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<h1>Chapter 2. Effectiveness (continued, 2)</h1>
<h2>National Healthcare Quality Report, 2009</h2> <div id="basic-modal"><!-- start: Basic Modal -->
<br /> <a id="mental" name="mental"></a> <h2>Mental Health and Substance Abuse</h2><h3>Importance</h3><table border="0" cellpadding="2" cellspacing="0" width="80%"><tbody><tr><td align="left" colspan="2" scope="row"><strong>Mortality</strong></td></tr><tr><td align="left" scope="row">Number of deaths due to suicide (2006)</td><td align="right">33,300<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref2">2</a></sup></td></tr><tr><td align="left" scope="row">Rank among causes of death in the United States&#8212;suicide (2006)</td><td align="right">11th<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref2">2</a></sup></td></tr><tr><td align="left" scope="row">Alcohol-impaired driving fatalities (2007)</td><td align="right">12,998<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref25">25</a></sup></td></tr><tr><td align="left" colspan="2" scope="row"><strong>Prevalence</strong></td></tr><tr><td align="left" scope="row">People age 12 and over with alcohol and/or illicit drug dependence or abuse in the past year (2007)</td><td align="right">22.3 million (9.0%)<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref26">26</a></sup></td></tr><tr><td align="left" scope="row">Adults age 18 and over with serious psychological distress in the past year (2007)</td><td align="right">24.3 million (10.9%)<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref26">26</a></sup></td></tr><tr><td align="left" scope="row">Adults age 18 and over with a major depressive episode during the past year (2007)</td><td align="right">16.5 million (7.5%)<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref26">26</a></sup></td></tr><tr><td align="left" scope="row">Adults with at least one major depressive episode in their lifetime (2006)</td><td align="right">30.4 million (13.9%)<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref27">27</a></sup></td></tr><tr><td align="left" colspan="2" scope="row"><strong>Cost</strong></td></tr><tr><td align="left" scope="row">National expenditures for the treatment of mental health and substance abuse disorders (2003 est.)</td><td align="right">$121 billion<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref28">28</a></sup></td></tr><tr><td align="left" scope="row">Cost-effectiveness of screening and brief counseling for problem drinking</td><td align="right">$0-$14,000/QALY<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref5">5</a>,<a href="#note21">xxi</a></sup></td></tr></tbody></table><h3>Measures</h3><p>The NHQR tracks measures of the quality of treatment for major depression and substance abuse. Mental health treatment includes counseling, inpatient care, outpatient care, and prescription medications. This section highlights three core measures of mental health and substance abuse treatment:</p><ul><li>Receipt of treatment for depression.</li><li>Suicide deaths.</li><li>Receipt of needed treatment for illicit drug use or alcohol problem.</li></ul><p>In addition, one noncore measure is discussed:</p><ul><li>Completion of substance abuse treatment.</li></ul><h3>Findings</h3><h4>Treatment: Receipt of Treatment for Depression</h4><p>Almost 14% of the U.S. population will have a major depressive episode in their lifetime. Treatment can be very effective in reducing symptoms and associated illnesses and returning individuals to a productive lifestyle. For example, the Sequenced Treatment Alternatives to Relieve Depression study provides a blueprint for reasonable medication and psychosocial options for the outpatient management of depression in primary care as well as specialty settings. It showed that by using a measurement-based approach, outcomes in primary care can match those in specialty mental health settings.<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref29">29</a></sup> Ongoing National Institute of Mental Health-funded efforts seek to improve remission rates with existing treatments<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref30">30</a></sup> and to formulate new approaches to treat people with major depression.</p><p><a id="fig2-26a" name="fig2-26a">&#160;</a></p><p><strong>Figure 2.26. Adults with a major depressive episode in the past year who received treatment for depression in the past year, by age, 2004-2007</strong></p><p class="size2"><span><img src="/research/findings/nhqrdr/nhqr09/images/fig2-26.jpg" alt="Trend line chart. In Percentages. Total, 2004, 65.1; 2005, 65.6; 2006, 69.1; 2007, 64.5; 18 through 44, 2004, 59.5; 2005, 58.7; 2006, 60.8; 2007, 57.6; 45 through 64, 2004, 73.5; 2005, 75.5; 2006, 82.1; 2007, 75.4." title="Trend line chart. In Percentages. Total, 2004, 65.1; 2005, 65.6; 2006, 69.1; 2007, 64.5; 18 through 44, 2004, 59.5; 2005, 58.7; 2006, 60.8; 2007, 57.6; 45 through 64, 2004, 73.5; 2005, 75.5; 2006, 82.1; 2007, 75.4." border="0" /></span>
