Chartpack 2008 PDF
Transcript of Chartpack 2008 PDF
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JULY 2008
COMMISSION ON A HIGH PERFORMANCE HEALTH SYSTEM
ONE EAST 75TH STREET
NEW YORK, NY 10021-2692
TEL 212.606.3800
FAX 212.606.3500
www.commonwealthfund.org
National Scorecard on
U.S. Health System Performance, 2008
Chartpack
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This Chartpack presents data forall indicators scored in theNational Scorecard on U.S. HealthSystem Performance, 2008. Charts
display average performancefor the U.S. as a whole and therange of performance foundwithin the U.S or compared withother countries.
The charts accompany theCommissions July 2008 report,Why Not the Best? Results from aNational Scorecard on U.S. Health
System Performance, 2008.
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Scores: Dimensions of a High Performance Health System
75
72
67
52
70
67
72
71
58
53
71
65
0 100
Healthy Lives
Quality
Access
Efficiency
Equity
OVERALL SCORE
2006 Revised
2008
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 2
HEALTHY LIVES
SECTION 1. HEALTHY LIVES
Scored Indicators:
1. Mortality amenable to health care
2. Infant mortality rate
3. Healthy life expectancy at age 60*
4. Adults under 65 limited in any activities because of health problems
5. Children who missed 11 or more days of school due to illness orinjury*
* Indicator was not updated due to lack of data. Baseline figures from 2006 Scorecard are presented.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 3
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7681
8884
89 89
99 9788
97
109 106
116 115 113
130 134
128
115
65 71 71 74 74 77 80
82 82 84 84 90 93 96
101 103 103 104 110
0
50
100
150
France
Japan
Australia
Spain
Italy
Canada
Norway
Netherlands
Sweden
Greece
Austria
Germany
Finland
New
Zealan
Denmark
United
Kingdo
Ireland
Portugal
United
States
1997/98 2002/03
Deaths per 100,000 population*
* Countries age-standardized death rates before age 75; including ischemic heart disease, diabetes, stroke, and bacterial infections.
See report Appendix B for list of all conditions considered amenable to health care in the analysis.
Data: E. Nolte and C. M. McKee, London School of Hygiene and Tropical Medicine analysis of World Health Organization mortality
files (Nolte and McKee 2008).
Mortality Amenable to Health Care
HEALTHY LIVES
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 4
7.2 7.0 6.9 6.8 7.0 6.8 6.8
10.3
11.1
10.2 9.9 9.9 9.610.1
5.3 5.1 5.0 4.9 4.8 4.7 4.7
0
4
8
12
1998 1999 2000 2001 2002 2003 2004
U.S. average Bottom 10% states Top 10% states
National Average and State Distribution International Comparison, 2004
2.8 2.8 3.1 3.2 3.3
4.4
5.3
6.8
Japan
Icelan
d
Sweden
Norway
Finlan
d
Denm
ark
Canada U.S
.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 5
Infant Mortality Rate
Infant deaths per 1,000 live births
^ Denotes baseline year.
Data: National and stateNational Vital Statistics System, Linked Birth and Infant Death Data (AHRQ 2003, 2004, 2005,
2006, 2007a); international comparisonOECD Health Data 2007, Version 10/2007.
HEALTHY LIVES
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Healthy Life Expectancy at Age 60, 2002
222020 2020 201919 19 1919191919 1818 18 18 18181817 1718 17 1716 1717 161616 1616 16
181616 16 1616 1515 1515
14
0
10
20
30
Japan
Switz
erlan
FranceSp
ain
Sweden
Australia Ita
ly
Austria
Cana
da
Belgium
Germ
any
Norw
ay
Iceland
Finland
Netherlan
ds
NewZe
alan
Greece
Unite
dKing
do
Unite
dStates
Portu
gal
Irelan
d
Denm
ark
CzechRepubli
Women Men
Years
Note: Indicator was not updated due to lack of data. Baseline figures are presented.
Data: The World Health Report 2003 (WHO 2003, Annex Table 4).
Developed by the World Health Organization, healthy life expectancy is based on
life expectancy adjusted for time spent in poor health due to disease and/or injury
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 6
HEALTHY LIVES
Working-Age Adults with Health Limits on Activities or Work
Data: D. Belloff, Rutgers Center for State Health Policy analysis of Behavioral Risk Factor Surveillance System.
7
Percent of adults (ages 1864) limited in any activities because of physical,mental, or emotional problems
8.3
13.4
24.2
10.3
15.4
27.4
Age 1829 Age 3049 Age 5064
2004 2006
14.9
11.5
20.1
17.5
13.2
23.4
0
10
20
30
40
U.S. Average Top 10% States Bottom 10%
States
2004 2006
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 7
National Average and State Distribution By Age Group
HEALTHY LIVES
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Note: Indicator was not updated due to lack of data. Baseline figures from Scorecard 2006 are presented.
Data: 2003 National Survey of Childrens Health (HRSA 2005; retrieved f rom Data Resource Center for Child and Adolescent
Health database at http://www.nschdata.org).
Percent of children (ages 617) who missed 11 or more school daysdue to illness or injury during past year
School Absences Due to Illness or Injury, by Top and Bottom States,Race/Ethnicity, Family Income, and Insurance, 2003
4.7
4.2
3.6
4.8
5.5
8.1
3.8
5.2
8.0
4.2
0 5 10
Uninsured
Private insurance
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Effective Care
Scored Indicators:
1. Adults received recommended screening and preventive care
2. Children received recommended immunizations and preventive care
Received all recommended doses of five key vaccines
Received both medical and dental preventive care visits*
3. Needed mental health care and received treatment
Adults
Children*
4. Chronic disease under control
Adults with diabetes whose HbA1c level
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Immunizations for Young Children
^ Denotes baseline year.
* Recommended vaccines include: 4 doses of diphtheria-tetanus-pertussis (DTP), 3+ doses of polio, 1+ dose of measles-mumps-
rubella, 3+doses of Haemophilus influenzae type B, and 3+ doses of hepatitis B vaccine. **Data by insurance was from 2003.
Data: National Immunization Survey (NCHS National Immunization Program, Allred 2007).
Percent of children (ages 1935 months) who received all recommended doses of five key vaccines*
73 74 7579 81 81 81
82 80 84
89 88 88 86
66 66 65
71 72 71 72
0
25
50
75
100
2000 2001 2002 2003 2004 2005 2006
U.S. average Top 10% states Bottom 10% states
QUALITY: EFFECTIVE CARE
By Family Income, Insurance Status**,and Race/Ethnicity, 2006
71
75
83
82
77
80
77
82
0 25 50 75 100
Uninsured all year
Insured part year
Insured all year
100%+ of poverty
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50
87
80
52
69
60
71
73
65
0 20 40 60 80 100
Uninsured
Medicare**
Medicaid
Private
Hispanic
Black
White
2006
2004
QUALITY: EFFECTIVE CARE
Adults with Major Depressive Episode Who Received Treatment
U.S. Variation 2006
U.S. Average
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 14
Percent of adults (ages 18+) with major depressive episode who received
treatment in the past year*
Note: Indicator definition has been modified from 2006 Scorecard.
*Major depressive episode is defined as a period of at least 2 weeks when a person experienced a depressed mood or loss of
interest or pleasure in daily activities and had a majority of the symptoms for depression. **Medicare includes other insurance such
as military and veterans health care.
