How has the quality of the U.S. healthcare system changed over time?

How can we know if the performance of the health system overall in the U.S. is good and if it is getting better or worse over time?  This collection of charts explores trends in quality metrics in the United States over time. A related chart collection shows quality measures in the U.S. compared to peer countries. 

Gauging the quality of healthcare systems is often difficult and restricted by the availability of data. One method for measuring quality is to look at mortality rates, which, though influenced by a myriad of factors, are in part affected by the quality of the healthcare system in addressing diseases for which mortality is amenable to health care.

Mortality rates in the U.S. have generally declined over time

The overall mortality rate (number of deaths per 100,000 people) in the U.S. reached an all-time low of 725 deaths per 100,000 in 2014 — a 30 percent decline from 1039 deaths per 100,000 in 1980. Similarly wealthy countries have a lower mortality rate.

Since 2014, however, the mortality rate in the U.S. has trended upward a bit, as the overall mortality rates in 2015, 2016, and 2017 were each higher than in 2014. 

Deaths amenable to healthcare in the U.S. have declined

Researchers have looked at mortality that results from medical conditions for which there are recognized healthcare interventions expected to prevent death. While the healthcare system might not be expected to prevent death in all of these instances, changes in mortality for these conditions provide information about how effectively healthcare is being delivered. From 2003 to 2013, the mortality rate for deaths amenable to healthcare in the US declined by about 17 percent. More recently, the rate has increased slightly.

After more than two decades of decline, the rate of premature deaths has increased

The U.S. has made progress in reducing premature death, which is measured in years of life lost (YLL). Between 1990 and 2013, the rate of premature deaths declined by 26 percent (from 15,890 to 11,794 YLL per 100,000 people), but that downward trend has since reversed. From 2013 to 2017, the rate of premature deaths increased 4 percent (from 11,794 to 12,282 YLL per 100,000 people).

After two decades of steady decline, disease burden in the U.S. is on the rise

The U.S. has seen a reduction in disease burden — as measured by disability adjusted life years (or DALYs) — in recent years. DALYs are a measure of disease burden that takes into account years of life lost due to premature death as well as years of productive life lost to poor health or disability. In assessing how health outcomes have changed and making judgments about where to target health resources, DALYs provide a more complete picture of the burden of disease than mortality rates.

The U.S. disease burden rate dropped by 14 percent from 1990 to 2013, while similarly wealthy countries saw an average decrease of 22 percent. Since then, disease burden has continued to decrease in comparable countries but has increased by approximately three percent in the U.S.

The overall percentage of adults reporting worse health has increased, particularly among women and Whites

The percentage of adults reporting worse general health (either fair or poor health) has increased slightly among women and Whites, while other groups have not seen statistically significant changes in self-report of health status. Hispanics and non-Hispanic Blacks are more likely to report being in worse health than other groups.

More adults report that poor health prevented their usual activities at least one day in the past month

In both 2011 and 2017, roughly 36 percent of adults reported experiencing at least one day in the past 30 days when their health was not good due to physical illness and injury, and the same share reported having at least one day when their health was not good specifically due to stress, depression, and emotional problems. Compared to 2011, a higher percentage of adults (44 percent in 2017 vs 42 percent in 2011) now report that poor physical or mental health kept them from doing their usual activities for at least one day in the past month.

The average number of self-reported Healthy Days per month has not changed over time

“Healthy Days” is a measure of health-related quality of life developed by the Centers for Disease Control and Prevention. It represents the average number of days in the past 30 that survey respondents report having had good mental and physical health. Since 2011, the average number of general “Healthy Days” (both mental and physical) has been about 23 days.

Just eight percent of adults ages 35+ have received all recommended high-priority preventive services

A recent study of Medical Expenditure Panel Survey data found that only eight percent of US adults age 35 and older received all recommended high priority, clinical preventive services, based on recommendations by the US Preventive Services Task Force and Advisory Committee on Immunization Practices. Comprehensive recommended preventive care includes high-priority, age- and gender-appropriate screenings, counseling, preventive medications, and vaccinations.

Most children are receiving routine vaccinations

The percent of children receiving recommended vaccinations is an indicator of appropriate preventive care. According to the CDC, while most children receive routine vaccinations, coverage for most vaccines is lower for uninsured and Medicaid-insured children and those living in non-metropolitan areas, and the number of children with no vaccinations – though small – has recently increased. Although vaccination coverage among children aged 19 to 35 months is above 90 percent for some individual vaccines, the percent of children in this age group who have received the recommended combined 7-vaccine series (including vaccinations for DTaP, polio, measles, Hib, Hepatitis B, varicella, and PCV) has been relatively low (70.4% in 2017).

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The teen pregnancy rate has declined

The teen birth rate in the U.S. has declined overall, but there is considerable variation across racial/ethnic groups. Pregnancy rates among Hispanic and Black teens have generally been higher than among White teens, although the long-term decline has helped to shrink the gap. Research indicates the overall decline in teen pregnancy reflects more teens waiting to have sexual intercourse and using effective contraceptives.

The prevalence of obesity among adults in the U.S. has been increasing for some time

Obesity is classified as having a body mass index (BMI) at or above 30. Between 1988 and 1994, the prevalence of obesity among adults age 20 and over averaged 22.9 percent. By the period from 2015 to 2016, the prevalence of adult obesity reached 39.6 percent – a 73 percent increase over 28 years. In that time, the prevalence of obesity increased by 88 percent among men and 62 percent among women.