</p><p class="size2"><strong>Source:</strong> Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2004-2007.</p><p class="size2"><strong>Denominator:</strong> Adults ages 18-64 with a major depressive episode in the past year.</p><p class="size2"><strong>Note:</strong> Total includes adults age 65 and over, but sample sizes are too small to allow separate estimates for this age group.</p><ul><li>In 2007, 64.5% of adults under age 65 with a major depressive episode received treatment for depression (<a href="#fig2-26a">Figure 2.26</a>). There was no significant improvement in this measure compared with 2004.</li><li>In all years, adults ages 18-44 were less likely to receive treatment for depression than those ages 45-64.</li></ul><h4>Outcome: Suicide Deaths</h4><p>More than 90% of patients who die by suicide have mental illnesses, such as depression, schizophrenia, or substance abuse.<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref31">31</a></sup> Suicide may be prevented when its warning signs are detected and treated. A previous suicide attempt is among the strongest predictors of subsequent suicide. Cognitive therapy can help those who have attempted suicide consider alternative actions when thoughts of self-harm arise and has been shown to reduce suicide attempts by half during a year of followup.<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref32">32</a></sup></p><p><a id="fig2-27a" name="fig2-27a">&#160;</a></p><p><strong>Figure 2.27. State variation: Suicide deaths per 100,000 population, 2006</strong></p><p class="size2"><span><img src="/research/findings/nhqrdr/nhqr09/images/fig2-27.jpg" alt="Best: California, Texas, Hawaii, Illinois, Georgia, New York, Massachusetts, Rhode Island, Connecticut, New Jersey, Maryland, District of Columbia. Second: Nebraska, Minnesota, Iowa, Louisiana, Mississippi, Michigan, Ohio, Maine, New Hampshire, Rhode Island, Pennsylvania, Delaware, Virginia. Third: Washington, North Dakota, Kansas, Missouri, Arkansas, Wisconsin, Indiana, Tennessee, Alabama, Florida, South Carolina, North Carolina, West Virginia, Vermont. Worst: Alaska, Oregon, Idaho, Nevada, Montana, Wyom" title="Best: California, Texas, Hawaii, Illinois, Georgia, New York, Massachusetts, Rhode Island, Connecticut, New Jersey, Maryland, District of Columbia. Second: Nebraska, Minnesota, Iowa, Louisiana, Mississippi, Michigan, Ohio, Maine, New Hampshire, Rhode Island, Pennsylvania, Delaware, Virginia. Third: Washington, North Dakota, Kansas, Missouri, Arkansas, Wisconsin, Indiana, Tennessee, Alabama, Florida, South Carolina, North Carolina, West Virginia, Vermont. Worst: Alaska, Oregon, Idaho, Nevada, Montana, Wyom" border="0" /></span>
</p><p class="size2"><strong>Key:</strong> Best quartile indicates States with lowest rates of suicide deaths; worst quartile indicates States with highest rates.<br>
<strong>Source:</strong> Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System-Mortality, 2006.<br>
<strong>Denominator:</strong> U.S. population.<br>
<strong>Note:</strong> Rates are age adjusted to the 2000 U.S. standard population.</p><ul><li>Twelve States<sup><a href="#note22">xxii</a></sup> and the District of Columbia were in the best quartile (lowest rates of suicide deaths) in 2006 and had a combined average rate of 8.0 deaths per 100,000 population (<a href="#fig2-27a">Figure 2.27</a>). These States are primarily located in the Northeast.</li><li>The 13 States<sup><a href="#note23">xxiii</a></sup> in the worst quartile (highest rates) in 2006 had a combined average rate of 17.1 deaths per 100,000 population. These States are primarily located in the West.</li></ul><h4>Treatment: Receipt of Needed Treatment for Illicit Drug Use or Alcohol Problem</h4><p>Substance abuse is a medical problem that requires timely treatment, not only because of its health effects but also because drug use is associated with other adverse effects, such as violent behavior. In addition, overall health care costs may be reduced by effective substance abuse and mental health treatment.<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref33">33</a>,<a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref34">34</a></sup> Thus, appropriate receipt and completion of treatment have both clinical and economic implications.</p><p><a id="fig2-28a" name="fig2-28a">&#160;</a></p><p><strong>Figure 2.28. People age 12 and over who needed treatment for illicit drug use or an alcohol problem and who received such treatment at a specialty facility in the last 12 months, overall composite and two components, by age, 2002-2007</strong></p><p class="size2"><span><img src="/research/findings/nhqrdr/nhqr09/images/fig2-28a.jpg" alt="Trend line chart. Illicit drug use or alcohol problem. Healthy People 2010 target: 16%. Total, 2002, 10.3; 2003, 8.5; 2004, 9.9; 2005, 10.0; 2006, 10.8; 2007, 10.4; Ages 12-17, 2002, 8.2; 2003, 7.4; 2004, 8.1; 2005, 8.6; 2006, 8.7; 2007, 7.6; Age 18 plus, 2002, 10.5; 2003, 8.6; 2004, 10.1; 2005, 10.1; 2006, 11.0; 2007, 10.7." title="Trend line chart. Illicit drug use or alcohol problem. Healthy People 2010 target: 16%. Total, 2002, 10.3; 2003, 8.5; 2004, 9.9; 2005, 10.0; 2006, 10.8; 2007, 10.4; Ages 12-17, 2002, 8.2; 2003, 7.4; 2004, 8.1; 2005, 8.6; 2006, 8.7; 2007, 7.6; Age 18 plus, 2002, 10.5; 2003, 8.6; 2004, 10.1; 2005, 10.1; 2006, 11.0; 2007, 10.7." border="0" /></span>
</p><p class="size2"><span><img src="/research/findings/nhqrdr/nhqr09/images/fig2-28b.jpg" alt="Illicit drug use. Healthy People 2010 target: 24%. Total, 2002, 18.2; 2003, 15.0; 2004, 17.7; 2005, 17.0; 2006, 20.3; 2007, 17.8; Ages 12-17, 2002, 10.1; 2003, 8.5; 2004, 9.6; 2005, 11.3; 2006, 11.2; 2007, 9.9; Age 18 plus, 2002, 20.1; 2003, 16.5; 2004, 19.4; 2005, 18.1; 2006, 22.0; 2007, 19.2." title="Illicit drug use. Healthy People 2010 target: 24%. Total, 2002, 18.2; 2003, 15.0; 2004, 17.7; 2005, 17.0; 2006, 20.3; 2007, 17.8; Ages 12-17, 2002, 10.1; 2003, 8.5; 2004, 9.6; 2005, 11.3; 2006, 11.2; 2007, 9.9; Age 18 plus, 2002, 20.1; 2003, 16.5; 2004, 19.4; 2005, 18.1; 2006, 22.0; 2007, 19.2." border="0" /></span>