Data: National Survey on Drug Use and Health (SAMHSA 2006 and 2007).
Note: Indicator was not updated due to lack of data. Baseline figures are presented.
* Children with current emotional, developmental, or behavioral health condition requiring treatment or counseling who received
needed care during the year.Data: 2003 National Survey of Childrens Health (HRSA 2005; Retrieved f rom Data Resource Center for Child and Adolescent
Health database at http://www.nschdata.org).
Percent of children (ages
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Chronic Disease Under Control: Diabetes and Hypertension
81
41
63
21
Diabetes under
control*
High blood pressure
under control**
Insured Uninsured
*Refers to diabetic adults whose HbA1c is
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9691
87
99 9895
88
7176
Heart Attack Heart Failure Pneumonia
Median 90th %ile 10th %ile
84
99
91
75
90
10096
78
0
25
50
75
100
Median Best 90th %ile 10th %ile
2004 2006
Overall Composite for All Three Conditions
QUALITY: EFFECTIVE CARE
Hospitals: Quality of Care for Heart Attack, Heart Failure,and Pneumonia
* Composite for heart attack care consists of 5 indicators; heart failure care, 2 indicators; and pneumonia care, 3 indicators.
Overall composite consists of all 10 clinical indicators. See report Appendix B for description of clinical indicators.
Data: A. Jha and A. Epstein, Harvard School of Public Health analysis of data from CMS Hospital Compare.
Percent of patients who received recommendedcare for all three conditions*
Individual Composites by Condition, 2006
Percent of patients who received recommendedcare for each condition*
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 18
87
74
91 89
82
94100
0
25
50
75
100
Median Best 90th %ile 10th %ile Best 90th %ile 10th %ile
Percent of patients who received recommended care for all three conditions
Hospital Quality of Care for Heart Attack, Heart Failure, and Pneumonia:
Overall Composite Using Expanded Set of 19 Clinical Indicators*, 2006
*Consists of original 10 "starter set" indicators and 9 new indicators for which data was made available as of December 2006;
heart attack care includes 3 new indicators; heart failure care, 2 new indicators; and pneumonia, 4 new indicators)
Data: A. Jha and A. Epstein, Harvard School of Public Health analysis of data from CMS Hospital Compare.
Hospitals States
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 19
QUALITY: EFFECTIVE CARE
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Hospital Quality of Care by Condition: Composites for Heart Attack,Heart Failure, and Pneumonia
6983
7991
8292
6676
8895
99100
7887
(Original: 3 indicators)
20042006
758790619510083(Expanded: 4 indicators*) 2006
929798879810095(Expanded: 8 indicators*) 2006
Pneumonia
Heart failure
Acute myocardial infarction
839091779410087(Expanded: 7 indicators*) 2006
STATESHOSPITALS
79
81
89
93
91
94
62
71
94
98
100
100
83
91
(Original: 2 indicators)
2004
2006
89
93
96
97
97
98
80
88
98
99
100
100
92
96
(Original: 5 indicators)
2004
2006
10thpercentile
90thpercentile
Best10th
percentile90th
percentileBestMedian
Percent of patients who received
recommended care:
20Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 20
QUALITY: EFFECTIVE CARE
*Consists of original "starter set" indicators and new indicators for which data was made available as of December 2006.
Data: A. Jha and A. Epstein, Harvard School of Public Health analysis of data from CMS Hospital Compare.
Coordinated Care
Scored Indicators:
1. Adults under 65 with an accessible primary care provider
2. Children with a medical home*
3. Care coordination at hospital discharge
Hospitalized patients with new Rx: Medications were reviewedat discharge*
Heart failure patients received written instructions at discharge
Follow-up within 30 days after hospitalization for mental healthdisorder
4. Nursing homes: hospital admissions and readmissions
5. Home health: hospital admissions
QUALITY: COORDINATED CARE
* Indicator was not updated due to lack of data. Baseline figures from 2006 Scorecard are presented.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 21
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37
51
74
63
69
65
66
49
53
73
59
0 20 40 60 80 100
Uninsured all year
Uninsured part year
Insured all year
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86
7773 72
69 67
0
25
50
75
100
GER AUS UK CAN NZ US
Percent of hospitalized patients with new prescription who reportedprior medications were reviewed at discharge
Medications Reviewed When Discharged from the Hospital,Among Sicker Adults, 2005
Note: Indicator was not updated due to lack of data. Baseline figures from Scorecard 2006 are presented.
AUS=Australia; CAN=Canada; GER=Germany; NZ=New Zealand; UK=United Kingdom; US=United States.
Data: 2005 Commonwealth Fund International Health Policy Survey.
QUALITY: COORDINATED CARE
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 24
50
87
9
49
61
33
68 69
80
56
36
94
0
25
50
75
100
U.S. mean 90th %ile 10th %ile Median 90th %ile 10th %ile
2004 2006
Percent of heart failure patients discharged home with written instructions*
Heart Failure Patients Given Complete Written Instructions WhenDischarged, by Hospitals and States
QUALITY: COORDINATED CARE
* Discharge instructions must address all of the following: activity level, diet, discharge medications, follow-up appointment,
weight monitoring, and what to do if symptoms worsen.
Data: A. Jha and A. Epstein, Harvard School of Public Health analysis of data from CMS Hospital Compare;
State 2004 distribution Retrieved from CMS Hospital Compare database at http://www.hospitalcompare.hhs.gov.
Hospitals States
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 25
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Home Health Care: Hospital Admissions
28
17
47
20
35
28
19
48
20
37
0
20
40
60
Mean Top 25% Bottom 25% Top 10% Bottom 10%
2003-2004^ 2006-2007
^ 2003 data for state estimates.
Data: Outcome and Assessment Information Set (Retrieved from CMS Home Health Compare database at
http://www.medicare.gov/HHCompare, Pace et al. 2005)
Percent of home health care patients who had to be admitted to the hospital
QUALITY: COORDINATED CARE
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 28
Home Health Agencies States
Safe CareScored Indicators:
1. Patients reported medical, medication, or lab test error
2. Unsafe drug use
Ambulatory care visits for treating adverse drug effects
Children prescribed antibiotics for throat infection withouta strep test
Elderly used 1 of 33 inappropriate drugs
3. Nursing home residents with pressure sores
4. Hospital-standardized mortality ratios
Other Indicators:
1. Surgical infection prevention
2. Adverse events and complications of care in hospitals
QUALITY: SAFE CARE
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 29
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Medical, Medication, and Lab Errors, Among Sicker Adults
3432
1921 22
2628
30
0
10
20
30
40
GER NETH UK NZ CAN AUS
International Comparison
AUS=Australia; CAN=Canada; GER=Germany; NETH=Netherlands; NZ=New Zealand; UK=United Kingdom.
Data: 2005 and 2007 Commonwealth Fund International Health Policy Survey.
EXHIBIT 16
2005 2007
United States
QUALITY: SAFE CARE
Percent reporting medical mistake, medication error, or lab error in past two years
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 30
Ambulatory Care Visits for Treating Adverse Drug Effects
20
22
18
21
17
9
28
1716
22
0
10
20
30
Total
Male
Fema
leWh
iteBl
ack
Othe
r
North
eas
Midw
est
Sout
hW
est
* Denotes baseline year.Data: C. Zhan, AHRQ analysis of National Ambulatory Medical Care Survey and National Hospital Ambulatory
Medical Care Survey.
