% of surgical specialists had adopted an EHR system.

  Figure 8.3. Electronic health record use by physician age and practice size, 2011

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Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Ambulatory Medical Care Survey, 2011 Electronic Medical Record Mail Survey Supplement.

Patient Demographics

• In 2011, 72.4% of office-based physicians with an EHR system had a component for patient demographics (Figure 8.3).
• In 2011, the percentage of practices with EHRs with a component for patient demographics was significantly higher for physicians under age 35 than for all other age groups.
• In 2011, 87.8% of practices with an EHR system and 11 or more physicians had a component for patient demographics. This rate was significantly higher than the rate for physicians in solo practices (60.1%) and practices with 3 to 5 physicians (75.2%).
• In 2011, 73.9% of physicians in the West and Midwest, 72.3% of physicians in the Northeast, and 70.8% of physicians in the South with an EHR system had a component for patient demographics (data not shown).

Clinical Notes

• In 2011, 61.6% of office-based physicians with an EHR system had a component for clinical notes.
• In 2011, 81.5% of physicians under age 35 and 73.1% of physicians ages 35-44 with an EHR system had a component for clinical notes, which were both significantly higher than for physicians age 45 years and over.
• In 2011, 87.2% of practices with an EHR system and 11 or more physicians had a component for clinical notes; 70.1% of practices with 6 to 10 physicians, and 64.5% of practices with 3 to 5 physicians had EHRs with a component for clinical notes. Less than half of practices with one or two physicians had EHRs with a component for clinical notes (44.5%).
• In 2011, 67.6% of physicians in the West, 64.1% of physicians in the Midwest, 58.4% of physicians in the South, and 58.3% of physicians in the Northeast with an EHR system had a component for clinical notes (data not shown).

Prescription Ordering

• In 2011, 64.8% of office-based physicians with an EHR system had a component for ordering prescriptions.
• In 2011, the percentage of physicians who had an EHR system with a component for ordering prescriptions was much higher for physicians age 35 and under than for any other age group.
• In 2011, 88.1% of practices with 11 or more physicians and an EHR system had a component for ordering prescriptions; 73.9% of practices with 6 to 10 physicians, and 67.0% of practices with 3 to 5 physicians that had EHRs had a component for ordering prescriptions. Only about 50% of practices with one or two physicians and an EHR system had a component for ordering prescriptions.
• In 2011, 66.9% of physicians in the Midwest, 66.8% of physicians in the West, 64.8% of physicians in the Northeast, and 62.2% of physicians in the South with an EHR system had a component for ordering prescriptions (data not shown).

Clinical Decision Support

• In 2011, 32.8% of office-based physicians with an EHR system had a CDS component.
• In 2011, 50.1% of physicians under age 35 had an EHR system with a component for CDS, which is significantly higher than the percentage of physicians age 45 and over.
• In 2011, 47.3% of practices with an EHR system and 11 or more physicians had a component for CDS; 35.9% of practices that had EHRs and 6 to 10 physicians, and 35.4% of practices that had EHRs and 3 to 5 physicians had a CDS component. Only 23% of practices that had EHRs and one or two physicians had a CDS component.
• In 2011, 38.0% of physicians in the West, 35.8% of physicians in the Midwest, 30.3% of physicians in the Northeast, and 29.2% of physicians in the South with an EHR system had a CDS component (data not shown).

Clinical Reminders

• In 2011, 40.0% of office-based physicians with an EHR system had a component for clinical reminders.
• In 2011, 57.2% of physicians under age 35 who had an EHR system had a component for clinical reminders, which is significantly higher than the percentage of physicians age 45 and over.
• In 2011, 53.2% of physicians who worked in practices that had EHRs and 11 or more physicians, 42.4% of physicians in practices with 6 to 10 physicians, and 41.6% of physicians in practices with 3 to 5 physicians had a component for clinical reminders. Only 32% of practices that had EHRs and one or two physicians had a component for clinical reminders.
• In 2011, 44.7% of physicians in the West, 42.6% of physicians in the Midwest, 37.5% of physicians in the South, and 36.9% of physicians in the Northeast with an EHR system had a component for clinical reminders (data not shown).

Also, in the NHDR:

• In 2011, office-based physicians located in areas with a non-Hispanic White population greater than 70% had the highest implementation rate of EHRs with components for patient demographics, clinical notes, and prescription ordering. Office-based physicians located in areas with a non-Hispanic White population greater than 80% had the highest implementation rate of EHRs with components for clinical decision support and clinical reminders.

