NATIONAL HEALTHCARE QUALITY & DISPARITIES REPORT 2018 2015 National Healthcare Quality and Disparities Report and National Quality Stategy 5th Anniversary Update c This document is in the public domain and may be used and reprinted without permission. Citation of the source is appreciated. Suggested citation: 2018 National Healthcare Quality and Disparities Report. Rockville, MD: Agency for Healthcare Research and Quality; September 2019. AHRQ Pub. No. 19-0070-EF. 2018 NATIONAL HEALTHCARE QUALITY AND DISPARITIES REPORT U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Agency for Healthcare Research and Quality 5600 Fishers Lane Rockville, MD 20857 www.ahrq.gov AHRQ Publication No. 19-0070-EF September 2019 www.ahrq.gov/research/findings/nhqrdr/index.html ACKNOWLEDGMENTS The National Healthcare Quality and Disparities Report (QDR) is the product of collaboration among agencies from the U.S. Department of Health and Human Services (HHS), other federal departments, and the private sector. Many individuals guided and contributed to this effort. Without their magnanimous support, the report would not have been possible. Specifically, we thank: Primary AHRQ Staff: Gopal Khanna, Francis Chesley, Virginia Mackay-Smith, Jeff Brady, Erin Grace, Karen Chaves, Nancy Wilson, Darryl Gray, Barbara Barton, Doreen Bonnett, and Irim Azam. HHS Interagency Workgroup (IWG) for the QDR: Susan Jenkins (ACL), Irim Azam (AHRQ), Barbara Barton (AHRQ), Doreen Bonnett (AHRQ), Karen Chaves (AHRQ), Fran Chevarley (AHRQ), Camille Fabiyi (AHRQ), Darryl Gray (AHRQ), Kevin Heslin (AHRQ), Lan Liang (AHRQ), Iris Mabry- Hernandez (AHRQ), Kamila Mistry (AHRQ), Nancy Wilson (AHRQ), Doris Lefkowitz (AHRQ), Adelle Simmons (ASPE), Caroline Taplin (ASPE), Deron Burton (CDC), Kathleen Palso (CDC), Asel Ryskulova (CDC), Melissa Evans (CMS), Ed Huff (CMS), Loida Tamayo (CMS), Shari Ling (CMS), Richardae Araojo (FDA), Martin Mendoza (FDA), Girma Alemu (HRSA), Amy Chanlongbutra (HRSA), Sarah Heppner (HRSA), Jesse Lichstein (HRSA), Marlene Matosky (HRSA), Tracy Matthews (HRSA), Kirk Greenway (IHS), Ying Zhang (IHS), Dianne Rucinski (OASH), Virginia Cargill (NIH-OD-ORWH), Rajasri Roy (NIH- OD-ORWH), Emmanuel Taylor (NIH-NCI), Ellen Werner (NIH-NHLBI), Nancy Breen (NIH-NIMHD), DeLoris Hunter (NIH-NIMHD), Victoria Chau (SAMHSA), Xiuhua Chen (SSS), Anil Koninty (SSS), and Ernest Moy (VHA). IWG Subgroup - Cancer: Emmanuel Taylor (Chair, NIH-NCI), Barbara Barton (Co-Chair, AHRQ), Nancy Breen (NIH-NIMHD), Sue Sabatino (CDC), and Diane St. Germain (NIH-NCI). IWG Subgroup - Dementia: Susan Jenkins (Chair, ACL) Barbara Barton (Co-Chair, AHRQ), Rhona Limcangco (AHRQ), and Debbie Perfetto (AHRQ). IWG Subgroup - Maternal Morbidity and Mortality: Kamila Mistry (Co-Chair, AHRQ) and Camille Fabiyi (Co-Chair, AHRQ), Kirk Greenway (IHS), Violanda Grigorescu (CDC), Erofile Gropiotis (AHRQ), Megan Hambrick (AHRQ), Kevin Heslin (AHRQ), Elena Kuklina (CDC), Jesse Lichstein (HRSA), and Ying Zhang (IHS). IWG Subgroup - Opioids: Nancy Wilson (Chair, AHRQ), Victoria Chau (Co-Chair, SAMHSA), Girma Alemu (HRSA), Juliet Bui (OASH), Fran Chevarley (AHRQ), Kirk Greenway (IHS), Holly Hedegaard (CDC), Kevin Heslin (AHRQ), Lan Liang (AHRQ), and Ying Zhang (IHS). QDR Team: Irim Azam (CQuIPS), Barbara Barton (CQuIPS), Doreen Bonnett (OC), Xiuhua Chen (SSS), Frances Chevarley (CFACT), James Cleeman (CQuIPS), Diane Cousins (CQuIPS), Noel Eldridge (CQuIPS), Camille Fabiyi (OEREP), Erin Grace (CQuIPS), Darryl Gray (CQuIPS), Kevin Heslin (CFACT), Anil Koninty (SSS), Lan Liang (CFACT), Kamila Mistry (OEREP), Margie Shofer (CQuIPS), Nancy Wilson (CQuIPS), and Yanfang Zhang (SSS). HHS Data Experts: Cuong Bui (HRSA), Lara Bull (CDC), Frances Chevarley (AHRQ), Robin Cohen (CDC-NCHS), Joann Fitzell (CMS), Elizabeth Goldstein (CMS), Irene Hall (CDC-HIV), Norma Harris (CDC-HIV), Kevin Heslin (AHRQ), Jessica King (NPCR), Amanda Lankford (CDC), Denys Lau (CDC- NCHS), Lan Liang (AHRQ), Sharon Liu (SAMHSA), Marlene Matosky (HRSA), Tracy Matthews (HRSA), Robert Morgan (CMS), Richard Moser (NIH-NCI), Kathleen Palso (CDC-NCHS), Robert Pratt (CDC), Neil Russell (SAMHSA), Asel Ryskulova (CDC-NCHS), Alek Sripipatana (HRSA), Reda Wilson (CDC- NCCDPHP-ONDIEH), Emily Zammitti (CDC-NCHS), and Xiaohong (Julia) Zhu (HRSA). Other Data Experts: Mark Cohen (ACS NSQIP), Ashley Eckard (University of Michigan), Sheila Eckenrode (MPSMS-Qualidigm), Michael Halpern (American Cancer Society), Clifford Ko (ACS NSQIP), Vivian Kurtz (University of Michigan), Robin Padilla (University of Michigan KECC), Bryan Palis (NCDB, American College of Surgeons), and Yun Wang (MPSMS-Qualidigm). Other AHRQ Contributors: Cindy Brach, Iris Mabry-Hernandez, Edwin Lomotan, Karen Migdail, Pamela Owens, Wendy Perry, Mary Rolston, Bruce Seeman, Randie Siegel, and Michele Valentine. Data Support Contractors: Social & Scientific Systems (SSS). ii CONTENTS EXECUTIVE SUMMARY ..................................................................................................... 