health care disparities research: using the national health care surveys jane e. sisk and nancy...
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Health Care Disparities Research:Using the National Health Care Surveys
Jane E. Sisk and Nancy SonnenfeldAcademyHealth Annual Research Meeting
June 8, 2008
Division of Health Care StatisticsNational Center for Health StatisticsCenters for Disease Control and Prevention
Concept of Disparity
• Defining a disparity– lies along a causal pathway through which
race/ethnicity affects health care or health– has roots in injustice
• Identifying a disparity differs from analyzing its causes
*Hebert P, Sisk JE, Howell EA. Health Affairs 2008;374-382.*Hebert P, Sisk JE, Howell EA. Health Affairs 2008;374-382.
The National Health Care Surveys
• Physicians in offices
• Hospital emergency and outpatient departments
• Hospital inpatient departments
• Ambulatory surgery facilities
• Nursing homes
• Home and hospice care agencies
• Residential care facilities
Examples of Data
Provider OrganizationsSetting
Sources of revenue
Ownership/staffing
Technologies
Electronic medical records
Provider OrganizationsSetting
Sources of revenue
Ownership/staffing
Technologies
Electronic medical records
CliniciansSpecialty and training
Visits
Region
Gender
Race/ethnicity
CliniciansSpecialty and training
Visits
Region
Gender
Race/ethnicity
PatientsDemographics, including race/ethnicity
Medical conditions
Continuity
Vital signs
Insurance status
Residential zip code
PatientsDemographics, including race/ethnicity
Medical conditions
Continuity
Vital signs
Insurance status
Residential zip code
Clinical ManagementMedications
Services provided/ordered
Duration of visit
Disease Management
Counseling
Disposition
Clinical ManagementMedications
Services provided/ordered
Duration of visit
Disease Management
Counseling
Disposition
New Patients Whom Physicians WereNot Accepting , 2001-2006
0 5 10 15 20 25 30 35 40 45 50
Self-pay/1
Noncapitated private insurance
Medicare
Medicaid/1
Capitated private insurance
Worker's compensation/1
No charge/ charity/1
Percent of physicians
2001-02
2005-06
1/Trend is statistically significant (p<0.05).Source: National Ambulatory Medical Care Survey, 2001-2006Hing et al. National Health and Vital Statistics Series 13 2008; no 266
Difficulty Referring PatientsFor Specialty Consultation, 2005-2006
Source: National Ambulatory Medical Care Survey, 2005-2006Hing et al. National Health and Vital Statistics Series 13 2008; no 266
0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0
Medicaid
Uninsured
Private
Medicare
Percent of office-based physicians
Ambulatory Visits by Setting, 2005
Sources: National Ambulatory and National Hospital Ambulatory Medical Care Surveys, 2005.Burt C. et al. Advance Data 2007;388.
49%
35%
7%9%
40%
26%
15%
19%
WhiteWhite Black/African-AmericanBlack/African-American
61%
27%
6% 6%
2
AsianAsian
40%
26%
15%
19%Primary Care Offices
Medical+Surgical Specialties
Hospital Outpatient Departments
Emergency Departments
74.9
11.4
13.7
84.2
6.89.0
Ambulatory Visits in Different Settings by Poverty in Patient Zip Code, 2001-2005
Sources: National Ambulatory and National Hospital Ambulatory Medical Care Surveys, 2001-2005.
69.7
14.5
15.9
65.5
16.8
17.7
< 20% Poverty< 20% Poverty
20-29% Poverty20-29% Poverty
30-39% Poverty30-39% Poverty
40% or more Poverty40% or more Poverty
Physician officesOutpatient departmentsEmergency Departments
Emergency Department Waiting Times, 1997-2004
*Chi-square test among categories; p < .0001. Significant differences remained after adjusting for age, gender, payment source, initial triage assessment, presenting complaint of chest pain, admitted, and ultimate ED diagnosis of AMI.Source: National Hospital Ambulatory Medical Care Survey, 1997-2004. Adapted from Wilper, et al. Health Affairs 2008(2):27:w84-95.
*Chi-square test among categories; p < .0001. Significant differences remained after adjusting for age, gender, payment source, initial triage assessment, presenting complaint of chest pain, admitted, and ultimate ED diagnosis of AMI.Source: National Hospital Ambulatory Medical Care Survey, 1997-2004. Adapted from Wilper, et al. Health Affairs 2008(2):27:w84-95.
10
31
10
33
12
24
10
24
0
5
10
15
20
25
30
35
All adult patients* Adult emergent patients
Me
dia
n (
in m
inu
tes
)
Non-Hispanic White
Non-Hispanic Black
Hispanic, any race
Other
Appropriate Medication Therapy*Adult Visits with Atrial Fibrillation (AF)
Excerpted from Ma J, et al. Arch Intern Med 2005;165:1354-1361. Excerpted from Ma J, et al. Arch Intern Med 2005;165:1354-1361.