Visits per 1,000 population per year
QUALITY: SAFE CARE
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 31
11.3
12.9
15.3
11.3
17.4
19.8
1999 2000 2001* 2002 2003 2004
Total
Physician Office
Hospital Emergency Department Visits
Hospital Outpatient Department Visits
By Gender, Race, and Region, 2004 Annual Averages, by Care Setting
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Pressure Sores Among High-Risk and Short-Stay Residentsin Nursing Facilities
13
8
18
13
7
17
0
10
20
30
U.S. average Top 10% states Bottom 10%
states
2004 2006
Percent of nursing home residents with pressure sores
19
14
24
17
12
23
U.S. average Top 10% states Bottom 10%
states
2004 2006
High-Risk Residents Short-Stay Residents
Data: Nursing Home Minimum Data Set (AHRQ 2005, 2007a).
QUALITY: SAFE CARE
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 34
Hospital-Standardized Mortality Ratios
101
8593 94
97 100 103 106 106
112 118
8274
78 78 79 81 83 83 85 86
89
0
20
40
60
80
100
120
140
U.S. 1 2 3 4 5 6 7 8 9 10
2000-2002 2004-2006
Ratio of actual to expected deaths in each decile (x 100)
Decile of hospitals ranked by actual to expected deaths ratios
Standardized ratios compare actual to expected deaths, risk-adjusted forpatient mix and community factors.* Medicare national average for 2000=100
QUALITY: SAFE CARE
mean
* See report Appendix B for methodology.
Data: B. Jarman analysis of Medicare discharges from 2000 to 2002 and from 2004 to 2006 for conditions leading to 80 percent of
all hospital deaths.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 35
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80
60
90 87
73
92
100
0
25
50
75
100
Median Best 90th %ile 10th %ile Best 90th %ile 10th %ile
Surgical Infection Prevention, 2006
Hospitals States
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 36
QUALITY: SAFE CARE
Percent of surgical patients who received appropriate timing of antibiotics
to prevent infections*
* Comprised of two indicators: antibiotics started within 1 hour before surgery and stopped 24 hours after surgery.
Data: A. Jha and A. Epstein, Harvard School of Public Health analysis of data from CMS Hospital Compare.
Nosocomial Infections in Intensive Care Unit Patients, 2006
9.54.11.70.00.036Neonatal (NICU)(infants weighing 750 grams or less)
10.06.44.11.80.061Surgical
6.23.81.60.00.099Medical-surgicalall others
7.35.12.51.30.058Medical-surgicalmajor teaching
7.24.62.80.90.064Medical
955No. of unitsType of ICUPercentile
Ventilator-associated pneumoniarate, per 1,000 days use
15.611.05.22.50.042NeonatalLevel III(infants weighing 750 grams or less)
7.44.42.00.90.072Surgical
4.52.31.00.00.0102Medical-surgicalall others
5.53.11.90.60.063Medical-surgicalmajor teaching
6.24.22.20.00.073Medical
955No. of unitsType of ICUPercentile
Central line-associated bloodstreaminfection rate, per 1,000 days use
Data: Reported by 211 hospitals participating in the National Healthcare Safety Network (Edwards et al. 2007).
37
QUALITY: SAFE CARE
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 37
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Potentially Preventable Adverse Events and Complicationsof Care in Hospitals, National and Medicare Trends
25
16
34
48
53
82
131
105
98
89
276
261
2004
25
16
34
47
50
86
120
92
92
86
267
248
2003
Accidental puncture or laceration
NA474438National
35363231Medicare
NA151412National
15242020Medicare
Infection due to medical care
59463425Medicare
NA807263National
Postoperative respiratory failure
1211119780Medicare
NA928163National
Postoperative sepsis
100867162Medicare
NA796658National
Postoperative pulmonary embolismor deep vein thrombosis
282251225206Medicare
NA236221195National
Decubitus ulcer (pressure sore)
2005200220001997/1998**Risk-adjusted rate per 10,000discharges*
* Rates exclude complications present on admission and are adjusted for gender, comorbidities,
and diagnosis-related group clusters. ** National rate is for 1997, Medicare rate is for 1998. NA=data not available.
Data: National figuresHealthcare Cost and Utilization Project, Nationwide Inpatient Sample (retrieved from HCUPNet at
http://hcupnet.ahrq.gov); Medicare figuresMedPAC analysis of Medicare administrative data using AHRQ indicators andmethods (MedPAC 2005, Chart 3-3 and 2007, Chart 4-2).
38
QUALITY: SAFE CARE
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 38
Potentially Preventable Adverse Events and Complications
of Care in Hospitals Among Medicare Beneficiaries, 20042005
2.4
9.8
4.6
1.9
8.8
3.63.6
10.6
6.0
0
5
10
15
Postoperative
complications composite*
Adverse drug events
composite**
Pressure sores
US Average Top 10% States Bottom 10% States
Percent
39Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 39
QUALITY: SAFE CARE
*Surgical patients with postoperative pneumonia, urinary tract infection (2005 only), or venous thromboembolic event
** Patients with serious bleeding associated with intravenous heparin, low molecular weight heparin, or warfarin, or hypoglycemia
associated with insulin or oral hypoglycemics.
Data: M. Pineau, Qualidigm analysis of Medicare Patient Safety Monitoring System.
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Patient-Centered, Timely Care
Scored Indicators:
1. Ability to see doctor on same/next day when sick or need medicalattention
2. Very/somewhat easy to get care after hours without going to theemergency room
3. Doctorpatient communication: always listened, explained, showedrespect, spent enough time
4. Adults with chronic conditions given self-management plan*
5. Patient-centered hospital care
Other Indicator:
1. Physical restraints in nursing homes
QUALITY: PATIENT-CENTERED, TIMELY CARE
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 40
* Indicator was not updated due to lack of data. Baseline figures from 2006 Scorecard are presented.
Waiting Time to See Doctor When Sick or Need Medical Attention,Among Sicker Adults
47 46
7469
6358 57
32
0
25
50
75
100
NZ NETH GER AUS UK CAN
International Comparison
AUS=Australia; CAN=Canada; GER=Germany; NETH=Netherlands; NZ=New Zealand; UK=United Kingdom.
Data: 2005 and 2007 Commonwealth Fund International Health Policy Survey.
EXHIBIT 16
2005 2007
United States
QUALITY: PATIENT-CENTERED, TIMELY CARE
Percent of adults who could get an appointment on the same or next day
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 41
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Difficulty Getting Care on Nights, Weekends, Holidays WithoutGoing to the Emergency Room, Among Sicker Adults
61
73
48 49 50
6168 69
0
25
50
75
100
NETH NZ GER UK AUS CAN
International Comparison
QUALITY: PATIENT-CENTERED, TIMELY CARE
Percent of adults who sought care reporting very or somewhat difficult
AUS=Australia; CAN=Canada; GER=Germany; NETH=Netherlands; NZ=New Zealand; UK=United Kingdom.
Data: 2005 and 2007 Commonwealth Fund International Health Policy Survey.
