Transcript Document

Overview Of The National Health
Care Survey (NHCS)
American Public Health Association
134 Annual Meeting & Exposition
November 4, 2006
William S. Pearson, Ph.D.
Division of Health Care Statistics
Centers for Disease Control and Prevention
National Center for Health Statistics
National Health Care Survey
Basic Components
Ambulatory care
Long-term care
Hospital &
Surgical care
National Health Care Survey
Ambulatory Care
National Ambulatory Medical Care Survey
National Hospital Ambulatory Medical Care Survey
Hospital & Surgical Care
National Hospital Discharge Survey
National Survey of Ambulatory Surgery
Long-term Care
National Nursing Home Survey
National Home and Hospice Care Survey
How are NHCS data used?
To understand health care practice
To identify and track problems
To identify inequalities in the provision
of services
To establish national priorities
To serve as comparison points for
states
To measure Healthy People objectives
NHCS Common Methodology
• National probability sample surveys
• Complex sample designs
• Common definitions, data items, sampling
frames
• Medical diagnoses
• Data collected by Census Bureau
• High response rates
• Data processed by private contractor
Data users-NHCS
Over 150 journal publications in last 2
years
Health professional associations
State and federal policy makers
Health services researchers
Epidemiologists
Universities and medical schools
Broadcast & print media
Where are people going for their
health care and has the setting
changed over the years?
Hospital discharge rate, 1980-2003
180
Rate per 1,000 persons
160
140
120
100
80
60
40
20
0
1980
1985
Source: National Hospital Discharge Survey
1990
1995
2000
2003
Average length of
hospital stay: 1980-2003
8
7
6
Days
5
4
3
2
1
0
1980
1985
Source: National Hospital Discharge Survey
1990
1995
2000
2003
Average length of hospital
stay by age: 1970-2000
14
12
Days
10
65 years & over
8
45-64 years
6
15-44 years
Under 15 years
4
2
0
1970
1980
1985
1990
Source: National Hospital Discharge Survey
1995
2000
2003
Trends in ED visit rates by age
65 years and over
50
45
22-49 years
40
35
50-64 years
30
25
20
03
20
01
19
99
19
97
19
95
20
19
93
Number of visits per 100 persons
55
NOTE: All trends shown are significant (p<0.05).
Percent of live hospital discharges transferred to
LTC institutions: United States, 1985-2000
50-64
65 years & over
25
20
19.1
17.7
14.0
15
12.4
10
5
3.6
2.0
4.5
2.4
0
1985
1990
Note: Percentages exclude deaths and unknown disposition
Source: NCHS/CDC: National Hospital Discharge Survey
1995
2000
Percent of nursing home residents admitted
from hospital: United States, 1985-1999
Percent
50
40
37.4
44.6
46.3
1997
1999
40.5
30
20
10
0
1985
1995
Source: NCHS/CDC: National Nursing Home Surveys
Year
NHCS strengths
Amount of utilization
Health care users
Sentinel events
Treatment patterns
Trends over time
Springboard for further research
NHCS limitations
Few outcome measures
Longitudinal purposes
Episode of illness
Community measures
Rare event estimation
Key concepts
Encounter vs. person data
Incidence & prevalence
Utilization rates
National and regional estimate
NAMCS and NHAMCS
National Ambulatory Medical Care
Survey (NAMCS)
– Patient visits to non-federal,
office-based physicians
National Hospital Ambulatory
Medical Care Survey (NHAMCS)
– Patient visits to EDs and OPDs
of non-federal, short-stay
hospitals
History of NAMCS
Planning began in 1967
Survey began in 1973
Fielded 1973-1981, 1985, 1989-present
Database covering 30 years
History of NHAMCS
Planning began in 1976
Survey began in 1992
Fielded annually
14th year of operation
NAMCS and NHAMCS
Methodology
NAMCS Sample Design
Three stage design
(1) 112 PSUs
(2) Physician practices within PSUs
(3) Patient visits within practices
One-week reporting period
For 2003-- 3,000 doctors sampled;
data collected for 25,288 office visits
Scope of the NAMCS
Basic unit of sampling is the physicianpatient visit
Physicians must be:
– Classified by AMA or AOA as primarily
engaged in office-based patient care
– nonfederally employed
– not in anesthesiology, radiology, or
pathology
Starting in 2006:
– Community Health Centers
– Physicians & mid-level providers
In-Scope NAMCS Locations
Private solo or group practice
Freestanding clinic/urgicenter (not part of a
hospital outpatient department)
Community Health Center (e.g., Federally
Qualified Health Center (FQHC), federally
funded clinics or 'look alike' clinics
Mental health center
Non-federal government clinic (e.g., state,
county, city, maternal and child health etc.)
