Overview Of The National Overview Of The National HealthHealth

Care Survey (NHCS)Care Survey (NHCS)

Centers for Disease Control and PreventionNational Center for Health Statistics

American Public Health AssociationAmerican Public Health Association134 Annual Meeting & Exposition134 Annual Meeting & Exposition

November 4, 2006November 4, 2006

William S. Pearson, Ph.D.William S. Pearson, Ph.D.

Division of Health Care StatisticsDivision of Health Care Statistics

National Health Care SurveyBasic Components

Ambulatory care

Long-term care

Hospital & Surgical care

National Health Care SurveyNational Health Care Survey

National Ambulatory Medical Care SurveyNational Ambulatory Medical Care SurveyNational Hospital Ambulatory Medical Care SurveyNational Hospital Ambulatory Medical Care Survey

National Hospital Discharge SurveyNational Hospital Discharge SurveyNational Survey of Ambulatory SurgeryNational Survey of Ambulatory Surgery

National Nursing Home SurveyNational Nursing Home SurveyNational Home and Hospice Care SurveyNational Home and Hospice Care Survey

Ambulatory CareAmbulatory Care

Hospital & Surgical CareHospital & Surgical Care

Long-term CareLong-term Care

How are NHCS data used?How are NHCS data used?

To understand health care practiceTo understand health care practice

To identify and track problemsTo identify and track problems

To identify inequalities in the provision of To identify inequalities in the provision of servicesservices

To establish national prioritiesTo establish national priorities

To serve as comparison points for statesTo serve as comparison points for states

To measure Healthy People objectivesTo measure Healthy People objectives

• National probability sample surveysNational probability sample surveys

• Complex sample designsComplex sample designs

• Common definitions, data items, sampling Common definitions, data items, sampling framesframes

• Medical diagnosesMedical diagnoses

• Data collected by Census BureauData collected by Census Bureau

• High response ratesHigh response rates

• Data processed by private contractorData processed by private contractor

NHCS Common MethodologyNHCS Common Methodology

Data users-NHCSData users-NHCS

Over 150 journal publications in last 2 Over 150 journal publications in last 2 yearsyears

Health professional associationsHealth professional associations

State and federal policy makersState and federal policy makers

Health services researchersHealth services researchers

EpidemiologistsEpidemiologists

Universities and medical schoolsUniversities and medical schools

Broadcast & print mediaBroadcast & print media

Where are people going for their Where are people going for their health care and has the setting health care and has the setting

changed over the years?changed over the years?

Hospital discharge rate, 1980-2003Hospital discharge rate, 1980-2003

0

20

40

60

80

100

120

140

160

180

1980 1985 1990 1995 2000 2003

Rat

e pe

r 1,

000

pers

ons

Source: National Hospital Discharge Survey

Average length of Average length of hospital stay: 1980-2003hospital stay: 1980-2003

0

1

2

3

4

5

6

7

8

1980 1985 1990 1995 2000 2003

Day

s

Source: National Hospital Discharge Survey

Average length of hospital Average length of hospital stay by age: 1970-2000stay by age: 1970-2000

0

2

4

6

8

10

12

14

1970 1980 1985 1990 1995 2000 2003

Day

s

65 years & over

45-64 years

15-44 years

Under 15 years

Source: National Hospital Discharge Survey

NOTE: All trends shown are significant (p<0.05).

20

25

30

35

40

45

50

55

Num

ber

of

vis

its

per

10

0 p

ers

ons

Trends in ED visit rates by age

65 years and over

22-49 years

50-64 years

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 Percent of live hospital discharges transferred to LTC institutions: United States, 1985-2000LTC institutions: United States, 1985-2000

Percent of nursing home residents admitted Percent of nursing home residents admitted from hospital: United States, 1985-1999from hospital: United States, 1985-1999

37.440.5

44.6 46.3

0

10

20

30

40

50

1985 1995 1997 1999Year

Percent

Source: NCHS/CDC: National Nursing Home Surveys

NHCS strengths NHCS strengths

Amount of utilizationAmount of utilization

Health care usersHealth care users

Sentinel eventsSentinel events

Treatment patternsTreatment patterns

Trends over timeTrends over time

Springboard for further researchSpringboard for further research

NHCS limitationsNHCS limitations

Few outcome measuresFew outcome measures

Longitudinal purposesLongitudinal purposes

Episode of illnessEpisode of illness

Community measuresCommunity measures

Rare event estimationRare event estimation

Key conceptsKey concepts

Encounter vs. person dataEncounter vs. person data

Incidence & prevalenceIncidence & prevalence

Utilization ratesUtilization rates

National and regional estimateNational and regional estimate

NAMCS and NHAMCSNAMCS and NHAMCS

National Ambulatory Medical Care National Ambulatory Medical Care Survey (NAMCS)Survey (NAMCS)– Patient visits to non-federal, office-Patient visits to non-federal, office-

based physiciansbased physicians

National Hospital Ambulatory Medical National Hospital Ambulatory Medical Care Survey (NHAMCS)Care Survey (NHAMCS)– Patient visits to EDs and OPDs of Patient visits to EDs and OPDs of

