Healthcare Utilization
Healthcare Utilization
Anderson, Acting Associate Director for International Statistics Jennifer H. Madans, Ph.D., Associate Director for Science Lawrence H. Cox, Ph.D., Associate Director for Research and Methodology Diane M. Makuc, Dr.P.H., Acting Associate Director for Analysis, Epidemiology, and Health Promotion Edward L. Hunter, Associate Director for Planning, Budget, and Legislation Michael Sadagursky, Associate Director for Management and Operations Margot A. Palmer, Acting Associate Director for Information Technology and Services
Division of Health Care Statistics Thomas McLemore, Acting Director Irma Arispe, Ph.D., Associate Director for Science Catharine W. Burt, Ed.D., Chief, Ambulatory Care Statistics Branch Robert Pokras, Chief, Hospital Care Statistics Branch Robin E. Remsburg, Ph.D., A.P.R.N., Chief, Long-Term Care Statistics Branch Charles A. Adams, Chief, Technical Services Branch
Suggested citation: Bernstein AB, Hing E, Moss AJ, Allen KF, Siller AB, Tiggle RB. Health care in America: Trends in utilization. Hyattsville, Maryland: National Center for Health Statistics. 2003.
Contents
Contents
Acknowledgments .............................................................................................. vii
1
3
Major Policy Initiatives Affecting Health Care Utilization ............................................. 10 Chart 4: Selected major Federal policy initiatives affecting health care utilization ............................... 11 Acute Care Supply ...................................................................................................... 12 Chart 5: Selected acute care providers accredited by the Joint Commission on Accreditation of Healthcare Organizations ........................................................................................................ 13 Long-Term Care SupplyNursing Homes .................................................................... 14 Chart 6: Rehabilitative and other services offered by nursing homes: United States, 1985, 1995, 1999 .................................................................................................................... 15 Special Care Units and Other Long-Term Care Residences ............................................ 16 Chart 7: Some names of long-term care residences ......................................................................... 17 Postacute, Rehabilitation, and End-of-Life Care Supply ................................................ 18 Chart 8A: Number of Medicare-certified providers, 19852000 ...................................................... 19 Chart 8B: Home health agencies and Medicare-certified agencies: United States, 19922000 ............ 19
iii
Contents
Hospital Emergency Department Visits, by Age and Race ............................................ 32 Chart 14A: Hospital emergency department visits, by race: United States: 19922000. ..................... 33 Chart 14B: Hospital emergency department visits, by race and age: United States, 19922000 . ........................................................................................................ 33 Hospital Discharges, by Age and Race ........................................................................ 34 Chart 15A: Hospital discharges, by age: United States, 19922000 ................................................ 35 Chart 15B: Hospital discharges, by race: United States, 19922000. .............................................. 35 Ambulatory and Inpatient Procedures ........................................................................ 36 Chart 16: Ambulatory and inpatient procedures: United States, 19941996 .................................... 37 Duration of Hospitalizations, Physician Office Visits, and Hospital Outpatient Departments Visits ..................................................................................................... 38 Chart 17: Mean duration of medical encounters for physician office visits and hospital stays: United States, 19902000 .......................................................................................................... 39 Use of Home Health Care Services .............................................................................. 40 Chart 18A: Use of home health care by the population 65 years of age and over: United States, 19922000 .......................................................................................................... 41 Chart 18B: Use of home health care by population of all ages: United States, 19922000 ................. 41 Home Health Patient Characteristics............................................................................ 42 Chart 19A: Current home health patients, by age: United States, 19922000 ................................... 43 Chart 19B: Current home health patients, by race: United States, 19922000 ................................... 43 Use of Nursing Homes ................................................................................................ 44 Chart 20: Nursing home residents and nursing home discharges: United States, 19851999 .............. 45 Nursing Home Resident Characteristics ....................................................................... 46 Chart 21A: Age distribution of nursing home residents: United States, 1985 and 1999 ...................... 47 Chart 21B: Nursing home residents 65 years and over, by race and sex: United States, 19851999 ......... 47
