Morbidity and Mortality

• Patient-centered decision making (when physicians take into account the needs and circumstances of a patient) for planning a patient’s care has been shown to improve healthcare outcomes.¹⁰
• Patient-centered approaches to care have been shown to improve patients’ health status. These approaches rely on building a provider-patient relationship, improving communication, fostering a positive atmosphere, and encouraging patients to actively participate in provider-patient interactions.¹¹
• Patient-centered care can reduce the chance of misdiagnosis due to poor communication.¹²

Overall, effective communication leads to increased patient and clinician satisfaction, increased trust with the clinician, and functional and psychological well-being. Effective communication also leads to improved outcomes in specific diseases, including:

• A small but significant absolute risk reduction of mortality from coronary artery disease,
• Improved control of diabetes and hyperlipidemia,
• Better adherence to antihypertensives,
• Bereavement adjustment in caregivers of cancer patients, and
• Higher self-efficacy of adherence to HIV medications.¹³

Cost

• Poor communication, lack of collaboration, and lack of support for self-care are associated with suffering and waste in healthcare.¹⁴
• Patient centeredness has been shown to reduce overuse of medical care.¹⁵
• Patient centeredness can reduce the strain on system resources and save money by reducing the number of diagnostic tests and referrals.¹⁶
• Improving provider-patient communication during medical decision making can reduce costs.¹⁷

Improving Trend: Usual Source of Care for Patients With Limited English Proficiency

Adults who have limited English proficiency may experience disparities in their care and gaps in communication with their healthcare team.¹⁸ According to the Migration Policy Institute, in 2015, an estimated 25.9 million individuals living in the United States reported having limited English proficiency.¹⁹ “More than one in four people aged 5 and over with LEP are born in the U.S.”²⁰ Language assistance such as access to translation services, health education materials written in a known language, and other resources are required by law, but not all patients have access to these services at their usual source of care.²¹

Figure 2

Adults with limited English proficiency who had a usual source of care, 2014-2017.

• From 2014 to 2017, overall, the percentage of adults with limited English proficiency who had a usual source of care increased from 58.5% to 65.9% (Figure 2).

Among the 19 person- and family-centered care measures in this year’s report, one measure showed the top three greatest reductions in disparities over time between high-income populations and other income groups. This measure is Adults with limited English proficiency who had a usual source of care (see Disparities section, Income).

Improving Trend: Clear Instructions From Health Providers

Many patients leave their healthcare visit unsure of what their provider asked them to do or what was discussed. Nationwide, only 12% of adults have proficient health literacy.²² That means almost 9 out of 10 Americans find it challenging “to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”²³ Several communication strategies help patients and providers understand each other better, including the teach-back method. It is an evidence-based technique to confirm that people have explained things in a manner others understand.²⁴

Figure 3

Adults who had a doctor’s office or clinic visit in the last 12 months whose health providers always gave them easy-to-understand instructions about what to do for a specific illness or health condition, 2011-2017.

• From 2011 to 2017, overall, the percentage of adults who had a doctor’s office or clinic visit in the last 12 months whose health providers always gave them easy-to-understand instructions about what to do for a specific illness or health condition increased from 64.1% to 73.0% (Figure 3).

Improving Trend: Adequate Doctor’s Explanation

When healthcare providers use teach-back with their patients, they ask them to describe in their own words what they have heard. If patients cannot teach the information back correctly, providers have to instruct them again using a different way of explaining, until patients are able to teach back what they have learned correctly.²⁵ The use of strategies such as teach-back and shared decision making are contributing to improvements in patient-provider communication. Breakdowns in communication still exist and require close examination of modes communication, implicit bias and trust building.²⁶

Figure 4

Adults who had a doctor’s office or clinic visit in the last 12 months whose health providers sometimes or never explained things in a way they could understand, 2002-2017. Note: For this measure, lower rates are better.

• From 2002 to 2017, overall, the percentage of adults who had a doctor’s office or clinic visit in the last 12 months whose health providers sometimes or never explained things in a way they could understand decreased from 9.0% to 7.4% (Figure 4).

Resources

Efforts to promote person-centered care are underway within the Department of Health and Human Services (HHS). For example:

• The HHS Office of Minority Health has developed Think Cultural Health, a website featuring information, resources, and continuing education opportunities related to culturally and linguistically appropriate services (CLAS) and the National CLAS Standards for healthcare professionals.
• The HHS Office for Civil Rights’ (OCR) Medical School Curriculum Initiative educates college students, medical students, and health professionals about health disparities, cultural competency, and OCR’s civil rights authorities. As part of this initiative, OCR takes part in the Association of American Medical Colleges’ Summer Health Professionals Education Program (SHPEP). Through the SHPEP, OCR has provided training to nearly 1,000 premedical and predental college students at a dozen universities every summer since 2014.
  Currently, SHPEP trainings consist of two presentations. The first presentation has been given to SHPEP students every summer since 2014. It covers racial and ethnic health disparities, cultural and linguistic competence in healthcare, and compliance with Title VI of the Civil Rights Act of 1964. It also covers other civil rights authorities, such as authorities prohibiting sex discrimination (including sexual harassment) in education and health programs or activities funded by HHS. In 2020, OCR added a second presentation on effective communication requirements for individuals who are deaf or hard of hearing, per Section 504 of the Rehabilitation Act of 1973, Title II of the Americans With Disabilities Act, and Section 1557 of the Affordable Care Act.

Patient experience is also affected by a patient’s health literacy levels. The Agency for Healthcare Research and Quality (AHRQ) has produced a toolkit called the SHARE approach, which involves a five-step process for shared decision making and tools to help patients and providers ensure clear understanding and communication with one another.

Examining Person-Centered Care Quality Measures by Setting of Care

Figure 5

Number and percentage of all person-centered care measures improving, not changing, or worsening from 2002 to 2018, by setting of care. Key: n = number of measures. Note: For each measure with at least four data points over time, the estimates are realigned (more...)