</p><p class="size2"><span><img src="/research/findings/nhqrdr/nhqr09/images/fig2-28c.jpg" alt="Alcohol problem. Healthy People 2010 target: 11.9%. Total, 2002, 8.3; 2003, 7.1; 2004, 7.9; 2005, 8.4; 2006, 8.0; 2007, 8.1; Ages 12-17, 2002, 8.1; 2003, 6.3; 2004, 8.0; 2005, 8.1; 2006, 7.2; 2007, 5.9; Age 18 plus, 2002, 8.3; 2003, 7.2; 2004, 7.9; 2005, 8.4; 2006, 8.0; 2007, 8.3." title="Alcohol problem. Healthy People 2010 target: 11.9%. Total, 2002, 8.3; 2003, 7.1; 2004, 7.9; 2005, 8.4; 2006, 8.0; 2007, 8.1; Ages 12-17, 2002, 8.1; 2003, 6.3; 2004, 8.0; 2005, 8.1; 2006, 7.2; 2007, 5.9; Age 18 plus, 2002, 8.3; 2003, 7.2; 2004, 7.9; 2005, 8.4; 2006, 8.0; 2007, 8.3." border="0" /></span>
</p><p class="size2"><strong>Source:</strong> Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2002-2007.<br>
<strong>Denominator:</strong> Civilian noninstitutionalized population age 12 and over who needed treatment for any illicit drug use or alcohol problem.<br>
<strong>Note:</strong> Treatment refers to treatment at a specialty facility, such as a drug and alcohol inpatient and/or outpatient rehabilitation facility, inpatient hospital setting, or a mental health center.</p><ul><li>In 2007, 10.4% of people age 12 and over who needed treatment for illicit drug use or an alcohol problem received such treatment. There was no significant change from 2002 to 2007 overall or for any age group (<a href="#fig2-28a">Figure 2.28</a>). For 4 of the 6 data years, adolescents ages 12-17 were significantly less likely to receive treatment for illicit drug use or an alcohol problem compared with adults age 18 and over. As of 2007, the Healthy People 2010 target of 16% had not been met for people who needed treatment and received it for illicit drug use or an alcohol problem.</li><li>Overall, 17.8% of people age 12 and over who met criteria for needing treatment for illicit drug use actually received it in 2007, and this rate has not changed significantly since 2002. In all years, children ages 12-17 who needed treatment for illicit drug use were less likely than adults age 18 and over to receive such treatment. As of 2007, the Healthy People 2010 target of 24% had not been met for people who needed treatment and received it for illicit drug use.</li><li>Overall, 8.1% of people age 12 and over who needed treatment for an alcohol problem received treatment at a specialty facility, and this rate has not changed significantly since 2002. In 2007, adults age 18 and over were more likely than adolescents ages 12-17 to receive treatment for an alcohol problem. As of 2007, the Healthy People 2010 target of 11.9% had not been met for people who needed treatment for an alcohol problem and received it.</li></ul><h4>Treatment: Completion of Substance Abuse Treatment</h4><p><a id="fig2-29a" name="fig2-29a">&#160;</a></p><p><strong>Figure 2.29. People age 12 and over treated for substance abuse who completed treatment course, by age, 2005-2006</strong></p><p class="size2"><span><img src="/research/findings/nhqrdr/nhqr09/images/fig2-29.jpg" alt="Trend line chart. In percentages. Total, 2005, 45.0; 2006, 47.5; Ages 12-19, 2005, 41.3; 2006, 42.6; Ages 20-39, 2005, 42.7; 2006, 45.2; Age 40 and over, 2005, 49.4; 2006, 52.0." title="Trend line chart. In percentages. Total, 2005, 45.0; 2006, 47.5; Ages 12-19, 2005, 41.3; 2006, 42.6; Ages 20-39, 2005, 42.7; 2006, 45.2; Age 40 and over, 2005, 49.4; 2006, 52.0." border="0" /></span>
</p><p class="size2"><strong>Source:</strong> Substance Abuse and Mental Health Services Administration, Treatment Episode Data Set, Discharge Data Set, 2005-2006.<br>
<strong>Denominator:</strong> Discharges age 12 and over from publicly funded substance abuse treatment facilities.</p><ul><li>From 2005 to 2006, the percentage of people age 12 and over treated for substance abuse who completed the treatment course increased from 45.0% to 47.5% (<a href="#fig2-29a">Figure 2.29</a>). A significant increase was also seen for those ages 20-39 and 40 and over.</li><li>In 2006, people ages 12-19 were less likely to complete substance abuse treatment compared with those age 20 and over.&#160;</li></ul><p><a id="respir" name="respir">&#160;</a></p><h2>Respiratory Diseases</h2><h3>Importance</h3><table border="0" cellpadding="2" cellspacing="0" width="80%"><tbody><tr><td align="left" colspan="2" scope="row"><strong>Mortality</strong></td></tr><tr><td align="left" scope="row">Number of deaths due to chronic lower respiratory diseases<sup><a href="#note24">xxiv</a></sup> (2006)</td><td align="right">124,583<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref2">2</a></sup></td></tr><tr><td align="left" scope="row">Number of deaths, influenza and pneumonia combined (2006)</td><td align="right">56,326<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref2">2</a></sup></td></tr><tr><td align="left" scope="row">Cause of death rank, chronic lower respiratory diseases (2006)</td><td align="right">4th<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref2">2</a></sup></td></tr><tr><td align="left" colspan="2" scope="row"><strong>Prevalence</strong></td></tr><tr><td align="left" scope="row">Adults age 18 and over who have asthma (2007)</td><td align="right">16.2 million<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref35">35</a></sup></td></tr><tr><td align="left" scope="row">Children under age 18 who have asthma (2007)</td><td align="right">6.7 million<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref36">36</a></sup></td></tr><tr><td align="left" colspan="2" scope="row"><strong>Incidence</strong></td></tr><tr><td align="left" scope="row">Annual number of pneumonia cases due to <em>Streptococcus pneumoniae</em></td><td align="right">500,000<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref37">37</a></sup></td></tr><tr><td align="left" scope="row">New cases of tuberculosis (2008)</td><td align="right">12,898<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref38">38</a></sup></td></tr><tr><td align="left" colspan="2" scope="row"><strong>Cost</strong></td></tr><tr><td align="left" scope="row">Total cost of lung diseases (2009 est.)