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2021 National Healthcare Quality and Disparities Report [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2021 Dec.
The National Academy of Medicine defines healthcare quality as “the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” Many factors contribute to the quality of care in the United States, including access to timely care, affordability of care, and use of evidence-based guidelines to drive treatment.
This section of the report highlights utilization of healthcare services, healthcare workforce statistics, healthcare expenditures, and major contributors to morbidity and mortality. These factors help paint an overall picture of the U.S. healthcare system, particularly areas that need improvement. Quality measures show whether the healthcare system is adequately addressing risk factors, diseases, and conditions that place the greatest burden on the healthcare system and if change has occurred over time.
The NHQDR tracks care delivered by providers in many types of healthcare settings. The goal is to provide high-quality healthcare that is culturally and linguistically sensitive, patient centered, timely, affordable, well coordinated, and safe. The receipt of appropriate high-quality services and counseling about healthy lifestyles can facilitate the maintenance of well-being and functioning. In addition, social determinants of health, such as education, income, and residence location can affect access to care and quality of care.
Improving care requires facility administrators and providers to work together to expand access, enhance quality, and reduce disparities. It also requires coordination between the healthcare sector and other sectors for social welfare, education, and economic development. For example, Healthy People 2030 includes 5 domains (shown in the diagram below) and 78 social determinants of health objectives for federal programs and interventions.
Healthy People 2030 social determinants of health domains.
The numbers of health service encounters and people working in health occupations illustrate the large scale and inherent complexity of the U.S. healthcare system. The tracking of healthcare quality measures in this report iii attempts to quantify progress made in improving quality and reducing disparities in the delivery of healthcare to the American people.
Number of healthcare service encounters, United States, 2018 and 2019.
In 2018, there were 860 million physician office visits (Figure 1). In 2019, patients spent 149 million days in hospice. In 2019, there were 100 million home health visits.The National Institutes of Health defines disease burden as the impact of a health problem, as measured by prevalence, incidence, mortality, morbidity, extent of disability, financial cost, or other indicators.
This section of the report highlights two areas of disease burden that have major impact on the health system of the United States: years of potential life lost and leading causes of death. The NHQDR tracks measures of quality for most of these conditions. Variation in access to care and care delivery across communities contributes to disparities related to race, ethnicity, sex, and socioeconomic status.
The concept of years of potential life lost (YPLL) involves estimating the average time a person would have lived had he or she not died prematurely. This measure is used to help quantify social and economic loss from premature death, and it has been promoted to emphasize specific causes of death affecting younger age groups. YPLL inherently incorporates age at death, and its calculation mathematically weights the total deaths by applying values to death at each age. 1
According to the Centers for Disease Control and Prevention (CDC), unintentional injuries include opioid overdoses (unintentional poisoning), motor vehicle crashes, suffocation, drowning, falls, fire/burns, and sports and recreational injuries. Overdose deaths involving opioids, including prescription opioids, heroin, and synthetic opioids (e.g., fentanyl), have been a major contributor to the increase in unintentional injuries. Opioid overdose has increased to more than six times its 1999 rate. 2
Age-adjusted years of potential life lost before age 65, by cause of death, 2010–2019. Key: YPLL = years of potential life lost. Note: The perinatal period occurs from 22 completed weeks (154 days) of gestation and ends 7 completed days after (more. )
From 2010 to 2019, there were no changes in the ranking of the top 10 leading diseases and injuries contributing to YPLL. The top 5 were unintentional injury, cancer, heart disease, suicide, and complications during the perinatal period (Figure 2). The remaining 5 were homicide, congenital anomalies, liver disease, diabetes, and cerebrovascular disease.
Unintentional injury increased from 791.8 per 100,000 population in 2010 to 1,024.3 per 100,000 population in 2019.
Cancer decreased from 635.2 per 100,000 population in 2010 to 533.3 per 100,000 population in 2019.Heart disease decreased from 474.3 per 100,000 population in 2010 to 453.2 per 100,000 population in 2019.
Age-adjusted years of potential life lost before age 65, by cause of death and race, 2019. Key: AI/AN = American Indian or Alaska Native; PI = Pacific Islander.
In 2019, among American Indian and Alaska Native (AI/AN) people, the top five contributing factors for YPLL were unintentional injuries (1,284.6 per 100,000 population), suicide (457.7 per 100,000 population), liver disease (451.6 per 100,000 population), heart disease (399.8 per 100,000 population), and cancer (339.6 per 100,000 population) (Figure 3).
In 2019, among Asian and Pacific Islander people, the top five contributing factors for YPLL were cancer (375.7 per 100,000 population), unintentional injuries (299.4 per 100,000 population), complications in the perinatal period (203.4 per 100,000 population), suicide (198.5 per 100,000), and heart disease (197.7 per 100,000 population).
