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<li><a href="/research/findings/nhqrdr/nhdr12/index.html">Main Page</a></li>
<li><a href="/research/findings/nhqrdr/nhdr12/acknow.html">Acknowledgments</a></li>
<li><a href="/research/findings/nhqrdr/nhdr12/highlights.html">Highlights From the National Healthcare Quality and Disparities Report</a></li>
<li><a href="/research/findings/nhqrdr/nhdr12/chap1.html">Chapter 1. Introduction and Methods</a></li>
<li><a href="/research/findings/nhqrdr/nhdr12/chap2-text.html">Chapter 2. Effectiveness of Care</a></li>
<li><a href="/research/findings/nhqrdr/nhdr12/chap3.html">Chapter 3. Patient Safety</a></li>
<li><a href="/research/findings/nhqrdr/nhdr12/chap4.html">Chapter 4. Timeliness</a></li>
<li><a href="/research/findings/nhqrdr/nhdr12/chap5.html">Chapter 5. Patient Centeredness</a></li>
<li><a href="/research/findings/nhqrdr/nhdr12/chap6.html">Chapter 6. Care Coordination</a></li>
<li><a href="/research/findings/nhqrdr/nhdr12/chap7.html">Chapter 7. Efficiency</a></li>
<li><a href="/research/findings/nhqrdr/nhdr12/chap8.html">Chapter 8. Health Systems Infrastructure&#160;</a></li>
<li><a href="/research/findings/nhqrdr/nhdr12/chap9.html">Chapter 9. Access to Health Care</a></li>
<li><a href="/research/findings/nhqrdr/nhdr12/chap10.html">Chapter 10. Priority Populations</a></li>
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<span><a href="/research/findings/nhqrdr/nhdr12/2012nhdr.pdf">2012 National Healthcare Disparities Report (NHDR)</a> [ <img src="/resources/file_logos/pdf.gif" alt="PDF file" title="PDF file" class="icon" /> - 8.74&nbsp;MB]</span>
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<h1>2012 National Healthcare Disparities Report</h1>
<h2>Chapter 2. Effectiveness (continued)</h2> <div id="basic-modal"><!-- start: Basic Modal -->
<div class="body_field_publication">
<h2>Chronic Kidney Disease</h2>
<h3>Importance</h3>
<table border="1" cellpadding="2" cellspacing="0" width="90%"><tbody>
<tr>
<th align="left" colspan="2" scope="col"><strong>Mortality</strong></th>
</tr>
<tr valign="top">
<td scope="row">Total ESRD deaths (2009)</td>
<td>86,262 (<a href="/research/findings/nhqrdr/nhdr12/chap2e.html#USRDS2011">USRDS, 2011</a>)</td>
</tr>
<tr>
<td colspan="2" scope="row"><strong>Prevalence</strong></td>
</tr>
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<td scope="row">Total ESRD cases (2009)</td>
<td>571,414 (<a href="/research/findings/nhqrdr/nhdr12/chap2e.html#USRDS2011">USRDS, 2011</a>)</td>
</tr>
<tr>
<td colspan="2" scope="row"><strong>Incidence</strong></td>
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<td scope="row">Number of new ESRD cases (2009)</td>
<td>116,395 (<a href="/research/findings/nhqrdr/nhdr12/chap2e.html#USRDS2011">USRDS, 2011</a>)</td>
</tr>
<tr>
<td colspan="2" scope="row"><strong>Cost</strong></td>
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<td scope="row">Total ESRD Medicare program expenditures (2009)</td>
<td>$29 billion (<a href="/research/findings/nhqrdr/nhdr12/chap2e.html#USRDS2011">USRDS, 2011</a>)</td>
</tr>
</tbody></table>
<h3>Measures</h3>
<p>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%. Three measures are highlighted here:</p>
<ul>
<li>Nephrology care before kidney failure.</li>
<li>Use of arteriovenous fistula (AVF) at first outpatient dialysis.</li>
<li>Registration for transplantation.</li>
</ul>
<h3>Findings</h3>
<h4>Management: Nephrology Care Before Kidney Failure</h4>
<p>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 (<a href="/research/findings/nhqrdr/nhdr12/chap2e.html#USRDS2010">USRDS, 2010</a>).</p>
<h4 class="figcaption"><a id="fig215" name="fig215"> </a>Figure 2.15. New adult end stage renal disease patients beginning nephrology care more than 12 months before start of dialysis, by race and ethnicity, 2008-2009</h4>
<img alt="For Text Description, select the link below the image." src="/research/findings/nhqrdr/nhdr12/images/fig2-15a.jpg" /><br />
<br />
<img alt="For Text Description, select the link below the image." src="/research/findings/nhqrdr/nhdr12/images/fig2-15b.jpg" />
<p><a href="/research/findings/nhqrdr/nhdr12/chap2-text2.html#fig215">[D] Select for Text Description</a></p>
<p class="size2"><strong>Source:</strong> National Institute of Diabetes and Digestive and Kidney Diseases, U.S. Renal Data System, 2008-2009.<br />
<strong>Denominator:</strong> New end stage renal disease patients age 18 and over.</p>
<ul>