Workforce Distribution

The IOM defines primary care as the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. Primary care physicians are specifically trained and skilled in comprehensive first contact and continuing care for persons with any undiagnosed sign, symptom, or health concern (the “undifferentiated” patient) not limited by problem origin (biologic, behavioral, or social), organ system, or diagnosis. Primary care physicians include family physicians, general internists, pediatricians, and obstetrician-gynecologists.ⁱⁱ

Family medicine physicians emphasize disease prevention and health promotion and coordinate care when referral is indicated and multiple providers are involved. Areas of subspecialty include adolescent medicine, geriatric medicine, hospice and palliative medicine, sleep medicine, and sports medicine.

Internal medicine specialists are trained in adult medicine and provide comprehensive acute and chronic care to adolescents, adults, and older adults. Internists can focus on general internal medicine or on one of the 13 subspecialties, which include adolescent medicine, allergy and immunology, cardiology, endocrinology, gastroenterology, geriatrics, hematology, infectious disease, nephrology, oncology, pulmonology, rheumatology, and sports medicine.

According to the American Academy of Pediatrics, pediatricians focus on prevention, detection, and management of physical, behavioral, developmental, and social problems that affect children. Pediatric subspecialties include adolescent medicine, pediatric cardiology, pediatric emergency medicine, pediatric gastroenterology, pediatric nephrology, and pediatric pulmonology.

Obstetrician-gynecologists are skilled in the medical and surgical care of the female reproductive system and associated disorders. This distinguishes them from other physicians and enables them to serve as consultants to other physicians and as primary physicians for women. Subspecialties of obstetrics and gynecology include critical care medicine, female pelvic medicine and reconstructive surgery, gynecologic oncology, hospice and palliative medicine, maternal and fetal medicine, and reproductive endocrinology/infertility.

One way to improve health care is to ensure the adequacy and proportional distribution of the primary care physician supply. Unfortunately, the United States is currently facing a primary care physician workforce shortage. The number of physicians per capita grew rapidly at the end of the 20th century from 115 active patient care physicians per 100,000 population in 1965 to 190 in 1992. Almost the entire increase was among specialists. The primary care physician to population ratio grew by 14%, but the specialist to population ratio grew by 120%. Fifty-six percent of visits to physicians’ offices are for primary care but only 37% of physicians practice primary care medicine, resulting in adult patients having difficulty gaining timely access to primary care (Bodenheimer & Pham, 2010).

The problem is even more acute in rural areas. The ratio of primary care physicians to populations in urban areas is 100 per 100,000 population but in rural areas it is less than half that rate, 46 per 100,000 (Bodenheimer & Pham, 2010).

Primary care physicians have been shown to play an important role in the health of the communities in which they serve. This year, the NHQR presents the geographic distribution of primary care and primary care subspecialty physicians.

  Figure 8.4. U.S. active non-Federal general and specialist physicians and surgeons, by geographic region and metropolitan status, 2008

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Source: U.S. Department of Health and Human Services, Health Resources and Services Administration, Area Resource File.
Note: Nonmetropolitan family medicine subspecialist rate did not meet criteria for statistical reliability.

• In 2008, the Midwest, South, and West all had higher rates of general family medicine physicians than the Northeast but only the Midwest had a significantly higher rate of family medicine subspecialists than the Northeast. Nonmetropolitan areas had a slightly higher rate of general family medicine physicians but the difference was not statistically significant (Figure 8.4).
• In 2008, the Northeast had higher rates of general internal medicine physicians and internal medicine subspecialists than the Midwest, South, and West. The rate of general internal medicine physicians in metropolitan areas was 4 times the rate for nonmetropolitan areas, and the metropolitan rate of internal medicine subspecialists was more than 10 times the nonmetropolitan rate.
• In 2008, the Northeast had higher rates of pediatricians and pediatric subspecialists than the Midwest, South, and West. The rate of pediatricians in metropolitan areas was more than five times the rate for nonmetropolitan areas, and the metropolitan rate of pediatric subspecialists was nine times the nonmetropolitan rate.
• In 2008, the Northeast had higher rates of obstetrician-gynecologists and obstetrics and gynecology subspecialists than the Midwest, South, and West. The rate of obstetrician-gynecologists in metropolitan areas was more than four times the rate for nonmetropolitan areas, and the metropolitan rate of obstetrics and gynecology subspecialists was five times the nonmetropolitan rate.

Also, in the NHDR:

• In all years, Asians had significantly higher rates of physicians and surgeons than all other racial groups. In 2010, the rate of Asian physicians and surgeons was 4 times the rate for Whites, 10 times the rate for Blacks, 14 times the rate for American Indians and Alaska Natives, and more than 5 times the rate for multiple-race individuals.
• In all years, the rates for non-Hispanic Whites were about three times the rates for Hispanic physicians and surgeons.

