national scorecard, 2008: chartpack this chartpack presents data for all indicators scored in the...
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National Scorecard, 2008: Chartpack
This Chartpack presents data for all indicators scoredin the National Scorecard on U.S. Health System Performance, 2008. Charts display average performance for the U.S. as a whole and the range of performance found within the U.S or compared with other countries.
The charts accompany the Commission’s July 2008 report, Why Not the Best? Results from a National Scorecard on U.S. Health System Performance, 2008.
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 or injury*
* 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
7681
88 8489 89
99 9788
97
109 106116 115 113
130134
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 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
10.311.1
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
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 state—National Vital Statistics System, Linked Birth and Infant Death Data (AHRQ 2003, 2004, 2005, 2006, 2007a); international comparison—OECD Health Data 2007, Version 10/2007.
HEALTHY LIVES
Healthy Life Expectancy at Age 60, 2002
2220 20 20 20 20 19 19 19 19 19 19 19 19 18 18 18 18 18 18 18 17 1718 17 17 16 17 17 16 16 16 16 16 16
1816 16 16 16 16 15 15 15 15
14
0
10
20
30 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 18–64) limited in any activities because of physical, mental, or emotional problems
8.3
13.4
24.2
10.3
15.4
27.4
Age 18–29 Age 30–49 Age 50–64
2004 2006
14.9
11.5
20.117.5
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
Note: Indicator was not updated due to lack of data. Baseline figures from Scorecard 2006 are presented. Data: 2003 National Survey of Children’s Health (HRSA 2005; retrieved from Data Resource Center for Child and AdolescentHealth database at http://www.nschdata.org).
Percent of children (ages 6–17) who missed 11 or more school days due 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
<100% of poverty
400%+ of poverty
Hispanic
Black
White
Bottom 10% states
Top 10% states
U.S. average
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 8
HEALTHY LIVES
SECTION 2. QUALITY
Quality includes indicators organized into four groups:
1. Effective care
2. Coordinated care
3. Safe care
4. Patient-centered, timely care
The Scorecard scores each group of indicators separately, and then averages the four scores to create the overall score for Quality.
QUALITY
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 9
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 <9%• Adults with hypertension whose blood pressure <140/90 mmHg
5. Hospitalized patients receive recommended care for heart attack, heart failure, and pneumonia
QUALITY: EFFECTIVE 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 10
32
46
53
47
49
50
58
39
0 20 40 60 80 100
Uninsured all year
Uninsured part year
Insured all year
<200% of poverty
200%–399% of poverty
400%+ of poverty
2005
2002
QUALITY: EFFECTIVE CARE
Receipt of Recommended Screening and Preventive Care for Adults
Percent of adults (ages 18+) who received all recommended screening andpreventive care within a specific time frame given their age and sex*
* Recommended care includes seven key screening and preventive services: blood pressure, cholesterol, Pap, mammogram,fecal occult blood test or sigmoidoscopy/colonoscopy, and flu shot. See report Appendix B for complete description.Data: B. Mahato, Columbia University analysis of Medical Expenditure Panel Survey.
U.S. Variation 2005
U.S. Average
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 11
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 19–35 months) who received all recommended doses of five key vaccines*
73 74 7579 81 81 8182 80
8489 88 88 86
66 66 6571 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
<100% of poverty
Hispanic
Black
White
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 12
National Average and State Distribution
Percent of children (ages <18) who received BOTH a medical and dental preventive care visit in past year
Preventive Care Visits for Children, by Top and Bottom States, Race/Ethnicity, Family Income, and Insurance, 2003
35
63
70
58
62
48
73
59
48
49
0 20 40 60 80 100
Uninsured
Private insurance
<100% of poverty
400%+ of poverty
Hispanic
Black
White
Bottom 10% states
Top 10% states
U.S. average
Note: Indicator was not updated due to lack of data. Baseline figures from 2006 Scorecard are presented. Data: 2003 National Survey of Children’s Health (HRSA 2005; retrieved from Data Resource Center for Child and AdolescentHealth database at http://www.nschdata.org).
QUALITY: EFFECTIVE CARE
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 13
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 Children’s Health (HRSA 2005; Retrieved from Data Resource Center for Child and Adolescent Health database at http://www.nschdata.org).
Percent of children (ages <18) who needed and received mental health care in past year*
Mental Health Care for Children, by Top and Bottom States, Race/Ethnicity, Family Income, and Insurance, 2003
34
63
64
52
65
47
74
59
53
42
0 20 40 60 80 100
Uninsured
Private insurance
<100% of poverty
400%+ of poverty
Hispanic
Black
White
Bottom 10% states
Top 10% states
U.S. average
QUALITY: EFFECTIVE CARE
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 15
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 <9.0 **Refers to hypertensive adults whose blood pressure is <140/90 mmHg. Data: J. M. McWilliams, Harvard Medical School analysis of National Health and Nutrition Examination Survey.