non-federal, short-stay hospitalsnon-federal, short-stay hospitals

History of NAMCSHistory of NAMCS

Planning began in 1967Planning began in 1967

Survey began in 1973Survey began in 1973

Fielded 1973-1981, 1985, 1989-presentFielded 1973-1981, 1985, 1989-present

Database covering 30 yearsDatabase covering 30 years

History of NHAMCSHistory of NHAMCS

Planning began in 1976Planning began in 1976

Survey began in 1992Survey began in 1992

Fielded annuallyFielded annually

1414thth year of operation year of operation

NAMCS and NHAMCS NAMCS and NHAMCS MethodologyMethodology

NAMCS Sample DesignNAMCS Sample Design

Three stage designThree stage design(1) 112 PSUs(1) 112 PSUs

(2) Physician practices within PSUs(2) Physician practices within PSUs

(3) Patient visits within practices(3) Patient visits within practices

One-week reporting periodOne-week reporting period

For 2003-- 3,000 doctors sampled; For 2003-- 3,000 doctors sampled;

data collected for 25,288 office visitsdata collected for 25,288 office visits

Scope of the NAMCSScope of the NAMCS

Basic unit of sampling is the physician-patient visit Basic unit of sampling is the physician-patient visit

Physicians must be:Physicians must be:– Classified by AMA or AOA as primarily engaged in Classified by AMA or AOA as primarily engaged in

office-based patient careoffice-based patient care– nonfederally employednonfederally employed– not in anesthesiology, radiology, or pathology not in anesthesiology, radiology, or pathology

Starting in 2006: Starting in 2006: – Community Health CentersCommunity Health Centers– Physicians & mid-level providersPhysicians & mid-level providers

In-Scope NAMCS LocationsIn-Scope NAMCS Locations

Private solo or group practicePrivate solo or group practiceFreestanding clinic/urgicenter (not part of a hospital Freestanding clinic/urgicenter (not part of a hospital outpatient department)outpatient department)Community Health Center (e.g., Federally Qualified Community Health Center (e.g., Federally Qualified Health Center (FQHC), federally funded clinics or 'look Health Center (FQHC), federally funded clinics or 'look alike' clinicsalike' clinicsMental health centerMental health centerNon-federal government clinic (e.g., state, county, city, Non-federal government clinic (e.g., state, county, city, maternal and child health etc.)maternal and child health etc.)Family planning clinic (including Planned Parenthood)Family planning clinic (including Planned Parenthood)Health maintenance organization or other prepaid Health maintenance organization or other prepaid practice (e.g., Kaiser Permanete)practice (e.g., Kaiser Permanete)Faculty practice planFaculty practice plan

Out-of-Scope NAMCS LocationsOut-of-Scope NAMCS Locations

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

Federal Government operated clinicFederal Government operated clinic

Laser vision surgeryLaser vision surgery

NHAMCS Sample DesignNHAMCS Sample Design

Multistage probability designMultistage probability design(1) First stage sample of 112 PSUs(1) First stage sample of 112 PSUs(2) Hospitals within PSUs(2) Hospitals within PSUs(3) Clinics within OPDs, ESA within EDs(3) Clinics within OPDs, ESA within EDs(4) Patient visits within clinics, ESAs(4) Patient visits within clinics, ESAs

4-week reporting period4-week reporting period546 hospitals sampled in 2003; 40,253 ED 546 hospitals sampled in 2003; 40,253 ED visits and 33,492 OPD visitsvisits and 33,492 OPD visits

Scope of the NHAMCSScope of the NHAMCS

Basic unit of sampling is patient visitBasic unit of sampling is patient visitEmergency and outpatient departments of Emergency and outpatient departments of noninstitutional general and short-stay noninstitutional general and short-stay hospitalshospitalsNot Federal, military, or Veterans Not Federal, military, or Veterans Administration facilitiesAdministration facilitiesLocated in 50 states and D.C.Located in 50 states and D.C.

Data CollectionData Collection

Bureau of the Census is our field agentBureau of the Census is our field agentIntroductory letter sent 2-3 months in Introductory letter sent 2-3 months in advance of reporting periodadvance of reporting periodInduction interview to train staff, obtain Induction interview to train staff, obtain data on practice or facility characteristicsdata on practice or facility characteristicsPhysician’s office/hospital staff is Physician’s office/hospital staff is responsible for completion of Patient responsible for completion of Patient Record forms Record forms Census abstracts as a last resortCensus abstracts as a last resort

Data ItemsData Items

Patient characteristics Patient characteristics – Age, sex, race, ethnicityAge, sex, race, ethnicityVisit characteristicsVisit characteristics– Source of payment, continuity of care, reason Source of payment, continuity of care, reason

for visit, diagnosis, treatmentfor visit, diagnosis, treatment Provider characteristicsProvider characteristics– Physician specialty, hospital ownership…Physician specialty, hospital ownership…Drug characteristics added in 1980Drug characteristics added in 1980

Coding Systems UsedCoding Systems Used

Reason for Visit Classification (NCHS)Reason for Visit Classification (NCHS)

Drug Classification System (NCHS)Drug Classification System (NCHS)

National Drug Code DirectoryNational Drug Code Directory

ICD-9-CM ICD-9-CM – diagnosesdiagnoses– causes of injury causes of injury – proceduresprocedures

Drug Data in NAMCS/ NHAMCSDrug Data in NAMCS/ NHAMCSRespondents can list up to 8 medications Respondents can list up to 8 medications (including Rx and OTC medications, (including Rx and OTC medications, immunizations, allergy shots, anesthetics, and immunizations, allergy shots, anesthetics, and dietary supplements) that were ordered, dietary supplements) that were ordered, supplied, administered, or continued during the supplied, administered, or continued during the visit. visit. Each entry is called a drug mention. Visits with Each entry is called a drug mention. Visits with one or more drug mentions are called drug visits.one or more drug mentions are called drug visits.Respondents are asked to report trade names or Respondents are asked to report trade names or generic names only (not dosage, administration, generic names only (not dosage, administration, or regimen). Can’t link drugs with diagnosisor regimen). Can’t link drugs with diagnosis. .