Trends in Utilization by Selected Condition, Drug, Procedure, Outcome, and Site of Care
Injuries ....................................................................................................................... 50 Chart 22: Injury care rates: United States, 19922000 .................................................................. 51 Injuries Treated in Nursing Homes and Home Health Agencies .................................... 52 Chart 23A: Nursing home discharges admitted with injuries: United States, 19922000 ................... 53 Chart 23B: Home health discharges admitted with injuries: United States, 19922000 ...................... 53 Chronic Obstructive Pulmonary Disease (COPD) .......................................................... 54 Chart 24A: COPD utilization rates: United States, 19922000 ...................................................... 55 Chart 24B: COPD discharges from short-stay hospitals, by age: United States, 19922000 .......................................................................................................... 55 Diabetes ..................................................................................................................... 56 Chart 25A: Diabetes care utilization rates: United States, 19922000 ............................................. 57 Chart 25B: Diabetes discharges from short-stay hospitals, by age: United States, 19922000 ............ 57 Lipid-lowering and Diabetes Drugs ............................................................................. 60 Chart 26A: Hyperlipidemia drug mention during physician office and hospital outpatient department visits, by sex: United States, 19942000 ....................................................................................... 61
iv
Contents
Chart 26B: Blood glucose regulator drug mention during physician office and hospital outpatient department visits, by age: United States, 19932000 .....................................................................
61
Antidepressant Drug Mentions in Physician Office and Hospital Outpatient Department Visits, by Age .......................................................................................... 62 Chart 27A: Antidepressant drug mention during physician office visits, by age: United States, 19932000 .......................................................................................................... 63 Chart 27B: Antidepressant drug mention during outpatient department visits, by age: United States, 19932000 .......................................................................................................... 63 Antihistamines ............................................................................................................ 64 Chart 28: Antihistamine drug mention during physician office and hospital outpatient department visits, by age: United States, 19932000 ...................................................................................... 65 Acid Reducing/Peptic Disorder Drugs .......................................................................... 66 Chart 29: Acid reducing/peptic disorder drug mention during physician office and hospital outpatient department visits, by age: United States, 19942000 ...................................................... 67 Estrogen/Progestin Drug Mentions During Physician Office and Outpatient Department Visits for Women, by Age and Race ......................................................... 68 Chart 30A: Estrogen/Progestin mentions during physician office and hospital outpatient departments for women 18 years of age and over: United States, 19932000 .................................................... 69 Chart 30B: Estrogen/Progestin mentions during physician office visits for women 45 years of age and over, by race: United States, 19932000 ............................................................................... 69 Mammograms Ordered or Provided During Physician Office and Hospital Outpatient Department Visits, by Race ........................................................................ 72 Chart 31A: Physician office visits with mammograms ordered or provided for women 45 years of age and over, by race: United States, 19902000. ....................................................................... 73 Chart 31B: Hospital outpatient department visits with mammograms ordered or provided for women 45 years of age and over, by race: United States, 19922000 ........................................... 73 Tonsillectomy and Myringotomy ................................................................................. 74 Chart 32: Hospital inpatient tonsillectomy procedures and myringotomy with tube insertion among children under 18 years of age: United States, 19902000 .................................................. 75 Selected Cardiac Procedures, by Age .......................................................................... 76 Chart 33A: Coronary artery bypass graph surgeries for discharges from short-stay hospitals, by age: United States, 19902000 .............................................................................................. 