1 Linda McCaig and David Woodwell Ambulatory Care Statistics Branch Division of Health Care Statistics Overview of the NAMCS Overview of the NAMCS and NHAMCS and NHAMCS U .S.D EP A R TM ENT O F HEALTH AND HUM AN SERVICES C enters forD isease C ontroland Prevention N ationalC enterforH ealth Statistics U .S.D EP A R TM ENT O F HEALTH AND HUM AN SERVICES C enters forD isease C ontroland Prevention N ationalC enterforH ealth Statistics
Overview of the NAMCS and NHAMCS. Linda McCaig and David Woodwell Ambulatory Care Statistics Branch Division of Health Care Statistics. Overview. Background Data uses Survey methodology Current and proposed survey items User considerations Methodological studies Data dissemination - PowerPoint PPT Presentation
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Linda McCaig and David Woodwell
Ambulatory Care Statistics BranchDivision of Health Care Statistics
Overview of the NAMCSOverview of the NAMCSand NHAMCSand NHAMCS
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICESCenters for Disease Control and PreventionNational Center for Health Statistics
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICESCenters for Disease Control and PreventionNational Center for Health Statistics
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OverviewOverviewBackgroundData usesSurvey methodologyCurrent and proposed survey itemsUser considerationsMethodological studiesData disseminationNCHS Research Data Center
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National probability sample National probability sample surveyssurveys
National Ambulatory Medical Care Survey (NAMCS)– Patient visits to non-federal office-
based physiciansNational Hospital Ambulatory
Medical Care Survey (NHAMCS)– Patient visits to EDs and OPDs of non-
federal short-stay hospitals
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Original NAMCS survey Original NAMCS survey goalsgoals
• National statistics• Professional education• Health policy formulation• Medical practice management• Quality assurance
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NAMCS historyNAMCS history
Survey began in 1973 Annual data collection through
1981 (NORC)Conducted in 1985 (NORC)Annual began again in 1989
(Census)
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NHAMCS historyNHAMCS history
Survey began in 1992 Annual data collection (Census)
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How are NAMCS and How are NAMCS and NHAMCS data used?NHAMCS data used?
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Data usesData usesUnderstand health care practiceExamine the quality of careTrack certain conditionsFind health disparitiesMeasure Healthy People 2010
objectivesServe as benchmark for states
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Data usersData usersOver 100 journal publications in last 2
yearsMedical associationsGovernment agenciesHealth services researchersUniversity and medical schoolsBroadcast and print media
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Total Ambulatory Care Visits
SOURCE: CDC/NCHS, NAMCS and NHAMCS, 2001.
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Annual rate of injury-related Annual rate of injury-related ED visits for seniors by patient ED visits for seniors by patient
residenceresidence
Age in yearsInstitution CommunityNumber of visits per 100 persons
65-79 41 880+ 37 14
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Percent of physician office Percent of physician office visits by type of cardiac visits by type of cardiac rhythm modifying agentrhythm modifying agent
01020304050607080
Ventricular ratecontrol
Sinus rhythmmaintenance
Neither
Perc
ent o
f vis
its
1991-92 1999-00
Fang et al. Arch Intern Med 2004;164(1):55-60.Fang et al. Arch Intern Med 2004;164(1):55-60.
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Percent of selected ED visit Percent of selected ED visit characteristics among released characteristics among released
patients who had a blood culturepatients who had a blood cultureVisitcharacteristic
Antibiotics prescribed
Antibiotics not prescribed
Total
Fever 19% 17% 36%No fever 28% 36% 64%
Total 47% 53% 100%
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Potentially inappropriate drug Potentially inappropriate drug prescribing at elderly physician prescribing at elderly physician
office visitsoffice visits
01234567
1 2 3 4 5 6
Number of prescription drugs
Adj
uste
d od
ds ra
tio
Goulding. Arch Intern Med 2004;164(3):305-312.Goulding. Arch Intern Med 2004;164(3):305-312.
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Number and rate of physician Number and rate of physician office visits for diabetesoffice visits for diabetes
Grant et al. Arch Intern Med 2004;164(10):1134-1139.Grant et al. Arch Intern Med 2004;164(10):1134-1139.