2005 2007
United States
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 42
DoctorPatient Communication: Doctor Listened Carefully,
Explained Things, Showed Respect, and Spent Enough Time,National and Managed Care Plan Type
70 7067
75 74 73
65 6359
Private Medicare** Medicaid
Mean 90th %ile 10th %ile
43
Percent of adults (ages 18+) reporting always
Managed Care Plan Distribution, 2006
* Denotes baseline year. **2005 data due to delays in the Medicare CAHPS survey.
Data: National averageMedical Expenditure Panel Survey (AHRQ 2005, 2006, 2007a); Plan distributionCAHPS (data provided
by NCQA).
54 57 57
0
25
50
75
100
2002* 2003 2004
National Average
QUALITY: PATIENT-CENTERED, TIMELY CARE
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 43
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65
58 5650
45
37
0
25
50
75
100
CAN US NZ AUS UK GER
Adults with Chronic Conditions: Receipt of Self-Management Plan,Among Sicker Adults, 2005
Note: Indicator was not updated due to lack of data. Baseline figures are presented.* Adult reported at least one of six conditions: hypertension, heart disease, diabetes, arthritis, lung problems (asthma, emphysema,
etc.), or depression.
AUS=Australia; CAN=Canada; GER=Germany; NZ=New Zealand; UK=United Kingdom; US=United States.
Data: 2005 Commonwealth Fund International Health Policy Survey.
Percent of adults with chronic conditions* whose doctor gave plan to manage care at home
QUALITY: PATIENT-CENTERED, TIMELY CARE
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 44
Patient-Centered Hospital Care: Staff Managed Pain, RespondedWhen Needed Help, and Explained Medicines, by Hospitals, 2007
6760 58
9791
96
75 7266
60
48 49
0
25
50
75
100
Staff managed pain well Staff responded when needed
help
Staff explained medicines and
side effects
Mean Best hospital 90th %ile hospitals 10th %ile hospitals
Percent of patients reporting always
* Patients pain was well controlled and hospital staff did everything to help with pain.
** Patient got help as soon as wanted after patient pressed call button and in getting to the bathroom/using bedpan.
*** Hospital staff told patient what medicine was for and described possible side effects in a way that patient could understand.
Data: CAHPS Hospital Survey (Retrieved from CMS Hospital Compare database at http://www.hospitalcompare.hhs.gov).
*** ***
45
QUALITY: PATIENT-CENTERED, TIMELY CARE
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 45
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Physical Restraints in Nursing Facilities
9.7
8.07.4
6.85.9
18.4
3.72.6
2.4 2.2 1.9
11.7
13.214.1
14.7
0
5
10
15
20
2002 2003 2004 2005 2006
U.S. average Bottom 10% states Top 10% states
PI=Pacific Islander; AI/AN=American Indian or Alaskan Native.
Data: Nursing Home Minimum Data Set (AHRQ 2004, 2005, 2006, 2007a).
7.86.9
10.7 10.2
7.66.6
5.8
8.79.8
7.7
White Black Hispanic Asian/PI AI/AN
2003 2005
By Race/Ethnicity
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 46
QUALITY: PATIENT-CENTERED, TIMELY CARE
Percent of nursing home residents who were physically restrained
National Average and State Distribution
SECTION 3. ACCESS
Access includes indicators organized into two groups:
1. Participation
2. Affordability
The Scorecard scores each group of indicators separately, and thenaverages the two scores to create the overall score for Access.
ACCESS
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 47
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Participation
Scored Indicators:
1. Adults under 65 insured all year, not underinsured
2. Adults with no access problem due to costs
Other Indicator:
1. Uninsured under 65: national and state trends
ACCESS: PARTICIPATION
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 48
Uninsured and Underinsured Adults, 2007 Compared with 2003
ACCESS: PARTICIPATION
Total 200% of poverty or moreUnder 200% of poverty
* Underinsured defined as insured all year but experienced one of the following: medical expenses equaled 10% or more of income,
or 5% or more of income if low-income (
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Access Problems Because of Costs
4037
58
12
21
25 26
0
25
50
NETH UK CAN GER NZ AUS
International Comparison
* Did not get medical care because of cost of doctors visit, skipped medical test, treatment, or follow-up because of cost, or did
not fill Rx or skipped doses because of cost.
AUS=Australia; CAN=Canada; GER=Germany; NETH=Netherlands; NZ=New Zealand; UK=United Kingdom.
Data: 2005 and 2007 Commonwealth Fund International Health Policy Survey.
EXHIBIT 16
2005 2007
United States
ACCESS: PARTICIPATION
Percent of adults who had any of three access problems* in past year because of costs
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 50
5 8
12
2125 26
37
0
25
50
75
NETH UK CAN GER NZ AUS US
6 9
18
24
32 30
52
3
8 7
1822 21
25
NETH UK CAN GER AUS NZ US
Below average income Above average income
51
* Did not get medical care because of cost of doctors visit, skipped medical test, treatment, or follow-up because of cost, or did
not fill Rx or skipped doses because of cost.
AUS=Australia; CAN=Canada; GER=Germany; NETH=Netherlands; NZ=New Zealand; UK=United Kingdom; US=United States.
Data: 2007 Commonwealth Fund International Health Policy Survey.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 51
Access Problems Because of Costs, By Income, 2007
Percent of adults who had any of three access problems* in past year because of costs
ACCESS: PARTICIPATION
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Data: Two-year averages 19992000, updated with 2007 Current Population Survey correction, and 20052006 from the
Census Bureaus March 2000, 2001 and 2006, 2007 CPS.
WA
OR
ID
MT ND
WY
NV
CA
UT
AZ NM
KS
NE
MN
MO
WI
TX
IA
ILIN
AR
LA
AL
SC
TNNC
KY
FL
VA
OH
MI
WV
PA
NY
AK
MD
MEVT
NH
MA
RI
CT
DE
DC
HI
CO
GAMS
OK
NJ
SD
WA
OR
ID
MT ND
WY
NV
CA
UT
AZ NM
KS
NE
MN
MO
WI
TX
IA
ILIN
AR
LA
AL
SC
TNNC
KY
FL
VA
OH
MI
WV
PA
NY
AK
ME
DE
DC
HI
CO
GAMS
OK
NJ
SD
19%22.9%
Less than 14%
14%18.9%
23% or more
19992000 20052006
MA
RI
CT
VTNH
MD
Percent of Adults Ages 1864 Uninsured by State
ACCESS: PARTICIPATION
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 52
Data: Two-year averages 19992000, updated with 2007 Current Population Survey correction, and 20052006 from the
Census Bureaus March 2000, 2001 and 2006, 2007 CPS.
WA
OR
ID
MT ND
WY
NV
CA
UT
AZ NM
KS
NE
MN
MO
WI
TX
IA
ILIN
AR
LA
AL
SC
TNNC
KY
FL
VA
OH
MI
WV
PA
NY
AK
MD
MEVT
NH
MA
RI
CT
DE
DC
HI
CO
GAMS
OK
NJ
SD
WA
OR
ID
MT ND
WY
NV
CA
UT
AZ NM
KS
NE
MN
MO
WI
TX
IA
ILIN
AR
LA
AL
SC
TNNC
KY
FL
VA
OH
MI
WV
PA
NY
AK
ME
DE
DC
HI
CO
GAMS
OK
NJ
SD
10%15.9%
Less than 7%
7%9.9%
16% or more
19992000 20052006
MA
RI
CT
VTNH
MD
Percent of Children Ages 017 Uninsured by State
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 53
ACCESS: PARTICIPATION
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Population Under Age 65 Without Health Insurance
17
12
16
20
12
18
0
10
20
30
All under 65 Children under 18 Adults 1864
2000 2006
Percent uninsured
9 8 8 8 8 8 8 9
29 30 31 34 35 35 36
38
0
20
40
60
1999 2000 2001 2002 2003 2004 2005 2006
Adults 1864
Children under 18
Millions uninsured
38 3839
4243
47
43
Data: Analysis of Current Population Survey, March 19952007 supplements. Updated data from March 2007 Current Population
Survey.
