Analyzing data on medications collected in the National Health Care Survey
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Analyzing data on medications Analyzing data on medications collected in the National Health Care collected in the National Health Care
SurveySurvey
Centers for Disease Control and PreventionNational Center for Health Statistics
Catharine W. Burt , Ed.D.
Chief, Ambulatory Care Statistics Branch
June 6, 2004 AcademyHealth Conference
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TopicsTopics
Overview of the NHCSOverview of the NHCS Background of the ambulatory care Background of the ambulatory care
surveyssurveys Using public use files for drug analysisUsing public use files for drug analysis Examples of drug analysesExamples of drug analyses
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Ambulatory care
Long-term care
National Health Care SurveyNational Health Care SurveyBasic Components
Hospital &surgical care
Health ProviderInventory
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National Health Care SurveyNational Health Care Survey(Year began collecting drug data)(Year began collecting drug data)
National Ambulatory Medical Care Survey National Ambulatory Medical Care Survey (1980)(1980)
National Hospital Ambulatory Medical Care National Hospital Ambulatory Medical Care Survey Survey (1992)(1992)
National Hospital Discharge Survey National Hospital Discharge Survey (in research)(in research) National Survey of Ambulatory Surgery National Survey of Ambulatory Surgery (1994-6)(1994-6)
National Nursing Home Survey National Nursing Home Survey (2004)(2004) National Home and Hospice Care SurveyNational Home and Hospice Care Survey
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Increasing drug mentions at ambulatory care visitsIncreasing drug mentions at ambulatory care visits
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NHCS Common MethodologyNHCS Common Methodology
National probability sample surveys Complex sample designs Common definitions, data items, sampling
frames Medical diagnoses coded to ICD-9-CM Data collected by Census Bureau High response rates Data processed by private contractor
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Antibiotic prescribing rates at Antibiotic prescribing rates at
physician office visits for childrenphysician 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
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NAMCS and NHAMCS NAMCS and NHAMCS background background
NAMCS NAMCS Fielded 1973-1981, 1985, 1989-presentFielded 1973-1981, 1985, 1989-present 3-stage sample3-stage sample
• PSUs – PSUs – physicians – physicians – visits during 1 weekvisits during 1 week
NHAMCS NHAMCS Fielded annually since 1992Fielded annually since 1992 4-stage sample4-stage sample
• PSUs – PSUs – hospitals – hospitals – ED/OPD clinics – ED/OPD clinics –
visits during 4 weeksvisits during 4 weeks
SEs
rates
percents
drugsproviders
visits
sample
records
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Scope of the NAMCSScope of the NAMCS
Physicians must be: Physicians must be: Primarily engaged in office-based, patient Primarily engaged in office-based, patient
carecare Nonfederally employedNonfederally employed Not in anesthesiology, radiology, or Not in anesthesiology, radiology, or
pathology pathology
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In-Scope Visits for NAMCSIn-Scope Visits for NAMCS
Basic unit of sampling is the physician-Basic unit of sampling is the physician-patient visit patient visit
Visit must occur in a physician’s officeVisit must occur in a physician’s office Visits must be for medical purposesVisits must be for medical purposes Out-of-scope contacts include:Out-of-scope contacts include:
Visits for administrative purposesVisits for administrative purposes House calls, phone calls, emails, visits in House calls, phone calls, emails, visits in
hospital setting unless physician has private hospital setting unless physician has private office thereoffice there
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In-Scope NAMCS Locations In-Scope NAMCS Locations Freestanding private solo or group Freestanding private solo or group
practicepractice Freestanding clinic/urgicenterFreestanding clinic/urgicenter Neighborhood medical and mental health Neighborhood medical and mental health
centerscenters Privately operated clinicsPrivately operated clinics Non-Federal government clinicNon-Federal government clinic Health maintenance organizationHealth maintenance organization Federally qualified health centerFederally qualified health center Faculty practice planFaculty practice plan
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Out-of-Scope NAMCS Out-of-Scope NAMCS LocationsLocations
Hospital ED’s and OPD’sHospital ED’s and OPD’s Ambulatory surgicenterAmbulatory surgicenter Institutional setting (schools, prisons)Institutional setting (schools, prisons) Industrial outpatient facilityIndustrial outpatient facility Federally operated clinicFederally operated clinic Laser vision surgeryLaser vision surgery
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Scope of the NHAMCSScope of the NHAMCS
Basic unit of sampling is patient visitBasic unit of sampling is patient visit Emergency and outpatient departments of Emergency and outpatient departments of
non-federal, general and short-stay non-federal, general and short-stay hospitalshospitals
Not Federal, military, or Veterans Not Federal, military, or Veterans Administration facilitiesAdministration facilities
Located in 50 states and D.C.Located in 50 states and D.C.