Organizational Capacity: Focus on the Health Care Safety Net

Concern has arisen about the composition and distribution of the health workforce and whether the Nation’s health workforce will be able to meet the increasing demand for care that a growing and aging U.S. population will have. In his seminal work on health care quality, Donabedian (1980) describes a robust health care "structure"—the setting or infrastructure supporting the delivery of care (e.g., hospitals, providers)—as necessary to ensure that processes of care contribute to good outcomes. Structural deficiencies in the United States health care delivery system resulting from shortages of providers, growing demand, and a high rate of uninsurance and underinsurance have contributed to unmet need and could result in increased morbidity and health care costs.

Safety net providers play an integral role in relieving unmet needs. As defined in an IOM report, the U.S. health care safety net is composed of "[t]hose providers that organize and deliver a significant level of health care and other health-related services to the uninsured, Medicaid, and other vulnerable populations" (IOM, 2010). Safety net providers act as a default system, or providers "of last resort," by ensuring access to care for millions of Americans lacking medical coverage or provider access, regardless of education, social status, language competency, or ability to pay.

The safety net includes many different types of providers, including public health departments, hospitals, and Health Resources and Services Administration (HRSA) supported health centers (HSHCs). For the 50 million uninsured people and individuals with low income, safety net providers serve an essential function, eliminating financial barriers to care and enhancing access to services. As workforce shortages escalate, demand for safety net services is likely to increase.

This section includes a measure on trauma center utilization for severe injuries. Trauma centers often provide care unavailable elsewhere in the community and thus can become part of the safety net. This section also highlights the role of HSHCs as safety net providers by describing (1) the characteristics of people with an HSHC visit in 2010 and (2) the quality of care rendered to patients with hypertension and diabetes who are treated at these facilities.

Trauma Center Utilization for Severe Injuries

Trauma remains a considerable cause of mortality and morbidity worldwide, constituting a tangible public health burden with significant associated social and economic cost (Mansoor & DuBose, 2012). Trauma care systems, which were developed because it was recognized that trauma requires complex medical care, include a network of care facilities that provides a range of care for all injured patients. Trauma systems usually have a lead hospital, which should be the highest level available within the system. Levels range from level I to level III, with level I denoting the most clinically sophisticated hospitals.

Level I facilities are required to have a specific number of surgeons and anesthesiologists on duty at all times, as well as education, prevention, and outreach programs. The 24-hour coverage of surgery provides trauma patients with many surgical specialties as well, including neurosurgery, radiology, internal medicine, and critical care.

Level II trauma centers provide initial definitive trauma care regardless of the severity of the injury. When a level II center cannot provide the required care, the patient is transferred to a level I center.

Level III trauma centers are often considered community or rural-based hospitals and provide prompt assessment, resuscitation, emergency operations, and stabilizations and also arrange for transfer to a facility that can provide necessary care.

  Figure 8.5. Trauma center utilization for severe injuries in the United States, by age and geographic location, 2009

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Source: Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project, Nationwide Emergency Department Sample, 2009.
Note: Trauma level III for large central metropolitan areas did not meet criteria for statistical reliability, data quality, or confidentiality.

• People ages 25-44 were more likely to use level I and II trauma centers than people age 45 and over (Figure 8.5).
• In 2009, level I and II trauma centers located in large fringe metropolitan areas had significantly higher utilization rates than centers in small metropolitan, micropolitan, and nonmetropolitan areas.
• In 2009, level III trauma centers located in small metropolitan areas were used for severe injuries at 10 times the rate of trauma centers located in large fringe metropolitan areas, 7 times the rate for medium metropolitan areas, and more than twice the rate for micropolitan and nonmetropolitan areas.
• In 2009, large fringe metropolitan areas had a significantly lower utilization rate for nontrauma centers than micropolitan and nonmetropolitan areas.

Also, in the NHDR:

• In 2009, males were more likely to use level I and II trauma centers than females.
• In 2009, there were no statistically significant differences in the level I and II utilization rates of people living in communities at different income levels.
• In 2009, people living in communities with income in the second and third quartiles were more likely to use level III trauma centers than residents of communities with the highest income.

Patients Using HRSA Supported Health Centers

HSHCs include health care organizations that receive a grant under Section 330 of the Public Health Service Act, including community health centers, migrant health centers, Health Care for the Homeless programs, and Public Housing Primary Care programs. These organizations typically render services to low-income populations, uninsured people, people with limited English proficiency, migrant and seasonal agricultural workers, individuals and families experiencing homelessness, and public housing residents.

To obtain Federal grant funding, these public and nonprofit organizations agree to provide a minimum set of services, including primary and preventive care, referrals to mental health, and dental services. Access to care is available to all persons, regardless of ability to pay. Charges for services rendered are based on a sliding scale linked to patients’ family income. More than 20 million people visited an HSHC in 2011.