Drug CharacteristicsDrug CharacteristicsGeneric Name (for single ingredient drugs)Generic Name (for single ingredient drugs)Prescription Status – Rx or OTCPrescription Status – Rx or OTCComposition Status – single or multiple Composition Status – single or multiple ingredientingredientControlled Substance Status – DEA Controlled Substance Status – DEA schedulescheduleNDC Therapeutic Class (4-digit)NDC Therapeutic Class (4-digit)Up to 5 Ingredients (for multiple ingredient Up to 5 Ingredients (for multiple ingredient drugs)drugs)

NAMCS or NHAMCS drug data can NAMCS or NHAMCS drug data can be analyzed be analyzed – at the visit level (for example, the at the visit level (for example, the

number of visits at which a number of visits at which a particular drug was prescribed)particular drug was prescribed)

– or at the medication level (for or at the medication level (for example, the number of “mentions” example, the number of “mentions” of a particular drug at ambulatory of a particular drug at ambulatory care visitscare visits

Analyzing DrugsAnalyzing Drugs

Sample WeightSample Weight

Each NAMCS record contains a Each NAMCS record contains a single weight, which we call Patient single weight, which we call Patient Visit WeightVisit Weight

Same is true for OPD records and Same is true for OPD records and ED recordsED records

This weight is used for both visits This weight is used for both visits and drug mentionsand drug mentions

How to Get the DataHow to Get the Data

19

NAMCS and NHAMCS NAMCS and NHAMCS MethodologyMethodology

Public Use Micro-data FilesPublic Use Micro-data Files

Downloadable filesDownloadable files

NAMCS, 1973-2003NAMCS, 1973-2003

NHAMCS, 1992-2003NHAMCS, 1992-2003

CD-ROMsCD-ROMs

NAMCS, 1990-2002NAMCS, 1990-2002

NHAMCS, 1992-2002NHAMCS, 1992-2002

Enhanced Public Use FilesEnhanced Public Use Files

Masked sample design variablesMasked sample design variables–Allow use of SUDAAN, Stata, etc.Allow use of SUDAAN, Stata, etc.–Available for 1993-2003 Available for 1993-2003

SAS input statements, label SAS input statements, label statements, and format statements statements, and format statements (1993-2003)(1993-2003)

SPSS and Stata code for 2002, 2003SPSS and Stata code for 2002, 2003

NCHS Research NCHS Research Data CenterData Center

Advantages of the Advantages of the Research Data CenterResearch Data Center

Gain access to information not available Gain access to information not available on public use fileson public use files

– Patient: ZIP code linked income, Patient: ZIP code linked income, education, etc.education, etc.

– Provider: physician sex and age, Provider: physician sex and age, board certification, teaching hospitalboard certification, teaching hospital

– Geographic: FIPS state and county Geographic: FIPS state and county codescodes

Research Data Center – cont.Research Data Center – cont.

Can merge with contextual variables Can merge with contextual variables (e.g., ARF, NHIS, Census, NHDS)(e.g., ARF, NHIS, Census, NHDS)– Health status levelHealth status level– HMO penetrationHMO penetration– Physician and specialist supplyPhysician and specialist supply– Medicaid reimbursementMedicaid reimbursement– Air qualityAir quality– Percent in povertyPercent in poverty

Research Data CenterResearch Data Center

E-mail: rdca@cdc.govE-mail: rdca@cdc.gov

Website: www.cdc.gov/nchs/r&d/rdc.htmWebsite: www.cdc.gov/nchs/r&d/rdc.htm

Call (301) 458-4277Call (301) 458-4277

For more information:For more information:

NCHS website: NCHS website: www.cdc.gov/nchs/nhcs.htmwww.cdc.gov/nchs/nhcs.htm

Call Ambulatory Care Statistics Branch at Call Ambulatory Care Statistics Branch at 301-458-4600301-458-4600

Information about the NAMCS:Information about the NAMCS:

Don Cherry or David WoodwellDon Cherry or David Woodwell

Information about NHAMCS:Information about NHAMCS:

Linda McCaig or Kim MiddletonLinda McCaig or Kim Middleton

National Hospital Discharge SurveyNational Hospital Discharge Survey

(NHDS)(NHDS)

and and

National Survey of Ambulatory SurgeryNational Survey of Ambulatory Surgery

(NSAS) (NSAS)

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICESCenters for Disease Control and PreventionNational Center for Health Statistics

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICESCenters for Disease Control and PreventionNational Center for Health Statistics

Overview of the Overview of the National Hospital Discharge National Hospital Discharge

SurveySurvey(NHDS)(NHDS)

NHDS Survey YearsNHDS Survey Years

Conducted annually 1965-present:Conducted annually 1965-present:– Latest data available: 2003Latest data available: 2003– 2004 to be available this Winter2004 to be available this Winter

NHDS Survey DesignNHDS Survey Design

Scope and coverage:Scope and coverage:

Short stay, non-Federal Short stay, non-Federal

hospitalshospitals

ALOS < 30 days ALOS < 30 days

General and children’s general General and children’s general

hospitalshospitals

NHDS Sampling PlanNHDS Sampling Plan

Three stage sampling:Three stage sampling:

1. Geographic units1. Geographic units

2. Hospitals2. Hospitals

3. Discharges3. Discharges

NHDS Sample SizeNHDS Sample Size

Hospitals:Hospitals:– About 500 hospitals sampled per About 500 hospitals sampled per

yearyear

Discharges:Discharges:– Over 300,000 sampled per yearOver 300,000 sampled per year

NHDS Data CollectionNHDS Data Collection

Manual hospitals - 57%Manual hospitals - 57%

Automated hospitals - 43%Automated hospitals - 43%

NHDS Data ProcessingNHDS Data Processing

NCHS:NCHS:

– EditingEditing

– EstimationEstimation

Health Insurance Portability Health Insurance Portability and Accountability Act and Accountability Act

(HIPAA)(HIPAA)

Variables onVariables on

NHDS Public Use NHDS Public Use

Data FilesData Files

Patient DataPatient Data

AgeAge

SexSex

RaceRace

Expected source of paymentExpected source of payment

Discharge statusDischarge status

Marital statusMarital status

Medical DataMedical Data

Diagnoses (up to 7)Diagnoses (up to 7)

Procedures (up to 4)Procedures (up to 4)

International Classification of International Classification of Diseases, 9Diseases, 9thth Revision, Clinical Revision, Clinical ModificationModification (ICD-9-CM) (ICD-9-CM)

Hospital CharacteristicsHospital Characteristics

Geographic regionGeographic region

Bed size Bed size

Ownership Ownership

Additional VariablesAdditional Variables

Days of careDays of care

Month of dischargeMonth of discharge

Diagnosis Related Group (DRG)Diagnosis Related Group (DRG)

Analysis weightAnalysis weight

Recently-added variablesRecently-added variables

Added in the 2001 NHDS:Added in the 2001 NHDS:

Source of AdmissionSource of Admission

Type of AdmissionType of Admission

NHDS provides data onNHDS provides data on

hospitalizationshospitalizations

not peoplenot people

DiagnosesDiagnoses

Disease, injury or other reason for Disease, injury or other reason for

hospitalizationhospitalization

Principal diagnosisPrincipal diagnosis: chiefly : chiefly

responsible for hospitalizationresponsible for hospitalization

First-listed diagnosisFirst-listed diagnosis: principal if : principal if

specified, otherwise first one listedspecified, otherwise first one listed

DiagnosesDiagnoses

All-listedAll-listed: counts the total number : counts the total number of times a diagnosis appears on of times a diagnosis appears on patient recordpatient record

Any-listedAny-listed: indicates that a : indicates that a diagnosis appears at least once, in diagnosis appears at least once, in any position, on discharge record any position, on discharge record

Surgical and Non-Surgical Surgical and Non-Surgical ProceduresProcedures

Surgical (appendectomy)Surgical (appendectomy)

Diagnostic (spinal tap)Diagnostic (spinal tap)

Therapeutic (chemotherapy)Therapeutic (chemotherapy)

NHDS provides data NHDS provides data onon

inpatient inpatient proceduresprocedures

not total not total proceduresprocedures

Reliability Reliability

RELATIVE STANDARD ERROR (RSE) RELATIVE STANDARD ERROR (RSE) measures reliability of an estimatemeasures reliability of an estimateEstimates with an RSE greater than Estimates with an RSE greater than 30 % are considered unreliable. 30 % are considered unreliable. Estimates must be based on at Estimates must be based on at least 30 records . least 30 records . Estimates based on 30-59 records Estimates based on 30-59 records should be used with caution.should be used with caution.

Examples of research

using the

National Hospital Discharge

Survey

Diagnoses studiedDiagnoses studied

Heart failureHeart failure

Atrial fibrillationAtrial fibrillation

ArthritisArthritis

DiabetesDiabetesSepsisSepsis

Chronic Obstructive Chronic Obstructive PulmonaryPulmonary

Disease (COPD)Disease (COPD)

Procedures studiedProcedures studied

Hip replacementsHip replacements

Knee replacementsKnee replacements

Cervical diskectomyCervical diskectomy

Coronary artery Coronary artery revascularizationrevascularization

Other Public Health Issues/Other Public Health Issues/Medical Care ResearchMedical Care Research

Length of hospital stays forLength of hospital stays for►women giving birthwomen giving birth►newborn infantsnewborn infants

Surgical treatments for Surgical treatments for ObesityObesity Pneumonia among the elderlyPneumonia among the elderly Mental disorders in childrenMental disorders in children

National Survey of Ambulatory National Survey of Ambulatory Surgery (NSAS)Surgery (NSAS)

Survey Years: Annually 1994-1996Survey Years: Annually 1994-1996

Collected data on ambulatory (outpatient) Collected data on ambulatory (outpatient) surgery in the U.S. surgery in the U.S.

NSAS DesignNSAS Design

National probability sampleNational probability sample– Short stay non-Federal hospitals Short stay non-Federal hospitals

(418)(418)– Freestanding ambulatory surgery Freestanding ambulatory surgery

centers (333)centers (333)

Sample size:Sample size:– 120,000 sampled visits per year120,000 sampled visits per year

Additional variables collected Additional variables collected for NSASfor NSAS

Hospital vs. freestanding centerHospital vs. freestanding center

Type of anesthesiaType of anesthesia

Anesthesia provider Anesthesia provider

Accessing Data

from the

National Hospital Discharge Survey

and the

National Survey of Ambulatory Surgery

What type of data are available?What type of data are available?