ProminentMeasure Denominator Numerator ExclusionsAntithrombotic AF visits AF visits with AF visits with GItherapy warfarin, bleeding,
dicumarol, duodenitis, anisindione, alcoholism, drug or aspirin abuse, Alzheimer’s,
gait abnormality,cerebral hemorrhage, seizure disorder,CNS tumors, renalinsufficiency, orthrombocytopenia
ProminentMeasure Denominator Numerator ExclusionsAntithrombotic AF visits AF visits with AF visits with GItherapy warfarin, bleeding,
dicumarol, duodenitis, anisindione, alcoholism, drug or aspirin abuse, Alzheimer’s,
gait abnormality,cerebral hemorrhage, seizure disorder,CNS tumors, renalinsufficiency, orthrombocytopenia
CNS = Central Nervous System
*Guidelines from American College of Cardiology/American Heart Association/European Society of Cardiology
CNS = Central Nervous System
*Guidelines from American College of Cardiology/American Heart Association/European Society of Cardiology
Appropriate Medication Therapy,* 1995-2002Percent of Visits
Sources: National Ambulatory Medical Care Survey and National HospitalAmbulatory Medical Care Survey, 1995-2002Excerpted from: Ma J, et al. Arch Intern Med 2005;165:1354-1361.
Sources: National Ambulatory Medical Care Survey and National HospitalAmbulatory Medical Care Survey, 1995-2002Excerpted from: Ma J, et al. Arch Intern Med 2005;165:1354-1361.
Non-Hispanic Non-HispanicMeasure White Black HispanicNo benzodiazepine for depression 84 87 77Antithrombotic therapy for AF 51 52 60Diuretic + β-blocker, HTN 57 63 54IC, asthma, adults 38 36 30ACE inhibitor, CHF 32§ 45§ 20IC, asthma, children 23 27 20β-blocker, CAD 29 25 28
§significant differences AF= atrial fibrillation CHF = congestive heart failure HTN = hypertension CAD = coronary artery disease ACE = angiotensin converting enzyme IC = inhaled corticosteroid
Non-Hispanic Non-HispanicMeasure White Black HispanicNo benzodiazepine for depression 84 87 77Antithrombotic therapy for AF 51 52 60Diuretic + β-blocker, HTN 57 63 54IC, asthma, adults 38 36 30ACE inhibitor, CHF 32§ 45§ 20IC, asthma, children 23 27 20β-blocker, CAD 29 25 28
§significant differences AF= atrial fibrillation CHF = congestive heart failure HTN = hypertension CAD = coronary artery disease ACE = angiotensin converting enzyme IC = inhaled corticosteroid
Hospitalizations For Diabetes
0
20
40
60
80
100
120
140
160
180
200
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
Year
Dis
char
ges
per
1,0
00 w
ith
dia
bet
es
Black
White
Sources: National Hospital Discharge Survey, National Health Interview Survey
Statistics computed by CDC/Division of Diabetes Translation, http://www.cdc.gov/diabetes/statistics/dmfirst/fig6.htm
Sources: National Hospital Discharge Survey, National Health Interview Survey
Statistics computed by CDC/Division of Diabetes Translation, http://www.cdc.gov/diabetes/statistics/dmfirst/fig6.htm
Adult Vaccinations
Nursing Home Residents, 2004
0
10
20
30
40
50
60
70
Pneumococcalvaccination (ever)
Influenza vaccination (past 12 months)
Pe
rce
nt
of
res
ide
nts
Non-Hispanic White
Non-Hispanic Black
Hispanic
Source: 2004 National Nursing Home SurveySource: 2004 National Nursing Home Survey
Methodological Challenges
• Encounter, not person-based
• Limited sample size
• Missing data
• Clustering
Recent Improvements• Increase sample size
– Community Health Centers, NAMCS from 2006– Oncologists, NAMCS 2006-07
• Expand providers covered– Ambulatory surgery facilities, 2006
• Improve methods– Imputation of race/ethnicity, NAMCS, 2006
• Add information on providers, patients, and care– Electronic medical records, NAMCS/NHAMCS, 2006– Screening for cervical cancer, NAMCS/NHAMCS 2006-10– Prior contacts, NHAMCS ED and NAMCS from 2006– Cancer stage, radiation therapy, NAMCS 2006-07
• Link to external data sets– National Nursing Home Survey linked to Medicare MDS files, 2004– Patient ZIP linked to Census data on income, education, poverty
levels, NAMCS/NHAMCS from 2006
Improvements Underway
• Laboratory results to be pilot tested, NAMCS, 2009• Routine coverage of ambulatory surgery in NHAMCS
– Hospital-based facilities from 2009– Free-standing facilities from 2010
• Redesigned National Hospital Discharge Survey, 2010- Clinical depth (medications, tests) - Better race data- Resource use/billings/payments - Prior and later admissions- Added facility characteristics - Link to National Death Index
• National Survey of Residential Care Facilities, 2010• Update samples, NAMCS/NHAMCS, 2011• National Nursing Home Survey, 2011