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Annual rate of injury-related ED Annual rate of injury-related ED visits for children by diagnosisvisits for children by diagnosis
0
5
10
15
20
25
30
1993/94 1995/96 1997/98 1999/00 2001/02
Year
Visi
ts p
er 1
00 p
erso
ns Head wound
Other wound
IntracranialPoisoning
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Variations in drug mention rates for Variations in drug mention rates for selected therapeutic classes by source selected therapeutic classes by source
of paymentof payment
0 5 10 15 20 25Drug mentions per 100 visits
Uninsured Private
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Variations in drug mention rates for Variations in drug mention rates for selected therapeutic classes by MSA selected therapeutic classes by MSA
statusstatus
0 5 10 15 20 25
Pain relief
Otologics
Antimicrobials
Drug mentions per 100 visits
Non-MSA MSA
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HP2010 Objectives on HP2010 Objectives on antibiotic prescribingantibiotic prescribing
Ear infections(Antibiotics per 1000 persons)
Common cold(Antibiotics per 1000 persons)
Baseline 693 251998/99 545 18
2000/01 595 18Target 561 13
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NAMCS and NHAMCS NAMCS and NHAMCS MethodologyMethodology
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NAMCS ScopeNAMCS Scope• Includes non-federal, office-based
physicians
• Excludes physicians whose main activity is teaching, research, administration, hospital-based care, or who are unclassified as to activity and those in certain specialties
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In-Scope NAMCS locations In-Scope NAMCS locations Freestanding clinic/urgicenterFederally qualified health centerNeighborhood and mental health
centersNon-federal government clinicFamily planning clinicHMOFaculty practice planPrivate solo or group practice
Hospital EDs and OPDsAmbulatory surgicenterInstitutional setting (schools, prisons)Industrial outpatient facilityFederal Government operated clinicLaser vision surgery
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NAMCS Sample designNAMCS Sample design
112 geographic PSUs3,000 physicians25,000 visits
– 1 week reporting period
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NHAMCS Scope NHAMCS Scope OPD was intended to be parallel to the
NAMCS in the hospital settingGeneral medicine, surgery, pediatrics,
ob/gyn, substance abuse, and “other” clinics are in-scope
Ancillary services are out of scope
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NHAMCS Sample designNHAMCS Sample design
112 geographic PSUs500 hospitals400 EDs and 250 OPDs37,000 ED and 35,000
OPD visits– 4-week reporting period
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Gaining cooperationGaining cooperation
Advance lettersEndorsement lettersPublic relations materialsConversion of refusal
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Data collection proceduresData collection proceduresInduction visit by Census field
representative (FR) FR training of office/hospital staffTake every numberProspective or retrospective method
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Items collected on Patient Items collected on Patient Record form (PRF)Record form (PRF)
Patient characteristics– age, race, sex
Visit characteristics– reason for visit, diagnosis, medication
NAMCS and OPD PRFNAMCS and OPD PRF- unique items- unique items
Does patient use tobaccoCounseling/education/therapySurgical proceduresTime spent with physician (NAMCS
only)
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2001-2004 NAMCS and OPD PRF2001-2004 NAMCS and OPD PRFcontinuity of care items continuity of care items
Patient’s primary care physician/providerWas patient referred for visitPatient seen beforeSeen how many times in past 12 monthsMajor reason for visitEpisode of careOther physicians share care
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ED Patient Record formED Patient Record form- unique items- unique items
Arrival timeDischarge timeTime seen by physicianMode of arrivalImmediacy
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ED Patient Record formED Patient Record form- unique items- unique items
Presenting level of painAlcohol related visitWork related visitProcedure checklist
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ED Patient Record formED Patient Record form- continuity of care items- continuity of care items
Seen ED within last 72 hoursEpisode of care
– Initial or followup visit
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Recycled items onRecycled items on 2003-04 ED PRF 2003-04 ED PRF
On– Time seen by
physician – Mode of arrival– Presenting level
of pain
Off– Visit related to an
adverse drug event
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NAMCS and OPD PRF NAMCS and OPD PRF revisions 2005-06 – revisions 2005-06 –
emphasis on chronic emphasis on chronic conditionsconditions
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NAMCS and OPD PRF-NAMCS and OPD PRF- new items for 2005-06 new items for 2005-06
Encourage uniform reporting and eliminate ambiguities
Pretest survey items and proceduresPerform quality control procedures –
consistency and edit checksTrain Census field representatives
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NAMCS Response rate NAMCS Response rate
55
60
65
70
75
89 90 91 92 93 94 95 96 97 98 99 '00 '01 '02
Year
Perc
ent
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NHAMCS Response ratesNHAMCS Response rates
50
60
70
80
90
100
92 93 94 95 96 97 98 99 '00 '01 '02
Year
Perc
ent
ED
OPD
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Attempts to improve response Attempts to improve response rate rate
Publicity Eliminating questions that have a high
item non-responseMethodological studies
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Methodological studiesMethodological studies
• Complement study 1997-1999• 500 physicians in each year• 17% of classified as nonoffice-based saw
patients• Represented 11% of total• Difference not accounted for in weighting
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Methodological studiesMethodological studies
• NAMCS Motivational insert• Conducted last half of 2000• Insert (n=513); no insert (n=499)• RR - 68% vs. 64%• No difference in RR
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Methodological studiesMethodological studies• NAMCS and OPD PRF length
• Conducted 2001• NAMCS: short (n=941); long (n=969)• OPD: short (n=132); long (n=129)• NAMCS RR - 68% (short) vs. 62% (long) • NAMCS short PRF had a higher RR• No effect on RR in OPD
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Methodological studiesMethodological studies
• Incentives test• Conducted last 3 quarters of 2002• 3 groups: control (n=418), gift (n=401), and
monetary (n=456)• RR – 73%, 68%, and 73%, respectively• No difference in RR between incentive
groups
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HIPAAHIPAA• No directly identifiable information
collected• PHS Act 308(d) / Title 15• Data Use Agreement w/ Limited Dataset• IRB approval w/ waiver of patient