</td><td align="right">$177.4 billion<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref4">4</a></sup></td></tr><tr><td align="left" scope="row">Direct medical costs of lung diseases (2009 est.)</td><td align="right">$113.6 billion<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref4">4</a></sup></td></tr><tr><td align="left" scope="row">Total cost of asthma (2007 est.)</td><td align="right">$19.7 billion<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref39">39</a></sup></td></tr><tr><td align="left" scope="row">Direct medical costs of asthma (2007 est.)</td><td align="right">$14.7 billion<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref39">39</a></sup></td></tr><tr><td align="left" scope="row">Cost-effectiveness of influenza immunization</td><td align="right">$0-$14,000/QALY<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref5">5</a></sup></td></tr></tbody></table><h3>Measures</h3><p>The NHQR tracks several quality measures for prevention and treatment of this broad category of illnesses that includes influenza, pneumonia, asthma, upper respiratory infection, and tuberculosis. The four core report measures highlighted in this section are:</p><ul><li>Pneumococcal vaccination.</li><li>Receipt of recommended care for pneumonia.</li><li>Completion of tuberculosis therapy.</li><li>Daily asthma medication.</li></ul><h3>Findings</h3><h4>Prevention: Pneumococcal Vaccination</h4><p>Vaccination is a cost-effective strategy for reducing illness and death associated with pneumococcal disease of the lungs (pneumonia) and influenza.</p><p><a id="fig2-30a" name="fig2-30a">&#160;</a></p><p><strong>Figure 2.30. Adults age 65 and over who ever received pneumococcal vaccination, by insurance status, 2000-2007</strong></p><p class="size2"><span><img src="/research/findings/nhqrdr/nhqr09/images/fig2-30.jpg" alt="Trend line chart. In percentages. Total, 2000, 53.4; 2001, 54.2; 2002, 56.2; 2003, 55.7; 2004, 57.0; 2005, 56.3; 2006, 57.3; 2007, 57.8; Medicare and private, 2000, 58.1; 2001, 59.3; 2002, 60.8; 2003, 60.0; 2004, 61.9; 2005, 62.2; 2006, 61.8; 2007, 61.6; Medicare and public, 2000, 44.6; 2001, 40.9; 2002, 49.6; 2003, 49.5; 2004, 53.3; 2005, 53.3; 2006, 57.1; 2007, 56.9; Medicare only, 2000, 45.3; 2001, 47.1; 2002, 49.9; 2003, 48.4; 2004, 48.9; 2005, 45.7; 2006, 49.0; 2007, 51.3." title="Trend line chart. In percentages. Total, 2000, 53.4; 2001, 54.2; 2002, 56.2; 2003, 55.7; 2004, 57.0; 2005, 56.3; 2006, 57.3; 2007, 57.8; Medicare and private, 2000, 58.1; 2001, 59.3; 2002, 60.8; 2003, 60.0; 2004, 61.9; 2005, 62.2; 2006, 61.8; 2007, 61.6; Medicare and public, 2000, 44.6; 2001, 40.9; 2002, 49.6; 2003, 49.5; 2004, 53.3; 2005, 53.3; 2006, 57.1; 2007, 56.9; Medicare only, 2000, 45.3; 2001, 47.1; 2002, 49.9; 2003, 48.4; 2004, 48.9; 2005, 45.7; 2006, 49.0; 2007, 51.3." border="0" /></span>
</p><p class="size2"><strong>Source:</strong> Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2000-2007.<br>
<strong>Denominator:</strong> Civilian noninstitutionalized population age 65 and over.<br>
<strong>Note:</strong> Age adjusted to the 2000 U.S. standard population.</p><ul><li>The percentage of adults age 65 and over who ever received a pneumococcal vaccination increased from 53.4% in 2000 to 57.8% in 2007 (<a href="#fig2-30a">Figure 2.30</a>). From 2000 to 2007, receipt of pneumococcal vaccination improved for all insurance groups.</li><li>In all years, adults with Medicare only were less likely to receive pneumococcal vaccination compared with adults with Medicare and private insurance. Prior to 2006, adults with Medicare and other public insurance were also less likely to receive pneumococcal vaccination compared with adults with Medicare and private insurance, but these differences were not significant in 2006 or 2007.</li><li>The Healthy People 2010 target of 90% is unlikely to be met at this rate of change.</li></ul><h4>Treatment: Receipt of Recommended Care for Pneumonia</h4><p>Recommended care for patients with pneumonia includes receipt of: (1) initial antibiotics within 6 hours of hospital arrival; (2) antibiotics consistent with current recommendations; (3) blood culture before antibiotics are administered; (4) influenza vaccination status assessment/vaccine provision; and (5) pneumococcal vaccination status assessment/vaccine provision. The NHQR tracks receipt of each process measure as well as an overall composite based on an opportunities model. A revision to one measure in 2007 should be noted. The measure of timeliness of initial antibiotic dose was changed from within 4 hours to within 6 hours of hospital arrival. This revised measure is included in the new composite.</p><p><a id="fig2-31a" name="fig2-31a">&#160;</a></p><p><strong>Figure 2.31. Hospital patients with pneumonia who received recommended hospital care: Overall composite and five components, 2005-2007</strong></p><p class="size2"><span><img src="/research/findings/nhqrdr/nhqr09/images/fig2-31.jpg" alt="Trend line chart; in percentages; Composite, 2005, NA; 2006, NA; 2007, 84.9; Antibiotics within 6 hours, 2005, NA; 2006, NA; 2007, 82.7; Antibiotic selection, 2005, 79.9; 2006, 85.2; 2007, 88.7; Blood culture before first antibiotic dose, 2005, 82.9; 2006, 90.0; 2007, 90.8; Influenza vaccination status / provision, 2005, 55.2; 2006, 68.5; 2007, 78.7; Pneumococcal vaccination status / provision, 2005, 61.2; 2006, 74.3; 2007, 82.5." title="Trend line chart; in percentages; Composite, 2005, NA; 2006, NA; 2007, 84.9; Antibiotics within 6 hours, 2005, NA; 2006, NA; 2007, 82.7; Antibiotic selection, 2005, 79.9; 2006, 85.2; 2007, 88.7; Blood culture before first antibiotic dose, 2005, 82.9; 2006, 90.0; 2007, 90.8; Influenza vaccination status / provision, 2005, 55.2; 2006, 68.5; 2007, 78.7; Pneumococcal vaccination status / provision, 2005, 61.2; 2006, 74.3; 2007, 82.5." border="0" /></span>
