Influenza Vaccination

Overall, adjusting for age, Black people had the highest flu-associated hospitalization rates across 10 flu seasons, followed by AI/AN and Hispanic people, with similar trends for intensive care admission rates. Among AI/AN children, rates were 3 to 3.5 times higher for all three severe flu-related outcomes.⁹

Current clinical guidelines show that people who are 6 months or older should receive an annual flu vaccine, but not all patients can access vaccines or treatment if they become ill. CDC details preventive strategies (https://www.cdc.gov/flu/prevent/index.html) to protect against the flu. Moreover, current research shows that influenza vaccination even provides effective flu protection in patients with chronic obstructive pulmonary disease (COPD).¹⁰

Figure 5

Hospital patients who received influenza vaccination, 2018. Key: AI/AN = American Indian or Alaska Native, NHPI = Native Hawaiian/Pacific Islander. Note: The benchmark calculation takes the average of the top 10% of states with statistically reliable (more...)

• In 2018, 81.6% of AI/AN hospital patients received influenza vaccinations compared with 92.7% of White patients (Figure 5).
• The 2016 achievable benchmark was 96.6%.
• The top 10% of states that contributed to the achievable benchmark were Florida, Indiana, Maine, Utah, and Virginia.

Patients With Colon Cancer

Healthy People 2020 objectives include reducing the colorectal cancer incidence rate to 40 per 100,000 people and the mortality rate to 14.5 per 100,000 people.¹¹ Healthy People 2020 also includes an objective for colorectal cancer screening. The USPSTF expanded the recommended ages for colorectal cancer screening to 45 to 75 years (previously, it was 50 to 75 years). The USPSTF continues to recommend selectively screening adults ages 76 to 85 years for colorectal cancer.¹²

The American Cancer Society’s newest guidelines recommend that colorectal cancer screenings begin at age 45. The recommended age was lowered from 50 to 45 because colorectal cancer cases are on the rise among young and middle-age people.¹³

Figure 6

Patients with colon cancer who received surgical resection of colon cancer that included at least 12 lymph nodes pathologically examined, 2017. Key: AI/AN = American Indian or Alaska Native, NHPI = Native Hawaiian/Pacific Islander. Note: The benchmark (more...)

• In 2017, the percentage of patients with colon cancer who received surgical resection of colon cancer that included examination of at least 12 lymph nodes was lower for AI/AN people (83.7%) compared with White people (93%) (Figure 6).
• The 2015 achievable benchmark was 95.5%.
• The top 10% of states that contributed to the achievable benchmark were District of Columbia, Maine, Massachusetts, Rhode Island, and Vermont.

New HIV Infections

Recent CDC data show new HIV infections fell 8% from 2015 to 2019, after a period of general stability in new infections in the United States.¹⁴ AI/AN people represent about 1.3% of the U.S. population and less than 1% (186) of the HIV diagnoses in 2018 in the United States and dependent areas.¹⁵

It is important for everyone to know their HIV status. People who do not know they have HIV cannot take advantage of HIV care and treatment and may unknowingly pass HIV to others.

The United States has 574 federally recognized AI/AN tribes and many different languages. Meaningful engagement with tribal nations is critically important in creating culturally appropriate prevention programs to reduce HIV transmission.

Poverty, including limited access to high-quality housing, directly and indirectly increases the risk of HIV infection and affects the health of people who have and are at risk for HIV infection. Additional structural factors that influence risks of HIV infection in tribal communities are high rates of poverty, lower levels of education, unemployment, and lack of health insurance.

Figure 7

New HIV cases per 100,000 population age 13 and over, 2019. Key: AI/AN = American Indian or Alaska Native, NHPI = Native Hawaiian/Pacific Islander. Note: The benchmark calculation takes the average of the top 10% of states with statistically reliable (more...)

• In 2019, the percentage of new HIV cases was higher for AI/AN people (10.5%) compared with White people (5.3%) (Figure 7).
• The 2015 achievable benchmark was 4.2 per 100,000 population.
• The top 10% of states that contributed to the achievable benchmark were Idaho, Iowa, Maine, West Virginia, and Wisconsin.

End Stage Renal Disease Due to Diabetes

Diabetes is the leading cause of kidney disease in the United States. According to the National Institute of Diabetes and Digestive and Kidney Diseases, White people experience diabetes and kidney disease at a lower rate than other racial and ethnic groups.^{16, 17}

Figure 10

Adjusted incident rates of end stage renal disease due to diabetes per million population, 2001–2018 (lower rates are better). Key: AI/AN = American Indian or Alaska Native.

• From 2001 to 2018, the disparity between AI/AN people and White people decreased for the adjusted incident rate of ESRD due to diabetes. For AI/AN people, the rate decreased from 526 per million population to 273.1 per million, and for White people, there were no statistically significant changes (from 133.3 per million to 152.2 per million) (Figure 10).
• Disparities have been persistent, with AI/AN people having higher incident rates of ESRD due to diabetes than White people in all years.

Providers With Language Assistance

Current research shows that Asian people continue to experience health disparities in several quality areas, including patient-centered care and satisfaction.¹⁸ Adults who have limited English proficiency may experience disparities in their care and gaps in communication with their healthcare team.¹⁹

According to the Migration Policy Institute, in 2015, an estimated 25.9 million individuals living in the United States reported having limited English proficiency.²⁰ “More than one in four people aged 5 and over with LEP are born in the U.S.”²¹ Language assistance such as access to translation services, health education materials written in a known language, and other resources are required by law, but not all patients have access to these services at their usual source of care.²²

Figure 13

Adults with limited English proficiency and a usual source of care (USC) whose USC had language assistance, 2018.

• In 2018, Asian people with limited English proficiency and a usual source of care were less likely than White people to have a USC with language assistance (68.5% compared with 94.0%) (Figure 13).

The Limited English Proficiency website²³ offers a repository of resources collated by the Department of Justice to support improved communication with patients. AHRQ has also established a Limited English Proficiency module as part of its TeamSTEPPS^® training that shows the importance of language assistance services in keeping patients safe and avoiding adverse events.²⁴

Treatment by Home Health Care Providers

Home health care providers are committed to delivering high-quality and compassionate care and services to patients in a respectful manner that supports each patient’s dignity. Home health performance is examined through several types of quality measures that look at areas such as efficiency, patient safety, and patient-centered care. Evaluation of patient experience of care is conducted with the Consumer Assessment of Healthcare Providers and Systems Home Health Care Survey.²⁵

Figure 14

Adults who reported that home health care providers always treated them with courtesy and respect in the last 2 months of care, 2019. Key: AI/AN = American Indian or Alaska Native, NHPI = Native Hawaiian/Pacific Islander. Note: The benchmark calculation (more...)