<li>In 2009, only 28% of new ESRD patients age 18 and over began nephrology care more than 12 months before start of dialysis (<a href="#fig215">Figure 2.15</a>).</li>
<li>In both years, 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.</li>
</ul>
<p>Also, in the NHQR:</p>
<ul>
<li>In 2008 and 2009, patients ages 45-64 and 65 and over were more likely to receive timely nephrology care than patients ages 18-44.</li>
</ul>
<h4>Management: Use of Arteriovenous Fistula at First Outpatient Dialysis</h4>
<p>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.</p>
<p>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 &#38; 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.</p>
<h4 class="figcaption"><a id="fig216" name="fig216"> </a>Figure 2.16. Incident hemodialysis patients who used an arteriovenous fistula at first outpatient dialysis, by race and ethnicity, 2008-2011</h4>
<img alt="For Text Description, select the link below the image." src="/research/findings/nhqrdr/nhdr12/images/fig2-16a.jpg" /><br />
<br />
<img alt="For Text Description, select the link below the image." src="/research/findings/nhqrdr/nhdr12/images/fig2-16b.jpg" />
<p><a href="/research/findings/nhqrdr/nhdr12/chap2-text2.html#fig216">[D] Select for Text Description</a></p>
<p class="size2"><strong>Key:</strong> API = Asian or Pacific Islander; AI/AN = American Indian or Alaska Native.<br />
<strong>Source:</strong> Medicare eligibility forms (Centers for Medicare &#38; Medicaid Services [CMS] Form 2728) (2008-2011), Fistula First Incident AVF Dataset, CMS.<br />
<strong>Denominator:</strong> New end stage renal disease hemodialysis patients, all ages.</p>
<ul>
<li>From 2008 to 2011, the percentage of dialysis patients who used an AVF at first dialysis increased from 13.7% to 15.8% (<a href="#fig216">Figure 2.16</a>).</li>
<li>In all years, Blacks had lower rates of AVF at first dialysis than Whites, and Hispanics had lower rates than non-Hispanic Whites.</li>
<li>The 2008 top 5 State achievable benchmark was 27%.<sup><a href="#xi">xi</a></sup> Overall, this benchmark could not be achieved for 15 years. Whites, Blacks, APIs, and non-Hispanic Whites also could not attain the benchmark for 15 years, while Hispanics would need 20 years. AI/ANs did not experience improvement toward the benchmark.</li>
</ul>
<p>Also, in the NHQR:</p>
<ul>
<li>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.</li>
</ul>
<h4>Management: Registration for Transplantation</h4>
<p>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.</p>
<h4 class="figcaption"><a id="fig217" name="fig217"> </a>Figure 2.17. Dialysis patients who were registered on a waiting list for transplantation, by race and ethnicity, 2000-2008</h4>
<img alt="For Text Description, select the link below the image." src="/research/findings/nhqrdr/nhdr12/images/fig2-17a.jpg" /><br />
<br />
<img alt="For Text Description, select the link below the image." src="/research/findings/nhqrdr/nhdr12/images/fig2-17b.jpg" />
<p><a href="/research/findings/nhqrdr/nhdr12/chap2-text2.html#fig217">[D] Select for Text Description</a></p>
<p class="size2"><strong>Key:</strong> API = Asian or Pacific Islander; AI/AN = American Indian or Alaska Native.<br />
<strong>Source:</strong> National Institute of Diabetes and Digestive and Kidney Diseases, U.S. Renal Data System, 2000-2008.<br />
<strong>Denominator:</strong> End stage renal disease hemodialysis patients and peritoneal dialysis patients under age 70.</p>
<ul>
<li>From 2000 to 2008, the percentage of dialysis patients who were registered on a waiting list for transplantation increased from 14.7% to 17% (<a href="#fig217">Figure 2.17</a>). Improvements were observed among all racial and ethnic groups.</li>
<li>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.</li>
<li>The 2008 top 5 State achievable benchmark was 27%.<sup><a href="#xii">xii</a></sup> Overall, at the current rate of improvement, the benchmark would not be attained for 25 years.</li>
<li>Although APIs have already surpassed the 2008 achievable benchmark, Blacks and AI/ANs could not attain the benchmark for 31 years and Whites could not attain it for 29 years.</li>
</ul>
<p>Also, in the NHQR:</p>
<ul>
<li>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.</li>
</ul>
<p><a href="/research/findings/nhqrdr/nhdr12/index.html">Return to Contents</a></p>
<h2><a id="diabetes" name="diabetes"> </a>Diabetes</h2>
<h3>Importance</h3>
<table border="1" cellpadding="2" cellspacing="0" width="90%"><tbody>
<tr>