</p><p class="size2"><strong>Source:</strong> Centers for Medicare &amp; Medicaid Services, Medicare Quality Improvement Organization Program, 2005-2007.<br>
<strong>Denominator:</strong> Patients hospitalized with a principal discharge diagnosis of pneumonia or a principal discharge diagnosis of either septicemia or respiratory failure and secondary diagnosis of pneumonia.<br>
<strong>Note:</strong> Data for antibiotics within 6 hours not available for 2005 and 2006.</p><ul><li>Among the five components of the composite measure, patients were most likely to receive blood cultures before antibiotics (90.8%) and least likely to have their influenza vaccination status assessed (78.7%) (<a href="#fig2-31a">Figure 2.31</a>).</li><li>From 2005 to 2007, rates of appropriate antibiotic selection, blood culture before first antibiotic dose, influenza vaccination, and pneumococcal vaccination all improved.</li></ul><p><a id="fig2-32a" name="fig2-32a">&#160;</a></p><p><strong>Figure 2.32. State variation: Hospital patients with pneumonia who received recommended hospital care, 2007</strong></p><p class="size2"><span><img src="/research/findings/nhqrdr/nhqr09/images/fig2-32.jpg" alt="Map of United States. Best: Idaho, Montana, Wyoming, South Dakota, Nebraska, Oklahoma, Iowa, Wisconsin, South Carolina, Maine, New Hampshire, Vermont, New Jersey. Second: Utah, North Dakota, Minnesota, Missouri, Michigan, Indiana, Ohio, Tennessee, Rhode Island, Connecticut, Pennsylvania, Virginia, North Carolina. Third: Oregon, California, Colorado, Texas, Arkansas, Illinois, Kentucky, Alabama, Florida, West Virginia, Delaware, New York, Massachusetts. Worst: Alaska, Hawaii, Washington, Nevada, Arizona, New" title="Map of United States. Best: Idaho, Montana, Wyoming, South Dakota, Nebraska, Oklahoma, Iowa, Wisconsin, South Carolina, Maine, New Hampshire, Vermont, New Jersey. Second: Utah, North Dakota, Minnesota, Missouri, Michigan, Indiana, Ohio, Tennessee, Rhode Island, Connecticut, Pennsylvania, Virginia, North Carolina. Third: Oregon, California, Colorado, Texas, Arkansas, Illinois, Kentucky, Alabama, Florida, West Virginia, Delaware, New York, Massachusetts. Worst: Alaska, Hawaii, Washington, Nevada, Arizona, New" border="0" /></span>
</p><p class="size2"><strong>Key:</strong> Best quartile indicates States with highest rates of receipt of recommended pneumonia care; worst quartile indicates States with lowest rates.<br>
<strong>Source:</strong> Centers for Medicare &amp; Medicaid Services, Medicare Quality Improvement Organization Program, 2007.<br>
<strong>Denominator:</strong> Civilian noninstitutionalized population age 65 and over.</p><ul><li>The 13 States<sup><a href="#note25">xxv</a></sup> in the best quartile (highest rates of receipt of recommended pneumonia care) in 2007 had a combined average rate of 88.8% (<a href="#fig2-32a">Figure 2.32</a>). These States are primarily located in the northern part of the country.</li><li>Eleven States,<sup><a href="#note26">xxvi</a></sup> the District of Columbia, and Puerto Rico were in the worst quartile (lowest rates) in 2007 and had a combined average rate of 77.5%.</li></ul><h4>Outcome: Completion of Tuberculosis Therapy</h4><p>To be effective for individuals as well as the public, tuberculosis therapy must be taken to its completion. Failure to complete tuberculosis therapy puts patients at increased risk for treatment failure and for spreading the disease to others. Even worse, it may result in the development of drug-resistant strains of the disease.<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref40">40</a></sup></p><p><a id="fig2-33a" name="fig2-33a">&#160;</a></p><p><strong>Figure 2.33. Patients with tuberculosis who completed a curative course of treatment within 1 year of initiation of treatment, by age, 2000-2005</strong></p><p class="size2"><span><img src="/research/findings/nhqrdr/nhqr09/images/fig2-33.jpg" alt="Trend line chart. Healthy People 2010 target: 90%. Total, 2000, 80.2; 2001, 80.5; 2002, 80.9, 2003, 81.8, 2004, 82.3, 2005, 82.8, Ages, 0-17; 2000, 89.9; 2001, 88.2; 2002, 89.7, 2003, 90.4, 2004, 90.1, 2005, 91.4, Ages 18-44, 2000, 78.2; 2001, 78.9; 2002, 79.7, 2003, 80.5, 2004 80.9, 2005, 82.2, Ages 45-64, 2000, 80.4; 2001, 80.5; 2002, 81.0, 2003, 81.2, 2004 81.6, 2005, 81.9, Age 65 and over, 2000, 81.1; 2001, 81.4; 2002, 79.6, 2003, 82.4, 2004 83.4, 2005, 81.6." title="Trend line chart. Healthy People 2010 target: 90%. Total, 2000, 80.2; 2001, 80.5; 2002, 80.9, 2003, 81.8, 2004, 82.3, 2005, 82.8, Ages, 0-17; 2000, 89.9; 2001, 88.2; 2002, 89.7, 2003, 90.4, 2004, 90.1, 2005, 91.4, Ages 18-44, 2000, 78.2; 2001, 78.9; 2002, 79.7, 2003, 80.5, 2004 80.9, 2005, 82.2, Ages 45-64, 2000, 80.4; 2001, 80.5; 2002, 81.0, 2003, 81.2, 2004 81.6, 2005, 81.9, Age 65 and over, 2000, 81.1; 2001, 81.4; 2002, 79.6, 2003, 82.4, 2004 83.4, 2005, 81.6." border="0" /></span>