Core measures listed below are noted as improving (green), not changing (yellow), or worsening (red) over time. For more information on how this analysis is conducted, consult the NHQDR Introduction and Methods. For more details about the measures shown here, visit the NHQDR website (https://nhqrnet.ahrq.gov/inhqrdr/).

Table 1

Hospital Measures. Among the core person-centered care measures, only one speaks to inpatient quality of care.

Table 2

Ambulatory Measures. Among 11 measures related to ambulatory care, 8 were improving over time and 3 were not changing. These measures include patient experience of care measures that examine communication between patients and their providers over the (more...)

Table 3

Home Health Care Measures. Among 9 home health care measures, 4 were noted as improving over time. The 4 outcome measures that improved pertained to adults reporting on how they engaged with their home health providers. Five measures showed no change. (more...)

Table 4

Hospice Care Measures. Among 8 hospice care outcome measures, only one improved over time.

Mortality

Number of Americans who die in hospitals each year from medical errors (1999 est.) …………………………………………………………………………… 44,000-98,00027

Age-standardized mortality rate due to adverse effects of medical treatment …………………………………………………… 1.15 per 100,000 population28

Prevalence

Number of hospital-acquired conditions in U.S. hospitals (2017) ………………. 2,550,00029

All-payer 30-day readmission rate (2016) …………………………………. 13.9% of admissions30

Cost

Additional hospital inpatient cost due to hospital-acquired conditions29:

• Central line-associated bloodstream infection ……………………………………… $48,108
• Ventilator-associated pneumonia ……………………………………………………….. $47,238
• Surgical site infection ………………………………………………………………………… $28,219
• Venous thromboembolism …………………………………………………………………. $17,367

Improving Trend: Adverse Drug Events With Heparin and Factor Xa

Adverse drug events (ADEs) include medication errors and adverse drug reactions, representing a major source of harm among hospitalized patients. Anticoagulant drugs, including warfarin, unfractionated heparin, and low-molecular-weight heparin, are among the most commonly implicated medications that cause ADEs in hospitalized patients. Low-molecular-weight heparin (LMWH) is used to prevent venous thromboembolic disease on acute or elective admission to the hospital and to treat deep vein thrombosis and pulmonary embolism.³¹

Figure 6

Adult inpatients with an anticoagulant-related adverse drug event to low-molecular-weight heparin (LMWH) and factor Xa, United States, 2014-2017. Note: For this measure, lower rates are better.

• From 2014 to 2017, overall, the percentage of adult inpatients with an anticoagulant-related adverse drug event to LMWH and factor Xa decreased from 3.5% to 1.7% (Figure 6).

Improving Trend: Inpatient Adverse Drug Events With Anticoagulants

Blood clots in arteries and veins can cause a blockage of blood flow and lead to strokes and heart attacks. Stroke survivors have an increased risk of another stroke, and individuals with obesity are at higher risk of blood clots. Anticoagulants, such as warfarin, reduce this risk but pose an increased risk of bleeding.³²

Figure 7

Adverse drug event with IV heparin in adult hospital patients who received an anticoagulant, 2014-2017. Note: For this measure, lower rates are better.

• From 2014 to 2017, overall, the percentage of inpatient adults who received an anticoagulant and experienced an adverse drug event associated with IV heparin decreased from 11.1% to 6.1% (Figure 7).

Improving Trend: Urinary Tract Infections Among Nursing Home Residents

Urinary tract infections are the second most frequent type of infection among nursing home residents. These residents typically have other comorbidities and may not receive timely diagnoses, “leading to increased rates of adverse drug effects and more recurrent infections with drug-resistant bacteria.”³³

Figure 8

Long-stay nursing home residents with a urinary tract infection, 2013-2017. Note: For this measure, lower rates are better.

• From 2013 to 2017, overall, the percentage of long-stay nursing home residents with a urinary tract infection decreased from 4.9% to 2.2% (Figure 8).
• The 2015 achievable benchmark was 2.8%. The national rate in 2017 was better than the benchmark percentage.
• The top 5 states that reached the achievable benchmark are California, Connecticut, Hawaii, New Jersey, and New Mexico.

Worsening Trend: Home Health Provider Checking Medication

Home health providers’ asking to see all medications is a preliminary step in ensuring that patients take only medications appropriate to their condition and understand why, when, and how much of each medication to take. This step may be especially important in protecting against medication errors and adverse events after transitions from facility-based care to home care.

This measure focuses on patients’ recollection of their experience with the home health agency. It is important to note that the skill sets and required background training of home health care workers varies substantially across States. While home health care workers in some States may be trained to assist providers in medication reconciliation, workers in other States may not. Medication reconciliation is a key part of ambulatory care.

Figure 9

Adults who reported a home health provider asking to see all the prescription and over-the-counter medicines they were taking when they first started getting home health care, 2012-2018.

• From 2012 to 2018, overall, the percentage of adults who reported a home health provider asking to see all the prescription and over-the-counter medicines they were taking when they first started getting home health care decreased from 78.8% to 76.5% (Figure 9).
• The 2015 achievable benchmark was 86%. There is no evidence of progress toward the benchmark.
• The top 10% of states and territories that reached the achievable benchmark are Alabama, Arkansas, Guam, Louisiana, Mississippi, Northern Mariana Islands, Puerto Rico, Texas, Virgin Islands, and West Virginia (more than 5 states reached the benchmark due to ties).

One home health measure showed widening disparities over time: Oral medication management among home health care patients (see Disparities section, Racial and Ethnic Disparities).