• In 2019, the percentage of adults who reported that home health providers always treated them with courtesy and respect in the last 2 months was lower for Asian people (85.5%) compared with White people (94.4%) (Figure 14).
• The 2015 achievable benchmark was 95.0%.
• The top 10% of states that contributed to the achievable benchmark were Alabama, Louisiana, Mississippi, Rhode Island, South Carolina, and West Virginia. Guam was not included in the benchmark but its percentage was in the benchmark range.

Figure 15

Adults who reported that home health care providers always treated them as gently as possible in the last 2 months of care, 2019. Key: AI/AN = American Indian or Alaska Native, NHPI = Native Hawaiian/Pacific Islander. Note: The benchmark calculation takes (more...)

• In 2019, 80.6% of Asian adults reported that home health providers always treated them as gently as possible compared with 91.1% of White adults (Figure 15).
• The 2015 achievable benchmark was 92.5%.
• The top 10% of states that contributed to the achievable benchmark were Alabama, Kentucky, Louisiana, Mississippi, and West Virginia.

Knowledge of HIV Status

HIV and other related stigmas hinder patients from getting tested, which may delay treatment and affect a patient’s health and quality of life.²⁶ According to CDC, people ages 13–24 are less likely to know their HIV status.²⁷ Accurate estimates of new HIV infection rates are crucial for preventing the spread of the disease.

Figure 18

People age 13 and over living with HIV who know their HIV status, 2010–2019. Key: AI/AN = American Indian or Alaska Native, NHPI = Native Hawaiian/Pacific Islander. Note: The benchmark calculation takes the average of the top 10% of states with (more...)

• Data from 2010 to 2019 show that the disparity between Asian people and White people is narrowing as the percentage of Asian people (68.1% to 86.6%) who know their HIV status increased at a faster rate compared with White people (85.8% to 89.2%) (Figure 18).
• The 2015 achievable benchmark was 90.2%. At the current rate of increase, overall, the benchmark could be achieved in 2 years.
• The top 10% of states that contributed to the achievable benchmark were Connecticut, District of Columbia, Massachusetts, New Hampshire, and New York. Puerto Rico was not included in the benchmark but its percentage was in the benchmark range.

Oral Medication Management

The ability to perform daily activities, such as taking medications correctly, is important to the health status and quality of life of people living in the community. Taking too much or too little can keep the drugs from working properly and may cause unintended harm, including death. The home health team can help teach patients ways to organize medications and to take them properly. If patients get better at taking medications correctly, it means the home health team is doing a good job teaching patients how to take their drugs and about the possible harm if they do not follow these instructions.

Specific items that should be discussed include all the prescriptions and other medications the patient takes, allergic or other adverse reactions to drugs experienced in the past, and actions to take if a medication is not working. This measure shows how often the home health team helped patients get better at taking their medications correctly (including prescription medications, over-the-counter medications, vitamins, and herbal supplements). Only medications the patient takes by mouth are considered.

Figure 19

Home health care patients whose management of oral medications improved, 2013–2018. Key: AI/AN = American Indian or Alaska Native, NHPI = Native Hawaiian/Pacific Islander.

• From 2013 to 2018, the percentage of home health care patients whose management of oral medications improved increased for both Asian and White populations. The percentage for White people, however, improved faster than for Asian people, so the disparity between the groups increased (Figure 19).
• The 2015 achievable benchmark was 66.2%. At the current rate of increase, the benchmark could be achieved by Asian people in 2 years; White people have already achieved the benchmark.
• The top 10% of states that contributed to the achievable benchmark were Delaware, Mississippi, New Jersey, North Dakota, and South Carolina.

New HIV Cases

According to CDC research, in 2018, Black people accounted for 13% of the nation’s population but represented 42% of all new HIV cases. Most of these cases affect Black male adolescents and adults.²⁸ The Office of Minority Health reports that in 2019, African Americans were 8.1 times more likely to be diagnosed with HIV infection compared with the White population.²⁹

Figure 22

New HIV cases per 100,000 population age 13 and over, 2019 (lower rates are better). Note: Black and White are non-Hispanic. Hispanic includes all races. The benchmark calculation takes the average of the top 10% of states with statistically reliable (more...)

• In 2019, Black people reported 45.3 new HIV cases per 100,000 population for people age 13 and over compared with 5.3 per 100,000 cases for White people (Figure 22).
• The 2015 achievable benchmark was 4.2 per 100,000 population.
• The top 10% of states that contributed to the achievable benchmark were Idaho, Iowa, Maine, West Virginia, and Wisconsin.

Deaths From HIV Infection

HIV mortality disproportionately affects some racial and ethnic groups more than others. According to CDC data, in 2019, HIV was the sixth leading cause of death for Black men ages 25–34 and seventh for Black women ages 35–44.³¹

Figure 23

HIV infection deaths per 100,000 population, 2018 (lower rates are better). Key: AI/AN = American Indian or Alaska Native. Note: The benchmark calculation takes the average of the top 10% of states with statistically reliable data. U.S. territories are (more...)

• In 2018, Black people had 6.2 HIV infection deaths per 100,000 population compared with 0.9 per 100,000 cases for White people (Figure 23). These cases represent mortality for which HIV was the primary cause of death.
• The 2015 achievable benchmark was 0.8 per 100,000 population.
• The top 10% of states that contributed to the achievable benchmark were Kansas, Kentucky, Minnesota, Missouri, Ohio, and Washington.

Hospital Admissions for Hypertension

Hypertension affects nearly half of all U.S. adults and is responsible for substantial burden of morbidity, mortality, and financial costs on the healthcare system.³⁵ The cumulative incidence of hypertension by age 55 years was substantially higher for Black men and women compared with White men and women. Based on the 2017 American College of Cardiology/American Heart Association blood pressure guideline definition,³⁶ 75.5% of Black men and 75.7% of Black women developed hypertension compared with 54.5% of White men and 40.0% of White women by age 55 years.³⁷

Figure 24

Hospital admissions for hypertension per 100,000 population, adults age 18 and over, 2018 (lower rates are better). Key: API = Asian/Pacific Islander. Note: API, Black, and White are non-Hispanic. Hispanic includes all races.

• In 2018, the rate of hospital admissions for hypertension was 212.9 per 100,000 population for Black adults compared with 38.4 per 100,000 cases for White adults (Figure 24).

End Stage Renal Disease Due to Diabetes

According to the Office of Minority Health, African American adults are 60 percent more likely than non-Hispanic White adults to have been diagnosed with diabetes by a physician and 3.5 times more likely to be diagnosed with end stage renal disease (ESRD) compared with non-Hispanic White people. During 2018, there were 131,636 newly reported cases of ESRD and diabetes was listed as the primary cause for nearly half (62,012).³⁸

Resource

The U.S. Renal Data System of the National Institute of Diabetes and Digestive and Kidney Diseases tracks cases of ESRD in the ESRD Incident Count.