  Figure 8.6. Characteristics of HSHC patients, by age, gender, and insurance status, 2011

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Source: Health Resources and Services Administration, Bureau of Primary Health Care, Uniform Data System, 2011.
Note: Data were obtained from 1,128 Section 330 grantees.

• In 2011, the largest group of HSHC patients comprised adults ages 20-64 (58.1%; Figure 8.6), whereas adults age 65 and over made up only a small proportion of HSHC patients (6.9%).
• In 2011, a substantially larger percentage of females (58.7%) than males (41.3%) received treatment at an HSHC.
• In 2011, 36.4% of patients seen at an HSHC were uninsured and 39.3% had Medicaid.

Also, in the NHDR:

• In 2011, approximately two-thirds of patients seen at an HSHC were White (Hispanics and non-Hispanics), and one-quarter were Black.
• For those for whom income is known, almost three-quarters of patients seen in an HSHC in 2011 had income at or below the Federal poverty level but only 7.5% of patients had an income over 200% of the poverty level.ⁱⁱⁱ

Control of Hypertension and Diabetes in HSHC Patients

More than 2.5 million adults treated at an HSHC in 2011 had a hypertension diagnosis, and almost 1.3 million had either type I or type II diabetes. The population with hypertension and diabetes may overlap, so the two numbers should not be added together. Control of hypertension and diabetes can help indicate quality of care at HSHCs since people with these conditions require frequent monitoring.

  Figure 8.7. HSHC patients with hypertension or diabetes whose conditions are controlled, 2011

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Source: Health Resources and Services Administration, Bureau of Primary Health Care, Uniform Data System, 2011.
Note: Data were obtained from 1,124 Section 330 grantees. Patients with hypertension include those ages 18-85. Hypertension is determined to be controlled if the patient’s last blood pressure reading was less than 140/90 mm Hg. Patients with diabetes include those ages 18-75. Diabetes is determined to be controlled if the patient’s most recent hemoglobin A1c level was 7% or less.

• In 2011, about 63% of HSHC patients with hypertension had controlled blood pressure at the time of their last blood pressure reading (Figure 8.7).
• Almost 40% of HSHC patients with diabetes were found to have a hemoglobin A1c (HbA1c) level below 7% at the time of their most recent test.
• Although the measure is based on a 4-year average for 2005-2008, the National Health and Nutrition Examination Survey estimates suggest that across the Nation, 54% of people with diabetes have their HbA1C levels under control (data not shown; for information, go to www.healthindicators.gov/).

Also, in the NHDR:

• In 2011, more than 70% of Asian, 65.5% of White, 64.8% of Pacific Islander, 60.2% of American Indians and Alaska Natives and 60.1% of Native Hawaiian patients had their hypertension under control. Only 56.7% of Black patients had their blood pressure under control. Among Hispanic HSHC patients with hypertension, almost two-thirds had controlled blood pressure; more than one-third of Hispanics with diabetes had their HbA1c under control.

References

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Devine EB, Hansen RN, Wilson-Norton JL, et al. The impact of computerized provider order entry on medication errors in a multispecialty group practice. J Am Med Inform Assoc 2010 Jan-Feb;17(1):78-84.

Donabedian A. The definition of quality and approaches to its assessment. Chicago: Health Administration Press; 1980.

Institute of Medicine, Board of Health Care Services. Future directions for the National Healthcare Quality and Disparities Reports. Washington, DC: National Academies Press; 2010.

Mansoor K, DuBose JJ. Improving trauma care in the ICU: best practices, quality improvement initiatives, and organization. Surg Clin N Am 2012;92(4)893-901.

McAlearney AS, Robbins J, Hirsch A, et al. Perceived efficiency impacts following electronic health record implementation: an exploratory study of an urban community health center network. Int J Med Inform 2010;79(12):807-16.

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Samantaray R, Njoku V, Brunner JW, et al. Promoting electronic health record adoption among small independent primary care practices. Am J Manag Care 2011;17(5):353-8.

Shih A, Davis K, Schoenbaum S, et al. Organizing the U.S. health care delivery system for high performance, 2008. New York, NY: The Commonwealth Fund Commission on a High Performance Health System; 2008. Available at: http://www.commonwealthfund.org/usr_doc/Shih_organizingushltcaredeliverysys_1155.pdf   [Plugin Software Help]. Accessed March 15, 2013.

^i. Available at the National Academies Press Web site at http://www.nap.edu/openbook.php?isbn=030908265X.  
^ii. American Board of Medical Specialties. http://www.abms.org/who_we_help/physicians/specialties.aspx.   Accessed July 11, 2012.
^iii. Includes only patients for whom income is known.