Chapter 4. Priority Populations (continued, 2)

American Indians and Alaska Natives

Previous NHDRs showed that AI/ANs had poorer quality of care and worse access to care than Whites for many measures tracked in the reports. Findings based on core report measures of quality and access that support estimates for AI/ANs are shown below.

Figure 4.14. AI/ANs compared with Whites on measures of quality and access

Better = AI/ANs receive better quality of care or have better access to care than Whites.
Same = AI/ANs and Whites receive about the same quality of care or access to care.
Worse = AI/ANs receive poorer quality of care or have worse access to care than Whites.
Key: AI/AN = American Indian or Alaska Native; CRM = core report measures (Table 1.2).
Note: Data presented are the most recent available.

Table 4.7. AI/ANs compared with Whites on measures of quality and access for most current data year: Specific measures

Figure 4.15. Change in AI/AN-White disparities over time

Improving >5% = AI/AN-White difference becoming smaller at an average annual rate greater than 5%.
Improving 1-5% = AI/AN-White difference becoming smaller at an average annual rate between 1% and 5%.
Same = AI/AN-White difference not changing.
Worsening 1-5% = AI/AN-White difference becoming larger at an average annual rate between 1% and 5%.
Worsening >5% = AI/AN-White difference becoming larger at an average annual rate greater than 5%.
Key: AI/AN = American Indian or Alaska Native; CRM = core report measures (Table 1.2).
Note: The time period for this figure is the most recent and oldest years of data used in the NHDR. Only 26 core report measures could be tracked over time for AI/ANs and Whites.

Table 4.8. Change in AI/AN-White disparities over time: Specific measures

Note: Measures in bold indicate improvement or worsening at a rate of greater than 5% per year.

Focus on Indian Health Service Facilities

Nationwide, many AI/ANs who are members of a federally recognized Tribe rely on the IHS to provide access to health care in the counties on or near reservations.^17,18,ix Due to low numbers and lack of data, information about AI/AN hospitalizations is difficult to obtain in most Federal and State hospital utilization data sources. The NHDR addresses this gap by examining utilization data from IHS, Tribal, and contract hospitals .

Diabetes is one of the leading causes of morbidity and mortality among AI/AN populations. Its prevention and control are a major focus of the IHS Director's Chronic Disease Initiative and the IHS Health Promotion/Disease Prevention Initiative. Addressing barriers to health care is a large part of the overall IHS goal of ensuring that comprehensive, culturally acceptable personal and public health services are available and accessible to AI/ANs.

Figure 4.16. Hospital admissions for uncontrolled diabetes per 100,000 population age 18 and over in IHS, Tribal, and contract hospitals , 2003-2006 (left), and community hospitals (right), by race and ethnicity, 2003-2006

Key: AI/AN = American Indian or Alaska Native; API = Asian or Pacific Islander; HCUP SID = Healthcare Cost and Utilization Project State Inpatient Databases; NPIRS = National Patient Information Reporting System.
Source: IHS, Tribal, and contract hospitals: IHS, Office of Information Technology/NPIRS, National Data Warehouse, Workload and Population Data Mart; community hospitals: Agency for Healthcare Research and Quality, HCUP SID disparities analysis file, 2003-2006.

Note: White, Black, and API are non-Hispanic populations. Data are adjusted for age and gender. The HCUP SID disparities analysis file is designed to provide national estimates using weighted records from a sample of hospitals from 25 States that have 66% of the U.S. resident population. Years of IHS data prior to 2003 use a denominator based on the 1990 census. This source is not comparable with estimates following those years, which are based on 2000 bridged census data. Therefore, for comparing IHS with national estimates, only 2003, 2004, 2005, and 2006 data from both data sources are presented.

• From 2003 to 2006, the age-adjusted rate of hospitalizations for uncontrolled diabetes decreased for AI/ANs in IHS, Tribal, and contract hospitals (from 37.8 per 100,000 to 26.3 per 100,000; Figure 4.16).
• There were no statistically significant changes for other racial and ethnic groups in community hospitals during this period.