77 Chart 33B: Percutaneous translumnal coronary angioplasty for discharges from short-stay hospitals, by age: United States, 19902000 ................................................................................ 77 Stent Insertion, by Age ............................................................................................... 78 Chart 34: Coronary artery stent insertion for discharges from short-stay hospitals, by age: United States, 19962000 .......................................................................................................... 79 Hip and Knee Procedures, by Age .............................................................................. 80 Chart 35A: Hip replacements performed in short-stay hospitals, by age: United States, 19912000 .......... 81 Chart 35B: Knee replacements performed in short-stay hospitals, by age: United States, 19912000 ......... 81 Adverse Effects Following Medical Treatment, by Age ................................................. 84 Chart 36A: Emergency department visits with diagnoses of adverse effects of medical treatment, by age: United States, 19922000 .......................... 85 Chart 36B: Hospital discharges with diagnoses of adverse effects of medical treatment, by age: United States, 19922000 .............................................................................................. 85
Contents
Hospital Transfers to Nursing Homes .......................................................................... 86 Chart 37A: Hospital discharge patients transferred to long-term care institutions: United States, 19852000 .......................................................................................................... 87 Chart 37B: Percentage of current and discharged nursing home residents admitted from hospitals: United States 19851999 ............................................................................................. 87 Hospital and Nursing Home Fatality Rates .................................................................. 90 Chart 38: Fatality rate among hospital and nursing home discharges: United States, 1985 and 1999 ........ 91 Deaths Occurring in Different Sites of Care .................................................................. 92 Chart 39A: Deaths occurring in hospitals or nursing homes, 1985 and 1999 ................................... 93 Chart 39B: Deaths occurring during emergency department visits or while enrolled in home health care or a hospice program: United States, 1992 and 2000 .......................................... 93 Site of Heart Disease and Cancer Deaths ..................................................................... 94 Chart 40A: Where cancer and heart disease deaths occur: United States, 1985 and 1999 ................ 95 Chart 40B: Where cancer and heart disease deaths occur: United States, 1992 and 2000 ................. 95 Use of Hospice Services, by Race ................................................................................ 96 Chart 41: Hospice discharges, by race: United States, 19922000 ................................................ 97 REFERENCES ..................................................................................................................... 100 INDEX .............................................................................................................................. 110 APPENDIX I: SOURCES AND LIMITATIONS OF THE DATA .................................................... 114 APPENDIX II: GLOSSARY ................................................................................................. 126 APPENDIX III: SELECTED PUBLICATIONS USING NATIONAL HEALTH CARE SURVEY DATA ..... 138
vi
Acknowledgments
Overall responsibility for planning and coordinating the content of this publication rested with the Division of Health Care Statistics (DHCS), National Center for Health Statistics (NCHS), Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, under the leadership of Amy B. Bernstein (now with the Office of Epidemiology, Analysis and Health Promotion, also at NCHS). Data and analysis for specific charts were prepared by Amy B. Bernstein, Esther Hing, Abigail J. Moss, Karen Frey Allen, and Ronald B. Tiggle of DHCS. Arlene Siller provided programming and analytic support. Adonikka Deare provided graphics and administrative support. Technical assistance and review were provided by the following NCHS staff: Catharine W. Burt, Lois A. Fingerhut, Marni J. Hall, L. Jean Kozak, Robert Pokras, Robin E. Remsburg, Genevieve W. Strahan, Susan M. Schappert, and David A. Woodwell. Expert medical review and comments were provided by Barry Saver, M.D., Assistant Professor, University of Washington, Seattle. Publications management was provided by Linda L. Bean, graphics supervision was provided by Sarah M. Hinkle, editorial review was provided by Klaudia M. Cox and Kathy J. Sedgwick of the Information Design and Publishing Branch, Division of Information Services. Graphics were produced by Edward L. Adams, Jr. Irma Arispe of the Division of Health Care Statistics provided valuable input and review to the concept, organization, and production of the report. Last of all, we acknowledge the support and input of Linda K. Demlo, former Director of the Division of Health Care Statistics.