Figure 27

Adjusted incident rates of end stage renal disease due to diabetes per million population, 2001–2018 (lower rates are better). Key: AI/AN = American Indian or Alaska Native.

• Data from 2001 to 2018 show that the disparity between Black people and White people is narrowing, but Black people are still showing a higher rate of ESRD due to diabetes (Figure 27).
• Disparities have been persistent, with Black people having a higher incident rate of ESRD due to diabetes than White people in all years.

New HIV Cases

Figure 28

New HIV cases per 100,000 population age 13 and over, 2008–2019 (lower rates are better). Key: AI/AN = American Indian or Alaska Native, NHPI = Native Hawaiian/Pacific Islander. Note: All racial groups are non-Hispanic.

• Data from 2008 to 2019 show that the disparity between Black people and White people was narrowing, but Black people are still showing a much higher rate of new HIV cases (45.3 per 100,000 population in 2019) compared with White people (5.3 per 100,000 population in 2019) (Figure 28).
• The 2015 achievable benchmark was 4.2 per 100,000 population.
• The top 10% of states that contributed to the achievable benchmark were Idaho, Iowa, Maine, West Virginia, and Wisconsin.

Health Insurance

Hispanic populations have the highest uninsured rates of any racial or ethnic group in the United States. Variation occurs among subgroups, with Cubans having the highest percentage and Central Americans the lowest percentage.³⁹ Disparities in insurance rates by income are also seen in the Hispanic population.

Figure 30

People under age 65 who were uninsured all year, 2018.

• In 2018, poor (20.8%), low-income (21.9%), and middle-income Hispanic people (15.6%) were more likely to be uninsured compared with high-income Hispanic people (7.3%) (Figure 30).

Figure 31

Number and percentage of quality measures for which Hispanic groups experienced better, same, or worse quality of care compared with non-Hispanic White groups for the most recent data year, 2015, 2017, 2018, or 2019. Key: n = number of measures. Note: (more...)

• Data for the most recent year show that quality care was worse for Hispanic groups compared with non-Hispanic White groups for 36% of all quality measures. Quality was better for Hispanic groups than for non-Hispanic White groups on 20% of all quality measures (Figure 31).

New HIV Cases

Approximately 1.2 million people in the United States have HIV and about 13% of them do not know it and need testing. HIV continues to have a disproportionate impact on certain populations, particularly racial and ethnic minorities and gay, bisexual, and other men who have sex with men. New HIV infections declined from 2015 to 2019, after a period of general stability.⁴⁰

Figure 32

New HIV cases per 100,000 population age 13 and over, 2019 (lower rates are better). Key: AI/AN = American Indian or Alaska Native; NHPI = Native Hawaiian/Pacific Islander. Note: Racial groups are non-Hispanic. Hispanic includes all races. The benchmark (more...)

• In 2019, the rate of new HIV cases per 100,000 population age 13 and over was higher for Hispanic people (20.0 per 100,000 population) compared with non-Hispanic White people (5.3 per 100,000 population) (Figure 32).
• The 2015 achievable benchmark was 4.2 per 100,000 population.
• The top 10% of states that contributed to the benchmark were Idaho, Iowa, Maine, West Virginia, and Wisconsin.

Influenza Vaccination Among Home Health Care Patients

Medicare defines home health care as a wide range of healthcare services that can be given in the home for an illness or injury. Patients can qualify for this service if they are under the care of a doctor who certifies that they need at least one service such as intermittent skilled nursing care, physical therapy, speech-language pathology, or continued occupational therapy services, and the patient must be home bound.

Home health care is usually less expensive, more convenient, and as effective as care in a hospital or skilled nursing facility. Home health care services include wound care for pressure sores or a surgical wound, patient and caregiver education, intravenous or nutrition therapy, and monitoring of serious illness and unstable health status.

Influenza vaccination is the primary method for preventing the illness and its severe complications, and annual vaccination is recommended for everyone age 6 months and over.⁴¹ All healthcare contacts, including hospitalizations, provide excellent opportunities for vaccination, particularly for people at the highest risk for complications and death from influenza.

Figure 33

Home health care patients who had influenza vaccination during flu season, 2018. Notes: The benchmark calculation takes the average of the top 10% of states with statistically reliable data. U.S. territories are not included in the calculations. Some (more...)

• In 2018, Hispanic home health care patients (90.4%) were less likely than non-Hispanic White home health care patients (96.0%) to receive an influenza vaccine (Figure 33).
• The 2015 achievable benchmark was 94.1%.
• The top 10% of states that contributed to the benchmark were Montana, Nebraska, North Dakota, South Dakota, Vermont, and Wisconsin.

Difficulty Accessing a Usual Source of Care

The AHRQ Medical Expenditure Panel Survey (MEPS) describes usual source of care as the particular medical professional, doctor’s office, clinic, health center, or other place where a person would usually go if sick or in need of advice about his or her health.

According to Healthy People 2020, patients with a usual source of care are more likely to receive recommended preventive services such as flu shots, blood pressure screenings, and cancer screenings.⁴²

Figure 34

People without a usual source of care who indicate a financial or insurance reason for not having a source of care, 2018 (lower rates are better).

• In 2018, the percentage of people without a usual source of care who indicate a financial or insurance reason for not having a source of care was higher for Hispanic people (26.3%) than for non-Hispanic White people (11.5%) (Figure 34).

End Stage Renal Disease

Diabetes is the leading cause of kidney disease in the United States. According to the National Institute of Diabetes and Digestive and Kidney Diseases, non-Hispanic White people experience diabetes and kidney disease at a lower rate than other racial and ethnic groups.⁴³

Figure 37

Adjusted incident rates of end stage renal disease due to diabetes per million population, 2001–2018 (lower rates are better).

• Data from 2001 to 2018 show that the disparity between Hispanic and non-Hispanic White people was narrowing (Figure 37).
• Rates of ESRD due to diabetes decreased for Hispanic people, from 410.0 per million population to 292.7 per million population.
• Disparities have been persistent, with Hispanic populations having higher incident rates of ESRD due to diabetes than White people in all years.

Improved Breathing Among Home Health Care Patients

To assess the quality of care received by home health care patients, measures of wait time to see provider, timely initiation of care, ambulation, ability to get in and out of bed, bathing, toileting, dressing, pain, confusion, management of oral medications, influenza and pneumococcal vaccination, and shortness of breath are tracked.

Shortness of breath is uncomfortable. Many patients with heart or lung problems experience difficulty breathing and may tire easily or be unable to perform daily activities. Doctors and home health staff should monitor shortness of breath and may give advice, therapy, medication, or oxygen to help lessen this symptom.