For the nearly 2 million AI/ANs estimated to be living on reservations or other trust lands in 2009 where the climate is inhospitable, roads are often impassable, and transportation is scarce, health care facilities are far from accessible.¹⁹ These conditions contribute to high rates of perforated appendix, a problem that is receiving particular attention by IHS. Perforated appendix hospitalization rates, which decreased from 2003 to 2006, are illustrative of the efforts underway, as well as the work that needs to continue to achieve high-quality, comprehensive care that is accessible to AI/ANs.²⁰

Figure 4.17. Perforated appendixes per 1,000 admissions with appendicitis, age 18 years and over in IHS, Tribal, and contract hospitals (left), and community hospitals (right), by race and ethnicity, 2003-2006

Key: AI/AN = American Indian or Alaska Native; API = Asian or Pacific Islander; HCUP SID = Healthcare Cost and Utilization Project State Inpatient Databases; NPIRS = National Patient Information Reporting System.
Source: IHS, Tribal, and contract hospitals: IHS, Office of Information Technology/NPIRS, National Data Warehouse, Workload and Population Data Mart, 2003-2006; community hospitals: Agency for Healthcare Research and Quality, HCUP SID disparities analysis file, 2003-2006.
Note: White, Black, and API are non-Hispanic populations. Data are adjusted for age and gender. The HCUP SID disparities analysis file is designed to provide national estimates using weighted records from a sample of hospitals from 25 States that have 66% of the U.S. resident population. Years of IHS data prior to 2003 use a denominator based on the 1990 census. This source is not comparable with estimates following those years, which are based on 2000 bridged census data. Therefore, for comparing IHS with national estimates, only 2003, 2004, 2005, and 2006 data from both data sources are presented.

• From 2003 to 2006, the age-adjusted rate of appendicitis hospitalizations with perforated appendix decreased for AI/ANs in IHS, Tribal, and contract hospitals (from 384.4 per 1,000 to 332.6 per 1,000; Figure 4.17).
• The rate in community hospitals during this period remained the same overall as well as for Whites and Blacks.

Hispanics or Latinos

Previous NHDRs showed that Hispanics had poorer quality of care and worse access to care than non-Hispanic Whites for many measures the reports track. Findings based on core report measures of quality and access to health care that support estimates for Hispanics are shown below.

Figure 4.18. Hispanics compared with non-Hispanic Whites on measures of quality and access

Better = Hispanics receive better quality of care or have better access to care than non-Hispanic Whites.
Same = Hispanics and non-Hispanic Whites receive about the same quality of care or access to care.
Worse = Hispanics receive poorer quality of care or have worse access to care than non-Hispanic Whites.
Key: CRM = core report measures (Table 1.2).
Note: Data presented are the most recent available.

Table 4.9. Hispanics compared with non-Hispanic Whites on measures of quality and access for most current data year: Specific measures

Figure 4.19. Change in Hispanic-non-Hispanic White disparities over time

Improving >5% = Hispanic-non-Hispanic White difference becoming smaller at an average annual rate greater than 5%.
Improving 1-5% = Hispanic-non-Hispanic White difference becoming smaller at an average annual rate between 1% and 5%.
Same = Hispanic-non-Hispanic White difference not changing.
Worsening 1-5% = Hispanic-non-Hispanic White difference becoming larger at an average annual rate between 1% and 5%.
Worsening >5% = Hispanic-non-Hispanic White difference becoming larger at an average annual rate greater than 5%.
Key: CRM = core report measures (Table 1.2).
Note: The time period for this figure is the most recent and oldest years of data used in the NHDR. Only 43 core report measures could be tracked over time for Hispanics and non-Hispanic Whites.

Table 4.10. Change in Hispanic-non-Hispanic White disparities over time: Specific measures

Note: Measures in bold indicate improvement or worsening at a rate of greater than 5% per year.

Focus on Hispanic Subpopulations

The Hispanic population in the United States is highly heterogeneous. Almost 60% of all Hispanics in the country are those of Mexican extraction, making this group the largest subpopulation. People originating from Puerto Rico, Central America, and South America are the next largest subgroups. Variation is seen in access to and quality of health care among Hispanics related to country of origin. Findings are presented below on differences among different Hispanic subpopulations on four quality measures focusing on prevention, chronic care management, and patient centeredness: colorectal cancer screening, diabetes management, and provider-patient communication. In addition, this section reports findings on one access measure, uninsurance.