Resources

Efforts to promote patient safety are underway within HHS. For example:

• The National Steering Committee for Patient Safety, which published the National Action Plan to Advance Patient Safety, is co-chaired by AHRQ and the Institute for Healthcare Improvement. The National Steering Committee for Patient Safety, with members from the healthcare, policy, regulatory, and advocacy communities, is charged with creating a national action plan to guide patient safety efforts across the country in a cohesive and coordinated fashion.
• AHRQ sponsors the Comprehensive Unit-based Safety Program (CUSP). This patient safety method combines improvement in safety culture, teamwork, and communication with a set or checklist of evidence-based practices known to be effective in preventing the target healthcare-associated infection or other harms. It builds the capacity to address safety issues by combining clinical best practices and the science of safety. The core CUSP principles can be applied to reduce and eliminate healthcare associated infections and perinatal safety events. AHRQ has sponsored 10 related programs to date.
• AHRQ, with the Department of Defense, sponsored the development of Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS). TeamSTEPPS® is an evidence-based set of teamwork tools aimed at optimizing patient outcomes by improving communication and teamwork skills among healthcare professionals. Today, TeamSTEPPS® training is available online and can be used to train inpatient, nursing home, and medical office providers.
• AHRQ has created the On-Time Pressure Ulcer Prevention Toolkit to help nursing homes with electronic medical records reduce the occurrence of in-house pressure ulcers.
• Communication and Optimal Resolution (CANDOR) is a process healthcare institutions and practitioners can use to respond in a timely, thorough, and just way when unexpected events cause patient harm. AHRQ has pilot tested and produced the CANDOR Toolkit for hospitals and healthcare systems to implement as a way to respond to harm events and initiate improvements in safety outcomes.

Examining Patient Safety Quality Measures by Setting of Care

Figure 10

Number and percentage of all patient safety measures improving, not changing, or worsening from 2002 to 2018, by setting of care. Key: n = number of measures. Note: For each measure with at least four data points over time, the estimates are realigned (more...)

Core measures listed below are noted as improving (green), not changing (yellow), or worsening (red) over time. For more information on how this analysis is conducted, consult the NHQDR Introduction and Methods. For more details about the measures shown here, visit the NHQDR website (https://nhqrnet.ahrq.gov/inhqrdr/).

Table 5

Hospital Measures. Among the core patient safety measures, 3 measures were improving and 8 were not changing in the inpatient setting. The improving measures include medication safety and procedural events.

Table 6

Ambulatory Measures. Both of the 2 ambulatory care process measures were improving over time. Both measures also pertain to prescription medication prescribing.

Table 7

Home Health Care Measures. Among 8 home health care measures, 3 measures were improving over time, one of which examines a healthcare outcome by looking at oral medication management. All other measures in this setting of care are process measures. One (more...)

Table 8

Nursing Home Care Measures. Among 5 nursing home care measures, 4 were improving over time. The one measure that was not changing over time examines long-stay nursing home patients who experience injuries after falls.

Morbidity and Mortality

Care coordination interventions have been shown to:

• Reduce mortality among patients with heart failure;
• Reduce mortality and dependency among patients with stroke;
• Reduce symptoms among patients with depression and at the end of life; and
• Improve glycemic control among patients with diabetes.³⁵

Cost

Care coordination interventions have been shown to:

• Reduce hospitalizations among patients with heart failure;
• Reduce readmissions among patients with mental health conditions; and
• Be cost-effective when applied to treatment of depression.³⁵

Improving Trend: Communication About Discharge Information

Effective care coordination begins with ensuring that accurate clinical information is available to support medical decisions by patients and providers. A common transition of care is discharge from the hospital. Giving patients and caregivers self-management support after discharge has been shown to reduce readmissions to the hospital and lower costs.³⁸

Figure 11

Adult hospital patients who did not receive good communication about discharge information, 2009-2018. Note: For this measure, lower rates are better.

• From 2009 to 2018, overall, the percentage of hospital patients who did not receive good communication about discharge information decreased from 15.8% to 10.7% (Figure 11).
• The 2015 achievable benchmark was 7.7%. At the current rate of decrease, overall, the benchmark could be achieved in 4 years.
• The top 5 states that reached the achievable benchmark are Colorado, Nebraska, New Hampshire, South Dakota, and Utah.

Improving Trend: Communication About Treatment From Other Doctors

Different providers may prescribe medications for the same patient. Patients are responsible for keeping track of all their medications, but medication information can be confusing, especially for patients on multiple medications. When care is not well coordinated and some providers do not know about all of a patient’s medications, patients are at greater risk for adverse events related to drug interactions, overdosing, or underdosing.

In addition, providers need to periodically review all of a patient’s medications to ensure that they are taking what is needed and only what is needed. Medication reconciliation has been shown to reduce both medication errors and adverse drug events.³⁹

Figure 12

People with a usual source of care who usually asks about prescription medications and treatments from other doctors, 2002-2017.

• From 2002 to 2017, overall, the percentage of people with a usual source of care who usually asks about prescription medications and treatments from other doctors increased from 75.1% to 81.5% (Figure 12).

Improving Trend: Home Health Care Provider Communication

Home health care providers play a critical role in the management of home health care patients, especially those receiving supportive and palliative care. Many of these patients are managing multiple chronic conditions, severe morbidities, and terminal illnesses. Effective home health care coordination and treatment management can prevent patients from experiencing recurring hospital admissions or having to resort to long-term care facilities.

Figure 13

Adults who reported that home health providers always seemed informed and up to date about all the care or treatments they got at home in the last 2 months of care, 2012-2018.

• From 2012 to 2018, overall, the percentage of adults who reported that home health providers always seemed informed about their care and treatment received at home during the last 2 months of care improved from 62.2% to 64.7% (Figure 13).
• The 2015 achievable benchmark was 67.6%. At the current rate of decrease, overall, the benchmark could be achieved in 7 years.
• The states and territories that reached the achievable benchmark are Alabama, Georgia, Kentucky, Louisiana, South Carolina, Tennessee, and Virgin Islands (more than 5 states reached the benchmark due to ties).

Worsening Trend: Emergency Department Visits of Home Health Patients

Home health care patients can usually manage their lives with a home health care provider’s support and coordination. When home health care cannot meet a patient’s needs, he or she may be referred to the emergency department.

An emergency department visit for an urgent need/assessment without a hospitalization is a positive outcome; however, without care coordination, patients may experience similar or related emergencies and find themselves in the emergency department again. Such recurrences can lead to increased costs to the patient and family and poor health outcomes for the patient.

Figure 14

Home health care patients who had an emergency department visit without a hospitalization, 2013-2017. Note: For this measure, lower rates are better.