<th align="left" colspan="2" scope="col"><strong>Mortality</strong></th>
</tr>
<tr valign="top">
<td scope="row">Number of deaths (2007)</td>
<td>71,382 (<a href="/research/findings/nhqrdr/nhdr12/chap2e.html#CDC2011b">CDC, 2011b</a>)</td>
</tr>
<tr valign="top">
<td scope="row">Cause of death rank (2007)</td>
<td>7<sup>th</sup> (<a href="/research/findings/nhqrdr/nhdr12/chap2e.html#CDC2011b">CDC, 2011b</a>)</td>
</tr>
<tr>
<td colspan="2" scope="row"><strong>Prevalence</strong></td>
</tr>
<tr valign="top">
<td scope="row">Total number of people with diabetes (2010)</td>
<td>25.8 million (<a href="/research/findings/nhqrdr/nhdr12/chap2e.html#CDC2011c">CDC, 2011c</a>)</td>
</tr>
<tr valign="top">
<td scope="row">Number of people with diagnosed diabetes (2010)</td>
<td>18.8 million (<a href="/research/findings/nhqrdr/nhdr12/chap2e.html#CDC2011c">CDC, 2011c</a>)</td>
</tr>
<tr valign="top">
<td scope="row">Number of people with undiagnosed diabetes (2007)</td>
<td>7.0 million (<a href="/research/findings/nhqrdr/nhdr12/chap2e.html#CDC2011c">CDC, 2011c</a>)</td>
</tr>
<tr>
<td colspan="2" scope="row"><strong>Incidence</strong></td>
</tr>
<tr valign="top">
<td scope="row">New cases (age 20 and over, 2010)</td>
<td>1.9 million (<a href="/research/findings/nhqrdr/nhdr12/chap2e.html#CDC2011c">CDC, 2011c</a>)</td>
</tr>
<tr>
<td colspan="2" scope="row"><strong>Cost</strong></td>
</tr>
<tr valign="top">
<td scope="row">Total cost (2007)</td>
<td>$174 billion (<a href="/research/findings/nhqrdr/nhdr12/chap2e.html#CDC2011c">CDC, 2011c</a>)</td>
</tr>
<tr valign="top">
<td scope="row">Direct medical costs (2007)</td>
<td>$116 billion (<a href="/research/findings/nhqrdr/nhdr12/chap2e.html#CDC2011c">CDC, 2011c</a>)</td>
</tr>
<tr valign="top">
<td scope="row">Indirect costs (2007)</td>
<td>$58 million (<a href="/research/findings/nhqrdr/nhdr12/chap2e.html#CDC2011c">CDC, 2011c</a>)</td>
</tr>
</tbody></table>
<h3>Measures</h3>
<p>Routine monitoring of blood glucose levels with hemoglobin A1c (HbA1c<sup><a href="#xiii">xiii</a></sup>) 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 (<a href="/research/findings/nhqrdr/nhdr12/chap2e.html#CDC2009">CDC, 2011a</a>). However, with appropriate and timely ambulatory care, it may be possible to prevent many hospitalizations for diabetes and related complications.</p>
<p>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:</p>
<ul>
<li>Receipt of four recommended diabetes services.</li>
<li>Control of HbA1c and blood pressure.</li>
<li>Hospital admissions for uncontrolled diabetes.</li>
<li>End stage renal disease due to diabetes.</li>
</ul>
<h3>Findings</h3>
<h4>Management: Receipt of Four Recommended Diabetes Services</h4>
<p>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.</p>
<h4 class="figcaption"><a id="fig218" name="fig218"> </a>Figure 2.18. 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 race/ethnicity and income, 2008-2009</h4>
<img alt="For Text Description, select the link below the image." src="/research/findings/nhqrdr/nhdr12/images/fig2-18a.jpg" /><br />
<br />
<img alt="For Text Description, select the link below the image." src="/research/findings/nhqrdr/nhdr12/images/fig2-18b.jpg" />
<p><a href="/research/findings/nhqrdr/nhdr12/chap2-text2.html#fig218">[D] Select for Text Description</a></p>
<p class="size2"><strong>Source:</strong> Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2008-2009.<br />
<strong>Denominator:</strong> Civilian noninstitutionalized population with diagnosed diabetes, age 40 and over.<br />
<strong>Note:</strong> Data include people with both type 1 and type 2 diabetes. Rates are age adjusted to the 2000 U.S. standard population. White and Black are non-Hispanic; Hispanic includes all races.</p>
<ul>
<li>Among adults age 40 and over with diagnosed diabetes, only 23% received all four recommended services in 2009 (<a href="#fig218">Figure 2.18</a>).</li>
<li>In 2009, Blacks and Hispanics were less likely than Whites to receive recommended care for diabetes.</li>
<li>In both years, poor, low-income, and middle-income adults were less likely to receive recommended care for diabetes than high-income adults.</li>
</ul>
<p>Also, in the NHQR:</p>
<ul>
<li>In both years, adults ages 40-59 were less likely to receive recommended care for diabetes than adults age 60 and over.</li>
</ul>
<p>Multivariate analyses were conducted to identify the independent effects of race/ethnicity and socioeconomic factors on several measures. Adjusted percentages are shown for receipt of diabetes services after controlling for race/ethnicity, family income, education, health insurance status, and location.</p>