79
31
88
41
0
25
50
75
100
Diabetes under
control*
High blood pressure
under control**
1999-2000 2003-2004
Percent of adults (age 18+)
National Average By Insurance, 1999-2004
QUALITY: EFFECTIVE CARE
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 16
Chronic Disease Under Control: Managed Care Plan Distribution, 2006
70 73
49
81
88
68
6056
30
0
25
50
75
100
Private Medicare Medicaid
Mean 90th %ile 10th %ile
Note: Diabetes includes ages 18–75; hypertension includes ages 18–85.Data: Healthcare Effectiveness Data and Information Set (NCQA 2007).
Percent of adults with diagnosed diabetes whose HbA1c level <9.0%
QUALITY: EFFECTIVE CARE
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 17
6057
53
68 67 66
4946
39
0
25
50
75
100
Private Medicare Medicaid
Mean 90th %ile 10th %ile
Percent of adults with hypertension whose blood pressure <140/90 mmHg
Diabetes Hypertension
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 recommended care for all three conditions*
Individual Composites by Condition, 2006
Percent of patients who received recommended care for each condition*
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 18
87
74
91 8982
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
Hospital Quality of Care by Condition: Composites for Heart Attack, Heart Failure, and Pneumonia
HOSPITALS STATES
Percent of patients who received recommended care:
Median Best90th
percentile10th
percentileBest
90th percentile
10th percentile
Acute myocardial infarction
(Original: 5 indicators)
2004
2006
92
96
100
100
98
99
80
88
97
98
96
97
89
93
(Expanded: 8 indicators*) 2006 95 100 98 87 98 97 92
Heart failure
(Original: 2 indicators)
2004
2006
83
91
100
100
94
98
62
71
91
94
89
93
79
81
(Expanded: 4 indicators*) 2006 83 100 95 61 90 87 75
Pneumonia
(Original: 3 indicators)
2004
2006
78
87
99
100
88
95
66
76
82
92
79
91
69
83
(Expanded: 7 indicators*) 2006 87 100 94 77 91 90 83
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 reviewed
at discharge*• Heart failure patients received written instructions at discharge• Follow-up within 30 days after hospitalization for mental health
disorder
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
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
<200% of poverty
200%–399% of poverty
400%+ of poverty
Hispanic
Black
White
2005
2002
U.S. Variation 2005
U.S. Average
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 22
Percent of adults ages 19–64 with an accessible primary care provider*
QUALITY: COORDINATED CARE
Adults with an Accessible Primary Care Provider
* An accessible primary care provider is defined as a usual source of care who provides preventive care, care for new and ongoing health problems, referrals, and who is easy to get to.Data: B. Mahato, Columbia University analysis of Medical Expenditure Panel Survey.
Note: Indicator was not updated due to lack of data. Baseline figures are presented. * Child had 1+ preventive visit in past year; access to specialty care; personal doctor/nurse who usually/always spent enoughtime and communicated clearly, provided telephone advice or urgent care and followed up after the child’s specialty care visits.Data: 2003 National Survey of Children’s Health (HRSA 2005; retrieved from Data Resource Center for Child and AdolescentHealth database at http://www.nschdata.org).
23
53
58
39
53
36
60
46
30
31
0 20 40 60 80 100
Uninsured
Private insurance
<100% of poverty
400%+ of poverty
Hispanic
Black
White
Bottom 10% states
Top 10% states
U.S. average
Children with a Medical Home, by Top and Bottom States, Race/Ethnicity, Family Income, and Insurance, 2003
Percent of children who have a personal doctor or nurse and receive care that is accessible, comprehensive, culturally sensitive, and coordinated*
QUALITY: COORDINATED CARE
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 23
86
7773 72 69 67
0
25
50
75
100
GER AUS UK CAN NZ US
Percent of hospitalized patients with new prescription who reported prior 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 When Discharged, 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
Managed Care Health Plans: 30-Day Follow-Up After Hospitalization for Mental Illness
76
56 58
8881 80
63
29
17
0
25
50
75
100
Private Medicare Medicaid
Mean 90th %ile 10th %ile
Percent of health plan members (ages >6) who received inpatient treatment for a mental health disorder and had follow-up within 30 days after hospital discharge
71 73 74 74 76 76 76
59 61 61 60 61 5956
55 5256 56 55 57 58
2000 2001 2002 2003 2004* 2005 2006
Private Medicare Medicaid
Annual averagesManaged Care Plans (2006)
* Denotes baseline year.Data: Healthcare Effectiveness Data and Information Set (NCQA 2007).