• From 2013 to 2017, overall, the percentage of home health care patients who had an emergency department visit without a hospitalization increased from 3.5% to 3.9% (Figure 14).
• The 2015 achievable benchmark was 2.8%. There is no evidence of progress toward the benchmark.
• The states and territories that reached the achievable benchmark are Alabama, District of Columbia, Florida, New Jersey, Puerto Rico, and Texas (more than 5 states or territories reached the benchmark due to ties).

Worsening Trend: Hospitalization of Home Health Patients

Acute care hospitalization is the hospital admission rate for Medicare beneficiaries receiving skilled home health benefits, and its reduction is seen as a way to improve quality and reduce healthcare costs. Nearly 20% of all Medicare beneficiaries discharged from hospitals are rehospitalized within 30 days and 34% are rehospitalized within 90 days.⁴⁰

Figure 15

Home health care patients who had an emergency department visit and were then hospitalized, 2013-2017. Note: For this measure, lower rates are better.

• From 2013 to 2017, overall, the percentage of home health care patients who had an emergency department visit and were then hospitalized increased from 11% to 12.2% (Figure 15).
• The 2015 achievable benchmark was 8.9%. There is no evidence of progress toward the benchmark.
• The top 10% of states and territories that reached the achievable benchmark are California, Colorado, District of Columbia, Montana, Puerto Rico, and Utah (more than 5 states or territories reached the benchmark due to ties).

Worsening Trend: Emergency Department Visits for Asthma Among Children

In 2018, 19.2 million adults and 5.5 million children in the United States had asthma.⁴¹ Access to care is hampered by socioeconomic disparities, shortages of primary care physicians in minority communities, and language and literacy barriers.⁴²

Figure 16

Emergency department visits for asthma per 10,000 population, ages 2-19, 2006-2016. Note: For this measure, lower rates are better.

• From 2006 to 2016, overall, the rate of emergency department visits for asthma among children ages 2–19 years increased from 82.5 to 102.7 per 10,000 population (Figure 16).

Resources

Efforts to promote care coordination are underway within HHS. AHRQ has produced several resources and reports to support improved care coordination in healthcare delivery, including:

• The Care Coordination Measures Atlas Update (published in 2014) expands on the atlas first published by AHRQ in 2011. The updated compendium of care coordination measures offers new measures with a focus on those that reflect coordination efforts within the primary care setting. It also includes a section on emerging trends in care coordination measurement.
• Care Coordination Accountability Measures for Primary Care Practice presents measures selected systematically from the Care Coordination Measures Atlas that are well suited for use by health plans and insurers to assess the quality of coordination in primary care practices. Primary care practices can also use the measures to assess their own performance.
• The Care Coordination Quality Measure for Primary Care (CCQM-PC) is a survey of adult patients’ experiences with care coordination in primary care settings. It was developed to comprehensively assess patient perceptions of the quality of their care coordination experiences. The CCQM-PC is designed to be used in primary care research and evaluation, with potential applications to primary care quality improvement. Guidance regarding the fielding of the survey is provided in addition to the full survey, which is in the public domain and may be used without additional permission.
• The Clinical-Community Relationships Measures Atlas was published in 2013 to identify ways to further define, measure, and evaluate programs based on clinical-community relationships for the delivery of clinical preventive services. This atlas provides a measurement framework and lists existing measures of clinical-community relationships and is intended to support research and evaluation in the field.

Examining Care Coordination Quality Measures by Topic Areas

Figure 17

Number and percentage of all care coordination measures improving, not changing, or worsening from 2002 to 2018, by sub-area. Key: n = number of measures. Note: For each measure with at least four data points over time, the estimates are realigned to (more...)

Core measures listed below are noted as improving (green), not changing (yellow), or worsening (red) over time. For more information on how this analysis was conducted, go to NHQDR Introduction and Methods. For more details about the measures shown here, visit the NHQDR website (https://nhqrnet.ahrq.gov/inhqrdr/).

Table 9

Medication Information Measures. Among all care coordination core measures, one medication information measure improved over time.

Table 10

Preventable Emergency Department Visit Measures. Among all care coordination core measures, one measure pertaining to emergency department visits for asthma worsened over time.

Table 11

Preventable Hospitalizations Among Home Health and Nursing Home Patient Measures. Among all care coordination core measures, one measure pertaining to preventable emergency department visits worsened over time.

Table 12

Supportive and Palliative Care Measures. Three measures under supportive and palliative care examine the experiences of home health patients. Patient reporting of home health provider awareness of their past treatment plan showed improvement whereas number (more...)

Table 13

Transitions of Care Measures. Among all care coordination core measures, one measure pertaining to communication about discharge information improved over time and another examining patient experience of providers who considered their preferences did (more...)

Morbidity and Mortality

Affordability of care remains a central barrier to access to care for many individuals and families. Several financial and nonfinancial barriers contribute to the inaccessibility of care. Financial barriers include high premiums, lack of insurance, and underinsurance. Nonfinancial barriers include transportation challenges, negative interactions with care teams, delayed access to a healthcare provider, and inability to access care due to competing demands (e.g., childcare, work schedules)⁴³ Past research continues to show that lack of insurance and inaccessible care are linked to patient mortality.^44,45

Cost

Care coordination interventions have been shown to:

• Reduce hospitalizations among patients with heart failure;
• Reduce readmissions among patients with mental health conditions; and
• Be cost-effective when applied to treatment of depression.³⁵

Improving Trend: Barriers to Medical Care

The high cost of care continues to be an affordability challenges for patients. In recent years, the United States has observed lower rates of inaccessibility due to improved insurance access. Underinsurance and cost barriers continue to pose challenges with accessibility.

Figure 18

People unable to get or delayed in getting needed medical care due to financial or insurance reasons, 2002-2017. Note: For this measure, lower rates are better.

• From 2002 to 2017, overall, the percentage of people who were unable to get or delayed in getting needed medical care due to financial or insurance reasons decreased from 52.3% to 41.1% (Figure 18).