Figure 38

Home health care patients whose shortness of breath decreased, 2013–2018.

• From 2013 to 2018, the disparity between Hispanic and non-Hispanic White people was narrowing for home health care patients whose shortness of breath decreased (Figure 38).
• Both Hispanic people (53.7% to 74.5%) and non-Hispanic White people (66.7% to 80.9%) showed improvement over time.

New HIV Cases

HIV can affect anyone regardless of sexual orientation, race, ethnicity, gender, age, or geographic location. However, in the United States, some racial/ethnic groups are more affected than others, given their percentage of the population. This disparity occurs because some population groups have higher rates of HIV in their communities, thus raising the risk of new infections with each sexual or injection drug use encounter.

In addition, a range of social, economic, and demographic factors such as stigma, discrimination, income, education, and geographic region can affect people’s risk for HIV. In 2018, 42% of new HIV diagnoses were among Black people and 29% were among Hispanic people.⁴⁴

While NHPI individuals represent 0.4% of the total population in the United States, their HIV case rate was more than twice that of the White population in 2019.

Figure 41

New HIV cases per 100,000 population age 13 and over, 2019. Key: NHPI = Native Hawaiian or Pacific Islander Note: All racial groups are non-Hispanic. Hispanic includes all races. The benchmark calculation takes the average of the top 10% of states with (more...)

• In 2019, the percentage of new HIV cases per 100,000 population age 13 and over was more than twice as high for NHPI groups (13.9 per 100,000 population) as for White groups (5.3 per 100,000 population) (Figure 41).
• The 2015 achievable benchmark was 4.2 per 100,000 population.
• The top 10% of states that contributed to the benchmark were Idaho, Iowa, Maine, West Virginia, and Wisconsin.

Treatment by Home Health Providers

Medicare defines home health care as a wide range of healthcare services that can be given in the home for an illness or injury. Patients can qualify for this service if they are under the care of a doctor who certifies that they need at least one service such as intermittent skilled nursing care, physical therapy, speech-language pathology, or continued occupational therapy services, and the patient must be home bound.

Home health care is usually less expensive, more convenient, and as effective as care in a hospital or skilled nursing facility. Home health care services include wound care for pressure sores or a surgical wound, patient and caregiver education, intravenous or nutrition therapy, and monitoring of serious illness and unstable health status.

The goal of home health care is to treat an illness or injury; help patients recover, regain independence, become as self-sufficient as possible, and maintain current condition or level of function; and slow decline.⁴⁵

Figure 42

Adults who reported that home health care providers always treated them with courtesy and respect in the last 2 months of care, 2019. Note: The benchmark calculation takes the average of the top 10% of states with statistically reliable data. U.S. territories (more...)

• In 2019, the percentage of adults who reported that home health care providers always treated them with courtesy and respect in the last 2 months was lower for NHPI people (90.7%) compared with White people (94.4%) (Figure 42).
• The 2015 achievable benchmark was 95%.
• The top 10% of states that contributed to the benchmark were Alabama, Louisiana, Mississippi, Rhode Island, South Carolina, and West Virginia. Guam was not included in the benchmark but its percentage was in the benchmark range.

Initiation of Home Health Care

Timely initiation of home health care is associated with lower risks of 30-day rehospitalization. Therefore, CMS requires that home health care services be initiated within 2 days of hospital discharge when ordered, except when the physician/provider authorizes a delay in the initiation of services due to an outpatient visit or the patient’s or family’s request.⁴⁶

Figure 43

Home health care patients who had timely initiation of care, 2018. Note: Initiation of care is defined by CMS as home health quality episodes in which the start or resumption of care date was on the physician-specified start or resumption of care date (more...)

• In 2018, NHPI home health patients were less likely than White patients to receive timely initiation of care (91% vs. 94.4%) (Figure 43).
• The 2015 achievable benchmark was 95%. At the current rate of progress, NHPI people should reach the benchmark in 5 years (trend data not shown).
• The top 10% of states that contributed to the benchmark were Louisiana, Nebraska, North Dakota, South Dakota, and West Virginia.

Knowledge of HIV Status

It is important for everyone to know his or her HIV status. Getting an HIV test is the first step for people living with HIV to get care and treatment and control the infection. Taking HIV medicine as prescribed helps people living with HIV to live a long, healthy life and protect their sex partners from HIV. About 85% of people with HIV in the United States know they have the virus. However, 15% (162,500) of people with HIV do not know they have the virus, and about 40% of new HIV infections come from them.

Half of people with HIV had the virus 3 years or more before diagnosis. Most people at high risk who did not get tested last year saw a healthcare provider during the year. Everyone should get tested at least once, and people at high risk should be tested at least once a year. Healthcare providers can diagnose HIV sooner if they test more people and test people at high risk more often.⁴⁷

Figure 46

People age 13 and over living with HIV who had knowledge of their HIV status, 2010–2019. Note: Data are statistically unreliable for NHPI groups in 2015. The benchmark calculation takes the average of the top 10% of states with statistically reliable (more...)

• Data from 2010 to 2019 show that the disparity between NHPI people and White people was narrowing due to a larger increase in the percentage of NHPI people (69.8% to 83.6%) than White people (85.8% to 89.2%) who are living with HIV and had knowledge of their HIV status (Figure 46).
• The 2015 achievable benchmark was 90.2%.
• The top 10% of states that contributed to the benchmark were Connecticut, District of Columbia, Massachusetts, New Hampshire, and New York.

Viral Load Monitoring

Viral load is the amount of HIV in the blood of a person who has HIV. Viral load is highest during the acute phase of HIV and when HIV is untreated. People with HIV who keep an undetectable viral load (or stay virally suppressed) can live long, healthy lives. Having an undetectable viral load also helps prevent transmitting the virus to others through sex or sharing needles, syringes, or other injection equipment, and from mother to child during pregnancy, birth, and breastfeeding. Higher viral load increases the risk of transmitting HIV.⁴⁸

Figure 47

People age 13 and over living with diagnosed HIV who had at least two CD4 or viral load tests performed at least 3 months apart during the last year, 2014–2018. Note: The benchmark calculation takes the average of the top 10% of states with statistically (more...)

• Data from 2014 to 2018 show that the disparity between NHPI and White populations was narrowing due to a larger increase in the percentage of NHPI people (50.2% to 55.7%) than White people (58.5% to 58.9%) living with diagnosed HIV who had at least two CD4 or viral load tests performed at least 3 months apart during the last year (Figure 47).
• The 2015 achievable benchmark was 66.2%.
• The top 10% of states that contributed to the benchmark were Connecticut, Iowa, Montana, and Oregon.