Family planning clinic (including Planned
Parenthood)
Health maintenance organization or other
prepaid practice (e.g., Kaiser Permanete)
Faculty practice plan
Out-of-Scope NAMCS Locations
Hospital ED’s and OPD’s
Ambulatory surgicenter
Institutional setting (schools, prisons)
Industrial outpatient facility
Federal Government operated clinic
Laser vision surgery
NHAMCS Sample Design
Multistage probability design
(1) First stage sample of 112 PSUs
(2) Hospitals within PSUs
(3) Clinics within OPDs, ESA within EDs
(4) Patient visits within clinics, ESAs
4-week reporting period
546 hospitals sampled in 2003; 40,253 ED
visits and 33,492 OPD visits
Scope of the NHAMCS
Basic unit of sampling is patient visit
Emergency and outpatient departments of
noninstitutional general and short-stay
hospitals
Not Federal, military, or Veterans
Administration facilities
Located in 50 states and D.C.
Data Collection
Bureau of the Census is our field agent
Introductory letter sent 2-3 months in
advance of reporting period
Induction interview to train staff, obtain
data on practice or facility characteristics
Physician’s office/hospital staff is
responsible for completion of Patient
Record forms
Census abstracts as a last resort
Data Items
Patient characteristics
– Age, sex, race, ethnicity
Visit characteristics
– Source of payment, continuity of
care, reason for visit, diagnosis,
treatment
Provider characteristics
– Physician specialty, hospital
ownership…
Drug characteristics added in 1980
Coding Systems Used
Reason for Visit Classification (NCHS)
Drug Classification System (NCHS)
National Drug Code Directory
ICD-9-CM
– diagnoses
– causes of injury
– procedures
Drug Data in NAMCS/ NHAMCS
Respondents can list up to 8 medications
(including Rx and OTC medications,
immunizations, allergy shots, anesthetics,
and dietary supplements) that were ordered,
supplied, administered, or continued during
the visit.
Each entry is called a drug mention. Visits
with one or more drug mentions are called
drug visits.
Respondents are asked to report trade
names or generic names only (not dosage,
administration, or regimen). Can’t link drugs
with diagnosis.
Drug Characteristics
Generic Name (for single ingredient
drugs)
Prescription Status – Rx or OTC
Composition Status – single or
multiple ingredient
Controlled Substance Status – DEA
schedule
NDC Therapeutic Class (4-digit)
Up to 5 Ingredients (for multiple
ingredient drugs)
Analyzing Drugs
NAMCS or NHAMCS drug data
can be analyzed
– at the visit level (for example,
the number of visits at which a
particular drug was prescribed)
– or at the medication level (for
example, the number of
“mentions” of a particular drug
at ambulatory care visits
Sample Weight
Each NAMCS record contains a
single weight, which we call Patient
Visit Weight
Same is true for OPD records and
ED records
This weight is used for both visits
and drug mentions
How to Get the Data
Public Use Micro-data Files
Downloadable files
NAMCS, 1973-2003
NHAMCS, 1992-2003
CD-ROMs
NAMCS, 1990-2002
NHAMCS, 1992-2002
Enhanced Public Use Files
Masked sample design variables
–Allow use of SUDAAN, Stata, etc.
–Available for 1993-2003
SAS input statements, label
statements, and format statements
(1993-2003)
SPSS and Stata code for 2002,
2003
NCHS Research
Data Center
Advantages of the
Research Data Center
Gain access to information not available
on public use files
– Patient: ZIP code linked income,
education, etc.