Publications, including annual reportsPublications, including annual reports

Data tabulations on selected topicsData tabulations on selected topics

Public-use data files (micro-data)Public-use data files (micro-data)

Annual Publications fromAnnual Publications fromHospital Care Statistics BranchHospital Care Statistics Branch2003 ADVANCE DATA report:2003 ADVANCE DATA report:

http://www.cdc.gov/nchs/data/ad/ad359.pdfhttp://www.cdc.gov/nchs/data/ad/ad359.pdf

VITAL AND HEALTH STATISTICS Series 13 VITAL AND HEALTH STATISTICS Series 13

reports, e.g. 2002 Annual Summaryreports, e.g. 2002 Annual Summary

http://www.cdc.gov/nchs/data/series/sr_http://www.cdc.gov/nchs/data/series/sr_13/13/

sr13_158.pdfsr13_158.pdf

Public-Use Files Public-Use Files Available on the WebAvailable on the Web

Data and documentation available Data and documentation available for free from the NCHS websitefor free from the NCHS website– NHDS: 1996 through 2003NHDS: 1996 through 2003– NSAS: 1994, 1995, 1996NSAS: 1994, 1995, 1996

Files are “raw” ASCII data that Files are “raw” ASCII data that require the use of standard require the use of standard statistical software packages, such statistical software packages, such as SAS, SPSS, Stata, etc.as SAS, SPSS, Stata, etc.

What to Know to Access What to Know to Access Data and Publications on the WebData and Publications on the Web

Publications, data tables, and data Publications, data tables, and data

file documentation are in file documentation are in Adobe Adobe

Acrobat PDFAcrobat PDF format. format.

Adobe Acrobat Reader software, Adobe Acrobat Reader software,

available free for download at available free for download at

www.adobe.comwww.adobe.com

What to Know to Access What to Know to Access Public-Use Files on the WebPublic-Use Files on the Web

Data files are in Data files are in ASCII formatASCII format

Must be downloaded via Must be downloaded via FTP serverFTP server, ,

then “unzipped” then “unzipped” To “Unzip” use: To “Unzip” use:

– WinZip (WinZip (www.winzip.comwww.winzip.com) ) – PKunzipPKunzip ( (www.pkware.comwww.pkware.com))

Data file documentation is available in Data file documentation is available in PDF formatPDF format

Multi-year public-use files Multi-year public-use files available on CD-ROMavailable on CD-ROM

Two separate multi-year files containing Two separate multi-year files containing 1979-2003 data years (ICD-9-CM coding)1979-2003 data years (ICD-9-CM coding)1970-1978 data years (ICD-8 coding)1970-1978 data years (ICD-8 coding)

IMPORTANT: DRGs are available on single IMPORTANT: DRGs are available on single year files only. Multi-year files do NOT year files only. Multi-year files do NOT have DRGs.have DRGs.

ICD-9-CMICD-9-CM

For full-text, addenda, and For full-text, addenda, and conversion tables of ICD-9-CM, see conversion tables of ICD-9-CM, see www.cdc.gov/nchs/icd9.htmwww.cdc.gov/nchs/icd9.htm

Full-text ICD-9-CM documents are Full-text ICD-9-CM documents are RTF (Rich Text Format) files and RTF (Rich Text Format) files and can be handled with any word can be handled with any word processing package.processing package.

Addenda and conversion tables Addenda and conversion tables are PDF documents.are PDF documents.

Restricted Data in NHDSRestricted Data in NHDS

HCSB maintains confidential information HCSB maintains confidential information

in files which are not publicly in files which are not publicly

disseminateddisseminated

Restricted data pose disclosure risks to Restricted data pose disclosure risks to

survey respondentssurvey respondents

Available to researchers through the Available to researchers through the

NCHS Research Data Center (RDC)NCHS Research Data Center (RDC)http://www.cdc.gov/nchs/r&d/rdc.htmhttp://www.cdc.gov/nchs/r&d/rdc.htm

New DirectionsNew Directions

National Hospital Discharge National Hospital Discharge SurveySurvey► survey redesignsurvey redesign

National Survey of Ambulatory National Survey of Ambulatory SurgerySurgery► re-fielding in 2006re-fielding in 2006

Inpatient clinical dataInpatient clinical dataCurrent limitations on information Current limitations on information

available in NHDS because data available in NHDS because data

collection is tied to UB92collection is tied to UB92

Great interest in expanding to collecting Great interest in expanding to collecting

more patient and clinical data more patient and clinical data

A study of the feasibility of collecting A study of the feasibility of collecting

drug data was performed in 2001-2003drug data was performed in 2001-2003

NHDS RedesignNHDS Redesign

Original survey design implemented in Original survey design implemented in

1965; statistical redesign in 19881965; statistical redesign in 1988

Updating and modernizing methods and Updating and modernizing methods and

measures to keep abreast of rapidly measures to keep abreast of rapidly

changing hospital use is neededchanging hospital use is needed

Contract with RAND was let in September Contract with RAND was let in September

to examine options for redesignto examine options for redesign

Results of Redesign ContractResults of Redesign Contract

Results will be available in summer Results will be available in summer

of 2007 and will address:of 2007 and will address:Conceptual framework of NHDSConceptual framework of NHDS

Proposed, expanded datasetProposed, expanded dataset

Feasibility of implementing new Feasibility of implementing new

concepts and additional data itemsconcepts and additional data items

Return of NSASReturn of NSAS

Funding has been approved for NSAS to Funding has been approved for NSAS to

return to the field in 2006return to the field in 2006

Data collection procedures will be Data collection procedures will be

updated to reflect changes in the way updated to reflect changes in the way

facilities store data, that is, the greater facilities store data, that is, the greater

use of electronic data systems.use of electronic data systems.