Pediatric Dental Caries

Dental caries is one of the most common chronic diseases of childhood in the United States. Untreated caries can cause pain and infections that may lead to problems with eating, speaking, playing, and learning. Children who have poor oral health often miss more school and receive lower grades than children who do not.⁵⁴

Figure 52

Children ages 5–17 with untreated dental caries, 2015–2018 (lower rates are better). Note: Poor refers to household incomes below the federal poverty level (FPL); low, the FPL to just below 200% of the FPL; middle, 200% to just below 400% (more...)

• In 2015–2018, the measure with the largest income disparities among all income groups was children ages 5–17 with untreated dental caries (Figure 52).
• In 2015–2018, the percentage of children ages 5–17 with untreated dental caries was higher for poor, low-income, and middle-income children compared with high-income children (19.4%, 16.9%, and 12.1%, respectively, vs. 4.5%).

Difficulty Accessing a Usual Source of Care

People with lower incomes may experience difficulty accessing affordable care and are less likely to have a usual source of care that is readily accessible.⁵¹ People who are unwell and have low incomes are also more likely to experience poverty.⁵¹

In 2018, the measure with the second largest income disparities among all income groups was people without a usual source of care who indicated a financial or insurance reason for not having a source of care.

Figure 53

People without a usual source of care who indicated a financial or insurance reason for not having a source of care, 2018 (lower rates are better).

• In 2018, the percentage of people without a usual source of care who indicated a financial or insurance reason for not having a source of care was higher for poor, low-income, and middle-income people compared with high-income people (23.6%, 25.9%, and 16.1%, respectively, vs. 7.2%) (Figure 53).

High Family Medical Expenditures

The most prominent barriers to healthcare coverage include affordability, eligibility for public coverage in a person’s state, immigration status, and lack of familiarity with signup procedures.⁵⁵ Poor health may require a family to spend more on healthcare, resulting in less income. Costs will vary based on each person or family’s needs and may inhibit a family’s ability to reach other goals.⁵¹

In 2018, the measure with the third largest income disparities among middle-income people was people under age 65 whose family’s health insurance premium and out-of-pocket medical expenditures were more than 10% of total family income

Figure 54

People under age 65 whose family’s health insurance premium and out-of-pocket medical expenditures were more than 10% of total family income, 2018 (lower rates are better).

• In 2018, the percentage of people under age 65 whose family’s health insurance premium and out-of-pocket medical expenditures were more than 10% of total family income was higher for middle-income people compared with high-income people (21.9% vs. 10.7%) (Figure 54).

Childhood Vaccinations

Childhood vaccinations are an important part of preventing disease. Consistently high childhood immunization rates have greatly reduced the rates of death, disability, and illness from communicable diseases such as chicken pox, diphtheria, measles, meningococcal meningitis, mumps, polio, rubella, tetanus, and whooping cough.

In the decade before the measles vaccine became available, an average of 549,000 measles cases and 495 measles deaths were reported annually in the United States. Of the reported cases, approximately 48,000 people were hospitalized from measles and each year, 1,000 people developed chronic disability from acute encephalitis caused by measles.⁵⁶

Mumps complications include orchitis, oophoritis, mastitis, meningitis, encephalitis, pancreatitis, and hearing loss.⁵⁷

Before the rubella vaccine became available, one noted outbreak infected 12.5 million people, 11,000 pregnant women lost their babies, 2,100 newborns died, and 20,000 babies were born with congenital rubella syndrome.⁵⁸

Figure 55

Children ages 19–35 months who received 1 or more doses of measles-mumps-rubella vaccine, 2018. Note: The benchmark calculation takes the average of the top 10% of states with statistically reliable data. U.S. territories are not included in the (more...)

• In 2018, the percentage of children ages 19–35 months who received 1 or more doses of measles-mumps-rubella vaccine was lower for children from poor (90.3%) and low-income (90.3%) families compared with children from high-income families (95.8%) (Figure 55).
• The 2015 achievable benchmark was 96.4%.
• The top 5 states that contributed to the achievable benchmark were Connecticut, Delaware, Iowa, Maine, Nebraska, and Vermont.

Hospital Admissions for Diabetes Complications

More than 100 million people living in the United States have diabetes or are at risk for diabetes.⁵⁹ Compared with some other countries, the rate of hospital admissions for short-term complications of diabetes, which include ketoacidosis, hyperosmolarity, and coma, is higher in the United States.⁶⁰ Such complications may be related to kidney disease, hypertension, vision problems, pain, or other issues.

Figure 56

Hospital admissions for short-term complications of diabetes per 100,000 population, adults, 2018 (lower rates are better).

• In 2018, the rate of hospital admissions for short-term complications of diabetes was three times as high for adults in the lowest income group (145.3 per 100,000 population) compared with adults in the highest income group (45.0 per 100,000 population) (Figure 56).

Adolescent Vaccination

Meningococcal disease refers to any illness caused by bacteria called Neisseria meningitidis, also known as meningococcus. These illnesses are often severe and can be deadly. They include infections of the lining of the brain and spinal cord (meningitis) and bloodstream infections (bacteremia or septicemia).⁶¹

Vaccines can help prevent meningococcal disease. Two types of meningococcal vaccines are available in the United States:

• Meningococcal conjugate or MenACWY vaccines, which help protect against four types of the bacteria that cause meningococcal disease (serogroups A, C, W, and Y).
• Serogroup B meningococcal or MenB vaccines, which help protect against serogroup B meningococcal disease.

According to CDC, all children ages 11 to 12 years old should get a meningococcal conjugate vaccine, with a booster dose at 16 years old.⁶²

Figure 59

Adolescents ages 16–17 who received 1 or more doses of meningococcal conjugate vaccine, 2008–2018. Note: The benchmark calculation takes the average of the top 10% of states with statistically reliable data. U.S. territories are not included (more...)

• In 2008, 31.9% of low-income adolescents ages 16–17 received 1 or more doses of meningococcal conjugate vaccine, and by 2018, the percentage had increased to 86.4% (Figure 59).
• From 2008 to 2018, the percentage of high-income adolescents ages 16–17 who received 1 or more doses of meningococcal conjugate vaccine increased from 46.8% to 89.8%.
• Data from 2008 to 2018 show that disparities between adolescents in high-income households and in poor households were narrowing over time and both populations were improving.
• The 2015 achievable benchmark was 96.2%. At the current rate of increase, the benchmark could be achieved in 2 years for all income groups.
• The top 5 states that contributed to the achievable benchmark were Indiana, Michigan, New Jersey, Pennsylvania, and Rhode Island.

Emergency Department Visits Involving Opioids

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

Figure 60

Emergency department visits related to opioid use per 100,000 population, 2005–2018. Key: 1^st Quartile = <$48000, 2^nd Quartile = $48,000–$60,999, 3^rd Quartile = $61,000–$81,999, and 4^th Quartile = >$82,000. Note: (more...)