– Provider: physician sex and age,
board certification, teaching hospital
– Geographic: FIPS state and county
codes
Research Data Center – cont.
Can merge with contextual variables
(e.g., ARF, NHIS, Census, NHDS)
– Health status level
– HMO penetration
– Physician and specialist supply
– Medicaid reimbursement
– Air quality
– Percent in poverty
Research Data Center
E-mail: [email protected]
Website: www.cdc.gov/nchs/r&d/rdc.htm
Call (301) 458-4277
For more information:
NCHS website:
www.cdc.gov/nchs/nhcs.htm
Call Ambulatory Care Statistics Branch at
301-458-4600
Information about the NAMCS:
Don Cherry or David Woodwell
Information about NHAMCS:
Linda McCaig or Kim Middleton
National Hospital Discharge Survey
(NHDS)
and
National Survey of Ambulatory Surgery
(NSAS)
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Disease Control and Prevention
National Center for Health Statistics
Overview of the
National Hospital Discharge Survey
(NHDS)
NHDS Survey Years
Conducted annually 1965-present:
– Latest data available: 2003
– 2004 to be available this Winter
NHDS Survey Design
Scope and coverage:
 Short stay, non-Federal hospitals
 ALOS < 30 days
 General and children’s general
hospitals
NHDS Sampling Plan
Three stage sampling:
1. Geographic units
2. Hospitals
3. Discharges
NHDS Sample Size
Hospitals:
– About 500 hospitals sampled per
year
Discharges:
– Over 300,000 sampled per year
NHDS Data Collection
Manual hospitals - 57%
Automated hospitals - 43%
NHDS Data Processing
NCHS:
– Editing
– Estimation
Health Insurance Portability
and Accountability Act
(HIPAA)
Variables on
NHDS Public Use
Data Files
Patient Data
Age
Sex
Race
Expected source of payment
Discharge status
Marital status
Medical Data
Diagnoses (up to 7)
Procedures (up to 4)
International Classification of Diseases,
9th Revision, Clinical Modification (ICD9-CM)
Hospital Characteristics
Geographic region
Bed size
Ownership
Additional Variables
Days of care
Month of discharge
Diagnosis Related Group (DRG)
Analysis weight
Recently-added variables
Added in the 2001 NHDS:
Source of Admission
Type of Admission
NHDS provides data on
hospitalizations
not people
Diagnoses
Disease, injury or other reason for
hospitalization
Principal diagnosis: chiefly
responsible for hospitalization
First-listed diagnosis: principal if
specified, otherwise first one listed
Diagnoses
All-listed: counts the total number of
times a diagnosis appears on patient
record
Any-listed: indicates that a diagnosis
appears at least once, in any position,
on discharge record
Surgical and Non-Surgical
Procedures
Surgical (appendectomy)
Diagnostic (spinal tap)
Therapeutic (chemotherapy)
NHDS provides data
on
inpatient procedures
not total
procedures
Reliability
RELATIVE STANDARD ERROR (RSE)
measures reliability of an estimate
Estimates with an RSE greater than
30 % are considered unreliable.
Estimates must be based on at least
30 records .
Estimates based on 30-59 records
should be used with caution.
Examples of research
using the
National Hospital Discharge Survey
Diagnoses studied
Heart failure
Atrial fibrillation
Arthritis
Diabetes
Sepsis
Chronic Obstructive Pulmonary
Disease (COPD)
Procedures studied
Hip replacements
Knee replacements
Cervical diskectomy
Coronary artery revascularization
Other Public Health Issues/
Medical Care Research
Length of hospital stays for
►women
giving birth
►newborn infants
Surgical treatments for Obesity
Pneumonia among the elderly
Mental disorders in children
National Survey of Ambulatory Surgery
(NSAS)
Survey Years: Annually 1994-1996
Collected data on ambulatory (outpatient)
surgery in the U.S.