Improving Trend: Barriers to Getting Prescription Medicines

Prescription medications costs continue to pose challenges with affordability and accessibility for patients, especially since prescription drug costs for some diseases continue to rise.⁴⁶ Many adults who are managing multiple chronic conditions and those who require specialty prescriptions and therapies may experience higher and unaffordable costs of treatment.

Figure 19

People unable to get or delayed in getting needed prescription medicines due to financial or insurance reasons, 2002-2017. Note: For this measure, lower rates are better.

• From 2002 to 2017, overall, the percentage of people who were unable to get or delayed in getting needed prescription medicines due to financial or insurance reasons decreased from 65.8% to 57.6% (Figure 19).

Resources

Efforts to promote affordable care are underway within the Department of Health and Human Services (HHS). For example:

• The Department is working to transform our system from one that pays for procedures and sickness (volume-based care) to one that pays for outcomes and health (value-based care, or VBC). The Centers for Medicare & Medicaid Services (CMS) operates multiple VBC programs, which span different settings of care (e.g., inpatient, home health) and conditions (e.g., end stage renal disease and hospital-acquired conditions). In January 2017, CMS implemented the Quality Payment Program for clinicians, which consists of two tracks: the Merit-based Incentive Payment Systems (MIPS); and participation in Advanced Alternative Payment Models (APMs). Both tracks commit clinicians to practicing VBC.
• Health Resources and Services Administration (HRSA)-sponsored Federally Qualified Health Centers function as part of the nation’s safety net. These providers receive funds from the HRSA Health Center Program to provide primary care services in underserved areas.
• CMS offers the Consumer Assistance Program, which originated as a state-based federal grant program. State CAPs offer direct assistance by phone, direct mail, email, or walk-in locations to help consumers learn how to obtain or use their insurance effectively.
• CMS’s Office of Minority Health produces Coverage to Care (C2C), which offers healthcare coverage information in multiple languages for providers and patients.

Examining Affordable Care Quality Measures by Sub-Areas

Figure 20

Number and percentage of all affordable care measures improving, not changing, or worsening from 2002 to 2017, by sub-areas. Key: n = number of measures. Note: For each measure with at least four data points over time, the estimates are realigned to the (more...)

Core measures listed below are noted as improving (green), not changing (yellow), or worsening (red) over time. For more information on how this analysis was conducted, consult the NHQDR Introduction and Methods. For more details about the measures shown here, visit the NHQDR website (https://nhqrnet.ahrq.gov/inhqrdr/).

Table 14

Usual Source of Care Measures. Among a total of 4 measures, 2 were improving over time and 2 were not changing over time. These include measures regarding affordability of medical and dental care.

Table 15

Financial Burden of Healthcare Measures. The core set of measures includes only one measure that specifically examines the financial burden of healthcare. This measure was not changing over time.

Morbidity and Mortality

Effective treatment interventions have been shown to reduce mortality and morbidity among patients with chronic diseases. The number of deaths for the following conditions show some of the leading causes of death in the United States in 2018:

• Heart disease: 655,381
• Cancer: 599,274
• Chronic lower respiratory diseases: 159,486
• Stroke (cerebrovascular diseases): 147,810
• Alzheimer’s disease: 122,019
• Diabetes: 84,946
• Influenza and pneumonia: 59,120
• Nephritis, nephrotic syndrome, and nephrosis: 51,386
• Intentional self-harm (suicide): 48,344⁴⁹

The prevention of these conditions and reductions in mortality can be supported with effective primary and preventive care.

Improving Trend: Dialysis Treatment for Patients on Hemodialysis

Dialysis or even a kidney transplant can improve the longevity of patients with kidney failure. Without adequate dialysis, patients on hemodialysis are more likely to incur frequent hospitalizations and emergency department visits. In 2016, nearly 125,000 people in the United States started treatment for end stage renal disease (ESRD), and 2 in every 1,000 people were on dialysis or were living with a kidney transplant. Each day, more than 240 people receiving dialysis will die.⁵⁰

Figure 21

Adult hemodialysis patients with adequate dialysis - Kt/V 1.2 or higher, 2015-2018.

• From 2015 to 2018, overall, the percentage of adult hemodialysis patients with adequate dialysis (kt/V 1.2 or higher) improved from 93% to 96.4% (Figure 21).
• The 2015 achievable benchmark was 96.5%. At the current rate of increase, overall, the benchmark could be achieved in 1 year.
• The top 10% of states that reached the achievable benchmark are Alaska, Hawaii, Maine, Rhode Island, Utah, and Vermont (more than 5 states reached the benchmark due to ties).

Improving Trend: Antibiotics for Common Cold

Most people around the world will have one or more common cold episodes each year. However, common colds are caused by viruses, which do not respond to antibiotics, and antibiotics can cause side effects, especially diarrhea. Overuse of antibiotics leads to bacteria becoming resistant to antibiotics.⁵¹

Figure 22

Doctor’s office and emergency department visits where antibiotics were prescribed for a diagnosis of common cold per 10,000 population, 2010-2011 to 2015-2016. Note: For this measure, lower rates are better.

• From 2010-2011 to 2015-2016, overall, the rate of doctor’s office and emergency department visits where antibiotics were prescribed for a diagnosis of common cold per 10,000 population decreased from 108.8 to 42.9 per 10,000 population (Figure 22).

Improving Trend: Colon Cancer Treatment

Surgical treatment is a typical treatment for early stage colon cancers.⁵² Oncology research has shown that the examination and removal of lymph nodes during surgical treatment of colon cancer is linked with better patient outcomes and survival.^53,54

Figure 23

Patients with colon cancer who received surgical resection of colon cancer that included at least 12 lymph nodes pathologically examined, 2005-2016.

• From 2005 to 2016, overall, the percentage of patients with colon cancer who received surgical resection of colon cancer that included at least 12 lymph nodes pathologically examined increased from 59.9% to 92.5% (Figure 23).
• The 2015 achievable benchmark was 95.4%. At the current rate of increase, overall, the benchmark could be achieved in 1 year.
• The top 10% of states that reached the achievable benchmark are District of Columbia, Hawaii, Iowa, Maine, Massachusetts, Rhode Island, Vermont, and Wyoming (more than 5 states reached the benchmark due to ties).