• In 2005, the rate of emergency department visits involving opioid-related diagnoses among people in the lowest income group was 104.9 per 100,000 population, and by 2018, the rate had increased to 348.1 per 100,000 population (Figure 60).
• In 2005, the rate of emergency department visits involving opioid-related diagnoses among people in the second lowest income group was 90.2 per 100,000 population, and by 2018, the rate had increased to 231 per 100,000 population.
• In 2005, the rate of emergency department visits involving opioid-related diagnoses among people in the third income group was 83.2 per 100,000 population, and by 2018, the rate had increased to 195.7 per 100,000 population.
• In 2005, the rate of emergency department visits involving opioid-related diagnoses among people in the highest income group was 65.5 per 100,000 population, and by 2018, the rate had increased to 146.8 per 100,000 population.
• Data from 2005 to 2018 show that disparities between high-income and poor and low-income people were widening over time and both populations were worsening.
• The 2015 achievable benchmark was 65.2 per 100,000. No income group showed progress toward the benchmark.
• The top 10% of states contributing to the achievable benchmark were Iowa, Kansas, Nebraska, and South Dakota.

Hospital Stays Involving Opioids

Increased availability and overuse of opioid medications have contributed to adverse outcomes for patients, including increased risk of opioid use disorder, misuse of medication, and overdoses.⁶⁴ The National Survey on Drug Use and Health shows that in 2020, nearly 9.5 million people age 12 and over misused opioids in the past year.⁶⁵ This treatment measure examines inpatient stays associated with opioid-related diagnoses.

Figure 61

Hospital inpatient stays involving opioid-related diagnoses per 100,000 population, 2005–2018. Key: 1^st Quartile = <$48000, 2^nd Quartile = $48,000–$60,999, 3^rd Quartile = $61,000–$81,999, and 4^th Quartile = >$82,000. (more...)

• In 2005, the rate of hospital inpatient stays involving opioid-related diagnoses among people in the lowest income group was 179.6 per 100,000 population, and by 2018, the rate had increased to 382.1 per 100,000 population (Figure 61).
• In 2005, the rate of hospital inpatient stays involving opioid-related diagnoses among people in the second lowest income group was 125.5 per 100,000 population, and by 2018, the rate had increased to 288.7 per 100,000 population.
• In 2005, the rate of hospital inpatient stays involving opioid-related diagnoses among people in the second highest income group was 117.2 per 100,000 population, and by 2018, the rate had increased to 252.1 per 100,000 population.
• In 2005, the rate of hospital inpatient stays involving opioid-related diagnoses among people in the highest income group was 98.1 per 100,000 population, and by 2018, the rate had increased to 191.6 per 100,000 population.
• Data from 2005 to 2018 show that disparities between people in the highest quartile and people in the other three quartiles were widening over time and all populations were worsening.
• The 2015 achievable benchmark was 102.9 per 100,000. There is no evidence of progress toward the benchmark.
• The top 10% of states that contributed to the achievable benchmark were Georgia, Iowa, Nebraska, Texas, and Wyoming.

Difficulty Accessing a Usual Source of Care

Having a usual primary care provider is associated with higher likelihood of receiving appropriate care, including preventive care services. Patients with a usual source of care also report better provider-patient communication and increased trust in the provider, both of which are linked to treatment adherence and better health.⁷²

Figure 63

People without a usual source of care who indicated a financial or insurance reason for not having a source of care, 2018 (lower rates are better).

• In 2018, the percentage of people without a usual source of care who indicated a financial or insurance reason for not having a source of care was more than twice as high for adults with public insurance (17.9%) compared with adults with private insurance (8.7%) (Figure 63).
• In 2018, the percentage of people without a usual source of care who indicated a financial or insurance reason for not having a source of care was more than 5 times as high for uninsured adults (43.8%) compared with adults with private insurance (8.7%).

Receiving Appropriate Treatment After Lumpectomy for Breast Cancer

When women with early stage breast cancer undergo breast-conserving surgery (also called lumpectomy), combining surgical treatment with radiation therapy improves outcomes.⁷³ Observational studies have reported that adding radiation therapy reduces the risk of recurrence by half and reduces the risk of death from breast cancer by a sixth.⁷⁴

Figure 64

Women under age 70 treated for breast cancer with breast-conserving surgery who received radiation therapy to the breast within 1 year of diagnosis, 2017.

• In 2017, the percentage of women who underwent breast-conserving surgery for breast cancer and received radiation therapy within 1 year of surgery was significantly lower for women with public insurance (83.2%) than for women with private insurance (91.3%) (Figure 64).
• The percentage of women who underwent breast-conserving surgery for breast cancer and received radiation therapy within 1 year of surgery was also lower for women with no insurance (88.7%) than for women with private insurance (91.3%).

Providers Who Showed Respect for What Patients Had to Say

Patient-centered care encompasses qualities of compassion, empathy, and responsiveness to the needs, values, and preferences of individuals. It is linked to greater patient participation in their care, lower risk of misdiagnosis due to poor communication, and better patient outcomes.^{75, 76}

Figure 65

Adults who had a doctor’s office or clinic visit in the last 12 months whose health providers sometimes or never showed respect for what they had to say, 2017 (lower rates are better).

• In 2017, the percentage of adults who had a doctor’s office or clinic visit in the last 12 months who reported their health providers sometimes or never showed respect for what they had to say was nearly twice as high for people with public insurance (12.2%) compared with people with private insurance (6.4%) (Figure 65).
• The percentage of adults who had a doctor’s office or clinic visit in the last 12 months who reported their health providers sometimes or never showed respect for what they had to say was also higher for people without health insurance (13.3%) than for people with private insurance (6.4%).

Wellness Visits for Children

Wellness visits are important opportunities to assess the physical, emotional, and social development of children and adolescents, screen for health risks, and influence health behaviors, such as eating habits and physical activity, which often extend into adulthood.⁷⁸ Having health insurance facilitates access to providers for recommended well-child visits.

Figure 66

Children ages 0–17 with wellness checkup in the past 12 months, by insurance status, 2019.

• In 2019, children with no insurance (74.1%) were less likely to receive a wellness visit in the preceding 12 months than children with either public (95.2%) or private (94.6%) insurance (Figure 66).

Blood Pressure Screening

Hypertension, also called high blood pressure, affects about one-third of U.S. adults. It can damage the heart, blood vessels, kidneys, and other parts of the body over time, but it is often asymptomatic until complications, such as stroke, heart attack, heart failure, and chronic kidney disease, develop. If hypertension is identified early, providers can offer patients a range of treatment that lowers the risk for complications.⁷⁹

Figure 67

Adults without hypertension who had their blood pressure measured in the last 2 years, 2019.

• In 2019, uninsured adults (75.6%) were less likely to receive screening for high blood pressure in the last 2 years than adults covered by public (94.4%) or private (94.1%) insurance (Figure 67).