In 2019 among Black people, the top five contributing factors for YPLL were unintentional injuries (1,085.8 per 100,000 population), heart disease (843.5 per 100,000 population), homicide (801.7 per 100,000 population), cancer (652.7 per 100,000 population), and complications in the perinatal period (560.4 per 100,000 population).
In 2019, among White people, the top five contributing factors for YPLL were unintentional injuries (1,080.0 per 100,000 population), cancer (530.1 per 100,000 population), heart disease (406.6 per 100,000 population), suicide (387.6 per 100,000 population), and complications in the perinatal period (215.7 per 100,000 population).
Leading causes of death for the total population, United States, 2018 and 2019.
In 2019, heart disease, cancer, unintentional injuries, chronic lower respiratory diseases, stroke, Alzheimer’s disease, and diabetes were among the leading causes of death for the overall U.S. population (Figure 4).
Overall, kidney disease moved from the 9 th leading cause of death in 2018 to the 8 th leading cause of death in 2019.
Suicide remained the 10 th leading cause of death in 2018 and 2019.The years of potential life lost, years with disability, and leading causes of death represent some aspects of the burden of disease experienced by the American people. Findings highlighted in this report attempt to quantify progress made in improving quality of care, reducing disparities in healthcare, and ultimately reducing disease burden.
The United States has almost 1 million staffed hospital beds; nearly 800,000 are community hospital beds and 107,000 are intensive care beds. Figure 5 shows the numbers of different types of staffed intensive care hospital beds.
Medical-surgical intensive care provides patient care of a more intensive nature than the usual medical and surgical care delivered in hospitals, on the basis of physicians’ orders and approved nursing care plans. These units are staffed with specially trained nursing personnel and contain specialized equipment for monitoring and supporting patients who, because of shock, trauma, or other life-threatening conditions, require intensified comprehensive observation and care. These units include mixed intensive care units.
Pediatric intensive care provides care to pediatric patients that is more intensive in nature than that usually provided to pediatric patients. The unit is staffed with specially trained personnel and contains monitoring and specialized support equipment for treating pediatric patients who, because of shock, trauma, or other life-threatening conditions, require intensified, comprehensive observation and care.
Cardiac intensive care provides patient care of a more specialized nature than the usual medical and surgical care, on the basis of physicians’ orders and approved nursing care plans. The unit is staffed with specially trained nursing personnel and contains specialized equipment for monitoring, support, or treatment for patients who, because of severe cardiac disease such as myocardial infarction, open-heart surgery, or other life-threatening conditions, require intensified, comprehensive observation and care.
Neonatal intensive care units (NICUs) are distinct from the newborn nursery and provide intensive care to sick infants, including those with the very lowest birth weights (less than 1,500 grams). NICUs may provide mechanical ventilation, care before or after neonatal surgery, and special care for the sickest infants born in the hospital or transferred from another institution. Neonatologists typically serve as directors of NICUs.
Burn care provides care to severely burned patients. Severely burned patients are those with the following: (1) second-degree burns of more than 25% total body surface area for adults or 20% total body surface area for children; (2) third-degree burns of more than 10% total body surface area; (3) any severe burns of the hands, face, eyes, ears, or feet; or (4) all inhalation injuries, electrical burns, complicated burn injuries involving fractures and other major traumas, and all other poor risk factors.
Other intensive care unit beds are in specially staffed, specialty-equipped, separate sections of a hospital dedicated to the observation, care, and treatment of patients with life-threatening illnesses, injuries, or complications from which recovery is possible. This type of care includes special expertise and facilities for the support of vital functions and uses the skill of medical, nursing, and other staff experienced in the management of conditions that require this higher level of care.
U.S. community hospital intensive care staffed beds, by type of intensive care, 2019. Note: Community hospitals are defined as all nonfederal, short-term general, and other special hospitals. Other special hospitals include obstetrics and gynecology; (more. )
In 2019, of the more than 900,000 staffed hospital beds in the United States, 86% were in community hospitals (data not shown).
Most of the more than 107,000 intensive care beds in community hospitals were medical-surgical intensive care (51.9%) and neonatal intensive care beds (21.1%) (Figure 5).
Critical access hospital (CAH) is a designation given to eligible rural hospitals by the Centers for Medicare & Medicaid Services (CMS). The CAH designation is designed to reduce the financial vulnerability of rural hospitals and improve access to healthcare by keeping essential services in rural communities. To accomplish this goal, CAHs receive certain benefits, such as cost-based reimbursement for Medicare services. As of July 16, 2021, 1,353 CAHs were located throughout the United States. 3 , iv
Distribution of critical access hospitals in the United States, 2021.
According to CMS, CAHs must be located in a rural area or an area that is treated as rural, v so the number of CAHs varies by state (Figure 6).
