# Presentation: 927430

## On the Health of the US Health Care System...Insights and analyses from the National Health Care Survey

- Irma E. Arispe, PhD
- Division of Health Care Statistics
- Data Users Conference, July 12, 2004

**Centers for Disease Control and Prevention**
**National Center for Health Statistics**

## Establishment-based surveys can tell you about...

**Use of services**
**The epidemiology of illness and disease**
**Patterns of access to care**
**Practice and practice variation**
**Diffusion of new technologies and the influence of technological innovation**
**The effect of changes in policies and the health care environment**
**The cumulative effects of prior contact (or lack of contact) with the health care system**

## An important distinction

- In population-based surveys, people tell you about themselves and their health care experience as they understand/remember it
- In establishment-based surveys, providers tell you about their practice, the health of their patients, the environment where care takes place, and the content of the medical encounter

## Insights into the health of the health care systemPart I

**Disparities redefined...Differential “burden” on the health care system**

## Pneumonia hospitalization rates in MSA and non-MSA areas, U.S. 2000

- Analysis of NHDS and ARF1
- Examines disparities in burden to health care system; disparities in access and utilization of health care services
- Hospitalization rate for non-MSA double that of MSA
- Shorter length of stay for non-MSA even though number of comorbidities and percent with serious comorbidities is higher in non-MSA areas

- 1 National Hospital Discharge Survey (NHDS)
-   Area Resource File (ARF)
- Source:  Owings and Hall  2002

- Rate per 10,000 population

## Physician and hospital availability in MSA and non-MSA areas2000 NHDS and ARF data

- Non-MSA areas have same rate of hospital beds but lower rate of active physicians compared to MSA areas
- Implications
- Manpower issue?
- Access to primary, secondary care?
- Planned study of rural/urban “crossovers”

- Rate per 1000 elderly

- Source:  Owings and Hall 2000

## Researchers also use the NHCS to understand burden within and across health care “systems”

- Uses NHDS and VA data to examines relationship between glycemic control and
- cardiovascular disease (CVD).
- Finds CVD accounts for 1⁄2 of hospitalization for persons with diabetes in VA and non-VA
- Settings.
- Coronary events and procedures and, to a lesser extent, cerebrovascular events and procedures are more common among VA hospitalizations.

- Source:  Smith NL, Maynard C.  Diabetes Care.  May 2004, Supplement

## “Hospitals cannot continue to provide services for which they don’t get paid...Either safety-net hospitals get funded or they cut their mission to survive.” 

- AHA Environmental Assessment
- Fall 2003

## Using NHAMCS to evaluate “within-system” disparities

- Using NHAMCS to evaluate “within-system” disparities

**Safety net hospital EDs...**
**	****- ****Are comprised mostly of Medicaid or uninsured, rarely in both**
**	****- Have a 40% chance of receiving some DSH payment**
**	****- Are three times more likely to be located in the south**

- Study using data from the National Hospital Ambulatory Medical Care Survey
-  (NHAMCS), ARF and Medicare Disproportionate Share Hospital (DSH) data
- Source:  Burt and Arispe 2004

## Insights into the health of the health care systemPart II

**Quality measurement and ****	****   improvement**

## Prescribing practicesDimensions of quality and “medical error”

**Prescribing practices****Dimensions of quality and “medical error”**

- Is practice consistent with current evidence about effectiveness?
- To what extent do providers use medications that are contraindicated?
- How big is the problem of adverse drug events and medical misadventures?

**Notes:**
One of the most frequently used types of data is NAMCS/NHAMCS data on medication use.  This year alone, clinical researchers have used these data to study conditions ranging from headaches to ADHD.  From antipsychotics to atopic dermatitis (12 articles have appeared in peer reviewed literature so far in 2002). 

Here are some examples of quality related issues that can be examined using our data:  the potential effect of direct to consumer advertising on patterns of use; appropriate use of medications (particularly for the elderly), and patient safety. 