Receipt of Flu Vaccine by Patients With Diabetes

Some patients are at higher risk of contracting the flu. These include children, older adults, and people with diabetes. The flu also has a greater likelihood of exacerbating diabetes in affected patients.⁸⁰ The only measure showing decreased disparities by insurance status is:

• Adults age 40 and over with diagnosed diabetes who received a flu vaccination in the calendar year.

The disparity reduction for this measure reflects stagnant outcomes for patients with private insurance while outcomes for uninsured patients showed improvement.

Figure 70

Adults age 40 and over with diagnosed diabetes who received a flu vaccination in the calendar year, 2008–2018. Note: Data for uninsured people did not meet criteria for statistical reliability in 2017 and 2018.

• The percentage of uninsured adults age 40 and over with diabetes who received a flu vaccine increased from 36.7% in 2008 to 49.7% in 2016.
• The percentage of adults with diabetes and public or private insurance who received a flu vaccine showed no statistically significant changes (Figure 70).

Deaths From HIV Infection

New HIV diagnoses and HIV prevalence are concentrated primarily in large U.S. metropolitan areas, with Atlanta, Baton Rouge, Miami, New Orleans, and Orlando leading the list of areas with the highest rate of new diagnoses. Atlanta, Baton Rouge, Miami, New Orleans, and New York lead the list of areas with the highest rates of people living with HIV.⁹⁴

Figure 73

HIV infection deaths per 100,000 population, 2018 (lower rates are better). Note: The benchmark calculation takes the average of the top 10% of states with statistically reliable data. U.S. territories are not included in the calculations. Some benchmarks (more...)

• In 2018, the death rate from HIV infections was higher in large central metro areas (2.3 per 100,000 population) compared with the rate in large fringe metro areas (1.1 per 100,000 population) (Figure 73).
• The 2015 achievable benchmark was 0.75 per 100,000 population. At the current rate of increase, overall, the benchmark could be achieved in 4 years for large central metro areas and in 2 years for large fringe metro areas (trend data not shown).
• The top 10% of states that contributed to the achievable benchmark were Kansas, Kentucky, Minnesota, Missouri, Ohio, and Washington.

An HHS initiative to eliminate new HIV infections is underway. The goal is “to reduce new HIV infections in the United States by 75 percent in five years and by 90 percent by 2030.”⁹⁵ Federal efforts to reduce HIV-related mortality include the promotion of treatment therapies such as antiretroviral therapy, as well as pre-exposure prophylaxis and postexposure prophylaxis.⁹⁶

Several HHS agencies provide a federal response to the HIV epidemic, including HRSA’s HIV/AIDS Bureau, which administers the Ryan White HIV/AIDS Program (RWHAP). RWHAP is the largest federal program focused exclusively on providing HIV care and treatment to patients with inadequate or no insurance. Through RWHAP’s partnerships, more than 512,000 people receive care annually.

Hospital Admissions for Asthma

Asthma is the most common chronic lung condition among children under 17 years in the United States.⁹⁷ Children with asthma may experience debilitating exacerbations triggered by environmental exposures, such as fumes, airborne viruses, and cold air, but appropriate treatment in ambulatory care settings can reduce patients’ risk for exacerbations.^{98, 99}

Research has linked access to primary care, continuity of care by a provider, and adherence to preventive care plans to improved quality of care and fewer hospital admissions for chronic conditions such as asthma.¹⁰⁰

Figure 74

Hospital admissions for asthma per 100,000 population, children ages 2–17, 2018 (lower rates are better).

• In 2018, the rate of hospital admissions for children ages 2–17 with asthma was more than 60% higher in large central metro areas (116.3 per 100,000 population) than in large fringe metro areas (71.3 per 100,000 population) (Figure 74).

Emergency Department Visits for Substance Use

Illicit drug use and subsequent overdose deaths have risen in both metropolitan and nonmetropolitan areas over the past two decades. Overdose death rates in rural areas exceeded rates in urban areas between 2007 and 2015,¹⁰¹ overlapping with the second wave of opioid overdose deaths.¹⁰² However, more recent data show that overdose death rates in the third wave of opioid overdose deaths are highest in urban communities.¹⁰³

Figure 75

Emergency department visits with a principal diagnosis related to substance use disorder only per 100,000 population, 2018 (lower rates are better).

• In 2018, the rate of adult emergency department visits with a principal diagnosis related to substance use disorder was 42% higher in large central metro areas (642.8 per 100,000 population) than in large fringe metro areas (452.7 per 100,000 population) (Figure 75).

Hospital Admissions for Short-Term Complications of Diabetes

Type 1 diabetes is one of the most common chronic diseases in childhood. It is caused by insulin deficiency, resulting from an autoimmune reaction that destroys insulin-producing beta-cells in the pancreas. In children and adolescents, the most common complications of diabetes are short-term problems that result from blood sugars going too low or too high: hypoglycemia, ketoacidosis, and diabetic coma.¹⁰⁴ Access to healthcare providers who can prescribe medications and teach patients how to self-manage their health can reduce risks for short-term complications and prevent emergency visits and hospitalizations.¹⁰⁵

Figure 76

Hospital admissions for short-term complications of diabetes per 100,000 population, children 6–17, 2018 (lower rates are better).

• In 2018, the rate of hospitalizations among children ages6–17 years due to short-term complications of diabetes mellitus was 36% higher in medium metro areas (32.1 per 100,000 population) than in large fringe metro areas (23.6 per 100,000 population) (Figure 76).

Cholesterol Check

Medications and lifestyle modifications that lower cholesterol reduce the risk of heart attacks and strokes in people who may have underlying atherosclerosis (i.e., cardiovascular disease).¹⁰⁶ Intermittent laboratory testing for cholesterol by a healthcare provider can identify atherosclerosis in otherwise healthy people and help them make informed treatment decisions to lower their risk of heart attacks and strokes. Thus, access to screening for cholesterol is an important component of efforts to improve cardiovascular health.¹⁰⁷

Figure 77

Adults who received a blood cholesterol measurement in the last 5 years, 2019.

• In 2019, the percentage of adults who received a blood cholesterol measurement in the last 5 years was lower in micropolitan (83.5%) and medium metropolitan areas (88.1%) than in large fringe metro areas (91.0%) (Figure 77).

Infant Mortality

Infant mortality is the death of infants before their first birthday. It is a key health indicator that reflects baseline maternal and infant health, as well as healthcare services delivered before, during, and immediately after an infant’s birth. In 2018, the five leading causes of infant death were birth defects, preterm birth and low birth weight, injuries (e.g., suffocation), sudden infant death syndrome, and maternal pregnancy complications.¹⁰⁸

Figure 78

Infant mortality per 1,000 live births, birth weight 2,500 grams or more, 2017 (lower rates are better).