</p><p class="size2"><strong>Source:</strong> Centers for Disease Control and Prevention, National TB Surveillance System, 2000-2005.<br>
<strong>Denominator:</strong> U.S. civilian noninstitutionalized population treated for tuberculosis.</p><ul><li>The percentage of adults ages 18-44 who completed tuberculosis therapy within 1 year increased from 78.2% in 2000 to 82.2% in 2005 (<a href="#fig2-33a">Figure 2.33</a>).</li><li>In all years, children ages 0-17 with tuberculosis were more likely to complete a curative course of treatment within 1 year of treatment than adults age 18 and over.</li><li>Since 2003, the rate among children has exceeded the Healthy People 2010 target of 90%, while rates among other age groups are not on track to meet this target by 2010.</li></ul><h4>Management: Daily Asthma Medication</h4><p>Improving quality of care for people with asthma can reduce the occurrence of asthma attacks and avoidable hospitalizations. The National Asthma Education and Prevention Program, coordinated by the National Heart, Lung, and Blood Institute, develops and disseminates science-based guidelines for asthma diagnosis and management.<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref41">41</a></sup> These recommendations are built around four essential components of asthma management critical for effective long-term control of asthma: assessment and monitoring, control of factors contributing to symptom exacerbation, pharmacotherapy, and education for partnership in care.<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref42">42</a></sup></p><p><a id="fig2-34a" name="fig2-34a">&#160;</a></p><p><strong>Figure 2.34. People under age 65 with current asthma who are now taking preventive medicine daily or almost daily (either oral or inhaler), by insurance status, 2003-2006</strong></p><p class="size2"><span><img src="/research/findings/nhqrdr/nhqr09/images/fig2-34.jpg" alt="Trend line chart; in percentages. Total, Less than 65; 2003, 28.4; 2004, 29.0; 2005, 30.9; 2006, 29.1; Any private; 2003, 30.8; 2004, 30.7; 2005, 32.8; 2006, 29.8; Public only; 2003, 28.6; 2004, 30.0; 2005, 30.1; 2006, 30.7; Uninsured; 2003, 12.8; 2004, 12.6; 2005, 16.9; 2006, 17.6." title="Trend line chart; in percentages. Total, Less than 65; 2003, 28.4; 2004, 29.0; 2005, 30.9; 2006, 29.1; Any private; 2003, 30.8; 2004, 30.7; 2005, 32.8; 2006, 29.8; Public only; 2003, 28.6; 2004, 30.0; 2005, 30.1; 2006, 30.7; Uninsured; 2003, 12.8; 2004, 12.6; 2005, 16.9; 2006, 17.6." border="0" /></span>
</p><p class="size2"><strong>Source:</strong> Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2003-2006.<br>
<strong>Denominator:</strong> Civilian noninstitutionalized population under age 65 who reported current asthma.<br>
<strong>Note:</strong> People with current asthma report that they still have asthma or had an asthma attack in the last 12 months.</p><ul><li>Of those with current asthma under age 65 in 2006, 29.1% reported taking preventive medicine daily or almost daily (<a href="#fig2-34a">Figure 2.34</a>).</li><li>In all 4 data years, uninsured people under age 65 with current asthma were less likely than those with private insurance to be taking preventive medicine daily or almost daily.&#160;</li></ul><p><a id="lifestyle" name="lifestyle">&#160;</a></p><h2>Lifestyle Modification</h2><h3>Importance</h3><table border="0" cellpadding="2" cellspacing="0" width="80%"><tbody><tr><td align="left" colspan="2" scope="row"><strong>Mortality</strong></td></tr><tr><td align="left" scope="row">Number of deaths per year attributable to smoking (2000-2004)</td><td align="right">443,000<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref43">43</a></sup></td></tr><tr><td align="left" colspan="2" scope="row"><strong>Prevalence</strong></td></tr><tr><td align="left" scope="row">Number of adult current cigarette smokers (2007)</td><td align="right">43.4 million<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref44">44</a></sup></td></tr><tr><td align="left" scope="row">Number of obese adults (2005-2006)</td><td align="right">&gt;72 million<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref45">45</a></sup></td></tr><tr><td align="left" scope="row">Number of adults with no leisure-time physical activity (2007)</td><td align="right">84.8 million<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref35">35</a></sup></td></tr><tr><td align="left" colspan="2" scope="row"><strong>Cost</strong></td></tr><tr><td align="left" scope="row">Total cost of smoking (2000-2004 est.)</td><td align="right">$193 billion<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref43">43</a></sup></td></tr><tr><td align="left" scope="row">Total health care cost related to obesity (2008 est.)</td><td align="right">$147 billion<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref46">46</a></sup></td></tr></tbody></table><h3>Measures</h3><p>Unhealthy behaviors place many Americans at risk for a variety of diseases. Lifestyle practices account for more than 40% of the differences in health among individuals.<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref47">47</a></sup> A recent study examined the effects on incidence of coronary heart disease, stroke, diabetes, and cancer of four healthy lifestyles: never smoking, not being obese, engaging in at least 3.5 hours of physical activity per week, and eating a healthy diet (higher consumption of fruits, vegetables, and whole grain bread and lower consumption of red meat). Engaging in one healthy lifestyle compared with none cut the risk of developing these diseases in half while engaging in all four cut risk by 78%.