<h4 class="figcaption"><a id="fig219" name="fig219"> </a>Figure 2.19. Composite measure: Adjusted percentages of adults ages 40-64 with diagnosed diabetes who received four recommended services for diabetes in the calendar year, by gender, race/ethnicity, family income, education, insurance status, and residence location, 2008/2009</h4>
<img alt="For Text Description, select the link below the image." src="/research/findings/nhqrdr/nhdr12/images/fig2-19.jpg" />
<p><a href="/research/findings/nhqrdr/nhdr12/chap2-text2.html#fig219">[D] Select for Text Description</a></p>
<p class="size2"><strong>Source:</strong> Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, pooled 2008/2009.<br />
<strong>Note:</strong> Adjusted percentages are predicted marginals from a statistical model that includes the covariates race/ethnicity, family income, education, health insurance, gender, and residence location. Chapter 1, Introduction and Methods, provides more information.</p>
<ul>
<li>After adjustment, among adults ages 40-64 with diagnosed diabetes, non-Hispanic Blacks were less likely than non-Hispanic Whites to receive the four recommended services for diabetes (<a href="#fig219">Figure 2.19</a>).</li>
<li>In addition, poor, low-income, and middle-income adults with diabetes were less likely than high-income adults to receive all four services.</li>
<li>High school graduates were less likely than adults with any college education to receive all four services.</li>
<li>Uninsured adults were less likely than adults with private insurance to receive all four services.</li>
</ul>
<h4>Outcome: Control of Hemoglobin A1c and Blood Pressure</h4>
<p>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 &#60;7%, total cholesterol &#60;200 mg/dL, and blood pressure &#60;140/80 mm Hg can decrease these risks.</p>
<h4 class="figcaption"><a id="fig220" name="fig220"> </a>Figure 2.20. Adults age 40 and over with diagnosed diabetes with hemoglobin A1c and blood pressure under control, by race/ethnicity, 1988-1994, 1999-2002, 2003-2006, and 2007-2010</h4>
<img alt="For Text Description, select the link below the image." src="/research/findings/nhqrdr/nhdr12/images/fig2-20a.jpg" /><br />
<br />
<img alt="For Text Description, select the link below the image." src="/research/findings/nhqrdr/nhdr12/images/fig2-20b.jpg" />
<p><a href="/research/findings/nhqrdr/nhdr12/chap2-text2.html#fig220">[D] Select for Text Description</a></p>
<p class="size2"><strong>Source:</strong> 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.<br />
<strong>Denominator:</strong> Civilian noninstitutionalized population with diagnosed diabetes, age 40 and over.<br />
<strong>Note:</strong> Age adjusted to the 2000 U.S. standard population using two age groups: 40-59 and 60 and over. White and Black are non-Hispanic; Mexican American includes all races.</p>
<ul>
<li>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 (<a href="#fig220">Figure 2.20</a>). Improvements were observed among all racial/ethnic groups although the change in HbA1c control among Mexican Americans did not meet our criteria for statistical significance.</li>
<li>Since 1999-2002, Mexican Americans have been less likely than Whites to achieve HbA1c less than 7%.</li>
<li>Except in 2003-2006, Blacks have been less likely than Whites to achieve blood pressure less than 140/80 mm Hg.</li>
</ul>
<p>Also, in the NHQR:</p>
<ul>
<li>Improvements in HbA1c control and blood pressure control were observed among all age groups.</li>
</ul>
<h4>Outcome: Admissions for Uncontrolled Diabetes</h4>
<p>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.</p>
<h4 class="figcaption"><a id="fig221" name="fig221"> </a>Figure 2.21. Hospital admissions for uncontrolled diabetes per 100,000 population, age 18 and over, by race/ethnicity and area income, 2001-2009</h4>
<img alt="For Text Description, select the link below the image." src="/research/findings/nhqrdr/nhdr12/images/fig2-21a.jpg" /><br />
<br />
<img alt="For Text Description, select the link below the image." src="/research/findings/nhqrdr/nhdr12/images/fig2-21b.jpg" />
<p><a href="/research/findings/nhqrdr/nhdr12/chap2-text2.html#fig221">[D] Select for Text Description</a></p>
<p class="size2"><strong>Key:</strong> API = Asian or Pacific Islander. Q1 represents the lowest income quartile and Q4 represents the highest income quartile based on the median income of a patient's ZIP Code of residence.<br />