vii
Introduction
The National Health Care Survey
People use health care services for many reasons: to cure illnesses and health conditions, to mend breaks and tears, to prevent or delay future health care problems, to reduce pain and increase quality of life, and sometimes merely to obtain information about their health status and prognosis. Health care utilization can be appropriate or inappropriate, of high or low quality, expensive or inexpensive. The study of trends in health care utilization provides important information on these phenomena and may spotlight areas that may warrant future indepth studies because of potential disparities in access to, or quality of, care. Trends in utilization may also be used as the basis for projecting future health care needs, to forecast future health care expenditures, or as the basis for projecting increased personnel training or supply initiatives. The health care delivery system of today has undergone tremendous change, even over the relatively short period of the past decade. New and emerging technologies, including drugs, devices, procedures, tests, and imaging machinery, have changed patterns of care and sites where care is provided (1,2). The growth in ambulatory surgery has been influenced by improvements in anesthesia and analgesia and by the development of noninvasive or minimally invasive techniques. Procedures that formerly required a few weeks of convalescence now require only a few days. New drugs can cure or lengthen the course of disease, although often at increased cost or increased utilization of medical practitioners needed to prescribe and monitor the effects of the medications. Over the past decade, both public and private organizations have made great strides in identifying causes of disease and disability, discovering treatments and cures, and working with practitioners to educate the public about how to reduce the incidence and prevalence of major diseases and the functional limitations and discomfort they may cause. Clinical practice guidelines have been created and disseminated to influence providers to follow recommended practices. Public education campaigns urge consumers to comply with behavioral recommendations (e.g., exercise and lose weight) and treatment regimens (e.g., take your medications) that may help to prevent or control diseases and their consequences. Health care utilization also has evolved as the populations need for care has changed over time. Some factors that influence need include aging, sociodemographic population shifts, and changes in the prevalence and incidence of different diseases. As the prevalence of chronic conditions increases, for example, residential and community-based health-related services have emerged that are designed to minimize loss of function and to keep people out of institutional settings. The growth of managed care and payment mechanisms employed by insurers and other payers in an attempt to control the rate of health care spending has also had a major impact on health care utilization. Efforts by employers to increase managed care enrollment, as well as major Medicare and Medicaid cost containment efforts such as the Prospective Payment System for hospitals and the Resource Based Relative Value Scale for physician payment, created incentives to shift sites where services are provided (3,4). They also created incentives to provide services differently; for example, the increase in capitated payment and use of gatekeepers has been associated with a changing mix of primary care and specialty care (see Visits to Primary Care and Specialty Physicians) (5). Numerous other factors also influence the type and amount of health care utilization that is provided in the United States (see Forces that Affect Overall Health Care Utilization) (6,7). The Centers for Disease Control and Prevention, National Center for Health Statistics (NCHS), Division of Health Care Statistics is charged with conducting surveys of health care providers and facilities. These surveys track the number of encounters these entities provide and describe characteristics of Health Care in America: Trends in Utilization 1
Introduction
those who seek care, the content of the encounters, and characteristics of providers. It accomplishes this mission in part by fielding a family of surveys that are collectively called the National Health Care Survey (NHCS). The NHCS produces important information on hospitalizations and surgeries, ambulatory physician visits, and long-term care use in the United States. It can be used to compare services received across different settings, to relate provider characteristics to patient utilization, to compare utilization rates among subpopulations, and, in general, to assess how the health care delivery system is being used and by whom. Each NHCS component survey obtains information about the facilities that supply health care, the services rendered, and the characteristics of the patients served. Each survey is based on a multistage sampling design that includes health care facilities or providers and patient records. Data collected directly from the establishments and/or their records rather than from the patients, identify health care eventssuch as hospitalizations, surgeries, and long-term staysand offer the most accurate and detailed data on diagnosis and treatment and institution characteristics. These data are used by policymakers, planners, researchers, and others in the health community for a variety of purposes, including monitoring changes in the use of health care resources, monitoring specific diseases, and examining the impact of new medical technologies (8). The NHCS includes the following surveys: National Ambulatory Medical Care Survey (NAMCS) National Hospital Ambulatory Medical Care Survey (NHAMCS) National Hospital Discharge Survey (NHDS) National Survey of Ambulatory Surgery (NSAS) National Home and Hospice Care Survey (NHHCS) National Nursing Home Survey (NNHS) These surveys are the major source of information in the United States on national trends in hospital length of stay and diagnoses associated with hospitalizations, ambulatory physician visits, nursing home stays, and home health and hospice care visits. Chart 1 shows component surveys of the NHCS, including typical sample sizes and years conducted. More detail on the component surveys and limitations of the data can be found in Appendix I. Appendix II presents definitions of terms used throughout this report. Only statistically significant differences between population groups or time trends are noted in the text, as well as on each chart. Computation of rates for hospital discharges and nursing homes, home health agencies, and hospices encounters use estimates of the civilian population of the United States based on the 1990 census and adjusted for underenumeration using the 1990 National Population Adjustment Matrix. Rates of physician, hospital outpatient, and hospital emergency department visits use the civilian noninstitutionalized population of the United States, also based on the 1990 census and adjusted for underenumeration. Although intercensal rates for the 1990s that incorporate data from the 2000 census are now available, they were not available at the time this report was compiled. The first section of this book uses selected trend data to illustrate howand to suggest some insights into whyhealth care utilization has changed over the past decade. The second section presents overall trends in health care, including use of inpatient hospital services; use of physician services in private offices, hospital outpatient departments, and emergency departments; and use of nursing 2 Health Care in America: Trends in Utilization
Introduction
Chart 1: Characteristics of National Health Care Survey component surveys
Survey National Ambulatory Medical Care Survey (NAMCS) National Hospital Ambulatory Medical Care Survey (NHAMCS) National Hospital Discharge Survey (NHDS) National Survey of Ambulatory Surgery (NSAS) National Home and Hospice Care Survey (NHHCS) National Nursing Home Survey (NNHS) Type of data Visits to office-based physicians Visits to hospital emergency and outpatient departments Hospital discharges Years fielded 19731981, 1985, 1989present 1992present Approximate responding sample size 1,0001,140 physicians 21,00036,000 encounters 440 hospitals 21,00036,000 ED1 encounters 29,00035,000 outpatient visits About 500 hospitals 300,000 discharges
1965present
Ambulatory surgery discharges Agency characteristics, current patients, and discharges Characteristics of nursing homes with 3 or more beds, current residents, and discharges
19941996
500 facilities 120,000 discharges 1,1001,800 agencies 3,4005,400 current patients 3,0004,900 discharges 1,1001,900 nursing homes 5,2008,200 current residents 6,0006,900 discharges
19921994, 1996, 1998, 2000 197374, 1977, 1985, 1995, 1997, 1999
ED is emergency department.
home, home health care, and hospice care services. Trends for the entire U.S. population are presented first, followed by trends for specific age and race groups (black versus white populations); trends in utilization for specific conditions, drugs, and procedures; and trends in utilization associated with place of death. In an attempt to show trends in utilization across the spectrum of care measured in our surveys, this book is not organized around specific surveys or specific populations (e.g., racial or age groups). Therefore, those interested in a particular type of care, such as home health care, will find charts illustrating trends in home health care by different population groups throughout the book. Similarly, overall trends in utilization by race appear throughout the book. When analyzing any of the trends in health care utilization presented in this book, it is critical to remember that all of the health care utilization data (doctor visits, emergency department or outpatient department visits, or discharges from hospitals, nursing homes, and home health agencies) from Health Care in America: Trends in Utilization 3
Introduction
the NHCS are derived from establishment- or provider-based surveys rather than population-based surveys. Thus, with the exception of daily census data from nursing homes and home health agencies, data from the surveys represent events, not persons. For example, persons who visited a physician more than once or were discharged from the hospital more than once during the period of data collection would be included multiple times in the list from which the sample was drawn. Utilization rates per capita (or per population) represent the magnitude of health care use by a particular population and can be compared across various population groups, but they cannot be used to examine the amount or type of care provided to individuals. In addition, examination of utilization trends for the entire U.S. population masks many underlying differences in utilization by subpopulation (e.g., race, age, or gender) and/or condition. Many of these underlying trends are presented in charts presented throughout this book. This book is the first attempt to integrate data from all of the NHCS components into one publication that examines how health care utilization is changing across multiple settings. This book is neither exhaustive nor comprehensive in the utilization trend data it presents. Although it provides examples of overall trends in health care utilization, many other trends in diagnoses, conditions, and discharge disposition across population groups defined by different characteristics are not presented here. Many of these data are available from published reports, and a bibliography of publications using data from the NHCS is included in Appendix III. Hopefully, this book will serve as a starting point for examining how health care utilization is changing and what data gaps exist in our understanding of the evolving health care delivery system.