QUALITY: COORDINATED CARE
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 26
Nursing Homes: Hospital Admission and Readmission RatesAmong Nursing Home Residents
17
1315
1922
18
1516
2022
0
20
40
Median 10th
%ile
25th
%ile
75th
%ile
90th
%ile
2000 2004
17
1113
21
26
19
1214
23
27
0
20
40
Median 10th
%ile
25th
%ile
75th
%ile
90th
%ile
2000 2004
QUALITY: COORDINATED CARE
Data: V. Mor, Brown University analysis of Medicare enrollment data and Part A claims data for all Medicare beneficiaries who entered a nursing home and had a Minimum Data Set assessment during 2000 and 2004.
Percent of long-stay residents with a hospital admission
Percent of short-stay residents re-hospitalized within 30 days of hospital discharge to nursing home
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 27
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 Care
Scored 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 without
a “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
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
* 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
11.312.9
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
Potentially Inappropriate Antibiotic Prescribingfor Children with Sore Throat
Percent of children prescribed antibiotics for throat infection without receiving a “strep” test*
32
4335
0
25
50
75
100
1997-2003 2004
National Average Managed Care Plan Distribution, 2006
QUALITY: SAFE CARE
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 32
27
44
14
23
43
74
Private Medicaid
Mean 10th %ile 90th %ile
Note: National average includes ages 3–17 and plan distribution includes ages 2–18.* A strep test means a rapid antigen test or throat culture for group A streptococcus.Data: National average—J. Linder, Brigham and Women's Hospital analysis of National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey; Plan distribution—Healthcare Effectiveness Data and Information Set (NCQA 2007).
Inappropriate Use of Medications by Elderly
19
17
191819
0
10
20
30
2000 2001 2002* 2003 2004
Percent of community-dwelling elderly adults (ages 65+) who reported taking at least 1 of 33 drugs that are potentially inappropriate for the elderly
* Denotes baseline year.Data: Medical Expenditure Panel Survey (AHRQ 2007a).
QUALITY: SAFE CARE
13
20
17 17
1413
17
20
15
By Gender, Race/Ethnicity, and Region, 2004National Average
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 33
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
112118
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 for patient 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
80
60
90 87
73
92100
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
Central line-associated bloodstream infection rate, per 1,000 days use Percentile
Type of ICU No. of units 10% 25% 50% 75% 90%
Medical 73 0.0 0.0 2.2 4.2 6.2
Medical-surgical—major teaching 63 0.0 0.6 1.9 3.1 5.5
Medical-surgical—all others 102 0.0 0.0 1.0 2.3 4.5
Surgical 72 0.0 0.9 2.0 4.4 7.4
Neonatal–Level III(infants weighing 750 grams or less) 42 0.0 2.5 5.2 11.0 15.6
Ventilator-associated pneumonia rate, per 1,000 days use Percentile
Type of ICU No. of units 10% 25% 50% 75% 90%
Medical 64 0.0 0.9 2.8 4.6 7.2
Medical-surgical—major teaching 58 0.0 1.3 2.5 5.1 7.3
Medical-surgical—all others 99 0.0 0.0 1.6 3.8 6.2
Surgical 61 0.0 1.8 4.1 6.4 10.0
Neonatal (NICU)(infants weighing 750 grams or less) 36 0.0 0.0 1.7 4.1 9.5
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
Potentially Preventable Adverse Events and Complicationsof Care in Hospitals, National and Medicare Trends
Risk-adjusted rate per 10,000 discharges* 1997/1998** 2000 2002 2003 2004 2005
Decubitus ulcer (pressure sore)
National 195 221 236 248 261 NA
Medicare 206 225 251 267 276 282
Postoperative pulmonary embolismor deep vein thrombosis
National 58 66 79 86 89 NA
Medicare 62 71 86 92 98 100
Postoperative sepsis
National 63 81 92 92 105 NA
Medicare 80 97 111 120 131 121
Postoperative respiratory failure
National 63 72 80 86 82 NA
Medicare 25 34 46 50 53 59
Accidental puncture or laceration
National 38 44 47 47 48 NA
Medicare 31 32 36 34 34 35
Infection due to medical care
National 12 14 15 16 16 NA
Medicare 20 20 24 25 25 15
* 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 figures—Healthcare Cost and Utilization Project, Nationwide Inpatient Sample (retrieved from HCUPNet at http://hcupnet.ahrq.gov); Medicare figures—MedPAC analysis of Medicare administrative data using AHRQ indicators and methods (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 Complicationsof Care in Hospitals Among Medicare Beneficiaries, 2004–2005
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% StatesPercent
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.