Experts have been consulted to modify Experts have been consulted to modify

and add data items to data collection and add data items to data collection

instruments.instruments.

New information collected in the New information collected in the 2006 NSAS2006 NSAS

Credentials of staffCredentials of staff

Ownership of the ambulatory surgery Ownership of the ambulatory surgery

facilityfacility

Access to careAccess to care

Use of electronic medical recordsUse of electronic medical records

Patient follow-up after surgery Patient follow-up after surgery

Timeline for NSASTimeline for NSAS

May 2006 – March 2007May 2006 – March 2007 : Data collection : Data collection

April – December 2007April – December 2007 : Coding, keying, : Coding, keying,

editing, and weightingediting, and weighting

Early 2008Early 2008 : NSAS 2006 data released : NSAS 2006 data released

Winter 2008Winter 2008 : Public use data file available : Public use data file available

NHDS or NSAS Questions?NHDS or NSAS Questions?

Phone: 301-458-4321Phone: 301-458-4321

Fax: 301-458-4032Fax: 301-458-4032

Email: Email: NHDS@cdc.govNHDS@cdc.gov

Homepage on the WEB:Homepage on the WEB:

www.cdc.gov/nchs/about/major/hdasd/nhds.htmwww.cdc.gov/nchs/about/major/hdasd/nhds.htm

Redesign of the Redesign of the NationalNational

Long-term Care Surveys Long-term Care Surveys

American Public Health AssociationAmerican Public Health Association134 Annual Meeting & Exposition134 Annual Meeting & Exposition

November 4, 2006November 4, 2006

Genevieve StrahanGenevieve StrahanLong-term Care Statistics BranchLong-term Care Statistics BranchDivision of Health Care StatisticsDivision of Health Care Statistics

National Center for Health StatisticsNational Center for Health Statistics

National Nursing Home National Nursing Home Survey (NNHS)Survey (NNHS)

Component of the National Health Component of the National Health Care Survey (NHCS)Care Survey (NHCS)

Nationally representative sample Nationally representative sample survey of nursing homessurvey of nursing homes

Collects information Collects information – ProvidersProviders– Recipients of careRecipients of care

Conducted 7 times since 1973 Conducted 7 times since 1973 (1973-74, 1977, 1985, 1995, 1997, (1973-74, 1977, 1985, 1995, 1997, 1999 and 2004)1999 and 2004)

ProcessProcess

1. Reviewed documents from expert meetings1. Reviewed documents from expert meetings – Future Directions for Residential LTC Future Directions for Residential LTC Health Services Research (October 1999)Health Services Research (October 1999)– Future Directions for Community-based LTC Health Future Directions for Community-based LTC Health

Services Research (June 2000) Services Research (June 2000) – Institute of Medicine Report from the Committee on Institute of Medicine Report from the Committee on

Improving Quality in LTC (2001). Improving Quality in LTC (2001).

2. Policy questions2. Policy questions– Characteristics of nursing homes residentsCharacteristics of nursing homes residents– Care and services provided by nursing homesCare and services provided by nursing homes– Cost/reimbursementCost/reimbursement– Quality/outcomesQuality/outcomes

Process Process (cont.)(cont.)

3. Identify data gaps3. Identify data gaps -1999 National Nursing Home Survey (NNHS)-1999 National Nursing Home Survey (NNHS)-1997 Medicare Current Beneficiary Survey -1997 Medicare Current Beneficiary Survey (MCBS)(MCBS)-Minimum Data Set (MDS)-Minimum Data Set (MDS)-Online Survey Certification and Reporting -Online Survey Certification and Reporting

Survey (OSCAR)Survey (OSCAR)-1996 Medical Expenditures Survey Nursing -1996 Medical Expenditures Survey Nursing Home Home

Component (MEPS NHC) Component (MEPS NHC) -1999 National Long-term Care Survey-1999 National Long-term Care Survey-Longitudinal Studies of Aging -Longitudinal Studies of Aging

Conceptual ModelConceptual Model

StructureStructure ProcessProcess OutcomesOutcomes

-Key Personnel-Immunization practices-ED/hospitalizations-Key Personnel-Immunization practices-ED/hospitalizations

-Advance practice RNs-Mechanical Lifts-Pressure sores-Advance practice RNs-Mechanical Lifts-Pressure sores

-Turnover-Permanent assignments-Falls-Turnover-Permanent assignments-Falls

-Benefits-Palliative care-Adverse Reactions-Benefits-Palliative care-Adverse Reactions

NNHS Redesign: MilestonesNNHS Redesign: Milestones

1. Computer Assisted Personal 1. Computer Assisted Personal Interview (CAPI)Interview (CAPI) – Developed (March 2002)Developed (March 2002)– Flexibility to accommodate future Flexibility to accommodate future

surveyssurveys– Pilot tested for NNHS (February 2003)Pilot tested for NNHS (February 2003)

Computer Assisted Telephone Computer Assisted Telephone Interview (CATI)Interview (CATI)

2. Expanded Content2. Expanded Content

Facility level dataFacility level data

Administrators, Medical Directors, & Administrators, Medical Directors, & Directors of NursingDirectors of Nursing

-Preparation-Preparation-Years of experience-Years of experience-Tenure at the facility-Tenure at the facility-Specialty certification-Specialty certification

Nursing StaffNursing Staff

-FTEs-FTEs-RN mix-RN mix-Specialty certification-Specialty certification-New roles----MDS nurses, case managers, -New roles----MDS nurses, case managers, QI, infection controlQI, infection control-APNs-APNs-Entry-level wages-Entry-level wages-Recruitment/retention strategies-Recruitment/retention strategies-Benefits-Benefits-Collective bargaining arrangements-Collective bargaining arrangements-Staff turnover and stability-Staff turnover and stability

2. Expanded Content (Cont.)Facility level data (cont.)

2. Expanded Content (Cont.)

Facility level data (cont.)