<strong>Source:</strong> Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, State Inpatient Databases disparities analysis file and Nationwide Inpatient Sample, 2001-2009, and AHRQ Quality Indicators, version 4.1.<br />
<strong>Denominator:</strong> U.S. resident population age 18 and over.<br />
<strong>Note:</strong> For this measure, lower rates are better. White, Black, and API are non-Hispanic; Hispanic includes all races. Data are adjusted for age and gender.</p>
<ul>
<li>Between 2001 and 2009, the rate of hospital admissions for adults for uncontrolled diabetes decreased overall and among all racial/ethnic and income groups (<a href="#fig221">Figure 2.21</a>).</li>
<li>In all years, the rate of hospital admissions for uncontrolled diabetes was higher for Blacks and Hispanics and lower for APIs compared with Whites.</li>
<li>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.</li>
<li>The 2008 top 4 State achievable benchmark was 5 per 100,000 population.<sup><a href="#xiv">xiv</a></sup> Most racial/ethnic and income groups could not achieve the benchmark for about 25 years. APIs would need 7 years and Hispanics would need 13 years, while adults living in the lowest income communities would need 51 years.</li>
</ul>
<p>Also, in the NHQR:</p>
<ul>
<li>In all years, adults ages 45-64 and 65 and over had higher admission rates for uncontrolled diabetes than adults ages 18-44.</li>
<li>In all years, residents of large central metropolitan areas and noncore areas had higher rates than residents of large fringe metropolitan areas.</li>
</ul>
<p><strong>Focus on Indian Health Service Facilities</strong></p>
<p>AI/ANs who are members of federally recognized Tribes are eligible for services provided by the Indian Health Service (IHS). About 2 million of the 3.4 million AI/ANs in the United States receive care directly from IHS, through tribally contracted and operated health programs or through services purchased by IHS from other providers (<a href="/research/findings/nhqrdr/nhdr12/chap2e.html#IHS">IHS, 2011</a>). 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 NHQR and NHDR address this gap by examining utilization data from IHS, Tribal, and contract hospitals.</p>
<p>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.</p>
<h4 class="figcaption"><a id="fig222" name="fig222"> </a>Figure 2.22. Hospital admissions for uncontrolled diabetes per 100,000 population in IHS, Tribal, and contract hospitals, age 18 and over, by age group, 2003-2010</h4>
<img alt="For Text Description, select the link below the image." src="/research/findings/nhqrdr/nhdr12/images/fig2-22.jpg" />
<p><a href="/research/findings/nhqrdr/nhdr12/chap2-text2.html#fig222">[D] Select for Text Description</a></p>
<p class="size2"><strong>Source:</strong> Indian Health Service, Office of Information Technology/National Patient Information Reporting System, National Data Warehouse, Workload and Population Data Mart, 2003-2010.<br />
<strong>Note:</strong> For this measure, lower rates are better. Total estimates are age adjusted using the total U.S. population for 2000 as the U.S. standard population. Service population does not include the Portland and California regions.</p>
<ul>
<li>From 2003 to 2010, the age-adjusted rate of total hospitalizations for uncontrolled diabetes in IHS, Tribal, and contract hospitals decreased from 37.8 to 22.4 per 100,000 population (<a href="#fig222">Figure 2.22</a>). Rates decreased among all age groups.</li>
<li>In all years, patients ages 18-44 had lower rates than patients age 65 and over.</li>
<li>The 2008 top 4 State achievable benchmark based on Healthcare Cost and Utilization Project State Inpatient Databases data was 5.<sup><a href="#xiv">xiv</a></sup> This benchmark could be achieved overall and by most age groups in 8 years. Adults ages 18-44 would need 15 years.</li>
</ul>
<h4>Outcome: End Stage Renal Disease Due to Diabetes</h4>
<p>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.</p>
<h4 class="figcaption"><a id="fig223" name="fig223"> </a>Figure 2.23. End stage renal disease due to diabetes per million population, by race and ethnicity, 2000-2009</h4>
<img alt="For Text Description, select the link below the image." src="/research/findings/nhqrdr/nhdr12/images/fig2-23a.jpg" /><br />
<br />
<img alt="For Text Description, select the link below the image." src="/research/findings/nhqrdr/nhdr12/images/fig2-23b.jpg" />