Worsening Trend: Emergency Department Visits Involving Opioids

The U.S. opioid overdose epidemic continues to evolve. In 2016, 66.4% of the 63,632 drug overdose deaths involved an opioid. In 2017, among 70,237 drug overdose deaths, 47,600 (67.8%) involved opioids, with increases across age groups, racial and ethnic groups, county urbanization levels, and multiple states. From 2013 to 2017, synthetic opioids contributed to increases in drug overdose death rates in several states. From 2016 to 2017, synthetic opioid-involved overdose death rates increased 45.2%.55

Figure 24

Emergency department visits involving opioid-related diagnoses per 100,000 population, 2005-2017. Note: For this measure, lower rates are better.

• From 2005 to 2017, overall, the rate of emergency department visits related to opioid use per 100,000 population increased from 89.1 to 249.1 per 100,000 population (Figure 24).
• The 2015 achievable benchmark was 65.3 per 100,000 population. There is no evidence of progress toward the benchmark.
• The top 4 states that reached the achievable benchmark are Iowa, Kansas, Nebraska, and South Dakota (only 30 states had data, but there were ties, yielding 4 top states).

Worsening Trend: Hospital Stays Involving Opioids

Increased availability and overuse of opioid medications (both prescription and nonprescription drugs) have contributed to adverse outcomes for patients, including increased risk of opioid use disorder, misuse of medication, and overdoses.⁵⁶ The National Survey on Drug Use and Health shows that in 2017, nearly 11.4 million people age 12 and over misused opioids in the past year.⁵⁷ This treatment measure examines inpatient stays associated with an opioid-related diagnoses.

Figure 25

Hospital inpatient stays involving opioid-related diagnoses per 100,000 population, 2005-2017. Note: For this measure, lower rates are better.

• From 2005 to 2017, overall, the rate of hospital inpatient stays related to opioid use increased from 136.8 to 300.0 per 100,000 population (Figure 25).
• The 2015 achievable benchmark was 103 per 100,000 population. There is no evidence of progress toward the benchmark.
• The top 5 states that reached the achievable benchmark are Georgia, Iowa, Nebraska, Texas, and Wyoming.

Worsening Trend: Suicide Mortality

Many patients who have completed suicide have encountered or sought healthcare treatment for comorbidities such as depression and anxiety within a year of their death. Still, some patients contemplating suicide go undetected by healthcare providers across multiple settings of care. Researchers have demonstrated that suicide ideation and completion is highest among adults age 65 and over, some of whom may receive care in long-term care facilities such as nursing homes.^58,59

Figure 26

Suicide deaths among people age 12 and over, per 100,000 population, 2008-2017.

• From 2008 to 2017, overall, the rate of suicide deaths among people age 12 and over increased from 14.0 to 16.9 per 100,000 population (Figure 26). In 2017, this rate represented more than 47,109 deaths.
• The 2015 achievable benchmark was 9.4 per 100,000 population. There is no evidence of progress toward the benchmark.
• The top 5 states that reached the achievable benchmark are District of Columbia, Maryland, Massachusetts, New Jersey, and New York.

Resources

Efforts to promote effective treatment are underway within HHS:

• At the Agency for Healthcare Research and Quality, the agency has published an evidence reviews, a rapid review, several statistical briefs on opioid use. In May 2020, the U.S. Preventive Services Task Force published a recommendation statement on Illicit Drug Use in Children, Adolescents, and Young Adults: Primary Care-Based Interventions.
• AHRQ has also sponsored the development of tools and grant programs, including:

  • Six Building Blocks: A Team-Based Approach to Improving Opioid Management in Primary Care. An AHRQ grantee developed a structured systems-based approach for primary care providers and their staff members to improve management of patients on chronic opioid therapy.
  • The Academy: Integrating Behavioral Health and Primary Care. AHRQ has previously sponsored the Academy works to expand the integration of behavioral healthcare and primary care. It also supports those who are implementing medication-assisted treatment (MAT) in primary care settings.
• Civil Rights and the Opioid Crisis, a public education campaign implemented by the HHS Office for Civil Rights (OCR) to improve access to evidence-based opioid use disorder treatment and recovery services, such as MAT. This campaign helps covered entities know their obligations under federal nondiscrimination laws, including laws prohibiting discrimination on the basis of disability or limited English proficiency. The campaign includes a video by OCR Director Roger Severino, fact sheets, digital postcards, and a newsletter.
• The National Institutes of Health published How To Help Someone Thinking of Suicide, a one-page handout available in 10 languages that teaches people how to help someone thinking of suicide. It identifies signs, symptoms, and behaviors of someone who may be thinking of suicide. It also provides a list of actions people can take to assist a person in crisis. Finally, the handout provides the phone number and web link for the Suicide Prevention Lifeline.
• The Centers for Disease Control and Prevention have published Preventing Suicide: A Technical Package of Policy, Programs, and Practices, a select group of strategies based on the best available evidence to help communities and states sharpen their focus on prevention activities with the greatest potential to prevent suicide. These strategies include strengthening economic supports; strengthening access and delivery of suicide care; creating protective environments; promoting connectedness; teaching coping and problem-solving skills; identifying and supporting people at risk; and lessening harms and preventing future risk.
• The Substance Abuse and Mental Health Services Administration (SAMHSA) has several suicide prevention resources, including tools focused on American Indian and Alaska Native communities, a toolkit for high schools, and videos.
• In fiscal year 2020, SAMHSA implemented a grant program called Implement Zero Suicide in Health Systems. The Zero Suicide model is a comprehensive, multisetting approach to suicide prevention in health systems. This program is designed to raise awareness of suicide, establish referral processes, and improve care and outcomes for individuals age 25 years and over who are at risk for suicide. Grant recipients, such as the Suicide Prevention Resource Center, work to implement the Zero Suicide model throughout their health system.

Examining Effective Treatment Measures by Topic Areas

Figure 27

Number and percentage of all effective treatment measures improving, not changing, or worsening from 2000 to 2018, by disease category. Key: n = number of measures. Note: For each measure with at least four data points over time, the estimates are realigned (more...)

