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 Analysis of NHDS and ARF 1 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 ½ 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 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” 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 Age difference statistically significant at the p=0.1 level * Opportunities for improvement Source: Hing and Holmes 2004

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

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

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 The effect of changes in policy

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

Percent change in hospital discharge rate by age, U.S (National Hospital Discharge Survey) Watching the tide

Note: Percentages exclude deaths and unknown disposition Source: NCHS/CDC: National Hospital Discharge Survey Percent of live hospital discharges transferred to LTC institutions: United States,

Policy can change in a matter of minutes

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