Patient-Centered, Timely Care
Scored Indicators:
1. Ability to see doctor on same/next day when sick or need medical attention
2. Very/somewhat easy to get care after hours without going to the emergency room
3. Doctor–patient communication: always listened, explained, showed respect, 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
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
Doctor–Patient 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 average—Medical Expenditure Panel Survey (AHRQ 2005, 2006, 2007a); Plan distribution—CAHPS (data provided by NCQA).
5457 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
6558 56
5045
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”
* Patient’s 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
Physical Restraints in Nursing Facilities
9.7
8.0 7.4 6.85.9
18.4
3.72.6 2.4 2.2 1.9
11.7
13.214.114.7
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 then averages the two scores to create the overall score for Access.
ACCESS
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 47
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 (<200% of poverty); or deductibles equaled 5% or more of income.Data: 2003 and 2007 Commonwealth Fund Biennial Health Insurance Survey.
Percent of adults (ages 19–64) who are uninsured or underinsured
26 28
49 48
13 16
914
19 24
411
0
25
50
75
100
2003 2007 2003 2007 2003 2007
Underinsured*
Uninsured during year
4235
17
27
6872
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 49
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 doctor’s 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
58
12
2125 26
37
0
25
50
75
NETH UK CAN GER NZ AUS US
69
1824
32 30
52
38 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 doctor’s 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
Data: Two-year averages 1999–2000, updated with 2007 Current Population Survey correction, and 2005–2006 from the Census Bureau’s March 2000, 2001 and 2006, 2007 CPS.
WA
ORID
MT ND
WY
NV
CAUT
AZ NM
KS
NE
MN
MO
WI
TX
IA
ILIN
AR
LA
AL
SCTN
NCKY
FL
VA
OH
MI
WV
PA
NY
AK
MD
MEVTNH
MARI
CT
DE
DC
HI
CO
GAMS
OK
NJ
SD
WA
ORID
MT ND
WY
NV
CAUT
AZ NM
KS
NE
MN
MO
WI
TX
IA
ILIN
AR
LA
AL
SCTN
NCKY
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
1999–2000 2005–2006
MA
RI
CT
VTNH
MD
Percent of Adults Ages 18–64 Uninsured by State
ACCESS: PARTICIPATION
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 52
Data: Two-year averages 1999–2000, updated with 2007 Current Population Survey correction, and 2005–2006 from the Census Bureau’s March 2000, 2001 and 2006, 2007 CPS.
WA
ORID
MT ND
WY
NV
CAUT
AZ NM
KS
NE
MN
MO
WI
TX
IA
ILIN
AR
LA
AL
SCTN
NCKY
FL
VA
OH
MI
WV
PA
NY
AK
MD
MEVTNH
MARI
CT
DE
DC
HI
CO
GAMS
OK
NJ
SD
WA
ORID
MT ND
WY
NV
CAUT
AZ NM
KS
NE
MN
MO
WI
TX
IA
ILIN
AR
LA
AL
SCTN
NCKY
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
1999–2000 2005–2006
MA
RI
CT
VTNH
MD
Percent of Children Ages 0–17 Uninsured by State
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 53
ACCESS: PARTICIPATION
Population Under Age 65 Without Health Insurance
17
12
16
20
12
18
0
10
20
30
All under 65 Children under 18 Adults 18–64
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 18–64
Children under 18
Millions uninsured
38 38 3942 43
4743
Data: Analysis of Current Population Survey, March 1995–2007 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% of income, 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’ earnings and overall inflation
ACCESS: AFFORDABLE CARE
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 55
Families with High Medical and Premium Costs Compared with Income, by Family Income
19
44 42
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-pocketmedical 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 <100% of federal poverty level (FPL); low income to 100–199% FPL; middle income to 200–399% FPL; and high income to 400%+ FPL. Data: P. Cunningham, Center for Studying Health System Change analysis of Medical Expenditure Panel Survey.