Core measures listed below are noted as improving (green), not changing (yellow) or worsening (red) over time. For more information on how this analysis was conducted, consult the NHQDR Introduction and Methods. For more details about the measures shown here, please visit the NHQDR website (https://nhqrnet.ahrq.gov/inhqrdr/).

Table 16

Cancer Measures. Among a total of 6 cancer measures, all measures improved over time. These include measures regarding colorectal, breast, and lung cancer.

Table 17

Cardiovascular Disease Measures. The core set of measures includes one measure examining hypertension. It is not changing over time.

Table 18

Chronic Kidney Disease Measures. All 6 chronic kidney measures pertain to the care of end stage renal disease (ESRD). Three measures improved, and 3 did not change over time.

Table 19

Diabetes Measures. Seven measures relate to diabetes care and none were changing over time.

Table 20

HIV/AIDS Measures. The core set of measures includes 3 measures that examine HIV management, among which one examines HIV infection mortality. All 3 measures were improving over time.

Table 21

Mental Health and Substance Use Disorder Measures. The core set of measures includes only one measure improving over time, which examines depression treatment among nursing home residents. Five measures were not changing and 3 were worsening. The worsening (more...)

Table 22

Musculoskeletal Disease Measures. The core set of measures includes only one measure that examines musculoskeletal disease. This measure was not changing over time.

Table 23

Respiratory Disease Measures. The core set of measures includes 3 measures pertaining to respiratory disease. Two measures pertaining to respiratory treatment were improving over time. The core set also includes a care coordination measure pertaining (more...)

Morbidity and Mortality

Healthy living is supported through preventive care strategies that cross all age groups and the care continuum. Among the most impactful preventive strategies include immunization and vaccination for children and prenatal care.

Advances in medical science protect children against more diseases than ever before. Some diseases that once injured or killed thousands of children have been eradicated completely and others are close to eradication, primarily due to safe and effective vaccines. Polio is one example of the great impact vaccines have had in the United States. Polio was once America’s most feared disease, causing death and paralysis across the country, but today, thanks to vaccination, there are no reports of polio in the United States.

Effective and continuous prenatal care can also improve the birth and health outcomes for mothers and children. Currently, the NHQDR tracks one preventive health measure related to maternal health (i.e., women who completed a pregnancy in the last 12 months who received early and adequate prenatal care).

Research has shown that most cases of maternal mortality and severe maternal morbidity are preventable, and prevention strategies can directly reduce morbidity and mortality.^60,61,62 Recognition is growing of the need to develop, monitor, and improve performance on quality measures in obstetrics care, particularly around disparities.⁶³ Addressing disparities in maternal health and birth outcomes is a national priority, covered in The Surgeon General’s Call to Action To Improve Maternal Health.⁶⁴

Cost

There is a strong body of research that shows the cost effectiveness of immunization; however, there are still opportunities for providers, patients and systems to optimize immunization participation. It is less expensive to prevent a disease using immunization than to treat it. In a 2005 study on the economic impact of routine childhood immunization in the United States, researchers estimated that for every dollar spent, the vaccination program saved more than $5 in direct costs and approximately $11 in additional costs to society.⁶⁵

Improving Trend: Influenza Vaccinations in Home Health Patients

Influenza vaccination is a proven preventative strategy for reducing the incidence of influenza. All people ages 6 months or older are recommended to receive the vaccination and vulnerable populations including home health patients are especially encouraged to do so.⁶⁶

Figure 28

Home health patients who had influenza vaccination during flu season, 2013-2017.

• From 2013 to 2017, overall, the percentage of home health patients who had influenza vaccinations during the flu season increased from 71.5% to 95.0% (Figure 28).
• The 2015 achievable benchmark was 94.1%. The outcome in 2017 was better than the benchmark.
• The top 10% of states that reached the achievable benchmark are Montana, Nebraska, North Dakota, South Dakota, Vermont, and Wisconsin (more than 5 states reached the benchmark due to ties).

Improving Trend: Physical Restraint Use in Nursing Home Residents

Long-stay residents typically enter a nursing facility because they can no longer care for themselves at home. They tend to remain in the facility for several months or years. Most residents want to care for themselves, and the ability to perform daily activities is important to their quality of life. While some functional decline among residents cannot be avoided, high-quality nursing home care should minimize the rate of decline and the number of patients experiencing decline.

Figure 29

Long-stay nursing home residents with physical restraints, 2013-2017. Note: For this measure, lower rates are better.

• From 2013 to 2017, overall, the percentage of long-stay nursing home patients with physical restraints decreased from 1.33% to 0.38% (Figure 29).
• The 2015 achievable benchmark was 0.27%. At the current rate of decrease, the benchmark could be met in about 1 year.
• The top 10% of states (based on 35 states with data) that reached the achievable benchmark are Arizona, Kansas, Minnesota, Nebraska, and New Hampshire (more than 4 states reached the benchmark due to ties).

Improving Trend: Adolescent Tdap Vaccination

CDC’s Advisory Committee on Immunization Practices recommends routine vaccination for tetanus, diphtheria, and pertussis. Infants and young children are recommended to receive a 5-dose series of diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccines, with one adolescent booster dose of Tdap vaccine. One study noted that the cost per quality-adjusted life-year saved from immunization would be approximately $163,361 (booster at 16 years) and $204,556 (booster at 21 years).⁶⁷

Figure 30

Adolescents ages 16-17 who received 1 or more doses of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) since the age of 10 years, 2008-2017.

• From 2008 to 2017, overall, the percentage of adolescents ages 16-17 years who received 1 or more doses of Tdap vaccine increased from 31.9% to 89.0% (Figure 30).
• The 2015 achievable benchmark was 96%. At the current rate of increase, overall, the benchmark could be achieved in 1 year.
• The top 5 states that reached the achievable benchmark are Alabama, Georgia, Missouri, Rhode Island, and Vermont.