44
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 54
ACCESS: PARTICIPATION
Affordable Care
Scored Indicators:
1. Families spending less than 10% of income or less than 5% ofincome, if low-income, on out-of-pocket medical costs and premiums
2. Population under 65 living in states where premiums foremployer-sponsored health coverage are less than 15% of under-65median household income
3. Adults under 65 with no medical bill problems or medical debt
Other Indicator:
1. Health insurance premium trends compared with workers earningsand overall inflation
ACCESS: AFFORDABLE CARE
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 55
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Families with High Medical and Premium Costs Compared with Income,by Family Income
19
4442
15
5
16
40
29
23
44 42
21
8
20
50
27
0
20
40
60
Total Poor* Low income* Middle
income*
High
income*
Private
employer
Private
nongroup
Public
2001 2005
Percent of nonelderly population with high out-of-pocket
medical costs and premiums relative to income^
^High out-of-pocket costs defined as having combined out-of-pocket expenses for services and premiums greater than 5 percent
for persons in families with incomes less than 200% of poverty, and out-of-pocket expenses greater than 10 percent for persons in
families with incomes of 200% of poverty or higher.* Poor refers to household incomes
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33
45
29
6168
56
Total Under 200% of
poverty
200% of poverty or
more
Insured all year Uninsured during year
34
41
0
25
50
75
100
2005 2007
Medical Bill Problems or Medical Debt
By Income and Insurance Status, 2007National Average
Percent of adults (ages 1964) with any medical bill problem or outstanding debt*
ACCESS: AFFORDABLE CARE
* Problems paying or unable to pay medical bills, contacted by a collection agency for medical bills, had to change
way of life to pay bills, or has medical debt being paid off over time.Data: 2005 and 2007 Commonwealth Fund Biennial Health Insurance Survey.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 58
*Estimate is statistically different from the previous year shown at p
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SECTION 4. EFFICIENCY
Scored Indicators:
1. Potential overuse or waste Duplicate medical tests Tests results or records not available at time of appointment Received imaging study for acute low back pain with no risk factors
2. ER use for condition that could have been treated by regular doctor
3. Hospital admissions for ambulatory caresensitive (ACS) conditions National ACS admissions: Heart failure, diabetes, pediatric asthma Medicare ACS admissions
4. Medicare hospital 30-day readmission rates
5. Medicare costs of care and mortality for heart attacks, hip fractures, orcolon cancer
6. Medicare costs of care for chronic diseases: diabetes, heart failure, COPD7. Health insurance administration as percent of total national health
expenditures
8. Physicians using electronic medical records
EFFICIENCY
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 60
International Comparison of Spending on Health, 19802005
$-
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
$7,000
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
United States
GermanyCanada
FranceAustraliaUnited Kingdom
0
2
4
6
8
10
12
14
16
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
United States
GermanyCanada
FranceAustralia
United Kingdom
* PPP=Purchasing Power Parity.
Data: OECD Health Data 2007, Version 10/2007.
Average spending on healthper capita ($US PPP*)
Total expenditures on healthas percent of GDP
61
EFFICIENCY
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 61
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Duplicate Medical Tests, Among Sicker Adults
1820
4
8 9
10
15 16
0
10
20
30
NETH CAN UK NZ AUS GER
International Comparison
AUS=Australia; CAN=Canada; GER=Germany; NETH=Netherlands; NZ=New Zealand; UK=United Kingdom.
Data: 2005 and 2007 Commonwealth Fund International Health Policy Survey.
EFFICIENCY
2005 2007
United States
Percent reporting that doctor ordered test that had already been done in past two years
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 62
Test Results or Medical Records Not Available atTime of Appointment, Among Sicker Adults
2322
9
1214
17 17 18
0
10
20
30
NETH GER NZ AUS UK CAN
International Comparison
AUS=Australia; CAN=Canada; GER=Germany; NETH=Netherlands; NZ=New Zealand; UK=United Kingdom.
Data: 2005 and 2007 Commonwealth Fund International Health Policy Survey.
EFFICIENCY
Percent reporting test results/records not available at time of appointment in past two years
2005 2007
United States
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 63
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Managed Care Health Plans: Potentially InappropriateImaging Studies for Low Back Pain, by Plan Type
26
22
19
15
35
29
0
10
20
30
40
Private Medicaid
Mean 10th %ile 90th %ile
Percent of health plan members (ages 1850) who received an imaging studywithin 28 days following an episode of acute low back pain with no risk factors
25 25 26
2221 22
2004* 2005 2006
Private Medicaid
Annual averagesManaged care plans (2006)
* Denotes baseline year.
Data: Healthcare Effectiveness Data and Information Set (NCQA 2007).
EFFICIENCY
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 64
Went to Emergency Room for Condition That Could Have Been Treatedby Regular Doctor, Among Sicker Adults
26
21
68 8
11
16
19
0
10
20
30
GER NETH NZ UK AUS CAN
International Comparison
AUS=Australia; CAN=Canada; GER=Germany; NETH=Netherlands; NZ=New Zealand; UK=United Kingdom.
Data: 2005 and 2007 Commonwealth Fund International Health Policy Survey.
EFFICIENCY
2005 2007
United States
Percent of adults who went to ER in past two years for condition that could have beentreated by regular doctor if available
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 65
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Ambulatory CareSensitive (Potentially Preventable) HospitalAdmissions for Select Conditions
178
62
242
156
49
230
U.S.
Average
Top 10%
states
Bottom 10%
states
EFFICIENCY
241
137
299
240
126
293
U.S.
Average
Top 10%
states
Bottom 10%
states
2002/2003 2004
Adjusted rate per 100,000 population
498
258
631
476
246
634
0
100
200
300
400
500
600
700
U.S.
Average
Top 10%
states
Bottom
10% states
Diabetes*Heart failure Pediatric asthma
^ 2002 data for heart failure and diabetes; 2003 data for pediatric asthma. *Combines four diabetes admission measures:
uncontrolled, short-term complications, long-term complications, and lower extremity amputations.
Data: National averageHealthcare Cost and Utilization Project, Nationwide Inpatient Sample; State distributionState InpatientDatabases; not all states participate in HCUP (AHRQ 2005, 2007a).
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 66
Medicare Admissions for Ambulatory CareSensitive Conditions,Rates and Associated Costs, by Hospital Referral Regions
771
499
610
887
1043
700
465
558
816
926
0
300
600
900
1200
National
mean
10th 25th 75th 90th
2003 2005
13.4
10.0
11.8
14.7
16.3
12.6
9.8
11.1
13.6
15.2
0
5
10
15
20
National
mean
10th 25th 75th 90th
2003 2005
Rate of ACS admissions per 10,000beneficiaries
Costs of ACS admissions as percent of alldischarge costs
Percentiles Percentiles
See report Appendix B for complete list of ambulatory care-sensitive conditions used in the analysis.Data: G. Anderson and R. Herbert, Johns Hopkins University analysis of Medicare Standard Analytical Files (SAF) 5% Inpatient
Data.