-Accreditation-Medical services-Electronic/computerized information

systems-Recreation activities-Dining practices-Mechanical lifts-Immunization policies & practices-End-of-life practices (POLST, Last Acts)-Special care programs (e.g., wound,

dementia)

2. Expanded Content (Cont.)2. Expanded Content (Cont.)

Resident level data (MDS items)Resident level data (MDS items)

-Advance directives-Advance directives-Cognitive skills-Cognitive skills-Mood-Mood-Behavioral symptoms-Behavioral symptoms-ADLs-ADLs-Continence-Continence-Accidents-Accidents-Weight change-Weight change-Nutritional therapy-Nutritional therapy-Pressure ulcers-Pressure ulcers-Restraints-Restraints

2. Expanded Content2. Expanded Content (Cont..) (Cont..)

Resident level data (Cont.)Resident level data (Cont.)

New ItemsNew Items-Admission to a specialty unit -Admission to a specialty unit

(Alzheimer’s, hospice)(Alzheimer’s, hospice)-Receiving specialty services -Receiving specialty services

(Alzheimer’s, hospice)(Alzheimer’s, hospice)-Hospitalizations-Hospitalizations-ED visits -ED visits -Pain assessment, management, relief-Pain assessment, management, relief-Medications-Medications-Recent drug adverse experiences-Recent drug adverse experiences-End-of-life care-End-of-life care-Out of pocket charges-Out of pocket charges

NNHS Redesign: Milestones NNHS Redesign: Milestones (Cont.)(Cont.)

33. . NNHS pretest (June – July 2003)NNHS pretest (June – July 2003)

4. NNHS national survey (August 4. NNHS national survey (August – December 2004)– December 2004)

Major featuresMajor features

Linkage to CMS’ Minimum Data Linkage to CMS’ Minimum Data Set Set – Expanded clinical contentExpanded clinical content– Care episodes Care episodes

New sample designNew sample design

Expanded sampleExpanded sample

National Nursing Assistant National Nursing Assistant Survey (NNAS)Survey (NNAS)

National Nurse National Nurse Assistant Survey Assistant Survey

(NNAS)(NNAS)– Reduces NNAS costs by utilizing a sub-Reduces NNAS costs by utilizing a sub-

sample of an existing sample frame sample of an existing sample frame and data collection methodologyand data collection methodology

– Enhances response rates and reduces Enhances response rates and reduces burdenburden

– Increases the analytical usefulness of Increases the analytical usefulness of NNAS and NNHSNNAS and NNHS

NNAS GoalsNNAS Goals

Describe characteristics of nurse assistantsDescribe characteristics of nurse assistants

Explore why workers remain in the field and Explore why workers remain in the field and determine factors that influence retentiondetermine factors that influence retention

Understand how these factors affect Understand how these factors affect workers’ attitudes, relationships with workers’ attitudes, relationships with managers and nursing home residents, and managers and nursing home residents, and job satisfactionjob satisfaction

Selected NNAS DataSelected NNAS Data ItemsItems

Recruitment Recruitment Education/TrainingEducation/TrainingJob HistoryJob HistoryFamily LifeFamily LifeManagement/SupervisionManagement/SupervisionClient RelationsClient RelationsJob SatisfactionJob SatisfactionWorkplace environmentWorkplace environmentInjuriesInjuriesDemographicsDemographicsReasons for leavingReasons for leaving

Uses of NNHS DataUses of NNHS Data

Nursing Home Resident and Facility Characteristics Nursing Home Resident and Facility Characteristics Associated with Pneumococcal Vaccination: Associated with Pneumococcal Vaccination: National Nursing Home Survey, 1995-1999National Nursing Home Survey, 1995-1999

Influenza Immunization in Nursing Homes: Who Does Not Get Immunized and Whose Status is Unknown 

Pneumococcal immunization in nursing homes: Does race make a difference?