100
1990
2000
80
60.9
60
49.0 46.1 43.0
40
23.4 23.7
20
10.0
3.0
05 years
617 years
1844 years
6574 years
7584 years
SOURCE: U.S. Census Bureau civilian population estimates based on the 1990 census.
1986 1987
1988
1999 2000
Hospital supply. The number of community hospitals in the United States decreased from 5,384 in 1990 to 4,915 in 2000. The number of beds per 1,000 population also declined, from 4.2 to 3.0 between 1990 and 2000. This reduction in hospital capacity was accompanied by increased staffing. Full-time equivalent personnel increased from about 3,420,000 to about 3,911,400 between 1995 and 2000 (24). Many of the additional staff are not devoted to patient care but to management or administration. Hospitals are also providing a greater percentage of their care on an outpatient basis. Data from the American Hospital Association show that outpatient department visits increased from 860 to 1,852 per 1,000 persons between 1990 and 2000, indicating that their capacity has been expanded over time (24,25). The number of hospital emergency departments (EDs), however, has decreased by about 8 percent between 1994 and 1999, with a large percentage of ED closures in rural areas (26,27). Physician supply. Unlike hospitals, the number of physicians serving the U.S. population continues to increase. There are also more specialists of all types, except general surgeons and radiologists (28). However, physicians are not evenly distributed throughout the Nation; they are concentrated in urban areas, causing considerable shortages in some rural areas. The Federal government estimates that more than 2,200 physicians would be needed in nonmetropolitan areas to eliminate primary care health professional shortage areas (29). New Types of Acute-Care Facilities. Not only is the supply of physicians increasing, physicians and other health care providers are also increasingly providing services in new types and sites of care. Chart 5 shows some of the relatively new types of facilities that the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) accredits. The number of ambulatory surgery centers, for example, has grown rapidly since the 1980s (30). The number of Medicare-certified ambulatory surgery centers alone increased from 1,197 in 1990 to 2,644 in 1998.
12
a b
The 1985 NNHS excludes an estimated 2,200 residential care homes. Patient care staff includes administrative, medical and therapeutic staff (dentists, dental hygienists, physical therapists, speech pathologists and/or audiologists, dieticians or nutritionists, podiatrists, and social workers), and nursing staff (registered nurses, licensed practical nurses, nurses aides, and orderlies).
85.1
Nursing services1
98.3 99.5
86.8
Medical services1
94.4 96.1
76.3
Physical therapy1
94.9 96.9
Speech/hearing therapy1
55.7
Occupational therapy1
87.2 94.0
Nutritional services1
20
40
60
80
100
trend is significant (p<0.05). SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Nursing Home Survey (NNHS).
72 164
186 825
531 2,344
590 2,317
522 2,326
SOURCE: Centers for Medicare & Medicaid Services, HCFA Statistics, 1998, 1999, and 2000.
Chart 8B: Home health agencies and Medicare-certified home health agencies: United States, 19922000
Number 14,000
12,200 Total Medicare-certified agencies
1998
2000
SOURCES: Haupt B, Hing E, Strahan G. The National Home and Hospice Survey (NHHS): 1992 summary. National Center for Health Statistics. Vital Health Stat 13(117). 1994; Jones A, Strahan G. The National Home and Hospice Care Survey (NHHCS): 1994 summary. National Center for Health Statistics. Vital Health Stat 13(126). 1997; Haupt B, Jones A. The National Home and Hospice Care survey (NHHCS): 1996 summary. National Center for Health Statistics. Vital Health Stat 13(141). 1999; The National Home and Hospice Care Survey (NHHCS), 1998, 2000. National Center for Health Statistics; Basic statistics about home care, online report available at http://www.nahc.org/Consumer/hcstats.html
Year
Rate per 1,000 population2 199091 199293 199495 199697 199899 2000 2,777 2,925 2,643 2,865 2,931 3,004 --236 256 271 296 304 --356 364 349 375 394 122 119 117 114 117 114
- - - Data not available. 1Time trend is signicant (p<0.05). 2See Appendix I, Sources and Limitations of the Data for descriptions of the population estimates used. SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Ambulatory Medical Care Survey (NAMCS), National Hospital Ambulatory Medical Care Survey (NHAMCS), and National Hospital Discharge Survey (NHDS).