EFFICIENCY
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 67
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18
16
2021
15 16
19 20
14
18
0
10
20
30
2003 2005 10th 25th 75th 90th 10th 25th 75th 90th
Medicare Hospital 30-Day Readmission Rates
Hospital Referral Region State Percentiles, 2005
Percent of Medicare beneficiaries admitted for one of 31 select conditions
who are readmitted within 30 days following discharge*
* See report Appendix B for list of conditions used in the analysis.
Data: G. Anderson and R. Herbert, Johns Hopkins University analysis of Medicare Standard Analytical Files (SAF) 5%
Inpatient Data.
EFFICIENCY
U.S. Mean
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 68
0.80
0.90
1.00
1.10
1.20
$0 $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000
Relative Resource Use**
Quality and Costs of Care for Medicare Patients Hospitalizedfor Heart Attacks, Hip Fractures, or Colon Cancer,
by Hospital Referral Regions, 2004
EFFICIENCY
* Indexed to risk-adjusted 1-year survival rate (median=0.70).
** Risk-adjusted spending on hospital and physician services using standardized national prices.
Data: E. Fisher, J. Sutherland, and D. Radley, Dartmouth Medical School analysis of data from a 20% national sample
of Medicare beneficiaries.
Median relative resource use=$27,499
Qua
lityo
fCare
*
(1-Year
Surv
iva
lIndex,
Me
dian=
70%)
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 69
Percentiles, 2005
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Quality and Costs of Care for Medicare Patients Hospitalizedfor Heart Attacks, Hip Fractures, or Colon Cancer,
by Hospital Referral Regions
30
27 28
30 31
3230
27 29
30 31
33
0
10
20
30
40
Mean of
highest
90%
10th 25th Median 75th 90th
2000-2002 2004
1-year mortality rate Annual relative resource use, 2004*
* Risk-adjusted spending on hospital and physician services using standardized national prices.
Data: E. Fisher, J. Sutherland, and D. Radley, Dartmouth Medical School analysis of data from a 20% national sample of
Medicare beneficiaries.
$28,011
$24,906$25,929
$27,499 $28,831
$30,263
Mean of
highest
90%
10th 25th Median 75th 90th
Deaths per 100 Dollars ($)
70
Percentiles Percentiles
EFFICIENCY
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 70
Costs of Care for Medicare Beneficiaries with Multiple ChronicConditions, by Hospital Referral Regions, 2001 and 2005
Heart Failure + COPD
1.48
1.36
2.03
1.77
$18,024
$20,062
$15,246
$17,180
$10,304
$12,665
$8,872
$11,317
$13,188
$15,367
2001
2005
1.43
1.40
2.14
1.99
$27,310
$32,199
$20,592
$26,035
$14,355
$18,649
$12,747
$16,144
$18,461$23,056
2001
2005
$20,960
$25,732
All 3 conditions
Ratio of percentilegroupsAverage annual reimbursement
2.13
1.89
2.102.06
90th to10th
$32,732
$37,450
$43,973
$53,019
90thpercentile
$22,415
$27,498
$31,792
$38,004
Average
$25,023
$31,709
$37,879
$44,216
75thpercentile
1.45
1.44
$17,312
$22,044
$15,355
$19,787
2001
2004
Diabetes + COPD
Diabetes + Heart Failure
1.58
1.48
$23,973
$29,936
2001
2005
75th to25th
25thpercentile
10thpercentile
COPD=chronic obstructive pulmonary disease.
Data: G. Anderson and R. Herbert, Johns Hopkins University analysis of Medicare Standard Analytical Files (SAF) 5%
Inpatient Data.
EFFICIENCY
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 71
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Percentage of National Health Expenditures Spent onInsurance Administration, 2005
a 2004 b1999
* Includes claims administration, underwriting, marketing, profits, and other administrative costs;
based on premiums minus claims expenses for private insurance.
Data: OECD Health Data 2007, Version 10/2007.
Net costs of health insurance administration as percent of national health expenditures
EFFICIENCY
1.92.3
2.83.3
3.9 4.2 4.3
4.8
5.6
6.97.5
0
2
4
6
8
10
Finland
Japan
Australia
UnitedKingdom
Austria
Canada
Netherlands
Switzerland
Germany
France
UnitedStates*
a aab
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 72
Physicians Use of Electronic Medical Records
17
28
9892
89
79
42
23
0
25
50
75
100
NETH NZ UK AUS GER CAN
International Comparison
AUS=Australia; CAN=Canada; GER=Germany; NETH=Netherlands; NZ=New Zealand; UK=United Kingdom.
Data: 2001 and 2006 Commonwealth Fund International Health Policy Survey of Physicians.
EFFICIENCY
Percent of primary care physicians using electronic medical records
2001 2006
United States
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 73
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SECTION 5: EQUITY
EQUITY
For equity, the Scorecard contrasts rates of risk by insurance, income, and
race/ethnicity. Specifically, the risk ratios compare: Insured to uninsured rates
High-income to low-income rates
White to black rates
White to Hispanic rates
Indicators used to score equity include a subset of main indicators and a few
equity-only indicators to highlight certain areas of concern. They are grouped
as follows:
Long, healthy & productive lives
Effective care
Safe care
Patient-centered, timely care
Coordinated and efficient care Universal participation and affordable care
Charts for equity indicators are interspersed throughout other sections as
appropriate.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 74
Infant Mortality
5.7
9
6.6
4.1
13.6
15.2
13.6
11.9
5.5 5.4 5.34.7
Total Less than high
school
High school
graduate
At least some
college
White Black Hispanic
EQUITY: LONG, HEALTHY & PRODUCTIVE LIVES
Infant deaths per 1,000 live births
14.7
9.0
6.35.7
13.6
6.3
5.5
5.34.7
8.4
0
5
10
15
20
1995
1996
1997
1998
1999
2000
2001
2002
^20
0320
04
White Black Hispanic Asian/PI AI/AN
By Mothers Education and Race/Ethnicity, 2004By Race/Ethnicity, 19952004
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 75
^ Denotes baseline year. PI=Pacific Islander; AI/AN=American Indian or Alaskan Native.
Data: National Vital Statistics System, Linked Birth and Infant Death Data (AHRQ 2007b, Mathews 2007).
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Working-Age Adults with Health Limits on Activities or Work, 2006
12.9
9.2 10.3
19.617.0
9.2
15.6
27.328.4
12.8
29.4
48.2
0
25
50
U.S.
Average
Age 1829 Age 3049 Age 5064
$50,000+ $25,000-49,000
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Coronary Heart Disease and Diabetes-Related Mortality,by Race/Ethnicity and Education Level, 2004
160 159
207
127
101
73
30
0
50
100
150
200
250
Total White Black Hispanic Lessthan highschool
Highschool
graduate
At leastsome
college
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 78
Coronary Heart Disease Mortality
Age-adjusted per 100,000 population
7668
135
90
62
40
17
0
50
100
150
200
250
Total White Black Hispanic Less thanhigh
school
Highschool
graduate
At leastsome
college
Diabetes-Related Mortality
Note: Data by education level based on total of 36 reporting states and D.C. for people ages 2564.