ACCESS: AFFORDABLE CARE
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 56
Family Income Insurance Coverage
Employer Premiums as Percentage of Median Household Incomefor Under-65 Population, Distribution by State, 2005
57
25
32
59
916
20%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2003 2005
Premium 18%+of income
Premium15%–17.9% ofincome
Premium12%–14.9% ofincome
Premium <12%of income
ACCESS: AFFORDABLE CARE
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 57
Under-65 population by premiumsas share of state median income
16 16
13 13
1820
0
15
30
Single household Families
Median 10th %ile states 90th %ile states
Premiums for private coverage aspercent of median income per state
Data: State averages private premium rates—2003 and 2005 Medical Expenditure Panel Survey;State median household incomes, under-65 population—2004–2005 and 2006–2007 Current Population Survey.
33
45
29
6168
56
Total Under 200% of
poverty
200% of poverty or
more
Insured all year Uninsured during year
3441
0
25
50
75
100
2005 2007
Medical Bill Problems or Medical Debt
By Income and Insurance Status, 2007National Average
Percent of adults (ages 19–64) 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<0.05. ^Estimate is statistically different from the previous year shown at p<0.1.Note: Data on premium increases reflect the cost of health insurance premiums for a family of four. Historical estimates of workers’ earnings have been updated to reflect new industry classifications (NAICS). Data: G. Claxton, J. Gabel et al., "Health Benefits in 2007: Premium Increases Fall To An Eight-Year Low, While Offer Rates And Enrollment Remain Stable," Health Affairs, September/October 2007 26(5):1407–1416. Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2007, and Commonwealth Fund analysis of National Health Expenditures data.
12.0
18.0
0.8
6.1*7.7*
13.9^
12.9*10.9*
8.2*
5.3*
11.2*
8.5 9.2*
0
5
10
15
20Health insurance premiums
Workers earnings
Overall inflation
Increases in Health Insurance Premiums Compared with Other Indicators, 1988–2007
Percent
ACCESS: AFFORDABLE CARE
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 59
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 care–sensitive (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, or colon cancer
6. Medicare costs of care for chronic diseases: diabetes, heart failure, COPD
7. 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, 1980–2005
$-
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
$7,000
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
United StatesGermanyCanadaFranceAustraliaUnited Kingdom
0
2
4
6
8
10
12
14
16
United StatesGermanyCanadaFranceAustraliaUnited Kingdom
* PPP=Purchasing Power Parity.Data: OECD Health Data 2007, Version 10/2007.
Average spending on healthper capita ($US PPP*)
Total expenditures on healthas percent of GDP
61
EFFICIENCY
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 61
Duplicate Medical Tests, Among Sicker Adults
1820
4
89
10
1516
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 1718
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
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 18–50) who received an imaging study within 28 days following an episode of acute low back pain with no risk factors
25 2526
22 21 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 been treated by regular doctor if available
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 65
Ambulatory Care–Sensitive (Potentially Preventable) Hospital Admissions 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
2002/2003̂ 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
Bottom10% 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 average—Healthcare Cost and Utilization Project, Nationwide Inpatient Sample; State distribution—State Inpatient Databases; 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 Care–Sensitive Conditions,Rates and Associated Costs, by Hospital Referral Regions
771
499
610
887
1043
700
465
558
816
926
0
300
600
900
1200
Nationalmean
10th 25th 75th 90th
2003 2005
13.4
10.0
11.8
14.7
16.3
12.6
9.811.1
13.6
15.2
0
5
10
15
20
Nationalmean
10th 25th 75th 90th
2003 2005
Rate of ACS admissions per 10,000 beneficiaries
Costs of ACS admissions as percent of all discharge 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
18
16
2021
1516
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 Percentiles, 2005
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
Qu
ali
ty o
f C
are
*(1
-Ye
ar
Su
rviv
al
Ind
ex
, M
ed
ian
=7
0%
)
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 69
Quality and Costs of Care for Medicare Patients Hospitalizedfor Heart Attacks, Hip Fractures, or Colon Cancer,
by Hospital Referral Regions
30
2728
30 31 3230
2729
30 3133
0
10
20
30
40
Mean ofhighest
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$30,263
Mean ofhighest
90%
10th 25th Median 75th 90th
Deaths per 100 Dollars ($)
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 Chronic Conditions, by Hospital Referral Regions, 2001 and 2005
Average annual reimbursementRatio of percentile
groups
Average10th
percentile25th
percentile75th
percentile90th
percentile90th to
10th75th to
25th
All 3 conditions
20012005
$31,792
$38,004
$20,960
$25,732
$23,973
$29,936
$37,879
$44,216
$43,973
$53,019
2.10 2.06
1.58
1.48
Diabetes + Heart Failure
20012005
$18,461 $23,056
$12,747
$16,144
$14,355
$18,649
$20,592
$26,035
$27,310
$32,199
2.14
1.99
1.43
1.40
Diabetes + COPD
20012005
$13,188
$15,367
$8,872
$11,317
$10,304
$12,665
$15,246
$17,180
$18,024
$20,062
2.03
1.77
1.48
1.36
Heart Failure + COPD
20012004
$22,415
$27,498
$15,355
$19,787
$17,312
$22,044
$25,023
$31,709
$32,732
$37,450
2.13
1.89
1.45
1.44
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
Percentage of National Health Expenditures Spent on Insurance Administration, 2005
a 2004 b 1999* 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
3.94.2 4.3
4.8
5.6
6.97.5
0
2
4
6
8
10
a a ab
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
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
5.55.3
4.7
8.4
0
5
10
15
20 White Black Hispanic Asian/PI AI/AN
By Mother’s Education and Race/Ethnicity, 2004By Race/Ethnicity, 1995–2004
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).