Medicare hospital admissions have decreased for many conditions

While not all hospital admissions are preventable, access to appropriate primary health care can prevent the onset of certain illnesses and conditions and associated hospital visits. In addition, proper management of diseases like asthma, chronic obstructive pulmonary disease, diabetes, and hypertension can help reduce hospital admissions. Data from the Centers for Medicare and Medicaid Services (CMS) indicate Medicare hospital admissions among beneficiaries aged 65 to 74 decreased overall for all major ambulatory care-sensitive conditions between 2007 to 2017, with the exception of lower extremity amputations.

Medicare patients report improved communication with hospital staff

Patients’ perspectives on hospital care provide another method for measuring the quality of the healthcare system. Based on Medicare patient self-report, hospital staff have improved on several measures of communication quality over a decade. Specifically, high percentages of hospitalized Medicare beneficiaries report that hospital staff always explained medicines and their side effects; always provided discharge information; and always responded when the patient pressed the call button or requested bathroom help.

More women are receiving biopsy at the time of mastectomy or lumpectomy

There are well established evidence-based courses of care for various diseases, such as breast cancer. In 2014, 94.1 percent of women received axillary node dissection or sentinel lymph node biopsy at the time of lumpectomy or mastectomy in order to ensure proper diagnosis and identify possible spread of cancer to the lymph nodes.

More people are receiving evidence-based care for heart attack when they arrive at a hospital

Mortality can be minimized by providing evidence-based treatment to heart attack patients upon their arrival at a hospital. Between 2005 and 2015, hospital patients with a heart attack increasingly received fibrinolytic medication within 30 minutes of arrival.

CMS publicly reports hospital quality measures each year in the National Healthcare Quality and Disparities Reports, retiring process measures that improve to an average performance level of 95% or better. Recently retired indicators include some measures of appropriate care provided to hospital patients presenting with heart conditions or pneumonia.

Hospital-acquired conditions decreased from 2014 to 2017

Hospital-acquired conditions (HACs) are conditions people develop while they are in the hospital that could reasonably have been prevented through the application of evidence-based guidelines. These include adverse drug events, pressure ulcers, ventilator-associated pneumonia, catheter-associated infections, and air embolisms. Between 2014 and 2017, the number of all types of HACs decreased, with the exception of pressure ulcers (increased) and surgical site infections (no change).

Medicare 30-day hospital readmission rates have declined

Hospital readmission within 30 days of being discharged from a hospital stay is not entirely preventable but can be reduced for certain diagnoses and services. Improvement in this area is often linked to improved quality of care. Medicare 30-day hospital readmission rates improved about eight percent from 2007 to 2017.

Among Medicare patients, mortality rates within 30 days after hospital admission for heart attack, stroke, and pneumonia have decreased

Mortality within 30 days of being discharged from a hospital stay is not entirely preventable, but can be reduced for certain diagnoses. Improvement in this area is often linked to improved quality of care. The 30-day mortality rates among Medicare patients for heart attack (acute myocardial infarction), ischemic stroke (caused by blood clots), and pneumonia improved slightly from 2013 to 2016.

The mortality rate for cancers has declined since 1990

The mortality rate for all cancers and tumors (neoplasms) has fallen in the U.S. over the past 27 years. Specifically, the age-adjusted cancer rate has fallen from 219 deaths per 100,000 people in 1990 to about 157 per 100,000 in 2017, a decrease of approximately 28 percent. While mortality rates are used to measure the outcomes for most diseases, the quality of cancer care is also often assessed through five-year survival rates, which have improved for some cancers. However, the use of five-year survival rates versus mortality rates has been debated recently, as survival rates may be more heavily influenced by the time and frequency of diagnoses than by the actual longevity of patients.

The mortality rate for diseases of the circulatory system has fallen dramatically

The U.S. has made dramatic progress in lowering mortality attributable to diseases of the circulatory system. The U.S. mortality rate for diseases of the circulatory system declined about 60 percent from 1980 to 2017, dropping from about 544 to 219 deaths per 100,000 people.

After rising for nearly two decades, the mortality rate for respiratory diseases has improved

In the U.S., the mortality rate for respiratory diseases increased for nearly two decades before declining. From 1980 to 1998, the mortality rate increased by 29 percent to a peak of 89.3 deaths per 100,000 population. Since then, the mortality rate has declined, albeit unsteadily, dropping by 20 percent to 71.4 deaths per 100,000 in 2017.

The mortality rate for endocrine, nutritional and metabolic diseases has risen over time

From 1980 to 2005, the mortality rate for endocrine, nutritional and metabolic diseases increased by 42 percent (from 24.2 to 34.3 deaths per 100,000 people). After declining by 13 percent between 2005 and 2010 (down to 29.8 deaths per 100,000 people), the mortality rate for these diseases has recently increased by 11 percent (up to 33 deaths per 100,000 in 2017).

The infant mortality rate has declined

From 1980 to 2016, the overall infant mortality rate in the U.S. improved by about 53 percent. While infant mortality has dropped among all races, non-Hispanic Blacks experience the highest infant mortality rate.

Maternal mortality has risen substantially over time

In the U.S., the maternal mortality rate (deaths per 100,000 live births) rose about 114 percent from 1990 to 2017 (from 14 to 29.9 deaths per 100,000 live births). Women in the U.S. are more than four times as likely to die due to complications from childbirth than women in comparable countries. Researchers point to multiple factors that contribute to the alarming maternal mortality rate in the United States, including: racial disparities; a lack of continuity between or access to primary care and maternal care services; a need for standardized and evidence-based protocols for child birth and clinical care; and poor data collection on maternal death and patterns of risk.

The Peterson Center on Healthcare and KFF are partnering to monitor how well the U.S. healthcare system is performing in terms of quality and cost.

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