Data: National Vital Statistics SystemMortality (Retrieved from DATA2010 at http://wonder.cdc.gov/data2010).
EQUITY: LONG, HEALTHY & PRODUCTIVE LIVES
4245
39
28 30
49
37
32
46
30
21
0
20
40
60
Total
White
Black
Hispan
icOth
er
400%+
ofpover
t
200%-
399%
ofpov
er
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18
14
4240
10
44
Total
White
Black
Mexic
an
400%+
ofpovert
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1712
23 26
15 15 14
2219
37
0
25
50
75
100
TotalWhite BlackHispanic High*Middle*
Nearpoor
*Poor*InsuredUn
insured
Adults with Poorly Controlled Chronic Diseases, by Race/Ethnicity,Family Income, and Insurance Status, 19992004
Percent of adults (ages 18+) with diagnoseddiabetes with HbA1c level 9%
Percent of adults (ages 18+) with hypertensionwith blood pressure 140/90 mmHg
* High refers to household incomes >400% of federal poverty level (FPL); middle to 200%399% FPL; near poor to
100%199% FPL; and poor to
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Medical, Medication, and Lab Errors, by Race/Ethnicity,Income, and Insurance Status, 2007
20 2022
1618
24
18
25
0
20
40
Total White Black Hispanic Above
average
Below
average
Insured all
year
Uninsured
any time
Race/ethnicity Income Insurance status
Data: 2007 Commonwealth Fund International Health Policy Survey.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 84
EQUITY: SAFE CARE
Percent of adults ages 1864 reporting medical mistake, medication error, or lab error inpast two years
Select AHRQ Patient Safety Indicators, 2004
9.27.91.317.6135.6Uninsured/self pay
PATIENT RESIDENCE
10.910.01.729.8121.5Urban
111.3
112.2
119.4
124.0
140.3
130.4
116.8
122.3
Failure to rescue
7.6
7.8
9.2
10.2
6.4
8.2
10.7
8.4
Postoperativepulmonary embolus ordeep vein thrombosis
INSURANCE
9.81.626.5$45,000 or more
8.71.219.0Private insurance
10.31.221.7Rural
14.91.629.6Less than $25,000
MEDIAN INCOME OFPATIENT ZIPCODE
12.41.422.4Asian/Pacific Islander
11.31.227.2Hispanic
10.91.936.0Black
10.41.724.3White
RACE/ETHNICITY
Postoperativesepsis
Selected infectionsdue to medical care
Decubitusulcers
Risk adjusted rate per
1,000 discharges*
* Rates exclude complications present on admission and are adjusted for gender, comorbidities, and diagnosis-related group
clusters.
Data: Race/ethnicityHCUP, State Inpatient Database (AHRQ 2007b); income area, insurance, and patient residence
Healthcare Cost and Utilization Project, Nationwide Inpatient Sample (AHRQ 2007a).
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 85
EQUITY: SAFE CARE
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Pressure Sores Among High-Risk and Short-Stay Residentsin Nursing Facilities by Race/Ethnicity, 2005
13
20
17
25
14
24
11
22
13
21
0
20
40
High risk residents Short stay residents
White Black Hispanic Asian/PI AI/AN
86Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 86
EQUITY: SAFE CARE
Percent of nursing home residents with pressure sores
PI=Pacific Islander; AI/AN=American Indian or Alaskan Native.
Data: Nursing Home Minimum Data Set (AHRQ 2007b).
Waiting Time to See Doctor When Sick, by Race/Ethnicity,Income, and Insurance Status, 2007
20
16
36
28
16
26
18
27
0
20
40
Total White Black Hispanic Above
average
Below
average
Insured all
year
Uninsured
any time
Race/ethnicity Income Insurance status
Data: 2007 Commonwealth Fund International Health Policy Survey.
Percent of adults ages 1864 who reported waiting six or more days for anappointment when sick or needed medical attention
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 87
EQUITY: PATIENT-CENTERED, TIMELY CARE
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DoctorPatient Communication by Race/Ethnicity, Family Income,Insurance, and Residence, 2004
Percent of adults (ages 18+) reporting health providers sometimes or never listen carefully,explain things clearly, respect what they say, and spend enough time with them
* Insurance for people ages 1864. ** Urban refers to metropolitan area >1 million inhabitants; Rural refersto noncore area
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Test Results or Medical Record Not Available at Time of Appointment,by Race/Ethnicity, Income, and Insurance Status, 2007
1715
20 20
12
23
14
23
0
10
20
30
Total White Black Hispanic Above
average
Below
average
Insured all
year
Uninsured
any time
Race/ethnicity Income Insurance status
Data: 2007 Commonwealth Fund International Health Policy Survey.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 90
EQUITY: COORDINATED AND EFFICIENT CARE
Percent reporting test results/records not available at time of appointment in past two years
Went to Emergency Room for Condition That Could Have Been Treatedby Regular Doctor, by Race/Ethnicity, Income, andInsurance Status, 2007
15 15
22
11 11
22
13
20
0
10
20
30
Total White Black Hispanic Above
average
Below
average
Insured all
year
Uninsured
any time
Race/ethnicity Income Insurance status
Data: 2007 Commonwealth Fund International Health Policy Survey.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 91
EQUITY: COORDINATED AND EFFICIENT CARE
Percent of adults who went to ER in past two years for condition that could have beentreated by regular doctor if available
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Cost-Related Access Problems, by Race/Ethnicity, Income,and Insurance Status, 2007
72
35
50
26
45
46
45
61
46
0 20 40 60 80 100
Uninsured during year
Insured all year
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Primary Care Medical Residency Positions Filled by U.S. MedicalSchool Graduating Seniors and Other Applicants: 1997-2007
3,167
1,9671,648 1,602
837
1,1551,384 1,406
0
1,000
2,000
3,000
4,000
5,000
1997 2002 2006 2007
Positions filled by other applicants*
Positions filled by U.S. medical school graduating seniors
Note: Includes family medicine, family medicine-psychiatry, internal medicine-primary, internal medicine-family medicine, internal
medicine-pediatrics, and pediatrics-primary positions. *Other applicants includes U.S. physicians, osteopaths, 5th Pathway,
Canadian students, and U.S. and non-U.S. graduates of international medical schools.
Data: American Academy of Family Physicians analysis of National Resident Matching Program Advanced Data Tables, 2007.
4,004
3,122 3,032 3,008
SYSTEM CAPACITY
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 96
Data: 2006 Press Ganey Associates, Inc. Data represent the experiences of 121,882 employees across 132 facilities in 2006.