NSAS Design
National probability sample
– Short stay non-Federal hospitals
(418)
– Freestanding ambulatory surgery
centers (333)
Sample size:
– 120,000 sampled visits per year
Additional variables collected
for NSAS
Hospital vs. freestanding center
Type of anesthesia
Anesthesia provider
Accessing Data
from the
National Hospital Discharge Survey
and the
National Survey of Ambulatory Surgery
What type of data are available?
Publications, including annual reports
Data tabulations on selected topics
Public-use data files (micro-data)
Annual Publications from
Hospital Care Statistics Branch
2003 ADVANCE DATA report:
http://www.cdc.gov/nchs/data/ad/ad359.pdf
VITAL AND HEALTH STATISTICS Series 13 reports,
e.g. 2002 Annual Summary
http://www.cdc.gov/nchs/data/series/sr_
13/sr13_158.pdf
Public-Use Files
Available on the Web
Data and documentation available
for free from the NCHS website
NHDS: 1996 through 2003
NSAS: 1994, 1995, 1996
Files are “raw” ASCII data that
require the use of standard statistical
software packages, such as SAS,
SPSS, Stata, etc.
What to Know to Access
Data and Publications on the Web
Publications, data tables, and data
file documentation are in Adobe
Acrobat PDF format.
Adobe Acrobat Reader software,
available free for download at
www.adobe.com
What to Know to Access
Public-Use Files on the Web
 Data files are in ASCII format
 Must be downloaded via FTP server,
then “unzipped”
 To “Unzip” use:
WinZip (www.winzip.com)
PKunzip (www.pkware.com)
Data file documentation is available in
PDF format
Multi-year public-use files
available on CD-ROM
Two separate multi-year files containing
1979-2003 data years (ICD-9-CM coding)
1970-1978 data years (ICD-8 coding)
IMPORTANT: DRGs are available on single
year files only. Multi-year files do NOT have
DRGs.
ICD-9-CM
For full-text, addenda, and
conversion tables of ICD-9-CM, see
www.cdc.gov/nchs/icd9.htm
Full-text ICD-9-CM documents are
RTF (Rich Text Format) files and can
be handled with any word
processing package.
Addenda and conversion tables
are PDF documents.
Restricted Data in NHDS
HCSB maintains confidential information in
files which are not publicly disseminated
Restricted data pose disclosure risks to
survey respondents
Available to researchers through the
NCHS Research Data Center (RDC)
http://www.cdc.gov/nchs/r&d/rdc.htm
New Directions
National Hospital Discharge Survey
►
survey redesign
National Survey of Ambulatory
Surgery
►
re-fielding in 2006
Inpatient clinical data
Current limitations on information
available in NHDS because data
collection is tied to UB92
Great interest in expanding to collecting
more patient and clinical data
A study of the feasibility of collecting drug
data was performed in 2001-2003
NHDS Redesign
Original survey design implemented in
1965; statistical redesign in 1988
Updating and modernizing methods and
measures to keep abreast of rapidly
changing hospital use is needed
Contract with RAND was let in September
to examine options for redesign
Results of Redesign Contract
Results will be available in summer of
2007 and will address:
Conceptual framework of NHDS
Proposed, expanded dataset
Feasibility of implementing new
concepts and additional data items
Return of NSAS
Funding has been approved for NSAS to
return to the field in 2006
Data collection procedures will be
updated to reflect changes in the way
facilities store data, that is, the greater use
of electronic data systems.
Experts have been consulted to modify
and add data items to data collection
instruments.
New information collected in the
2006 NSAS
Credentials of staff
Ownership of the ambulatory surgery
facility
Access to care
Use of electronic medical records
Patient follow-up after surgery
Timeline for NSAS
May 2006 – March 2007 : Data collection
April – December 2007 : Coding, keying,
editing, and weighting
Early 2008 : NSAS 2006 data released
Winter 2008 : Public use data file available
NHDS or NSAS Questions?