<p><a href="/research/findings/nhqrdr/nhdr12/chap2-text2.html#fig223">[D] Select for Text Description</a></p>
<p class="size2"><strong>Key:</strong> API = Asian or Pacific Islander; AI/AN = American Indian or Alaska Native.<br />
<strong>Source:</strong> National Institute of Diabetes and Digestive and Kidney Diseases, U.S. Renal Data System, 2000-2009.<br />
<strong>Denominator:</strong> U.S. resident population.<br />
<strong>Note:</strong> For this measure, lower rates are better. Rates are age adjusted. Hispanic and non-Hispanic include all races.</p>
<ul>
<li>Between 2000 and 2009, the overall incidence of ESRD due to diabetes did not change overall or for most racial and ethnic groups (<a href="#fig223">Figure 2.23</a>). The rate did decrease among Hispanics and AI/ANs.</li>
<li>In all years, AI/ANs, APIs, and Blacks had higher rates than Whites and Hispanics had higher rates than non-Hispanics.</li>
<li>The 2008 top 5 State achievable benchmark was 93 per million population.<sup><a href="#xv">xv</a></sup> Of all racial groups, only AI/ANs are progressing toward the benchmark but still will not achieve it for 18 years. Rates among non-Hispanics are not improving, and Hispanics will not achieve the benchmark for 54 years.</li>
</ul>
<p>Also, in the NHQR:</p>
<ul>
<li>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.</li>
</ul>
<p><a href="/research/findings/nhqrdr/nhdr12/index.html">Return to Contents</a></p>
<h2><a id="hiv" name="hiv"> </a>HIV and AIDS</h2>
<h3>Importance</h3>
<table border="1" cellpadding="2" cellspacing="0" width="90%"><tbody>
<tr>
<th align="left" colspan="2" scope="col"><strong>Mortality</strong></th>
</tr>
<tr valign="top">
<td scope="row">Number of deaths of people with AIDS (2009)</td>
<td>17,774 (<a href="/research/findings/nhqrdr/nhdr12/chap2e.html#CDC2012a">CDC, 2012</a>)</td>
</tr>
<tr>
<td colspan="2" scope="row"><strong>Prevalence</strong></td>
</tr>
<tr valign="top">
<td scope="row">Number of people living with HIV infection (2009)</td>
<td>784,701 (<a href="/research/findings/nhqrdr/nhdr12/chap2e.html#CDC2012a">CDC, 2012</a>)</td>
</tr>
<tr valign="top">
<td scope="row">Number of people living with AIDS (2009)</td>
<td>476,732 (<a href="/research/findings/nhqrdr/nhdr12/chap2e.html#CDC2012a">CDC, 2012</a>)</td>
</tr>
<tr>
<td colspan="2" scope="row"><strong>Incidence</strong></td>
</tr>
<tr valign="top">
<td scope="row">Number of new HIV diagnoses (2010)</td>
<td>47,129 (<a href="/research/findings/nhqrdr/nhdr12/chap2e.html#CDC2012a">CDC, 2012</a>)</td>
</tr>
<tr valign="top">
<td scope="row">Number of new AIDS diagnoses (2010)</td>
<td>33,015 (<a href="/research/findings/nhqrdr/nhdr12/chap2e.html#CDC2012a">CDC, 2012</a>)</td>
</tr>
<tr>
<td colspan="2" scope="row"><strong>Cost</strong></td>
</tr>
<tr valign="top">
<td scope="row">Federal spending on HIV/AIDS care, cash and housing assistance, prevention, and research (fiscal year 2013 est.)</td>
<td>$22 billion (<a href="/research/findings/nhqrdr/nhdr12/chap2e.html#Kaiser">KFF, 2012</a>)</td>
</tr>
</tbody></table>
<p>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.</p>
<p>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).</p>
<p>The spread of HIV is linked to complex social and economic factors, including:</p>
<ul>
<li>Poverty,</li>
<li>Concentration of the virus in specific geographic areas and smaller sexual networks,</li>
<li>Sexually transmitted co-infections,</li>
<li>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</li>
<li>Injection and noninjection drug use and associated behaviors (<a href="/research/findings/nhqrdr/nhdr12/chap2e.html#CDC2010">CDC, 2010</a>).</li>
</ul>
<p>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 (<a href="/research/findings/nhqrdr/nhdr12/chap2e.html#CDC2012a">CDC, 2012</a>). 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 (<a href="/research/findings/nhqrdr/nhdr12/chap2e.html#CDC2012a">CDC, 2012</a>). In addition to being seriously affected by HIV, Hispanics continue to face challenges in accessing health care, especially preventive services and HIV treatment.</p>
<p>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 (<a href="/research/findings/nhqrdr/nhdr12/chap2e.html#Carrillo">Carrillo &#38; DeCarlo, 2003</a>). In 2007, HIV/AIDS was the fourth leading cause of death among Hispanic men and women ages 35-44 (<a href="/research/findings/nhqrdr/nhdr12/chap2e.html#CDC2011a">CDC, 2011a</a>). 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 (<a href="/research/findings/nhqrdr/nhdr12/chap2e.html#Cunningham">Cunningham, et al., 2006</a>).</p>