This section also features selected measures from the CHIS. CHIS is an example of a data source that can provide data for Hispanic subgroups. In 2008, California's Hispanic population was nearly twice the percentage in the United States overall (36.6% in California compared with 15.4% of the 2008 U.S. population).⁹ Almost 30% of the Hispanic population in the United States lives in California.²¹

CHIS data show disparities among Hispanics in California, not only compared with non-Hispanic Whites but also within Hispanic subgroups (Mexican, Puerto Rican, Central American, and South American). The data also show disparities across Hispanic subgroups by income and insurance status. This section shows only some of the significant disparities for these groups in California from CHIS data. The selected measures in this section are limited to a subset of measures available to supplement the existing national measures used in the report.

Figure 4.20. Adults age 50 and over who received a sigmoidoscopy, colonoscopy, or fecal occult blood test in the past 5 years, California only, by race, Hispanic subgroup, income, and insurance status, 2007

Source: University of California, Los Angeles, Center for Health Policy Research, California Health Interview Survey, 2007.
Denominator: Civilian noninstitutionalized adults age 50 and over in California.
Note: Income groups are all Hispanic. For this measure, public insurance includes people with Medicare and/or Medicaid coverage.

• Overall, Hispanics had a lower percentage than Whites of adults age 50 and over who had colorectal cancer screening (59.2% compared with 69.2%; Figure 4.20). Mexicans also had a lower percentage than Whites (57.2% compared with 69.2%). There were no statistically significant differences among Hispanic subgroups.
• Among Hispanics, poor people and low-income people had a lower percentage than high-income people of adults age 50 and over who had colorectal cancer screening (46.8% and 57.5%, respectively, compared with 67.9%).
• Among Hispanics, adults age 50 and over with public insurance were less likely to have colorectal cancer screening than people with private insurance (52.6% compared with 62.2%). Adults age 50 and over who were uninsured were almost half as likely as people with private insurance to have colorectal cancer screening (32.4% compared with 62.2%).

Figure 4.21. People age 40 and over with diabetes who had hemoglobin A1c testing, eye examination, and foot examination within the past year, California only, by ethnicity, income, and insurance status, 2007

Source: University of California, Los Angeles, Center for Health Policy Research, California Health Interview Survey, 2007.
Denominator: Civilian noninstitutionalized adults age 40 and over in California with diabetes.
Note: Income groups are all Hispanic. Data did not meet criteria for statistical reliability for Puerto Ricans, South Americans, and uninsured Hispanics.

• Overall, Hispanics in California age 40 and over with diabetes were less likely than non-Hispanic Whites to have had all three recommended services for diabetes (36.0% compared with 51.4%; Figure 4.21).
• There were no statistically significant differences among Hispanic subgroups in recommended care for diabetes.
• Among Hispanics, the percentage of adults in California with diabetes who received all three recommended diabetes-related exams was lower for poor people (28.0%) and for low-income people (30.8%) than for high-income people (51.3%).
• The percentage of Hispanic adults age 40 and over with diabetes who received all three recommended services for diabetes was not significantly different between people with any private insurance and people with public insurance.

Figure 4.22. People under age 65 uninsured all year, California only, by ethnicity and Hispanic subgroup, 2001, 2003, 2005, and 2007; by Hispanic subgroup, stratified by income; by education; by English proficiency; and by place of birth, 2007

Source: University of California, Los Angeles, Center for Health Policy Research, California Health Interview Survey, 2001, 2003, 2005, and 2007.
Denominator: Civilian noninstitutionalized population under age 65 in California.
Note: Data did not meet criteria for statistical reliability for Puerto Ricans for data years 2001, 2005, and 2007, for Puerto Rican income and education groups, and for South American income and education groups except low income and some college.