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 18–29 Age 30–49 Age 50–64
$50,000+ $25,000-49,000 <$25,000
Percent of adults limited in any activities because of physical, mental, or emotional problems
EQUITY: LONG, HEALTHY & PRODUCTIVE LIVES
17.6
10.6
14.8
27.0
17.0
9.8
18.3
30.1
U.S.
Average
Age 18–29 Age 30–49 Age 50–64
Insured Uninsured
By Family Income By Insurance Status
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 76
Data: D. Belloff, Rutgers Center for State Health Policy analysis of Behavioral Risk Factor Surveillance System.
Five-Year Survival Rates for All Cancers,by Gender, Race/Ethnicity, and Census Tract Poverty Rate
White Black Hispanic Asian AI/AN
TOTAL (1988–1997)
Men 55 46 53 50 40
Women 58 47 57 61 47
MEN (1988–1994)
Low poverty, <10%* 61 58 60 55 38
High poverty, 20%+* 52 45 54 44 42
WOMEN (1988–1994)
Low poverty, <10%* 63 58 65 66 44
High poverty, 20%+* 55 48 60 56 53
Note: Equity indicator was not updated due to lack of data. Baseline figures are presented. *Low poverty denotes census tracts where less than 10% of households have incomes below the federal poverty level in 1990; high poverty denotes census tracts where 20% or more of households have incomes below the federal poverty level in 1990. AI/AN=American Indian or Alaskan Native.Data: Surveillance, Epidemiology, and End Results (SEER) Program (Clegg 2002; Singh 2003).
77
EQUITY: LONG, HEALTHY & PRODUCTIVE LIVES
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 77
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 high
school
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 25–64.Data: National Vital Statistics System—Mortality (Retrieved from DATA2010 at http://wonder.cdc.gov/data2010).
EQUITY: LONG, HEALTHY & PRODUCTIVE LIVES
4245
39
28 30
49
3732
46
30
21
0
20
40
60
3639
22
28
34
46
37
27
Receipt of Recommended Preventive Care for Older Adults,by Race/Ethnicity, Family Income, and Insurance Status, 2005
Percent of older adults who received all recommended screening andpreventive care within a specific time frame given their age and sex*
Adults ages 50–64 Adults ages 65+
* Recommended care includes seven key screening and preventive services: blood pressure, cholesterol, Pap, mammogram, fecal occult blood test or sigmoidoscopy/colonoscopy, and flu shot. See report Appendix B for complete description.Data: B. Mahato, Columbia University analysis of Medical Expenditure Panel Survey.
EQUITY: EFFECTIVE CARE
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 79
18
14
4240
10
44
23
19
2831
10
32
0
25
50
27
21
4138
13
46Children ages 6–19 Adults ages 20–64 Adults ages 65–74
Untreated Dental Caries, by Age, Race/Ethnicity,and Income, 2001–2004
Percent of persons with untreated dental caries
80
Data: Race/ethnicity—National Health and Nutrition Examination Survey (NCHS 2007); Total and income—J. M. McWilliams, Harvard Medical School analysis of National Health and Nutrition Examination Survey.