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Items CollectedItems Collected Patient characteristics Patient characteristics
Age, sex, race, ethnicityAge, sex, race, ethnicity Visit characteristicsVisit characteristics
Source of payment, continuity of care, reason for visit, Source of payment, continuity of care, reason for visit, diagnosis, treatment, medications ordered or provideddiagnosis, treatment, medications ordered or provided
Provider characteristicsProvider characteristics Physician specialty, hospital ownershipPhysician specialty, hospital ownership
Drug characteristicsDrug characteristics Therapeutic class, composition, control status, Therapeutic class, composition, control status,
ingredients, Rx or OTCingredients, Rx or OTC
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Using NAMCS/NHAMCS Using NAMCS/NHAMCS public use files for public use files for
analyzing drug dataanalyzing drug data
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Ambulatory Care Data StructureAmbulatory Care Data Structure
Providerprovider infopractice info
geographic info
Visit patient & visit info
treatment & outcome infomedications
Visit Visit
Medcode 1…Medcode 6
Class 1 Ingredient 1 ..ingredient 5
…Class 3
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File StructureFile Structure
Flat ASCII files for each setting and yearFlat ASCII files for each setting and year Use file layout to read the dataUse file layout to read the data Input and format code available forInput and format code available for
SASSAS STATASTATA SPSSSPSS
Can use SETS Can use SETS (but no sampling variance estimates)(but no sampling variance estimates)
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Visit File LayoutVisit File Layout
Patient In fosex, age,
race, ethnicity
Visit In fodate, reason for v is it,
paym ent source, d iagnosis,patient w eight
Treatm ent In fodiagnostic services,
counseling/education,therapeutic services
M edication Infodrug nam e,
generic nam e, ingredients,therapeutic c lass
O utcom e M easuresno FU p lanned,
return, refer,adm it to hospita l
Provider In fospecia lty, reg ion,
urban, so lo practice,ow nership
Setting & Year
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Sample WeightSample Weight
Each NAMCS, OPD and ED record Each NAMCS, OPD and ED record contains a single weight, which we call contains a single weight, which we call Patient Visit WeightPatient Visit Weight
This weight is used for both visits and This weight is used for both visits and drug mentionsdrug mentions
Weight must be applied or estimates of Weight must be applied or estimates of totals, percents and effects will be totals, percents and effects will be incorrect.incorrect.
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Drug codingDrug coding
Drug nameDrug name Generic nameGeneric name Therapeutic Therapeutic classclass
ProzacProzac
MED#=25674MED#=25674
FluoxetineFluoxetine
GEN#=80006GEN#=80006
AntidepressantAntidepressant
DRUGCL=0630DRUGCL=0630
FluoxetineFluoxetine
MED#=91079MED#=91079
FluoxetineFluoxetine
Gen#=80006Gen#=80006
AntidepressantAntidepressant
DRUGCL=0630DRUGCL=0630
Fluoxetine HCLFluoxetine HCL
MED#=91079MED#=91079
FluoxetineFluoxetine
GEN#=80006GEN#=80006
AntidepressantAntidepressant
DRUGCL=0630DRUGCL=0630
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Leading Rx at office visitsLeading Rx at office visits % of all Rx mentions% of all Rx mentions
Lipitor Lipitor 1.6% 1.6% AlbuterolAlbuterol 1.41.4 Amoxicillin Amoxicillin 1.31.3 Synthroid Synthroid 1.31.3 Lasix Lasix 1.2 1.2 Celebrex Celebrex 1.21.2 Vioxx Vioxx 1.11.1
Source: 2002 NAMCSSource: 2002 NAMCS
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Top OTC mentions at office visitsTop OTC mentions at office visits % of all OTC mentions% of all OTC mentions
Aspirin Aspirin 16.7% 16.7%Tylenol Tylenol 11.6 11.6Advil 4.1Advil 4.1Prenatal vitamins 3.4Prenatal vitamins 3.4Benadryl Benadryl 3.2 3.2
Source: 2002 NAMCSSource: 2002 NAMCS
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http://www.cdc.gov/nchs/about/major/ahcd/ahcd1.htmhttp://www.cdc.gov/nchs/about/major/ahcd/ahcd1.htm
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Drug Characteristics Database Search
on Generic: Fluoxetine
1999
Drug Code Drug Name Generic Name Mentions
25674 PROZAC FLUOXETINE
HYDROCHLORIDE 9,257,694
91079 FLUOXETINE FLUOXETINE
HYDROCHLORIDE 49,293
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Drug Characteristics Database
Drug Code\Name: 25674 - PROZAC
Generic Code\Name: 80006 – FLUOXETINE
HYDROCHLORIDE
Date Added: No Date
Prescription Status: 1 - Prescription Drug
Composition Status: 1 - Single Entity Drug
DEA Status: 6 - No Control
Therapeutic Class: 0630 Antidepressants
1999 Mentions: 9,257,694
1999 Mention Rate: 98.0
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Drug Characteristics Database
Drug Code\Name: 91079 - FLUOXETINE
Generic Code\Name: 80006 – FLUOXETINE
HYDROCHLORIDE
Date Added: No Date
Prescription Status: 1 - Prescription Drug
Composition Status: 1 - Single Entity Drug
DEA Status: 6 - No Control
Therapeutic Class: 0630 Antidepressants
1999 Mentions: 49,293
1999 Mention Rate: 1.0
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Drug mention rates at physician office Drug mention rates at physician office visits by patient’s age: 1985-2002visits by patient’s age: 1985-2002
1985
1989
-90
1995
-96
1997
-98
1999
-200
0
2001
-20
50
100
150
200
250
Dru
g m
en
ti on
s p
er
10
0 v
isits
<45 45-64 65+
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Drug mention rates for Drug mention rates for NSAIDs, antidepressants,NSAIDs, antidepressants, and antihistamines and antihistamines at physician office visits, at physician office visits,
1995-2002 1995-2002
3
4
5
6
7
8
9
1995 1996 1997 1998 1999 2000 2001 2002
Num
ber
of d
rug
men
tions
per
100
vis
its
NSAIDs are nonsteroidal anti-inflammatory drugs.Trends shown are significant (p<0.05).