<p>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 (<a href="/research/findings/nhqrdr/nhdr12/chap2e.html#CDC2012a">CDC, 2012</a>).</p>
<p>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.</p>
<h3>Measures</h3>
<p>This year, one measure is presented focusing on the quality of preventive care for HIV-infected individuals:</p>
<ul>
<li>New AIDS cases.</li>
</ul>
<p>Five measures are presented on access to care, retention in care, and treatment and prevention of opportunistic infections in HIV patients:</p>
<ul>
<li>Adult HIV patients who had at least two outpatient visits during the year.</li>
<li>Adult HIV patients who received two or more CD4 tests during the year.</li>
<li>Adult HIV patients who received highly active antiretroviral therapy (HAART).</li>
<li>Eligible patients receiving prophylaxis for <em>Pneumocystis</em> pneumonia (PCP).</li>
<li>Eligible patients receiving prophylaxis for <em>Mycobacterium avium</em> complex (MAC).</li>
</ul>
<p>In addition, one measure is presented on HIV infection deaths.</p>
<h3>Findings</h3>
<h4>Management: HIV Patients Receiving Care</h4>
<p>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.</p>
<p>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:</p>
<ul>
<li>Two or more medical visits in an HIV care setting in the measurement year.</li>
<li>Two or more CD4 cell counts performed in the measurement year.</li>
<li>HAART for patients with AIDS.</li>
<li>PCP prophylaxis for patients with CD4 cell count below 200 and MAC prophylaxis for patients with CD4 cell count below 50.</li>
</ul>
<h3>Outcome: New AIDS Cases</h3>
<p>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.</p>
<h4 class="figcaption"><a id="fig224" name="fig224"> </a>Figure 2.24. New AIDS cases per 100,000 population age 13 and over, by race/ethnicity, 2000-2009</h4>
<img alt="For Text Description, select the link below the image." src="/research/findings/nhqrdr/nhdr12/images/fig2-24.jpg" />
<p><a href="/research/findings/nhqrdr/nhdr12/chap2-text2.html#fig224">[D] Select for Text Description</a></p>
<p class="size2"><strong>Source:</strong> Centers for Disease Control and Prevention, National Center for HIV, STD, and TB Prevention, HIV/AIDS Surveillance System, 2000-2009.<br />
<strong>Denominator:</strong> U.S. population age 13 and over.</p>
<ul>
<li>Overall, in 2009, the total rate of new AIDS cases was 13.5 per 100,000 population (<a href="#fig224">Figure 2.24</a>).</li>
<li>From 2000 to 2009, rates of new AIDS cases decreased overall and for all racial/ethnic groups.</li>
<li>In 2009, non-Hispanic Blacks (55.2 per 100,000 population) and Hispanics (18.8 per 100,000 population) had higher rates of new AIDS cases than non-Hispanic Whites (5.5 per 100,000 population).</li>
<li>The 2009 top 4 State achievable benchmark for new AIDS cases was 4 per 100,000 population.<sup><a href="#xvi">xvi</a></sup> At the current rate, non-Hispanic Whites would take 10 years to achieve the benchmark, while the other racial/ethnic groups would take more than 15 years.</li>
</ul>
<p>Also, in the NHQR:</p>
<ul>
<li>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.</li>
</ul>
<h3>Management: Recommended Care for HIV</h3>
<p>Currently, national data on HIV care are not routinely collected. HIV measures tracked in the NHDR 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.</p>
<p>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.</p>
<p>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 (<a href="/research/findings/nhqrdr/nhdr12/chap2e.html#Yeargin">Yeargin, et al., 2003</a>), which is also tracked in the reports.</p>
<h4 class="figcaption"><a id="fig225" name="fig225"> </a>Figure 2.25. HIV patients who received recommended care, by race/ethnicity and gender, 2009</h4>
<img alt="For Text Description, select the link below the image." src="/research/findings/nhqrdr/nhdr12/images/fig2-25a.jpg" /><br />
<br />
<img alt="For Text Description, select the link below the image." src="/research/findings/nhqrdr/nhdr12/images/fig2-25b.jpg" />
<p><a href="/research/findings/nhqrdr/nhdr12/chap2-text2.html#fig225">[D] Select for Text Description</a></p>
<p class="size2"><strong>Key:</strong> HAART = highly active antiretroviral therapy; PCP = <em>Pneumocystis</em> pneumonia; MAC = <em>Mycobacterium avium</em> complex.<br />
<strong>Source:</strong> Agency for Healthcare Research and Quality, HIV Research Network, 2009.<br />