EQUITY: EFFECTIVE CARE
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 80
18
24
13
29
23
16
31
38
0
25
50
27
20
44 44
Children ages 6–19 Adults ages 20–64 Adults ages 65–74
Untreated Dental Caries, by Age and Insurance, 2001–2004
Percent of persons with untreated dental caries
81
Data: J. M. McWilliams, Harvard Medical School analysis of National Health and Nutrition Examination Survey.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 81
EQUITY: EFFECTIVE CARE
1712
23 26
15 15 14
2219
37
0
25
50
75
100
Adults with Poorly Controlled Chronic Diseases, by Race/Ethnicity, Family Income, and Insurance Status, 1999–2004
Percent of adults (ages 18+) with diagnosed diabetes with HbA1c level ≥ 9%
Percent of adults (ages 18+) with hypertension with 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 <100% FPL.Data: J. M. McWilliams, Harvard Medical School analysis of National Health and Nutrition Examination Survey.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 82
64 6366
71
6064
67 69
59
79
0
25
50
75
100
EQUITY: EFFECTIVE CARE
Receipt of All Three Recommended Services for Diabetics,by Race/Ethnicity, Family Income, Insurance, and Residence, 2004
47
48
47
38
42
58
49
47
47
38
39
0 20 40 60 80 100
Rural**
Urban**
Uninsured*
Private*
<100% of poverty
100%–199% of poverty
200%–399% of poverty
400%+ of poverty
Hispanic
Black
White
Total
Percent of diabetics (ages 40+) who received HbA1c test, retinal exam, and foot exam in past year
*Insurance for people ages 40–64. ** Urban refers to metropolitan area >1 million inhabitants; Rural refers to noncore area <10,000 inhabitants. NA=data not available. Data: Medical Expenditure Panel Survey (AHRQ 2007a).
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 83
NA
EQUITY: EFFECTIVE CARE
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 Aboveaverage
Belowaverage
Insured allyear
Uninsuredany 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 18–64 reporting medical mistake, medication error, or lab error in past two years
Select AHRQ Patient Safety Indicators, 2004
Risk adjusted rate per 1,000 discharges* Failure to rescue Decubitus ulcers
Selected infections due to medical care
Postoperative pulmonary embolus or deep vein
thrombosisPostoperative
sepsis
RACE/ETHNICITY
White 122.3 24.3 1.7 8.4 10.4
Black 116.8 36.0 1.9 10.7 10.9
Hispanic 130.4 27.2 1.2 8.2 11.3
Asian/Pacific Islander 140.3 22.4 1.4 6.4 12.4
MEDIAN INCOME OF PATIENT ZIPCODELess than $25,000 124.0 29.6 1.6 10.2 14.9
$45,000 or more 119.4 26.5 1.6 9.2 9.8
INSURANCE
Private insurance 112.2 19.0 1.2 7.8 8.7
Uninsured/self pay 135.6 17.6 1.3 7.9 9.2
PATIENT RESIDENCE
Urban 121.5 29.8 1.7 10.0 10.9
Rural 111.3 21.7 1.2 7.6 10.3
* Rates exclude complications present on admission and are adjusted for gender, comorbidities, and diagnosis-related group clusters.Data: Race/ethnicity—HCUP, 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
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 Aboveaverage
Belowaverage
Insured allyear
Uninsuredany time
Race/ethnicity Income Insurance status
Data: 2007 Commonwealth Fund International Health Policy Survey.
Percent of adults ages 18–64 who reported waiting six or more days for an appointment when sick or needed medical attention
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 87
EQUITY: PATIENT-CENTERED, TIMELY CARE
Doctor–Patient 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 18–64. ** Urban refers to metropolitan area >1 million inhabitants; Rural refers to noncore area <10,000 inhabitants.Data: Medical Expenditure Panel Survey (AHRQ 2007b).
710
199
168
1412
119
10
0 5 10 15 20
Rural**
Urban**
Uninsured*
Private insurance*
<100% of poverty
400+% of poverty
Asian
Hispanic
Black
White
Total
EQUITY: PATIENT-CENTERED, TIMELY CARE
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 88
Duplicate Medical Tests, by Race/Ethnicity, Income, and Insurance Status, 2007
1413 13
15
11
17
11
19
0
10
20
30
Total White Black Hispanic Aboveaverage
Belowaverage
Insured allyear
Uninsuredany 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 89
EQUITY: COORDINATED AND EFFICIENT CARE
Percent reporting that doctor ordered test that had already been done in past two years
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 Aboveaverage
Belowaverage
Insured allyear
Uninsuredany 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, and
Insurance Status, 2007
15 15
22
11 11
22
13
20
0
10
20
30
Total White Black Hispanic Aboveaverage
Belowaverage
Insured allyear
Uninsuredany 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 been treated by regular doctor if available
Diabetes**
98
374
144110
390
Heart failure Pediatric asthma
178
667
444
173
554
240
520
392
904
0
500
1000
Adjusted rate per 100,000 population
Ambulatory Care–Sensitive (Potentially Preventable) Hospital Admissions, by Race/Ethnicity and Patient Income Area, 2004/2005*
* 2004 data for diabetes and pediatric asthma; 2005 data for heart failure. ** Combines 4 diabetes admission measures: uncontrolled,short-term complications, long-term complications, and lower extremity amputations. Patient Income Area=median income of patient zip code. NA=data not available.Data: Race/ethnicity—Healthcare Cost and Utilization Project, State Inpatient Databases and National Hospital Discharge Survey (AHRQ 2007b); Income area—HCUP, Nationwide Inpatient Sample (AHRQ 2007a, retrieved from HCUPnet at http://hcupnet.ahrq.gov).