<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref48">48</a></sup> Unfortunately, healthy lifestyle practices have declined over the past two decades.<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref48">48</a></sup></p><p>Helping patients choose and maintain healthy lifestyles is a critical role of health care. The NHQR tracks several quality measures for modifying unhealthy lifestyles, including the following two core report measures:</p><ul><li>Counseling smokers to quit smoking.</li><li>Counseling obese adults about exercise.</li></ul><p>In addition, one noncore measure is presented:</p><ul><li>Counseling obese adults about overweight.</li></ul><h3>Findings</h3><h4>Prevention: Counseling Smokers To Quit Smoking</h4><p>Smoking harms nearly every organ of the body and causes or exacerbates many diseases. Smoking causes more than 80% of deaths from lung cancer and more than 90% of deaths from chronic obstructive pulmonary disease.<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref49">49</a></sup> Heart disease is the leading cause of death in the United States for both men and women,<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref50">50</a></sup> with approximately 135,000 deaths due to smoking.<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref51">51</a></sup> Cigarette smoking increases the risk of dying from coronary heart disease (CHD) two- to threefold.<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref51">51</a></sup></p><p>Quitting smoking has immediate and long-term health benefits. The risk of developing CHD attributed to smoking can be decreased by 50% after one year of cessation.<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref52">52</a></sup> Smoking is a modifiable risk factor, and health care providers can help encourage patients to change their behavior and quit smoking.</p><p><a id="fig2-35a" name="fig2-35a">&#160;</a></p><p><strong>Figure 2.35. Adult current smokers under age 65 with a checkup in the last 12 months who received advice to quit smoking, by insurance status, 2002-2006</strong></p><p class="size2"><span><img src="/research/findings/nhqrdr/nhqr09/images/fig2-35.jpg" alt="Trend line chart; in percentages. Total, 18-64, 2002, 62.6; 2003, 65.4; 2004, 63.2; 2005, 63.2; 2006, 62.9. Any private, 2002, 63.8; 2003, 67.2; 2004, 65.0; 2005, 64.0; 2006, 63.8. Public only, 2002, 65.6; 2003, 71.8; 2004, 68.5; 2005, 70.4; 2006, 69.9. Uninsured, 2002, 51.3; 2003, 46.3; 2004, 45.8; 2005, 48.8; 2006, 50.3." title="Trend line chart; in percentages. Total, 18-64, 2002, 62.6; 2003, 65.4; 2004, 63.2; 2005, 63.2; 2006, 62.9. Any private, 2002, 63.8; 2003, 67.2; 2004, 65.0; 2005, 64.0; 2006, 63.8. Public only, 2002, 65.6; 2003, 71.8; 2004, 68.5; 2005, 70.4; 2006, 69.9. Uninsured, 2002, 51.3; 2003, 46.3; 2004, 45.8; 2005, 48.8; 2006, 50.3." border="0" /></span>
</p><p class="size2"><strong>Source:</strong> Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2006.<br>
<strong>Denominator:</strong> Civilian noninstitutionalized adult current smokers under age 65 who had a checkup in the last 12 months.</p><ul><li>In 2006, 62.9% of adult current smokers under age 65 with a checkup in the last 12 months received advice to quit smoking (<a href="#fig2-35a">Figure 2.35</a>). From 2002-2006, there were no statistically significant changes overall or for any insurance group in the rates of advice to quit smoking.</li><li>In all years, uninsured adult current smokers under age 65 were less likely to receive advice to quit smoking compared with both privately and publicly insured adult smokers.</li></ul><h4>Prevention: Counseling Obese Adults About Overweight</h4><p>More than 34% of adults age 20 and over in the United States are obese (defined as having a BMI of 30 or higher),<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref45">45</a></sup> putting them at increased risk for many chronic, often deadly conditions, such as hypertension, cancer, diabetes, and CHD.<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref53">53</a></sup> Although physician guidelines recommend that health care providers screen all adult patients for obesity,<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref54">54</a></sup> obesity remains underdiagnosed among U.S. adults.<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref55">55</a></sup></p><p><a id="fig2-36a" name="fig2-36a">&#160;</a></p><p><strong>Figure 2.36. Adults with obesity who were told by a doctor they were overweight, by age, 1999-2002 and 2003-2006</strong></p><p class="size2"><span><img src="/research/findings/nhqrdr/nhqr09/images/fig2-36.jpg" alt="Trend line chart; in percentages. Total, 1999-2002, 67.8; 2003-2006, 64.8, Ages 20-44, 1999-2002, 60.7; 2003-2006, 58.9. Ages 45-64, 1999-2002, 77.4; 2003-2006, 69.7. Age 65 and over, 1999-2002, 71.6. 2003-2006, 73.0." title="Trend line chart; in percentages. Total, 1999-2002, 67.8; 2003-2006, 64.8, Ages 20-44, 1999-2002, 60.7; 2003-2006, 58.9. Ages 45-64, 1999-2002, 77.4; 2003-2006, 69.7. Age 65 and over, 1999-2002, 71.6. 2003-2006, 73.0." border="0" /></span>
</p><p class="size2"><strong>Source:</strong> Centers for Disease Control and Prevention, National Center for Health Statistics, National Health and Nutrition Examination Survey, 1999-2002 and 2003-2006.<br>