1 Key Findings ..................................................................................................................... 1 About the National Healthcare Quality and Disparities Report ..................................... 2 OVERVIEW OF U.S. HEALTHCARE SYSTEM LANDSCAPE ........................................... 3 Overview of the U.S. Healthcare System infrastructure ................................................. 3 Overview of Disease Burden in the United States .......................................................... 6 Overview of Healthcare Costs in the United States ........................................................ 9 Variation in Healthcare Quality and Disparities ...........................................................12 ACCESS TO HEALTHCARE AND DISPARITIES IN ACCESS ......................................... 17 Overall Trends in Access ................................................................................................. 17 Trends in Access Disparities ......................................................................................... 20 Trends in Health Insurance Coverage............................................................................21 Snapshot of Disparities in Access.................................................................................. 25 QUALITY AND QUALITY DISPARITIES ......................................................................... 33 Trends in Quality ........................................................................................................... 34 Trends in Person-Centered Care ............................................................................... 35 Trends in Patient Safety ............................................................................................. 40 Trends in Care Coordination ..................................................................................... 45 Trends in Effective Treatment ................................................................................... 52 Trends in Healthy Living ........................................................................................... 61 Disparities in Healthcare ............................................................................................... 67 Racial and Ethnic Disparities .................................................................................... 68 Overview of Racial and Ethnic Disparities ................................................................ 69 Disparities for Blacks .................................................................................................. 71 Disparities for Asians ................................................................................................. 80 Disparities for American Indians and Alaska Natives .............................................. 88 Disparities for Native Hawaiians and Pacific Islanders ............................................ 95 Disparities for Hispanics ......................................................................................... 102 Disparities by Income .............................................................................................. 109 Disparities by Insurance Status ............................................................................... 124 Disparities by Residence Location ........................................................................... 134 iii NEW MEASURES IN THE 2018 QDR DATABASE ....................................................... 149 Cancer Care .................................................................................................................. 149 Dementia Among Older Adults .................................................................................... 161 Opioid Use ................................................................................................................... 166 Maternal Morbidity and Mortality ............................................................................... 181 LOOKING FORWARD .................................................................................................... 185 Opportunities for Measurement ................................................................................. 185 HHS Research Priorities ............................................................................................. 185 Future Research and Work ......................................................................................... 188 REFERENCES............................................... ..................................................................