In 2019, California had a population of 39.5 million and 36 CAHs compared with Iowa, which had a population of only 3.2 million but 82 CAHs.
Healthcare access and quality can be affected by workforce shortages, particularly in rural areas. In addition, lack of racial, ethnic, and gender concordance between providers and patients can lead to miscommunication, stereotyping, and stigma, and, ultimately, suboptimal healthcare.
Improving quality of care, increasing access to care, and controlling healthcare costs depend on the adequate availability of healthcare providers. 4 Physician shortages currently exist in many states across the nation, with relatively fewer primary care and specialty physicians available in nonmetropolitan counties compared with metropolitan counties. 5
The Health Resources and Services Administration (HRSA) further projects that the supply of key professions, including primary care providers, general dentists, adult psychiatrists, and addiction counselors, will fall short of demand by 2030. 6 These concerns have the potential to influence the delivery of healthcare and negatively affect patient outcomes.
Number of people working in health occupations, United States, 2019. Key: EMT = emergency medical technician. Note: Doctors of medicine also include doctors of osteopathic medicine. Active physicians include those working in direct patient care, administration, (more. )
In 2019, there were 3.7 million registered nurses (Figure 7).In 2019, there were 2.4 million healthcare aides, which includes nursing, psychiatric, home health, and occupational therapy aides and physical therapy assistants and aides.
In 2019, there were 2.1 million health technologists.In 2019, 2.0 million other health practitioners provided care, including more than 145,000 physician assistants (PAs).
In 2019, there were 972,000 active medical doctors in the United States, which include doctors of medicine and doctors of osteopathy.
In 2019, there were 183,000 dentists.In recent decades, promising approaches that address the supply-demand imbalance have emerged as alternatives to simply increasing the number of physicians. One strategy relies on telehealth technologies to improve physicians’ efficiency or to increase access to their services. For example, Project ECHO is a telehealth model in which specialists remotely support multiple rural primary care providers so that they can treat patients for conditions that might otherwise require traveling to distant specialty centers. 7
Another strategy relies on peer-led models, in which community-based laypeople receive the training and support needed to deliver care for a (typically) narrow range of conditions. Successful examples of this approach exist, including the deployment of community health workers to manage chronic diseases, 8 promotoras to provide maternal health services, 9 peer counselors for mental health and substance use disorders, 10 and dental health aides to deliver oral health services in remote locations. 11
The National Institutes of Health, HRSA, and the Agency for Healthcare Research and Quality (AHRQ) have sponsored formative research to examine key issues that must be addressed to further develop these models, but all show promise for expanding access to care and increasing overall diversity within the healthcare workforce.
The number of full-time, year-round workers in healthcare occupations has almost doubled since 2000, increasing from 5 million to 9 million workers, according to the U.S. Census Bureau’s American Community Survey.
A racially and ethnically diverse health workforce has been shown to promote better access and healthcare for underserved populations and to better meet the health needs of an increasingly diverse population. People of color, however, remain underrepresented in several health professions, despite longstanding efforts to increase the diversity of the healthcare field. 12
Additional research has found that physicians from groups underrepresented in the health professions are more likely to serve minority and economically disadvantaged patients. It has also been found that Black and Hispanic physicians practice in areas with larger Black and Hispanic populations than other physicians do. 13
Gender diversity is also important. Women currently account for three-quarters of full-time, year-round healthcare workers. Although the number of men who are dentists or veterinarians has decreased over the past two decades, men still make up more than half of dentists, optometrists, and emergency medical technicians/paramedics, as well as physicians and surgeons earning over $100,000. 14
Women working as registered nurses, the most common healthcare occupation, earn on average $66,000. Women working as nursing, psychiatric, and home health aides, the second most common healthcare occupation, earn only $27,000. 14
The impact of unequal gender distribution in the healthcare workforce is observed in the persistence of gender inequality in heart attack mortality. Most physicians are male, and some may not recognize differences in symptoms in female patients. The fact that gender concordance correlates with whether a patient survives a heart attack has implications for theory and practice. Medical practitioners should be aware of the possible challenges male providers face when treating female heart attack patients. 15
Research has shown that some mental health workforce groups, such as psychiatrists, are more diverse than many other medical specialties, and this diversity has improved over time. However, this diversity has not translated as well to academic faculty or leadership positions for underrepresented minorities. It was found that there was more minority representation among psychiatry residents (16.2%) compared with faculty (8.7%) and practicing physicians (10.4%). This difference results in minority students and trainees having fewer minority mentors to guide them in the profession.
Diversification of the physician workforce has been a goal for several years and could improve access to primary care for underserved populations and address health disparities. Family physicians’ race/ethnicity has become more diverse over time but still does not reflect the national racial and ethnic composition. 16 , vi
Racial and ethnic distribution of all active physicians (left) and U.S. population racial and ethnic distribution (right), 2019. Note: White, Black, Asian, and >1 Race are non-Hispanic. Percentages of the U.S. population do not add to 100 due (more. )
In 2019, White people were 60% of the U.S. population and approximately 64% of physicians (Figure 8).