Worsening Trend: Pneumococcal Vaccinations in Nursing Home Residents

The Advisory Committee on Immunization Practices (ACIP) recommends that all adults over 65 years of age and those with risk factors including chronic disease diagnosis should receive pneumococcal vaccinations.⁶⁸

Figure 31

Long-stay nursing home residents who were assessed for pneumococcal vaccination, 2013-2017.

• From 2013 to 2017, overall, the percentage of long-stay nursing home residents who were assessed for pneumococcal vaccination decreased from 93.8% to 92.5% (Figure 31).
• The 2015 achievable benchmark was 97%. There is no evidence of progress toward the benchmark.
• The top 10% of states that reached the achievable benchmark are Delaware, Mississippi, New Hampshire, North Dakota, Utah, and Wisconsin (more than 5 states reached the benchmark due to ties).

Worsening Trend: Incontinence in Nursing Home Residents

Urinary and fecal incontinence affect 50% or more of nursing home residents. This condition is exacerbated by residents facing increased prevalence of dementia and inability to care for themselves independently.⁶⁹ Research has shown that incontinence can be cured or successfully managed. However, some caregivers lack sufficient knowledge to intervene appropriately.⁷⁰

Figure 32

Low-risk, long-stay nursing home residents with loss of control of bowels or bladder, 2013-2017.

• From 2013 to 2017, overall, the percentage of low-risk, long-stay nursing home residents with loss of control of bowels or bladders increased from 64.2% to 74.3% (Figure 32).
• The 2015 achievable benchmark was 63%. There is no evidence of progress toward the benchmark.
• The top 10% of states (based on 34 states) that reached the achievable benchmark are Missouri, Nebraska, and New Jersey.

Worsening Trend: Receipt of Pap Smear

The U.S. Preventive Services Task Force recommends cervical cancer screening as part of routine health maintenance for women ages 21 through 65. Cervical cancer incidence and mortality rates have declined since the introduction of the Pap smear in the mid-20th century, and rates continue to decline to this day; however, the overall rate of women receiving preventive care is declining.⁷¹

Figure 33

Women ages 21-65 who received a Pap smear in the last 3 years, 2000-2018. Note: The NHIS cancer supplement is not administered annually. U.S. Preventive Services Task Force guidelines for cervical cancer screening changed in 2012 and 2018 to include additional (more...)

• From 2000 to 2018, overall, the percentage of women ages 21-65 who received a Pap smear in the last 3 years decreased from 87.5% to 80.5%% (Figure 33).
• The 2015 achievable benchmark was 84.2%. There is no evidence of progress toward the benchmark.
• The top 10% of states (based on 43 states) that reached the achievable benchmark are District of Columbia, Illinois, Massachusetts, and North Carolina.

Resources

Efforts to promote healthy living are underway within HHS. For example:

• AHRQ sponsors the U.S. Preventive Services Task Force, a group of independent volunteer clinicians who review evidence-based clinical guidelines and offer clinical recommendations to the provider community. Their recommendations include preventive healthcare strategies, such as cervical cancer screening.
• The CAHPS Ambulatory Care Improvement Guide includes Strategy 6R, Reminder Systems for Immunizations and Preventive Services directed to patients and to clinicians.

Summarizing Healthy Living Measures by Topic Areas

The core healthy living measure trends in the 2019 NHQDR are summarized in Figure 34 by topic area. The topic areas are clinical preventive services, functional status preservation and rehabilitation, supportive and palliative care, lifestyle modification, and maternal and child health.

Figure 34

Number and percentage of all healthy living measures improving, not changing, or worsening from 2000 to 2018, by topic areas.

The Clinical Preventive Services measures (n=44) in the Healthy Living section are further broken out by sub-areas due to the volume of measures in Figure 34. These sub-areas include adult preventive care, childhood immunization, other childhood preventive care, and overall preventive care.

Figure 35

Number and percentage of all clinical preventive services measures improving, not changing, or worsening from 2000 to 2018, by sub-areas. Key: n = number of measures. Note: For each measure with at least four data points over time, the estimates are realigned (more...)

Core measures listed below are noted as improving (green), not changing (yellow), or worsening (red) over time. For more information on how this analysis was conducted, consult the NHQDR Introduction and Methods. For more details about the measures shown here, visit the NHQDR website (https://nhqrnet.ahrq.gov/inhqrdr/).

The measures represented in Figures 34 and 35 are represented in tables 24-31 below. For more information about the average annual percentage change and the statistical significance for these measures, visit {insert link here}.

Table 24

Clinical Preventive Measures: Adult Preventive Care. The core set of measures includes 7 measures that were improving. Improving measures included 1 measure examining adult cholesterol, 2 cancer screening measures, and 4 measures pertaining to influenza (more...)

Table 25

Clinical Preventive Measures: Childhood Immunization. The core set of childhood immunization measures includes 9 measures that were improving and 5 measures that were not changing over time. These measures pertain to vaccines for tetanus-diphtheria-acellular (more...)

Table 26

Clinical Preventive Measures: Other Childhood Preventive Care. Six improving measures pertain to multiple sub-areas, including height/weight measurement, wellness visits, vision screening, and counseling about travel safety. Five measures were not changing (more...)

Table 27

Clinical Preventive Measures: Overall Preventive Care. The core set of measures includes 2 measures improving over time that look at influenza vaccination in home health care and nursing home care. Two nursing home measures did not change over time and (more...)

Table 28

Functional Status Preservation and Rehabilitation Measures. The core set of measures includes four home health measures that were improving over time. One nursing home measure also improved and one measure was not changing over time.

Table 29

Supportive and Palliative Care Measures. Six measures pertaining to nursing home care and home health care improved over time. Two measures, one examining weight loss in nursing home residents and one related to home health care, did not change over time. (more...)

Table 30

Lifestyle Modification Measures. Five core measures improved over time. These measures examine related topics, including diet, obesity, smoking in adults, and exercise or fitness. Three measures were not changing over time and include measures examining (more...)

Table 31

Maternal and Child Health Measures. The core set of measures includes only one measure that examines breastfeeding and this measure improved over time. Two measures examined infant mortality and low birth weight. These measures were not changing over (more...)