• Overall, the percentage of Californians under age 65 who were uninsured all year decreased from 12.4% in 2001 to 11.2% in 2007 (Figure 4.22). For Hispanics, the percentage who were uninsured also decreased from 22.0% in 2001 to 18.0% in 2007.
• In 2007, the percentage of Californians under age 65 who were uninsured all year was about three times as high for Hispanics as for non-Hispanic Whites (18.0% compared with 5.8%) overall. Among Hispanic subgroups, the percentage was about three times as high for Mexicans (18.9%) and about four times as high for Central Americans (26.4%) compared with non-Hispanic Whites (5.8%).
• Among Hispanics, the percentage of people uninsured all year was more than five times as high for poor people (23.0%) as for high-income people (4.1%). For low-income people, the percentage was also more than five times as high (21.1%). The percentage was about three times as high for middle-income people (12.5%).
• Across all income groups, Mexicans were more likely to be uninsured all year than non-Hispanic Whites. However, Central Americans had the highest rate of being uninsured all year among poor people and low-income people.
• Among Hispanics, the percentage of people uninsured all year was more than four times as high for people with less than a high school education (24.7%) and more than twice as high for high school graduates (14.2%) compared with people with at least some college education (6.1%).
• Across all education groups, Central Americans had the highest rate of being uninsured all year. Mexicans also had higher rates than non-Hispanic Whites across all education groups.
• Among Hispanics, the percentage of people who were uninsured all year was five times as high for people who did not speak English well or at all as for people who were native English speakers (41.5% compared with 7.8%). The percentage of people who were uninsured all year was almost twice as high for people who speak English well or very well as for native English speakers (14.6% compared with 7.8%).
• Among Hispanics, the percentage of people who were uninsured all year was almost four times as high for people who were not born in the United States as for people who were born in the United States.

Figure 4.23. Adults age 18 and over who reported difficulty understanding their doctor during their last visit within the past 2 years, California only, by ethnicity, Hispanic subgroup, income, and insurance status, 2007

Source: University of California, Los Angeles, Center for Health Policy Research, California Health Interview Survey, 2007.
Denominator: Civilian noninstitutionalized adults in California age 18 and over.
Note: Income groups are all Hispanic. Data did not meet criteria for statistical reliability for Puerto Rican and South American subgroups.

• Overall, Hispanics age 18 and over were more likely than non-Hispanic Whites to have difficulty understanding their doctor (5.5% compared with 2.6%; Figure 4.23). Mexicans and Central Americans were also more likely than non-Hispanic Whites to have difficulty understanding their doctor (5.7% and 5.7%, respectively, compared with 2.6%).
• Among Hispanics, poor adults (8.5%), low-income adults (6.0%), and middle-income adults (3.8%) were more likely than high-income adults (2.2%) to have difficulty understanding their doctor.
• Among Hispanics, adults with public insurance and adults without insurance were more likely to have difficulty understanding their doctor than those with private insurance (6.9% and 6.1%, respectively, compared with 2.9%).

Figure 4.24. Adults age 18 and over who reported language as the reason they had difficulty understanding their doctor during their last visit within the past 2 years, California only, by ethnicity, Hispanic subgroup, income, and insurance status, 2007

Source: University of California, Los Angeles, Center for Health Policy Research, California Health Interview Survey, 2007.
Denominator: Civilian noninstitutionalized adults in California age 18 and over.
Note: Income groups are all Hispanic. Data did not meet criteria for statistical reliability for Puerto Rican and South American subgroups.

• Hispanics had a higher percentage than non-Hispanic Whites who reported language as the reason they had difficulty understanding their doctor during their last visit (3.7% compared with 1.5%; Figure 4.24). Among Hispanics, Mexicans (4.0%) and Central Americans (4.1%) had a higher percentage than non-Hispanic Whites (1.5%).
• Among Hispanics, poor and low-income adults had a higher percentage than high-income adults who reported language as the reason they had difficulty understanding their doctor during their last visit (5.3% and 5.7%, respectively, compared with 1.4%).
• Among Hispanics, people without insurance had a higher percentage than people with private insurance who reported language as the reason they had difficulty understanding their doctor during their last visit (5.0% compared with 2.9%).

^ix Of potentially eligible AI/ANs, 74% sought health care in 2004 at an IHS or tribally contracted facility, according to the most recent published IHS estimates developed by the Office of Public Health Support, Division of Program Statistics.

Proceed to Next Section