National Ambulatory Medical Care Survey: Redesigning for the future health care landscape

Sonja Williams, M.P.H., Brian Ward, Ph.D., Jill Ashman, Ph.D

Division of Health Care Statistics

National Center for Health Statistics

November 2021

National Center for Health Statistics

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Presentation Outline

National Ambulatory Medical Care Survey (NAMCS) overview

Health care changes 

Three stage redesign of NAMCS

Future of NAMCS

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What is NAMCS?

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NAMCS is conducted by the National Center for Health Statistics

The Centers for Disease Control and Prevention’s National Center for Health Statistics (NCHS) conducts NAMCS as part of a suite of National Health Care Surveys

NCHS is the main source of U.S. health statistics. Other NCHS surveys include:

National Hospital Care Survey (NHCS)

National Post-acute and Long-term Care Study (NPALS)

National Hospital Ambulatory Medical Care Survey

National Health and Nutrition Examination Survey (NHANES)

National Health Interview Survey (NHIS)

National Survey of Family Growth (NSFG)

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NAMCS

Background

National survey designed to meet the need for objective, reliable information about the provision and use of ambulatory medical care services in the United States

NAMCS has been conducted since 1973 and annually since 1989

Health Centers were added in 2006

Objective

Provide nationally representative data of ambulatory care provided at physicians’ offices and Health Centers

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Current Office Based Physician Scope

Physicians must:

Be classified by AMA or AOA as primarily engaged in office-based care

Not federally-employed

Not specializing in anesthesiology, radiology, or pathology

Not an intern, resident, or fellow

Visits must:

Occur in physician’s offices

Be for medical purposes

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Current Health Center Scope

Health centers (HCs) must meet one of the following criteria:

Federally Qualified Health Centers (FQHCs)

Look-Alike FQHCs

Urban Indian Health Center

HC Providers include:

Physicians

Physician assistants

Nurse practitioners

Certified nurse midwives

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Physician Data Collection Process

NAMCS Sampled Physician

Sample of Weekly Visits (Drawn on site)

Physician Induction Interview

Patient Visit Data Abstraction (n~30)

Sampled Calendar Week (Assigned prior to fielding)

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HC Data Collection Process

NAMCS Sampled HC

HC Facility Induction Interview

(includes listing of providers)

HC Sampled 

Provider 1

HC Provider 1 Induction Interview

Sampled Calendar Week (Assigned prior to fielding)

Sample of Weekly Visits (Drawn on site)

Patient Visit Data Abstraction (n~30)

HC Sampled 

Provider 2

HC Provider 2 Induction Interview

Sampled Calendar Week (Assigned prior to fielding)

Sample of Weekly Visits (Drawn on site)

Patient Visit Data Abstraction (n~30)

HC Sampled 

Provider 3

HC Provider 3 Induction Interview

Sampled Calendar Week (Assigned prior to fielding)

Sample of Weekly Visits (Drawn on site)

Patient Visit Data Abstraction (n~30)

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Why redesign is necessary?

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Health Care Has Changed

Changes in who delivers care

The advent of the advanced practice provider

Changes in where care is delivered

Ambulatory care happens in many more places

Fewer single physician offices

Large health networks now govern much of ambulatory care

Medical data no longer in a paper chart 

Proliferation of EHR makes abstraction difficult

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Declining Response Rates

Physician offices and health centers less likely to allow manual abstraction

COVID-19 closed many physician offices and/or severely limited our field representatives’ access

We were forced to stop physician visit manual abstraction 

2020 response rates for each component of NAMCS
| Response Rate | Physician | HC Facility | HC Provider | HC Visits |
|---------------|-----------|-------------|-------------|-----------|
| Unweighted    | 50.8%     | 71.2%       | 55.7%       | 48.4%     |
| Weighted      | 51.6%     | 69.0%       | 59.4%       | 53.1%     |

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NAMCS Response

Redesign in a 3-staged approach

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Three Main Components

Modernize data collection methods: Health Center Component

Broaden Provider Scope: Provider Interview Component

Exploration of electronic data collection sources for ambulatory visits: Electronic Visit Component

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Stage 1: Modernizing Data Collection – Health Center Component

Starting in 2021 Health Center component data collection moved from manual abstraction to full electronic data collection

Partnered with Health Resources and Services Administration (HRSA)

Requiring the use of the NCHS “HL7 CDA® R2 Implementation Guide: National Health Care Surveys DSTU Release 1, Release 1.2 – US Realm”

Sampled 50 health centers

Simplified the sampling process

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Stage 1: Modernizing Data Collection – Health Center Component

Simplified the sampling process

NAMCS Sampled HC

HC Facility Interview

All visits  (Annual)

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Stage 1: Modernizing Data Collection – EHR data

Requiring the use of our NHCS IG we gain more detailed data:

Diagnoses and Reason for visit

Procedures and laboratory/diagnostic tests

Medications (new and continuing) and Immunizations

Patient demographic characteristics

Expected payment source

Type of Provider

Clinical Notes

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Stage 2: Broadening Provider Scope

Starting in 2022 collecting data on physician and physician assistant experiences via our Provider Interview Pilot Study

Mixed-mode survey to collect information on several topics including:

Provider Autonomy

Use of culturally and linguistically appropriate services

COVID vaccination efforts and accessibility

Tentative fielding date: early Fall 2022

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Stage 3: Exploration of Electronic Data Collection Sources for Ambulatory Visits

Expansion of ambulatory visit data collection to multiple ambulatory settings

Large health care networks

Retail establishments

Expanded collection made possible by:

Severing the connection between sampled physicians and their visits

Exploring possibility of focusing on the care location versus specific physician specialties

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NAMCS Future

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Future Plans for NAMCS

Continue with NAMCS Health Center Component

PCORTF funding to look at maternal health outcomes and link data to outside sources such as HUD

Collect data through the Provider Interview

Expand to other advance practice providers 

Increase sample size

Collect ambulatory visit data

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Thank You!

Sonja Williams (presenter)

Ambulatory Care Team Lead

Ambulatory and Hospital Care Statistics Branch

Division of Health Care Statistics

National Center for Health Statistics 

Centers for Disease Control and Prevention

Office 301.458.4774

swilliams14@cdc.gov

Brian Ward

Branch Chief

Ambulatory and Hospital Care Statistics Branch

Division of Health Care Statistics

National Center for Health Statistics 

Centers for Disease Control and Prevention

Office 301.458.4568 

bwward@cdc.gov

Jill Ashman

Dissemination Team Lead

Ambulatory and Hospital Care Statistics Branch

Division of Health Care Statistics

National Center for Health Statistics 

Centers for Disease Control and Prevention

Office 301.458.4439 

jashman@cdc.gov

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