## Percent of patients with essential hypertension and no co-morbidities receiving first line drug therapy, by patient characteristics: U.S. 2001

- + Age difference statistically significant at the p=0.1 level

- *

**Opportunities for improvement**

- Source:  Hing and Holmes 2004

## Heading in the right direction

**Heading in the right direction**

## Antibiotic prescribing rates at physician office visits for children 

- Rate per 1000 population

- Rate per 1000 visits

- Source:  National Ambulatory Medical Care Survey 1989-2000

## Destination unknown

- Trends in c-section rates
- Data from the NHDS

**Destination unknown**

**Notes:**
...and sometimes you don’t.  Data from the NHDS showed an increase in c-sections from the 70s, peaking in 1985 at 1⁄4 of all deliveries.  This led to pressure from consumers and provider groups to lower rates.  There used to be a HEDIS measure for C-sec., and there was a HP 2000 objective to lower rates to 12%.

MDs started attempting V-bacs (vaginal birth after delivery) with sometimes limited success.  So the clinical community faced pressure from both sides....to lower c-sections (bottom story), and to allow for consumer choice (top story...first line reads, “Too posh to push?”).  

So there is no clinical consensus and we see more variation in the trend as we are in more of  a “watchful waiting period”. (The measure will not be used for the quality report.)

## Insights into the health of the health care systemPart III

**Evaluating changes in health care ****	****policy and the health care ****	****	****	****   environment**

## Number of current home health care patientsUS, 1992, 1994, 1996, 1998, 2000

- Number of current home health care patientsUS, 1992, 1994, 1996, 1998, 2000

**The effect of changes in policy**

## Percent of office-based physicians who do not accept new patients with certain payment methods:  United States, 2002National Ambulatory Medical Care Survey

**Physician as bellwether**

- Percent of office-based physicians who do not accept new patients with certain payment methods:  United States, 2002National Ambulatory Medical Care Survey

## Percent change in hospital discharge rate by age, U.S. 1970-2002(National Hospital Discharge Survey)

**Watching the tide**

## Percent of live hospital discharges transferred to 

**Note: Percentages exclude deaths and unknown disposition **

**Source: NCHS/CDC: National Hospital Discharge Survey**

**2.0**

**12.4**

**2.4**

**14.0**

**3.6**

**17.7**

**4.5**

**19.1**

**Percent of live hospital discharges transferred to **
**LTC institutions:  United States, 1985-2000**

**Notes:**
Now turn to long term care

Data from the NHDS (and also the NNHS) show an increasing trend in discharges to LTC facilities and we know this will only increase over time.

We also know that the nursing home of today is not the same as the nursing home of 1985.  Discharges for the under 65 are also increasing as the health care system evolves to include subacute, transitional and rehabilitative care.   In addition there has been growth in new types of long term care residential facilities.

We knew we had to do something, and did not have developmental money so we made “Sophie’s Choice” and we pulled the surveys out of the field.

We did have some support from the Department, however.  
	1) Inventory (ASPE, AHRQ)
	2) Typology (NIA)
	....

## Policy can change in a matter of minutes

**Policy can change in a matter of minutes**

**Notes:**
And finally the redesign of the nursing home survey

Pilot in 2003, aim for being back in the field in fall 2003. 

Working collaboratively with CMS, AHRQ and others for
	1)  Better information on facility characteristics that can relate to quality of care:  staffing, services, procedures
	2)  Expanded content:  palliative care, quality of care, medication use, health status
	3)  Linkage to MDS for longitudinal analysis. 

## Monitoring change in an ever changing industry

**Monitoring change in an ever changing industry**

## The NHCS is ripe for watching other important trends*

- Rise in overweight and obesity
- Increases in chronic diseases
- Widening gap between wealthy and poor
- Future investments in information technology, aimed at enhancing the quality and efficiency of clinical care
- Consumers and government purchasers will pay more and make more decisions about their health care
- Increased competition between and across health care facilities
- If current trends continue, the number of uninsured will climb from 38 million in 1999 to 51.2 million in 2006

- * Excerpted from AHA Environmental Assessment, fall 2003