1. Identification of Potential Disability Measures for the National Healthcare Quality and Disparities Report
Frances Chevarley, Barbara Altman, Ernest Moy
2007 APHA Annual Meeting--Session , Nov 5, 2007, 1:15 pm

2. Overview
Background of the National Healthcare Disparities and Quality Reports
NHDR Disability Working Group
Measurement of Disability
Where the group came out
Future plans

3. NHQR & NHDR Congressional Mandate
Annual reports on
“National trends in the quality of health care provided to the American people”
“Prevailing disparities in health care delivery as it relates to racial factors and socioeconomic factors in priority populations”
Priority Populations
Low-income
Minorities
Women
Children
Elderly
Special health care needs
Disability
Chronic care
End of life

4. NHQR & NHDR How they are Related
Snapshot of quality of health care in America
Snapshot of disparities in health care in American
Quality
Quality + Access
Variation across states
Variation across populations

5. Individuals with Disabilities in the 2003-2006 NHDRs
NHDR at
Section on disabilities in the Priority Populations Chapter—very short
Children with special health care needs
MEPS
National Survey of Children with Special Health Care Needs (2004)
Adults with disabilities
MCBS
Medicare beneficiaries <65
Medicare beneficiaries 65+ with one or more ADL/IADLs

6. Disability Working Group Charge to this Group
Representatives from AHRQ, AoA, ASPE, CDC-NCHS, CDC-NCBDDD, Census Bureau, CMS, HHS-OoD, NCD, NIDRR, NIH-NIA, NIH-NCMRR, HRSA, SAMHSA, SSA, VA
Recommend a consensus measurement of individuals with disabilities
Applicable across multiple data sources
MEPS, NHIS, MCBS, ??
Can be described to lay persons in a half page
Allows comparisons by race, ethnicity, and income
Sensitive to sample size limitations

7. Objective of Working Group
Reflect the ADA definition of Disability
Locate the area of consistency among the various data sets used in the two reports:
MEPS
NHIS
MCBS ?

8. Basis for Definition ADA definition of Disability
Has a physical or mental impairment that substantially limits one or more major life activities; or
Has a record of a substantially limiting impairment; or
Is regarded as having such an impairment
Ref – The Surgeon General’s Call to Action to Improve the Health and Wellness of Persons with Disabilities 2005

9. Tool to Guide Process
Used International Classification of Functioning, Disability and Health (ICF) Model as a guide to the conceptual components of the definition
Components of ICF
Body functions
Body structures
Activities and Participation
Environmental Factors

10. Identifying Domains of the ICF in the Survey Questions
Examples of Domains within ICF Components
Body Functions and structures
Sensory functions and pain
The eye, ear, and related structures
Activities and Participation
Learning and applying knowledge
Purposeful sensory experience
Applying knowledge
Mobility
Community, social and civic life

11. Identifying Domains of the ICF in the Survey Questions
Chapters of the Activities and Participation Component in which NHIS, MEPS, SIPP, NHANES, and MCBS all capture
Learning and applying knowledge—Chapter 1 (d110-d199)
Purposeful sensory experience
Applying knowledge
Mobility – Chapter 4 (d410-d499)
Selfcare – Chapter 5 (d510-d599)
Domestic Life – Chapter 6 (d610-d699)
Major life areas – Chapter 8 (d810-d899)
Community, social and civic life – Ch 9 (d910-d999)
Survey Estimates by Domain
Ref.— relied heavily on crosswalk by Cille Kennedy, ASPE

12. Brief Data Review
Disability is a continuum and not a dichotomous concept
Disability manifests itself across multiple domains
Disability can be short-lived or can be chronic or sporadic

13. Brief Data Review Surveys have different purposes
capture different # of disability questions
Surveys capture different domains and at different parts of the continuum
Survey tools to measure disability are not as precise as measurement tools for physical sciences

14. How NHIS and MEPS compare by Domain
Selfcare (ADLs)
NHIS —(Family Core)
Screener Question (needs help of other persons)
Needs help with at least 1 of 6 specific items
MEPS
Screener Question (receive help or supervision)
Expect to need help for at least 3 more months

15. How NHIS and MEPS compare by Domain
Mobility
NHIS (Sample Adult)
Not at all difficult, Only a little difficult, Somewhat difficult, Very difficult, Can’t do at all, Do not do this activity
MEPS individual questions
No difficulty, Some difficulty, A lot of difficulty, Completely unable to do it

16. How NHIS and MEPS compare by Domain
Hearing
NHIS (Adult Core)
Which statement best describes your hearing without a hearing aid: good, a little trouble, a lot of trouble, deaf?
MEPS
Screener – anyone with difficulty hearing
not hear any speech at all, that is deaf
(w/ a hearing aid) hear most of the things people say
(w/ a hearing aid) hear some of the things people say

17. Data Nuances due to Different questions/responses
Doing a crosswalk/translation with the ICF is not always straightforward (e.g., ADLs and IADLs do not map completely to a chapter)
A number of the domains have similar questions and estimates across MEPS and NHIS
In some domains, like Mobility, the questions are similar but the response options are very different
Different questions and/or different response options may produce different estimates

18. NHDR Disability Workgroup Recommendation
Broad inclusive definition of Disability
Focus within Activity limitations
Basic activities
Complex activities

19. NHDR Disability Workgroup Recommendation
Activity limitations
Basic activities
mobility, self care (ADLs), domestic life (IADLs), activities dependent on sensory functioning
Complex activities
limitations experienced in work; and in community, social and civic life activities

20. 2007 NHDR--Tentative Current plans for 2007 NHDR
Include MEPS disability data for adults
Use recommended two measures
Add charts and text to Chapter 4 Priority Populations
Include disability measures for ~50 MEPS tables in the Technical Appendix
Each MEPS table includes 4 tables (race, ethnicity, education, and income)--total tables ~ 200

21. Exploratory analysis for 2007 NHDR: Adults unable to receive or delayed in receiving needed medical care

22. Future Plans--Tentative
Plans for future NHDR reports
Expand disability data by including comparable disability data from NHIS and MCBS
Include additional tables/text/charts
Create similar working group to discuss options for measuring disability for children
Consider Including disability data from more data sources
Evolving process