Phone: 301-458-4321
Fax: 301-458-4032
Email: [email protected]
Homepage on the WEB:
www.cdc.gov/nchs/about/major/hdasd/nhds.htm
Redesign of the National
Long-term Care Surveys
American Public Health Association
134 Annual Meeting & Exposition
November 4, 2006
Genevieve Strahan
Long-term Care Statistics Branch
Division of Health Care Statistics
National Center for Health Statistics
National Nursing Home
Survey (NNHS)
Component of the National Health
Care Survey (NHCS)
Nationally representative sample
survey of nursing homes
Collects information
– Providers
– Recipients of care
Conducted 7 times since 1973
(1973-74, 1977, 1985, 1995, 1997,
1999 and 2004)
Process
1. Reviewed documents from expert meetings
– Future Directions for Residential LTC
Health Services Research (October 1999)
– Future Directions for Community-based LTC Health Services
Research (June 2000)
– Institute of Medicine Report from the Committee on
Improving Quality in LTC (2001).
2. Policy questions
–
–
–
–
Characteristics of nursing homes residents
Care and services provided by nursing homes
Cost/reimbursement
Quality/outcomes
Process (cont.)
3. Identify data gaps
-1999 National Nursing Home Survey (NNHS)
-1997 Medicare Current Beneficiary Survey
(MCBS)
-Minimum Data Set (MDS)
-Online Survey Certification and Reporting
Survey (OSCAR)
-1996 Medical Expenditures Survey Nursing
Home
Component (MEPS NHC)
-1999 National Long-term Care Survey
-Longitudinal Studies of Aging
Conceptual Model
Structure
Process
Outcomes
-Key Personnel-Immunization practices-ED/hospitalizations
-Advance practice RNs-Mechanical Lifts-Pressure sores
-Turnover-Permanent assignments-Falls
-Benefits-Palliative care-Adverse Reactions
NNHS Redesign: Milestones
1. Computer Assisted Personal
Interview (CAPI)
– Developed (March 2002)
– Flexibility to accommodate future surveys
– Pilot tested for NNHS (February 2003)
Computer Assisted Telephone
Interview (CATI)
2. Expanded Content
Facility level data
Administrators, Medical Directors, &
Directors of Nursing
-Preparation
-Years of experience
-Tenure at the facility
-Specialty certification
2. Expanded Content (Cont.)
Facility level data (cont.)
Nursing Staff
-FTEs
-RN mix
-Specialty certification
-New roles----MDS nurses, case managers, QI,
infection control
-APNs
-Entry-level wages
-Recruitment/retention strategies
-Benefits
-Collective bargaining arrangements
-Staff turnover and stability
2. Expanded Content (Cont.)
Facility level data (cont.)
-Accreditation
-Medical services
-Electronic/computerized information systems
-Recreation activities
-Dining practices
-Mechanical lifts
-Immunization policies & practices
-End-of-life practices (POLST, Last Acts)
-Special care programs (e.g., wound, dementia)
2. Expanded Content (Cont.)
Resident level data (MDS items)
-Advance directives
-Cognitive skills
-Mood
-Behavioral symptoms
-ADLs
-Continence
-Accidents
-Weight change
-Nutritional therapy
-Pressure ulcers
-Restraints
2. Expanded Content
(Cont..)
Resident level data (Cont.)
New Items
-Admission to a specialty unit (Alzheimer’s,
hospice)
-Receiving specialty services (Alzheimer’s,
hospice)
-Hospitalizations
-ED visits
-Pain assessment, management, relief
-Medications
-Recent drug adverse experiences
-End-of-life care
-Out of pocket charges
NNHS Redesign: Milestones
(Cont.)
3. NNHS pretest (June – July
2003)
4. NNHS national survey
(August – December 2004)
Major features
Linkage to CMS’ Minimum Data Set
– Expanded clinical content
– Care episodes
New sample design
Expanded sample
National Nursing Assistant Survey
(NNAS)
National Nurse Assistant
Survey (NNAS)
– Reduces NNAS costs by utilizing a subsample of an existing sample frame and
data collection methodology
– Enhances response rates and reduces
burden
– Increases the analytical usefulness of
NNAS and NNHS
NNAS Goals
Describe characteristics of nurse
assistants
Explore why workers remain in the field
and determine factors that influence
retention
Understand how these factors affect
workers’ attitudes, relationships with
managers and nursing home residents,
and job satisfaction
Selected NNAS Data Items
Recruitment
Education/Training
Job History
Family Life
Management/Supervision
Client Relations
Job Satisfaction
Workplace environment
Injuries
Demographics
Reasons for leaving
Uses of NNHS Data
Nursing Home Resident and Facility Characteristics
Associated with Pneumococcal Vaccination:
National Nursing Home Survey, 1995-1999
Influenza Immunization in Nursing Homes:
Who Does Not Get Immunized and Whose Status is
Unknown
Pneumococcal immunization in nursing homes: Does
race make a difference?
