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2021 National Healthcare Quality and Disparities Report [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2021 Dec.
Healthcare delivery is not experienced equitably by all populations. A healthcare disparity is a difference between population groups in the way they access, experience, and receive healthcare. Factors that influence healthcare disparities include social, economic, environmental, and other disadvantages, 1 , 2 some of which are explored in this report.
Unfortunately, Americans too often do not receive care they need, or they receive care that causes harm. Care can be delivered too late or without full consideration of a patient’s preferences and values. Many times, our healthcare system distributes services inefficiently and unevenly across populations. Some Americans receive worse care than others. These disparities may occur for a variety of reasons, including differences in access to care, social determinants, provider biases, poor provider-patient communication, and poor health literacy.
The Research Framework in Exhibit 1 was developed by the National Institutes of Health (NIH) National Institute on Minority Health and Health Disparities (NIMHD). This framework is based on an evolving conceptualization of factors relevant to the understanding and promotion of minority health and to the understanding and reduction of health disparities.
The framework serves as a vehicle for encouraging NIH-supported research that addresses the complex and multifaceted nature of minority health and health disparities. This research needs to span different domains of influence (Biological, Behavioral, Physical/Built Environment, Sociocultural Environment, Healthcare System) and different levels of influence (Individual, Interpersonal, Community, Societal) within those domains.
The framework also provides a classification structure that facilitates analysis of the NIMHD minority health and health disparities research portfolios to assess progress, gaps, and opportunities. Examples of factors are provided within each cell of the framework (e.g., Family Microbiome within the Interpersonal-Biological cell). These factors are not intended to be exhaustive. Health disparity populations, as well as other features of this framework, may be adjusted over time.
NIMHD Research Framework. * Health Disparity Populations: Race/ethnicity, low socioeconomic status, rural, sexual/gender minority. Other Fundamental Characteristics: Sex/gender, disability, geographic region.
The NHQDR reports on progress and opportunities for improving healthcare quality and reducing healthcare disparities. The NIMHD Minority Health and Health Disparities Research Framework highlights factors ranging from individual biology and behavior to social structure that affect disparities. To successfully reduce disparities, it is necessary to address all these factors.
All Americans should have equitable access to high-quality care. Instead, racial and ethnic minorities and poor people often face more barriers to care and receive poorer quality of care when they can get it. 3 In this report, measures were analyzed to assess disparities both by socioeconomic and cultural groups and by settings of care.
An increasing number of healthcare organizations and payers are experimenting with strategies to identify needs and connect patients to resources that address identified needs. The goals are to improve health outcomes, reduce avoidable use of costly health services, and improve health equity. 4
Inequitable health outcomes result from inequities in the distribution of or access to resources that promote good health outcomes. Differences refer to outcomes that result from biological risk or other factors that are not a matter of policy or discrimination in access. A difference may become a disparity when some subgroups and not others are given access to resources to manage their differential risk from biology or other factors and the groups without access have poorer outcomes. Thus, differences and disparities may have different determinants requiring different forms of intervention. 5
The Disparities in Healthcare section of the 2021 NHQDR examines the best and worst performing quality measures among the measures used in the report. These quality measures are analyzed in this section of the report by race and ethnicity, income, insurance status, and residence location. While these categories are broad, each section begins with key definitions to orient readers and includes analyses showing quality measure performance in the latest data year and analyses showing whether disparities were widening or narrowing over time.
More information on the measures included in this section of the report is available through the NHQDR Data Query Tool (https://datatools.ahrq.gov/nhqdr). The tool also allows readers to stratify NHQDR data by variables such as education, sex, and age, where available.
Researchers, patients, providers, and policymakers have worked to identify, understand, and eliminate the disparities experienced by different racial and ethnic groups across the healthcare system. In 1985, the Department of Health and Human Services published the Report of the Secretary’s Task Force on Black and Minority Health (Heckler Report), which marked the first comprehensive study of racial and minority health by the U.S. government. 6 Since then, the Department, along with other stakeholders, has continued this work, including throughout the NHQDR. The growing evidence base shows that patients of different racial and ethnic groups experience quality of care inequitably and disparately. 7 , 8
American Indian or Alaska Native (AI/AN). A person having origins in any of the original peoples of North and South America (including Central America) and maintains tribal affiliation or community attachment.
