on the health of the us health care system… insights and analyses from the national health care...
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On the Health of the US Health Care System…
Insights and analyses from the National Health Care Survey
Irma E. Arispe, PhDDivision of Health Care Statistics
Data Users Conference, July 12, 2004
Centers for Disease Control and PreventionNational 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 systemDisparities redefined…Differential “burden” on the health care system
Pneumonia hospitalization rates in MSA and non-MSA areas, U.S. 2000
78
38
0
10
20
30
40
50
60
70
80
90
Non-MSA MSA
• 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”
23
30
8
30
0
5
10
15
20
25
30
35
Active MDs Hospitalbeds
MSA Non-MSA
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 ½ of hospitalization for persons with diabetes in VA and non-VASettings.
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
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) dataSource: Burt and Arispe 2004
Insights into the health of the health care system
Part II
Quality measurement and improvement
Quality measurement and improvement
Prescribing practicesDimensions 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?
Percent of patients with essential hypertension and no co-morbidities receiving first line drug therapy, by patient characteristics: U.S. 2001
51.3
45.8
51.6
48.9
42.5
54.7
0 10 20 30 40 50 60
Female
Male
Black
White or other
Under 65 years
'65 years and over+
Percent+ Age difference statistically significant at the p=0.1 level
*
Opportunities for improvementOpportunities for improvement
Source: Hing and Holmes 2004
Heading in the right directionHeading in the right direction
Antibiotic prescribing rates at
physician office visits for children
0
200
400
600
800
1000
89/90 91/92 93/94 95/96 97/98 99/00
Year
Rate per 1000 population
Rate per 1000 visits
Source: National Ambulatory Medical Care Survey 1989-2000
Trends in c-section ratesData from the NHDS
Destination unknownDestination unknown
Insights into the health of the health care system
Part III
Evaluating changes in health care policy and the health care
environment
Evaluating changes in health care policy and the health care
environment
Number of current home health care patients
US, 1992, 1994, 1996, 1998, 2000
The effect of changes in policyThe effect of changes in policy
0 10 20 30 40 50
Self pay
Non-capitated private ins.
Medicare
Medicaid
Worker's comp
No charge
Capitated private ins.
Physician as bellwetherPhysician 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)
-35.5 -35.8
-15.1
13.9
-40
-30
-20
-10
0
10
20
Under 15 15-44 45-64 65+
Watching the tideWatching the tide
0
5
10
15
20
25
1985 1990 1995 2000
50-64 65 years & over
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
Policy can change in a matter of minutes
Policy can change in a matter of minutes
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