<strong>Denominator:</strong> Civilian noninstitutionalized obese adults age 20 and over.</p><ul><li>From 1999-2002 to 2003-2006, the total percentage of obese adults age 20 and over who were told by a doctor or health professional they were obese decreased significantly from 67.8% to 64.8% (<a href="#fig2-36a">Figure 2.36</a>). The decrease among adults ages 45-64 was also significant.</li><li>In both time periods, obese adults ages 20-44 were less likely than those ages 45-64 to be told by a doctor or health professional they were overweight.</li></ul><h4>Prevention: Counseling Obese Adults About Exercise</h4><p>Physician-based exercise and diet counseling is an important component of effective weight loss interventions,<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref54">54</a></sup> and it has been shown to produce increased levels of physical activity among sedentary patients.<sup><a href="/research/findings/nhqrdr/nhqr09/Chap2d.html#ref56">56</a></sup> Although every obese person may not need counseling about exercise and diet, many would likely benefit from improvements in these activities. Regular exercise and a healthy diet aid in maintaining normal blood cholesterol levels, weight, and blood pressure, reducing the risk of heart disease, stroke, diabetes, and other comorbidities of obesity.</p><p><a id="fig2-37a" name="fig2-37a">&#160;</a></p><p><strong>Figure 2.37. Adults with obesity who ever received advice from a health provider to exercise more, by insurance status, 2002-2006</strong></p><p class="size2"><span><img src="/research/findings/nhqrdr/nhqr09/images/fig2-37a.jpg" alt="Trend line chart. In percentages. Ages 18 through 64. Total, 18-64, 2002, 55.4; 2003, 57.1; 2004, 57.2; 2005, 56.9; 2006, 57.7; Any private, 2002, 58.8; 2003, 60.3; 2004, 61.3; 2005, 60.7; 2006, 61.0; Public only, 2002, 54.9; 2003, 58.9; 2004, 61.5; 2005, 59.4; 2006, 60.2; Uninsured, 2002, 39.7; 2003, 40.3; 2004, 36.0; 2005, 38.2; 2006, 41.2." title="Trend line chart. In percentages. Ages 18 through 64. Total, 18-64, 2002, 55.4; 2003, 57.1; 2004, 57.2; 2005, 56.9; 2006, 57.7; Any private, 2002, 58.8; 2003, 60.3; 2004, 61.3; 2005, 60.7; 2006, 61.0; Public only, 2002, 54.9; 2003, 58.9; 2004, 61.5; 2005, 59.4; 2006, 60.2; Uninsured, 2002, 39.7; 2003, 40.3; 2004, 36.0; 2005, 38.2; 2006, 41.2." border="0" /></span>
</p><p class="size2"><span><img src="/research/findings/nhqrdr/nhqr09/images/fig2-37b.jpg" alt="Age 65 and over. Total, 65 and over, 2002, 64.6; 2003, 64.9; 2004, 67.6; 2005, 66.0; 2006, 64.3; Medicare only, 2002, 59.8; 2003, 57.5; 2004, 64.4; 2005, 62.5; 2006, 59.9; Medicare and private, 2002, 69.4; 2003, 69.1; 2004, 70.1; 2005, 68.7; 2006, 68.0; Medicare and other public, 2002, 52.3; 2003, 58.9; 2004, 64.7; 2005, 62.4; 2006, 58.0." title="Age 65 and over. Total, 65 and over, 2002, 64.6; 2003, 64.9; 2004, 67.6; 2005, 66.0; 2006, 64.3; Medicare only, 2002, 59.8; 2003, 57.5; 2004, 64.4; 2005, 62.5; 2006, 59.9; Medicare and private, 2002, 69.4; 2003, 69.1; 2004, 70.1; 2005, 68.7; 2006, 68.0; Medicare and other public, 2002, 52.3; 2003, 58.9; 2004, 64.7; 2005, 62.4; 2006, 58.0." border="0" /></span>
</p><p class="size2"><strong>Source:</strong> Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2006.<br>
<strong>Denominator:</strong> Civilian noninstitutionalized adults age 18 and over with obesity.</p><ul><li>From 2002 to 2006, rates of advice about exercise did not change overall or for any insurance group (<a href="#fig2-37a">Figure 2.37</a>).</li><li>In all years, among adults under age 65, uninsured individuals were less likely to receive advice about exercise compared with privately or publicly insured individuals.</li><li>Among adults age 65 and over, individuals with Medicare only and Medicare and other public insurance were less likely to receive advice about exercise compared with individuals with Medicare and private insurance in 2002 and 2003, but these differences were not significant in more recent years.</li></ul><hr /><p class="size2"><a id="note21" name="note21"></a><sup>xxi</sup> Compared with other common preventive services such as screening for breast cancer or hypertension, screening for problem drinking is highly cost-effective.<br /> <a id="note22" name="note22"></a><sup>xxii</sup> The States are California, Connecticut, Delaware, Georgia, Hawaii, Illinois, Maryland, Massachusetts, New Jersey, New York, Rhode Island, and Texas.<br /> <a id="note23" name="note23"></a><sup>xxiii</sup> The States are Alaska, Arizona, Colorado, Idaho, Kentucky, Montana, Nevada, New Mexico, Oklahoma, Oregon, South Dakota, Utah, and Wyoming.<br /> <a id="note24" name="note24"></a><sup>xxiv</sup> Chronic lower respiratory diseases include emphysema and chronic bronchitis.<br /> <a id="note25" name="note25"></a><sup>xxv</sup> The States are Idaho, Iowa, Maine, Montana, Nebraska, New Hampshire, New Jersey, Oklahoma, South Carolina, South Dakota, Vermont, Wisconsin, and Wyoming.<br /> <a id="note26" name="note26"></a><sup>xxvi</sup> The States are Alaska, Arizona, Georgia, Hawaii, Kansas, Louisiana, Maryland, Mississippi, Nevada, New Mexico, and Washington.</p><hr /><p class="size2"><br /><a href="/research/findings/nhqrdr/nhqr09/Chap2c.html">Proceed to Next Section</a></p> </div><!-- end: Basic Modal -->
<div class="current-as-of">Page last reviewed March 2010</div>
<div class="citation">
<span>Internet Citation: Chapter 2. Effectiveness (continued, 2): National Healthcare Quality Report, 2009.
March 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://archive.ahrq.gov/research/findings/nhqrdr/nhqr09/Chap2b.html</span>
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