Asian. A person having origins in any of the original peoples of the Far East, Southeast Asia, or Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
Black or African American. A person having origins in any of the Black racial groups of Africa. Terms such as “Haitian” can be used in addition to “Black or African American.”
Hispanic or Latino. A person of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race. The term “Spanish origin” can be used in addition to “Hispanic or Latino.”
Native Hawaiian/Pacific Islander (NHPI). A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
White. A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Largest disparities for a single data year, focusing on the most recent data year.Trends in quality of care (number of measures improving, not changing, and worsening) for the population group.
Comparison with the reference group, focusing on the change in the gap between the two groups (gap is narrowing, widening, and not changing).
Figure 1 displays the number of quality measures for which each racial or ethnic group experienced better, same, or worse quality care compared with White populations in the latest data year. Figure 2 shows the number of quality measures with disparities at baseline that were narrowing (improving), widening (worsening), or not changing. xix
Number and percentage of quality measures for which members of selected groups experienced better, same, or worse quality of care compared with White people for the most recent data year, 2015, 2017, 2018, or 2019. Key: n = number of measures; AI/AN = (more. )
Black populations received worse care than White populations for 43% of quality measures (Figure 1). AI/AN populations received worse care than White populations for 40% of quality measures.Hispanic populations received worse care than non-Hispanic White populations for 36% of quality measures.
Asian and NHPI populations received worse care than White populations for about 30% of quality measures but Asian populations also received better care for about 30% of quality measures.
Number and percentage of quality measures with disparity at baseline for which disparities related to race and ethnicity were improving, not changing, or worsening over time, 2000 through 2015, 2016, 2017, 2018, or 2019. Key: n = number of measures; AI/AN (more. )
For all racial and ethnic groups, at least 90% of measures showed no change in disparities (Figure 2).
Three measures showed improvement in disparities between AI/AN populations and White populations. Black populations and NHPI populations each had two measures that showed improvement in disparities. Two measures showed improvement between Hispanic populations and non-Hispanic White populations.One measure for Asian populations showed improvement in disparities: People age 13 and over living with HIV who know their HIV status.
One measure for Asian populations showed worsening disparities: Home health care patients whose management of oral medications improved.
One measure for Black populations showed worsening disparities: Emergency department visits for asthma, ages 2–19.
No worsening disparities were observed for AI/AN, Hispanic, or NHPI populations. Fewer quality measures are available for select subpopulations overall.This section presents disparities in quality of care and, new in 2021, access to care for American Indian and Alaska Native (AI/AN) populations. To provide context, findings for other ethnic and racial populations may be included. Additional details on disparities of care for other priority populations are presented in population-specific sections of this report.
Number and percentage of access measures for which members of selected racial groups experienced better, same, or worse access to care compared with White people, 2017–2019. Key: AI/AN = American Indian or Alaska Native, NHPI = Native Hawaiian/Pacific (more. )
AI/AN people had worse access to care than White people for 50% of access measures (Figure 3).American Indian and Alaska Native people experienced worse quality care compared with White people for 40% of all quality measures and 63% of Person-Centered Care measures.
Number and percentage of quality measures for which American Indian and Alaska Native people experienced better, same, or worse quality of care compared with White people for the most recent data year, 2015, 2017, 2018, or 2019. Key: n = number of measures. (more. )
Data for the most recent year show that quality care was worse for AI/AN people than for White people for 40% of all quality measures and that quality was better for AI/AN people than for White people for 18% of all quality measures (Figure 4).
Hospital patients who received influenza vaccination.Patients with colon cancer who received surgical resection of colon cancer that included at least 12 lymph nodes pathologically examined.
New HIV cases per 100,000 population age 13 and over.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
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.
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
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.
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.
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.