• In 2017, the percentage of infant deaths among live births weighing 2,500 grams or more was significantly higher in medium metro (2.2%), small metro (2.4%), micropolitan (2.6%), and noncore (2.9%) areas than in large fringe metro areas (1.7%) (Figure 78).

Pediatric Vision Exams

Pediatric vision screenings are efficient eye examinations that primary care providers, trained laypeople (e.g., in schools), and eye care specialists perform to detect issues that warrant a more comprehensive eye examination by a specialist. They are crucial for identifying conditions that could lead to blindness, life-threatening illness, and problems with school performance if left untreated.¹⁰⁹

Research shows that periodic vision screening in early childhood reduces the risk of vision loss at age 7 years by more than 50%.¹¹⁰ Thus, access to vision screening throughout childhood is important to ensure children’s health.

Figure 79

Children ages 3–5 who ever had their vision checked by a health provider, 2018. Note: Data for noncore areas are not shown because the data were statistically unreliable.

• In 2018, the percentage of children ages 3–5 years who had their vision checked by a health provider was lower in micropolitan (58.9%) and small metropolitan areas (62.0%) than in large fringe metro areas (77.3%) (Figure 79).

Hospital and Emergency Visits for Heart Failure

Heart failure is an important cause of morbidity and mortality in the United States, accounting for 379,800 deaths in 2018.^{111, 112} It is also the most common and expensive reason for preventable hospitalizations, with more than 1 million admissions and $11.2 billion in total costs in 2017. Access to appropriate treatment in ambulatory care settings can help patients safely avoid emergency visits and hospital admissions for this condition.¹¹³

Figure 80

Hospitalizations and emergency department encounters for heart failure per 100,000 population, 2018 (lower rates are better).

• In 2018, the rate of emergency department visits and hospitalizations per 100,000 population for heart failure was significantly higher in micropolitan (663.6 visits) and noncore (713.3 visits) areas than in large fringe metro areas (434.9 visits) (Figure 80).

Emergency Department Visits for Dental Conditions

Oral health is a vital component of a person’s overall health and well-being. Untreated oral disease can affect appetite, leading to nutritional problems; cause chronic pain, interfering with sleep and work; and has been associated with diabetes, heart and lung disease, stroke, and poor birth outcomes.¹¹⁴

Preventive dental care, including early detection, treatment, and management of problems, promotes good oral health. When people lack access to a usual source of dental care, they often will seek relief in emergency departments, which are equipped to meet only emergency dental care needs.¹¹⁵

Figure 81

Emergency department visits with a principal diagnosis related to dental conditions per 100,000 population, 2018 (lower rates are better).

• In 2018, the rate of ED visits related to dental conditions in micropolitan and noncore areas combined (459.7 per 100,000 population) was more than twice the rate in large fringe metro areas (210.3 per 100,000 population) (Figure 81).

Hospital Admissions for Pneumonia

Community-acquired pneumonia (CAP) is an acute lung infection acquired outside of a hospital setting. A person with CAP may present with symptoms that range from mild fever and productive cough to severe infection and inability to breathe without mechanical ventilation.¹¹⁶

CAP results in substantial morbidity, mortality, and costs in the United States. As the fourth leading reason for hospitalizations in 2018, it accounted for 740,700 admissions and $7.7 billion in healthcare costs.¹¹⁷ In 2019, it was the underlying cause of death in 43,881 individuals (13.4 deaths per 100,000 population).¹¹⁸

CAP hospitalizations are often avoidable. Administering pneumococcal vaccines to high-risk groups can prevent infections, and early evaluation and treatment by a healthcare provider can prevent hospitalizations.

Figure 82

Hospital admissions for community-acquired pneumonia per 100,000 population, adults age 18 and over, 2018 (lower rates are better).

• In 2018, the rate of hospital admissions for CAP was nearly twice as high in noncore areas (330.2 per 100,000 population) as in large fringe metro areas (171.2 per 100,000 population) (Figure 82).

Unexpected Deaths After Hospital Admission

Death during a hospital admission may indicate that patients received unsafe or inappropriate care, particularly if a patient dies while being treated for problems with low mortality risk.

Figure 83

Deaths per 1,000 hospital admissions with expected low mortality, 2018 (lower rates are better).

• In 2018, the death rate for conditions with expected low mortality was nearly twice as high in noncore areas (0.81 per 1,000 admission) as in large fringe metro areas (0.45 per 1,000 admission) (Figure 83).

Inpatient Stays Due to Opioid Use

The opioid epidemic constitutes a continuing public health emergency¹¹⁹ that affects the entire United States. The 2020 National Survey on Drug Use and Health estimates that nearly 9.5 million people misused opioids in the past year,⁶⁵ and data from the Centers for Disease Control and Prevention (CDC) indicate that rates of nonfatal and fatal overdose continue to rise in multiple states and territories.

CDC estimates that 49,860 of 70,630 drug overdose deaths (70.6%) involved opioids in 2019, affecting multiple age groups, racial and ethnic groups, and geographic regions.¹²⁰ Rising rates of hospital admissions for opioid-related diagnoses echo this trend. They also indicate that narrowing disparities between geographic locations represent worsening trends in large fringe metro areas instead of improving trends in large central metro areas.

Figure 86

Hospital inpatient stays involving opioid-related diagnoses per 100,000 population, 2005–2018 (lower rates are better). Note: The benchmark calculation takes the average of the top 10% of states with statistically reliable data. U.S. territories (more...)

• From 2005 to 2018, the gap in opioid-related hospitalization rates in large central metro areas and in large central fringe metro areas narrowed (Figure 86). However, the reduced disparity was due to rates of opioid-related hospitalizations rising faster in large fringe metro areas. This undesirable trend began to plateau in 2016 but remains well above the 2015 achievable benchmark of 102.9 hospitalizations per 100,000 population. (For this measure, a low value is more desirable, so rates above the achievable benchmark indicate suboptimal quality of care.)
• In 2005, the rate was 111.5 per 100,000 population in large fringe metro areas vs. 195.8 per 100,000 population in large central metro areas. In 2017, rates in both geographic areas had risen to peak 288.4 admissions per 100,000 population in large fringe metro areas and 314.6 admissions per 100,000 population in large central metro areas.
• In 2018, the most recent year for which data are available, hospitalization rates for opioid-related disorders had plateaued at 268.7 per 100,000 population in large fringe metro areas and 307.3 per 100,000 population in large central metro areas, approximately 3 times as high as the achievable benchmark of 102.9 per 100,000 population.
• The top 10% of states that contributed to the achievable benchmark were Georgia, Iowa, Nebraska, Texas, and Wyoming. In 2016–2017, no state reached the benchmark.