Asian people were about 6% of the U.S. population and approximately 22% of physicians. Black people were 12% of the U.S. population but only 5% of physicians. Hispanic people were 18% of the U.S. population but only 7% of physicians. People of more than race made up about 3% of the U.S. population but less than 2% of physicians.AI/AN people and Native Hawaiian/Pacific Islander (NHPI) people accounted for 1% or less of the U.S. population and 1% or less of physicians (data not shown).
Preventive care, including screenings, is key to reducing death and disability and improving health. Evidence has shown that patients with providers of the same gender have higher rates of breast, cervical, and colorectal cancer screenings. 17
Physicians by race/ethnicity and sex, 2018. Key: AI/AN = American Indian or Alaska Native; NHPI = Native Hawaiian/Pacific Islander. Note: Physicians (federal and nonfederal) who are licensed by a state are considered active, provided they are working (more. )
In 2018, among Black physicians, females (53.0%) constituted a larger percentage than males (47.0%) (Figure 9).
Among White physicians, 65.5% were male. Among Asian physicians, 55.7% were male. Among AI/AN physicians, 60.1% were male. Among Hispanic physicians, 59.5% were male.White physicians by age and sex, 2018. Note: Physicians (federal and nonfederal) who are licensed by a state are considered active, provided they are working at least 20 hours per week. Physicians who are retired, semiretired, temporarily not in practice, (more. )
In 2018, among White physicians, males were the vast majority of those age 65 years and over (79.3%) and of those ages 55–64 years (71.5%) (Figure 10).
A little more than half of White physicians age 34 and younger were females (50.6%).Among White physicians age 35 and over, males made up a larger percentage of the workforce than females. This percentage increased with age.
Black physicians by age and sex, 2018. Note: Physicians (federal and nonfederal) who are licensed by a state are considered active, provided they are working at least 20 hours per week. Physicians who are retired, semiretired, temporarily not in practice, (more. )
In 2018, among Black physicians under age 55, females made up a larger percentage of the workforce than males. This percentage decreased with increasing age (Figure 11).
Females were 44.2% of Black physicians ages 55–64 and 34.9% of Black physicians age 65 and over.Asian physicians by age and sex, 2018. Note: Physicians (federal and nonfederal) who are licensed by a state are considered active, provided they are working at least 20 hours per week. Physicians who are retired, semiretired, temporarily not in practice, (more. )
In 2018, among Asian physicians, males were the vast majority of those age 65 years and over (72.7%) and of those ages 55–64 years (66.3%) (Figure 12).
Among Asian physicians age 34 and younger, there were more females (52.0%) than males (48.0%).Among Asian physicians age 35 and over, males made up a larger percentage of the workforce than females. This percentage increased with age.
American Indian or Alaska Native physicians by age and sex, 2018. Note: Physicians (federal and nonfederal) who are licensed by a state are considered active, provided they are working at least 20 hours per week. Physicians who are retired, semiretired, (more. )
In 2018, among AI/AN physicians, males were the vast majority of those age 65 years and over (73.2%) and of those ages 55–64 years (62.6%) (Figure 13).
Among AI/AN physicians age 34 and younger, there were more females (57.9%) than males (42.1%).Among AI/AN physicians age 45 and over, males made up a larger percentage of the workforce than females. This percentage increased with age.
Hispanic physicians by age and sex, 2018. Note: Physicians (federal and nonfederal) who are licensed by a state are considered active, provided they are working at least 20 hours per week. Physicians who are retired, semiretired, temporarily not in practice, (more. )
In 2018, most Hispanic physicians age 65 years and over (77.5%) and ages 55–64 years (67.5%) were males (Figure 14).
Among Hispanic physicians age 34 and younger, there were more females (55.3%) compared with males (44.7%).
Among Hispanic physicians age 35 and over, males made up a larger percentage of the workforce than females. This percentage increased with age.
The racial and ethnic diversity of the oral healthcare workforce is insufficient to meet the needs of a diverse population and to address persistent health disparities. 18 However, among first-time, first-year enrollees in dental school, improved diversity has been observed. The number of African American enrollees nearly doubled and the number of Hispanic enrollees has increased threefold between 2000 and 2020. 19 Increased diversity among dentists may improve access and quality of care, particularly in the area of culturally and linguistically sensitive care.
Dentists by race (left) and U.S. population racial and ethnic distribution (right), 2019. Note: White, Black, Asian, and Other are non-Hispanic. If estimates for certain racial and ethnic groups meet data suppression criteria, they are recategorized into (more. )