Hospital Employee Satisfaction, 2006
58.3 61.2
65.8 68.0 71.4
60.3 63.1
66.2 68.8
71.5
0
25
50
75
100
10th percentile 25th percentile 50th percentile 75th percentile 90th percentile
Registered Nurses All Employees
97
SYSTEM CAPACITY
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 97
Overall Satisfaction Score
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Nursing Home Workforce Satisfaction, 2006
3844
5158
64
37
44
52
59
66
4449
5560
65
0
25
50
75
100
10th percentile 25th percentile 50th percentile 75th percentile 90th percentile
Nursing assistants* Nurses All nursing home employees
Composite satisfaction scores (average of 21 survey items) where 100=excellent and 0=poor
Data: MyInnerView, Inc., 2006 National Survey of Nursing Home Workforce Satisfaction. Scores are national estimates from
106,858 staff in 1,933 nursing facilities in every state (except Alaska) and the District of Columbia. *CNA/NA
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 98
SYSTEM CAPACITY
Hospital Nursing Staff Vacancy Rates, 2000
10
15 14
12
10
1211
9 9
0
5
10
15
20
National
average
Critical
care
Medical/
Surgical
ER Obstetrics West South Northeast Midwest
Percent
Data: American Organization of Nurse Executives 2000 Acute Care Hospital Survey of RN Vacancies and Turnover Rates.
Type of acute care Region
99
SYSTEM CAPACITY
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 99
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Hospital Organizational Culture: Staff Perceptionsof Teamwork and Learning Environment, 2007
79
70
57
44
96 9491
8287
80
72
56
71
61
44
32
0
25
50
75
100
Teamwork withinunits
Organizationallearning & continuous
improvement
Teamwork acrossunits
Nonpunitive responseto error
Average Best hospital 90th %tile hospitals 10th %tile hospitals
Percent of staff giving positive responses
Data: Hospital Survey on Patient Safety Culture Comparative Database, results for 160,176 staff in 519 participating hospitals
submitting data in 2007. Agency for Healthcare Research and Quality.
SYSTEM CAPACITY
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 102
Adoption of Culture Change by Nursing Homes, 2007
Categories of Nursing Homes, by Extent of Culture Change Adoption
SYSTEM CAPACITY
CULTURE CHANGEADOPTERS
31%
CULTURE CHANGESTRIVERS
25%
TRADITIONAL43%
Culture change definition*
describes nursing home only in a
few respects or not at all, and
leadership is not very committedto adopting culture change
Culture change definition*completely or for the most part
describes nursing home
Culture change definition* describes
nursing home only in a few respects
or not at all, but leadership is
extremely or very committed to
adopting culture change
* Culture change or a resident-centered approach means an organization that has home and work environments in which: care and
all resident-related activities are decided by the resident; living environment is designed to be a home rather than institution; close
relationships exist between residents, family members, staff, and community; work is organized to support and allow all staff torespond to residents' needs and desires; management allows collaborative and group decision making; and processes/measures
are used for continuous quality improvement.
Data: 2007 Commonwealth Fund National Survey of Nursing Homes.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 103
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National Health Expenditures Spent on Public Health ActivitiesCompared with Insurance Administration Costs
55
35
78
0
20
40
60
80
100
National health
expenditures
Government public
health activities
Insurance
administrative
costs
43.4
81.8
53.9
129.0
58.7
145.4
0
25
50
75
100
125
150
175
Government public health
activities
Insurance administrative
costs
2000 2004 2006
Data: CMS Office of the Actuary, National Health Statistics Group; and U.S. Dept. of Commerce,
Bureau of Economic Analysis and U.S. Bureau of the Census (Catlin et al. 2008).
Dollars (in billions) Percent growth from 2000 to 2006
104
SYSTEM CAPACITY
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 104
References
AHCA (American Health Care Association). 2003. Results of the 2002 AHCA survey of nursing staff vacancy and
turnover in Nursing Homes. Washington, D.C.: American Health Care Association.
AHRQ (Agency for Healthcare Research and Quality).
2007a. National Healthcare Quality Report, 2007: Data Tables Appendix. http://www.ahrq.gov/qual/nhqr07/
2007b. National Healthcare Disparities Report, 2007: Appendix D: Data Tables. http://www.ahrq.gov/qual/nhdr07/
2006. National Healthcare Quality Report, 2006. Data Tables Appendix. http://www.ahrq.gov/qual/nhqr06/
2005. National Healthcare Quality Report, 2005. Data Tables Appendix. http://www.ahrq.gov/qual/nhqr05/
2004. National Healthcare Quality Report, 2004. Data Tables Appendix. http://www.ahrq.gov/qual/nhqr04/
2003. National Healthcare Quality Report, 2003.
Allred, N., K. Wooten, and Y. Kong, The association of health insurance and continuous primary care in the medical
home on vaccination coverage for 19- to 35-month-old children, Pediatrics 119, no 1 (2007):4-11.
Catlin, A., et al., National health spending in 2006: a year of change for prescription drugs, Health Affairs 27, no 1
(2008):14-29.
Clegg, L., et al., Cancer survival among US whites and minorities: a SEER program population-based study,Archivesof Internal Medicine 162, no 17 (2002):1985-93.
Edwards, J., et al., National Healthcare Safety Network, data summary for 2006, issued June 2007,American Journal
of Infection Control35 (2007):290-301.
HRSA (Health Resources and Services Administration). 2005. The National Survey of Childrens Health 2003. Rockville,
M.D.: U.S. Department of Health and Human Services.Mathews, T., and M. MacDorman, Infant mortality statistics from the 2004 period linked birth/infant death data set,
National Vital Statistics Report55, no 15 (2007). Hyattsville, Md.: National Center for Health Statistics.
MedPAC (Medicare Payment Advisory Commission). 2007. Quality of care in the Medicare program.A Data Book:Healthcare Spending and the Medicare Program. Washington, D.C.: Medicare Payment Advisory Committee.
MedPAC (Medicare Payment Advisory Commission). 2005. Quality of care for Medicare beneficiaries.A Data Book:
Healthcare Spending and the Medicare Program. Washington, D.C.: Medicare Payment Advisory Committee.
Nolte, E., and C. M. McKee, Measuring the health of nations: updating an earlier analysis, Health Affairs 27, no 1
(2008):58-71.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 105
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References (continued)
NCHS (National Center for Health Statistics). 2007. Health, United States, 2007. Hyattsville, Md.: Centers for Disease
Control and Prevention.
NCQA (National Committee for Quality Assurance). 2007. HEDIS Audit Means, Percentiles and Ratios: 2006.Washington, D.C.: National Committee for Quality Assurance.
Pace, K., et al. 2005. Acute hospitalization of home health patients report of analyses, literature review and technical
expert panel. Paper presented at the 2005 National Association for Home Care Annual Meeting, Seattle,
Washington and 2005 Tri-Regional QIO Conference, St. Pete Beach, Fla.
SAMHSA (Substance Abuse and Mental Health Services Administration). 2007. Results from the 2006 National Survey
on Drug Use and Health: National Findings (Office of Applied Studies, NSDUH Series H-32, DHHS Publication No.
SMA 07-4293). Rockville, Md.
SAMHSA (Substance Abuse and Mental Health Services Administration). 2006. Results from the 2005 National Survey
on Drug Use and Health: National Findings (Office of Applied Studies, NSDUH Series H-30, DHHS Publication No.
SMA 06-4194). Rockville, Md.
Singh G., et al. 2003.Area socioeconomic variations in US cancer incidence, mortality, stage, treatment, and survival
1975-1999. NCI Cancer Surveillance Monograph Series, Number 4. NIH Publication No. 03-5417. Bethesda, Md.:National Cancer Institute.
WHO (World Health Organization). 2003. The World Health Report 2003: shaping the future. Geneva, Switzerland:
World Health Organization.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 106