2007 National Home and
Hospice Care Survey
Scheduled to be conducted – August-December 2007
National Home and Hospice Care
Survey (NHHCS)
Component of the National Health
Care Survey (NHCS)
Nationally representative sample
survey of home health agencies
and hospices
Collects information
– Providers
– Recipients of care
Conducted 6 times since 1992
(1992, 1993, 1994, 1996, 1998,
and 2000)
Process
1. Reviewed documents from expert
meetings
2. Policy questions
3. Identified data gaps
NHHCS Redesign: Milestones
1. Computer Assisted Personal
Interview (CAPI)
and the
Computer Assisted Telephone
Interview (CATI)
2. Expanded Content
Agency level data
–
–
–
–
–
–
JCAHO accreditation
electronic information systems
cultural competency
immunization polices and practices
end-of-life practices
special service programs
2. Expanded Content
Patient level data
hospitalizations/emergency department admissions
pain assessment and pain relief
medications
Out-of-pocket charges
family and caregiver services
end-of-life care and advance directives
community based waiver program participant
pressure ulcers
behavior/mood symptoms
falls
2. Expanded Content
(Cont.)
Staffing level data
Contract and agency employees
Key personnel (Medical Director,
Administrator, and Director of Nursing)
educational preparation
years of experience
tenure at the agency
specialty certification
2. Expanded Content
(Cont.)
Staffing level data (Cont)
RN mix---basic education, Diploma, BS, MS
advance practice providers---CNS, NPs, PAs
entry level wage for RNs, LPNs, HHAs/CNAs
recruitment/retention strategies
benefits
turnover -- new hires, terminations
3. NHHCS pretest (Oct – Nov
2006)
4. NNHS national survey
(August – December 2007)
Major features
Linkage to CMS’ OASIS
– Expanded clinical content
– Care episodes
New sample design
Expanded sample
National Home Health Aide Survey
(NHHAS)
National Home Health
Aide Survey (NHHAS)
– Reduces NHHAS costs by utilizing a subsample of an existing sample frame and
data collection methodology
– Enhances response rates and reduces
burden
– Increases the analytical usefulness of
NHHAS and NHHCS
Selected NHHAS Data Items
–
–
–
–
–
–
–
–
–
education/training
employment profile
family life
management/supervision
salary, compensation, benefits, reward,
and incentives
job satisfaction
organizational culture
Recruitment and training
demographics
Uses of NHHCS Data
Payment source and length of use among
home health agency discharges
The1997 Balanced Budget Act
and home services among
Medicare patients.
Ownership status and patterns of care in
hospice
National Survey of
Residential Care Facilities
First time survey of residential
and assisted living facilities
Scheduled for fall of 2008
Uses NNHS model
CAPI data collection system
Importing NNHS or NHHCS Files to Statistical Packages
Tab Delimited
ASCII File with
Variable Names
Fixed Format
ASCII File with
SAS Input
Statements
Fixed Format
ASCII File with
SPSS Input
Statements
SAS, SPSS
SAS
SPSS
Other software formats
e.g., spreadsheets (MS EXCEL),
databases, and
statistical software (STATA)
Plans for Dissemination
Data products
– Reports, journal articles
– Public use data files
Access data products
–
–
–
–
Downloadable from the Internet
Data files on CD-ROMS
Research Data Center
NCHS Office of Information Services
Telephone: 866-441-6247 (NCHS)
Fax: 301-458-4027
Email: [email protected]
To learn more--–
–
–
–
Listserv
www.cdc.gov/nchs/nnhs.htm
www.cdc.gov/nchs/nhhcs.htm
LTCSB 301-458-4747