NSAIDs
Antidepressants
Antihistamines
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Estrogen/progestinEstrogen/progestin mention rates for women at mention rates for women at physician office visits by patient age, 1995-2002physician office visits by patient age, 1995-2002
20
25
30
35
40
45
50
55
60
1995 1996 1997 1998 1999 2000 2001 2002
65 years and over
45-64 years
Num
ber
of d
rug
men
tions
per
100
fem
ales
.
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Rate of office visits for erectile dysfunction Rate of office visits for erectile dysfunction for men 25+: United States, 1985-2002for men 25+: United States, 1985-2002
"
"
"
"
"
1985
1989
-90
1995
-96
1999
-200
0
2001
-200
20
5
10
15
20
25
Num
ber
of v
isits
pe r
1, 0
0 0 m
a le s Viagra introduced
Figures are based on 2-year averages except 1985. SOURCE: NAMCS
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Example of NAMCS analysis for ViagraExample of NAMCS analysis for Viagra Prescribed at .4% of office visits by males; 15% of Prescribed at .4% of office visits by males; 15% of
erectile dysfunction (ED) visitserectile dysfunction (ED) visits 12% scripts written for men aged 25-44 and 9% for 75+12% scripts written for men aged 25-44 and 9% for 75+ Rate of scripts increases for patients who have seen Rate of scripts increases for patients who have seen
their physician between 1 and 5 times in past year. their physician between 1 and 5 times in past year. Rarely prescribed at an initial visit.Rarely prescribed at an initial visit.
Only 19% of scripts written are at ED visitsOnly 19% of scripts written are at ED visits Leading diagnoses when ED not listed– Leading diagnoses when ED not listed–
Essential hypertension 19%Essential hypertension 19% Hyperplasia of the prostate 11%Hyperplasia of the prostate 11% Diabetes 8%Diabetes 8%
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Analyzing trendsAnalyzing trends Be careful about trending diagnosis prior to 1980 Be careful about trending diagnosis prior to 1980
because of ICDAbecause of ICDA (based on ICD-8)(based on ICD-8) Even after 1980- be careful about changes in ICD-Even after 1980- be careful about changes in ICD-
9-CM9-CM Number of medications varies over yearsNumber of medications varies over years
1980-81 – 8 medications1980-81 – 8 medications1985, 1989-94 – 5 medications1985, 1989-94 – 5 medications1995-2002 – 6 medications1995-2002 – 6 medications2003-2006 – 8 medications2003-2006 – 8 medications
Number of therapeutic class codes varyNumber of therapeutic class codes vary1980-2001 – 1 class1980-2001 – 1 class2002-2006 – up to 3 classes2002-2006 – up to 3 classes
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Information available on the Information available on the InternetInternet
NCHS website is www.cdc.gov/nchsNCHS website is www.cdc.gov/nchs National Health Care Survey website National Health Care Survey website
Ambulatory Health Care Data (AHCD)Ambulatory Health Care Data (AHCD) National Hospital Discharge and National Hospital Discharge and
Ambulatory Surgery Data (NHDAS-data)Ambulatory Surgery Data (NHDAS-data) National Nursing Home Survey (NNHS)National Nursing Home Survey (NNHS) National Home and Hospice Care Survey National Home and Hospice Care Survey
(NHHCS)(NHHCS) Join our LISTSERVsJoin our LISTSERVs