NA
92
EQUITY: COORDINATED AND EFFICIENT CARE
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 92
Nonelderly Adults with Time Uninsured During the Year,by Family Income and Race/Ethnicity, 2004
21
11
22
3743
28
17
26
3833
43
18
42
5451
0
25
50
75
100
Total High income Middle income Near poor Poor
White Black Hispanic
Percent of nonelderly adults (ages <65) who had no health insurance coverage sometime during the year
Note: High refers to household incomes >400% of federal poverty level (FPL); middle to 200-399% FPL; near poor to 100% to 199% FPL; and poor to <100% FPL.Data: Medical Expenditure Panel Survey (AHRQ 2007b).
93
EQUITY: ACCESS
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 93
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
<200% of poverty
200%–399% of poverty
400%+ of poverty
Hispanic
Black
White
Total
Percent of adults (ages 19–64) who had any of four access problems* in past year because of cost
* Did not fill a prescription; skipped recommended medical test, treatment, or follow-up; had a medical problem but did not visit doctor or clinic; or did not see a specialist when needed.Data: 2007 Commonwealth Fund Biennial Health Insurance Survey.
94Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 94
EQUITY: ACCESS
SECTION 6. SYSTEM CAPACITY TO INNOVATE AND IMPROVE
Health Care Workforce• Primary care medical residency positions filled• Hospital employee satisfaction• Nursing home employee satisfaction• Hospital nursing staff vacancy rates (cannot update)• Nursing home staff turnover rates (cannot update)• Nursing home staff hours per patient day
Organizational Culture• Hospital organizational culture• Nursing home resident-centered care practices
Infrastructure• National health expenditures invested in research and public health
activities compared with insurance administration costs
SYSTEM CAPACITY
The Scorecard addresses but does not score indicators for system capacity to innovate and improve.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 95
Primary Care Medical Residency Positions Filled by U.S. Medical School 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
58.361.2
65.8 68.071.4
60.363.1
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
Nursing Home Workforce Satisfaction, 2006
3844
5158
64
3744
5259
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
Nationalaverage
Criticalcare
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
Nursing Homes: Turnover Rates of Certified Nursing Aidesin Nursing Homes, 2002
71
21
38
119
136
0
50
100
150
National average Lowest state Lowest 10%states
Highest 10%states
Highest state
Rate of terminations to established positions
Data: 2002 American Health Care Association Survey of Nursing Staff Vacancy and Turnover in Nursing Homes (AHCA 2002).
100
SYSTEM CAPACITY
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 100
Nursing Home Staff Hours Per Patient Day
0.75
1.30
2.80
0.66
1.40
2.98
0.10
0.86
2.00
0.3
1.1
2.3
0
1
2
3
4
Registered Nurses All Licensed Nursing Staff* Nursing Aides
Recommended Threshold# 90th %ile States 10th %ile States US Median
# Staffing thresholds as identified in Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes: Report to Congress: Phase II Final, December 2001. * Licensed staff includes registered and licensed nurses.Note: Staff positions are measured in full-time equivalents, which is based on a 35 hour workweek. Data: American Health Care Association, CMS OSCAR data, 2007.
101
Distribution by Direct Care Staff
SYSTEM CAPACITY
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 101
Hospital Organizational Culture: Staff Perceptionsof Teamwork and Learning Environment, 2007
79
70
57
44
96 94 91
8287
8072
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, 2007Categories of Nursing Homes, by Extent of Culture Change Adoption
SYSTEM CAPACITY
CULTURE CHANGE ADOPTERS
31%
CULTURE CHANGE STRIVERS
25%
TRADITIONAL43%
Culture change definition* describes nursing home only in a few respects or not at all, and leadership is not very committed to adopting culture change
Culture change definition* completely or for the most part
describes nursing home
Culture change definition* describesnursing home only in a few respectsor 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 to respond 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
National Health Expenditures Spent on Public Health Activities Compared 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 healthactivities
Insurance administrativecosts
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,” Archives of 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 Control 35 (2007):290-301.
HRSA (Health Resources and Services Administration). 2005. The National Survey of Children’s 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 Report 55, 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
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