2007 National Home and 2007 National Home and Hospice Care SurveyHospice Care Survey

Scheduled to be conducted – August-December 2007Scheduled to be conducted – August-December 2007

National Home and Hospice National Home and Hospice Care Survey (NHHCS)Care Survey (NHHCS)

Component of the National Health Component of the National Health Care Survey (NHCS)Care Survey (NHCS)

Nationally representative sample Nationally representative sample survey of home health agencies and survey of home health agencies and hospiceshospices

Collects information Collects information – ProvidersProviders– Recipients of careRecipients of care

Conducted 6 times since 1992 (1992, Conducted 6 times since 1992 (1992, 1993, 1994, 1996, 1998, and 2000)1993, 1994, 1996, 1998, and 2000)

ProcessProcess

1. Reviewed documents from 1. Reviewed documents from expert meetingsexpert meetings

2. Policy questions2. Policy questions

3. Identified data gaps3. Identified data gaps

NHHCS Redesign: MilestonesNHHCS Redesign: Milestones

1.1. Computer Assisted Personal Computer Assisted Personal Interview (CAPI)Interview (CAPI)

and the and the

Computer Assisted Computer Assisted Telephone Telephone Interview (CATI)Interview (CATI)

2. Expanded Content2. Expanded Content

Agency level dataAgency level data

– JCAHO accreditation JCAHO accreditation – electronic information systemselectronic information systems– cultural competencycultural competency– immunization polices and practicesimmunization polices and practices– end-of-life practices end-of-life practices – special service programsspecial service programs

2. Expanded Content2. Expanded Content

Patient level dataPatient level data

hospitalizations/emergency department admissions hospitalizations/emergency department admissions pain assessment and pain reliefpain assessment and pain relief

medicationsmedicationsOut-of-pocket chargesOut-of-pocket charges

family and caregiver services family and caregiver services end-of-life care and advance directivesend-of-life care and advance directives

community based waiver program participant community based waiver program participant pressure ulcerspressure ulcers

behavior/mood symptoms behavior/mood symptoms fallsfalls

2. Expanded Content2. Expanded Content (Cont.) (Cont.)

Staffing level data Staffing level data

Contract and agency employeesContract and agency employees

Key personnel (Medical Director, Key personnel (Medical Director, Administrator, and Director of Nursing)Administrator, and Director of Nursing)

educational preparationeducational preparation

years of experience years of experience

tenure at the agencytenure at the agency

specialty certificationspecialty certification

2. Expanded Content2. Expanded Content (Cont.) (Cont.)

Staffing level data (Cont) Staffing level data (Cont)

RN mix---basic education, Diploma, BS, MSRN mix---basic education, Diploma, BS, MS

advance practice providers---CNS, NPs, PAsadvance practice providers---CNS, NPs, PAs

entry level wage for RNs, LPNs, HHAs/CNAsentry level wage for RNs, LPNs, HHAs/CNAs

recruitment/retention strategiesrecruitment/retention strategies

benefitsbenefits

turnover -- new hires, terminationsturnover -- new hires, terminations

3. NHHCS pretest (Oct – Nov 3. NHHCS pretest (Oct – Nov 2006)2006)

4. NNHS national survey 4. NNHS national survey (August – December 2007)(August – December 2007)

Major featuresMajor features

Linkage to CMS’ OASIS Linkage to CMS’ OASIS – Expanded clinical contentExpanded clinical content– Care episodes Care episodes

New sample designNew sample design

Expanded sampleExpanded sample

National Home Health Aide National Home Health Aide Survey (NHHAS)Survey (NHHAS)

National Home Health National Home Health Aide Survey (NHHAS)Aide Survey (NHHAS)

– Reduces NHHAS costs by utilizing a Reduces NHHAS costs by utilizing a sub-sample of an existing sample sub-sample of an existing sample frame and data collection methodologyframe and data collection methodology

– Enhances response rates and reduces Enhances response rates and reduces burdenburden

– Increases the analytical usefulness of Increases the analytical usefulness of NHHAS and NHHCSNHHAS and NHHCS

Selected NHHAS Data ItemsSelected NHHAS Data Items

– education/trainingeducation/training– employment profileemployment profile– family life family life – management/supervisionmanagement/supervision– salary, compensation, benefits, reward, salary, compensation, benefits, reward,

and incentives and incentives – job satisfaction job satisfaction – organizational cultureorganizational culture– Recruitment and training Recruitment and training – demographicsdemographics

Uses of NHHCS DataUses of NHHCS Data

Payment source and length of use among home health Payment source and length of use among home health agency dischargesagency discharges

The1997 Balanced Budget Act and home services among Medicare patients.

Ownership status and patterns of care in hospice

National Survey of National Survey of Residential Care FacilitiesResidential Care Facilities

First time survey of residential First time survey of residential and assisted living facilitiesand assisted living facilities

Scheduled for fall of 2008Scheduled for fall of 2008

Uses NNHS modelUses NNHS model

CAPI data collection systemCAPI data collection system

SPSS

SAS Other software formats

e.g., spreadsheets (MS EXCEL), databases, and

statistical software (STATA)

SAS, SPSS

Importing NNHS or NHHCS Files to Statistical Packages

Fixed Format ASCII File with SAS Input Statements

Tab DelimitedASCII File withVariable Names

Fixed Format ASCII File with SPSS Input Statements

Plans for DisseminationPlans for DisseminationData productsData products– Reports, journal articles Reports, journal articles – Public use data filesPublic use data files

Access data productsAccess data products– Downloadable from the InternetDownloadable from the Internet– Data files on CD-ROMSData files on CD-ROMS– Research Data CenterResearch Data Center– NCHS Office of Information ServicesNCHS Office of Information Services

Telephone: 866-441-6247 (NCHS)Telephone: 866-441-6247 (NCHS)Fax: 301-458-4027Fax: 301-458-4027Email: Email: nchsquery@cdc.govnchsquery@cdc.gov

To learn more---To learn more---– ListservListserv– www.cdc.gov/nchs/nnhs.htmwww.cdc.gov/nchs/nnhs.htm– www.cdc.gov/nchs/nhhcs.htmwww.cdc.gov/nchs/nhhcs.htm– LTCSB 301-458-4747LTCSB 301-458-4747