<strong>Note:</strong> 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.</p>
<ul>
<li>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 (<a href="#fig225">Figure 2.25</a>). 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.</li>
<li>In 2009, there were no statistically significant differences by race/ethnicity or gender in the percentage of people with HIV receiving recommended services.</li>
</ul>
<p>Also, in the NHQR:</p>
<ul>
<li>In 2009, there were no statistically significant differences by age or insurance type in the percentage of people with HIV receiving recommended services.</li>
</ul>
<h4>Outcome: Deaths of People With HIV Infection</h4>
<p>Improved management of HIV infection has contributed to declines in the number of new AIDS cases in the United States since the 1990s (<a href="/research/findings/nhqrdr/nhdr12/chap2e.html#CDC2005">CDC, 2005</a>). 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.</p>
<h4 class="figcaption"><a id="fig226" name="fig226"> </a>Figure 2.26. HIV infection deaths per 100,000 population, by race/ethnicity and gender, 2000-2009</h4>
<img alt="For Text Description, select the link below the image." src="/research/findings/nhqrdr/nhdr12/images/fig2-26a.jpg" /><br />
<br />
<img alt="For Text Description, select the link below the image." src="/research/findings/nhqrdr/nhdr12/images/fig2-26b.jpg" />
<p><a href="/research/findings/nhqrdr/nhdr12/chap2-text2.html#fig226">[D] Select for Text Description</a></p>
<p class="size2"><strong>Source:</strong> Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System—Mortality, 2000-2009.<br />
<strong>Note:</strong> For this measure, lower rates are better. Rates are age adjusted to the 2000 U.S. standard population.</p>
<ul>
<li>Overall, in 2009, the total rate of HIV infection deaths was 3 per 100,000 population (<a href="#fig226">Figure 2.26</a>).</li>
<li>HIV infection death rates are decreasing for all racial/ethnic groups and both genders.</li>
<li>In 2009, HIV infection death rates were higher for the Black (14.4 deaths per 100,000) and Hispanic (3.3 deaths per 100,000) populations compared with the White population (1.2 deaths per 100,000).</li>
<li>In 2009, the HIV infection death rate was higher for males (4.4 deaths per 100,000) than for females (1.7 deaths per 100,000).</li>
<li>The 2008 top 4 State achievable benchmark for HIV deaths was 0.9 per 100,000.<sup><a href="#xvii">xvii</a></sup> At the current rate, Hispanics, Blacks, and Whites could achieve the benchmark in 7, 14, and 4 years, respectively. Males would take 9 years and females 11 years to reach the benchmark.</li>
</ul>
<p>Also, in the NHQR:</p>
<ul>
<li>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.</li>
<li>From 2004 to 2009, the rate of HIV infection deaths decreased for adults living in large central, large fringe, medium , and small metropolitan areas</li>
</ul>
<hr />
<p class="size2"><a id="xi" name="xi"> </a><sup>xi.</sup> The top 5 States that contributed to the achievable benchmark are Hawaii, Maine, Montana, New Hampshire, and Oregon.<br />
<a id="xii" name="xii"> </a><sup>xii.</sup> The top 5 States that contributed to the achievable benchmark are Delaware, Iowa, Minnesota, Montana, and Vermont.<br />
<a id="xiii" name="xiii"> </a><sup>xiii.</sup> HbA1c, or glycosylated hemoglobin, is a measure of average levels of glucose in the blood.<br />
<a id="xiv" name="xiv"> </a><sup>xiv.</sup> The top 4 States that contributed to the achievable benchmark are Colorado, Hawaii, Utah, and Vermont.<br />
<a id="xv" name="xv"> </a><sup>xv.</sup> The top 5 States that contributed to the achievable benchmark are Alaska, Montana, New Hampshire, Oregon, and Wyoming.<br />
<a id="xvi" name="xvi"> </a><sup>xvi.</sup> The top 4 States that contributed to the achievable benchmark are Iowa, New Hampshire, Utah, and Wisconsin.<br />
<a id="xvii" name="xvii"> </a><sup>xvii.</sup> The top 4 States that contributed to the achievable benchmark are Minnesota, Oregon, Utah, and Wisconsin.</p>
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<div class="current-as-of">Page last reviewed May 2013</div>
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<span>Internet Citation: 2012 National Healthcare Disparities Report: Chapter 2. Effectiveness (continued).
May 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://archive.ahrq.gov/research/findings/nhqrdr/nhdr12/chap2a.html</span>
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