Other specialty
1See Appendix 1: Sources and Limitations of the Data for a description of the population estimates used. 2Time trend is signicant (p<0.05). SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Ambulatory Medical Care Survey (NAMCS).
Chart 10B: Office visits to obstetricians and gynecologists: United States, 19922000
Visits per 1,000 females1 600 500 Females 400 300 200 100 0
199293
199495
199697
199899
2000
1See Appendix 1: Sources and Limitations of the Data for a description of the population estimates used. SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Ambulatory Medical Care Survey (NAMCS).
400
4564 years2
2000
1 See Appendix 1: Sources and Limitations of the Data for a description of the population estimates used. 2Time trend is significant (p<0.05). SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Ambulatory Medical Care Survey (NHAMCS).
3,000
2,500
2,000
1,500
1,000
500
0 199293
1See 3OPD
199495
199697
199899
2000
Appendix 1: Sources and Limitations of the Data for a description of the population estimates used. 2Time trend is significant (p<0.05). is outpatient department. 4Difference between black and white populations is significant for both physician office and OPD visits (p<0.05). SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS).
White2
200
Black2
150
100
50
0 199091
1 3
199293
199495
199697
199899
2000
See Appendix 1: Sources and Limitations of the Data for a description of the population estimates used. 2Time trend is significant (p<0.05). Difference between black and white population is significant (p<0.05). SOURCE: Centers for Disease Control and Prevention, National Center for Health Statisitics, National Ambulatory Medical Care Survey (NAMCS).
31
Black
White
199495
199697
199899
2000
Appendix 1: Sources and Limitations of the Data for a description of the population estimates used. 2Difference between black and white population is significant (p<0.05). SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Ambulatory Medical Care Survey (NHAMCS).
Chart 14B: Hospital emergency department visits, by race and age: United States, 19922000
Visits per 1,000 population1 800
Black 65 years and over2
600
400
Black 4564 years2 White 65 years and over2 White 4564 years2
200
0 199293
1See
199495
199697
199899
2000
Appendix 1: Sources and Limitations of the Data for a description of the population estimates used. 2Time trend is significant (p<0.05). SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Ambulatory Medical Care Survey (NHAMCS).
199495
199697
199899
2000
Appendix 1: Sources and Limitations of the Data for a description of the population estimates used. 2Time trend is significant (p<0.05). SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Discharge Survey (NHDS).
Black White
199293
199495
199697
199899
2000
See Appendix 1: Sources and Limitations of the Data for a description of the population estimates used. 2Difference between black and white populations is significant (p<0.05). SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Discharge Survey (NHDS).
160
140
120
109.0
119.3 112.6
100
80
60
40
20
0 Ambulatory
1See
Inpatient
Appendix 1: Sources and Limitations of the Data for a description of the population estimates used. SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Discharge Survey (NHDS) and National Survey of Ambulatory Surgery (NSAS).
Duration of visit to a physicians office or to a physician in a hospital outpatient department refers to the amount of time spent in face- to-face contact between the physician and the patient. This time is estimated and recorded by the physician and does not include time spent waiting to see the physician, time spent receiving care from someone other than the physician without the presence of the physician, or time spent by the physician in reviewing patient records and/or test results. In cases where the patient received care from a member of the physicians staff but did not actually see the physician during the visit, the duration was recorded as zero minutes.
Year 199091
199293
17.7
6.1
199495
17.4
5.6
199697
17.2
5.2
199899
18.0
5.0
2000
1
18.1
4.9
Time trend is significant (p<0.05). SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Ambulatory Medical Care Survey (NAMCS) and National Hospital Discharge Survey (NHDS)
Discharges may include persons discharged more than once from home health agencies during the year.
120
80
52.5 42.4 37.9 27.7
71.4
40
29.6
0
1See
Appendix 1: Sources and Limitations of the Data for a description of the population estimates used. 2Time trend before and after 1996 is significant (p<0.05). 3Time trend is significant (p<0.05). SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Home and Hospice Care Survey (NHHCS).
Chart 18B: Use of home health care by population of all ages: United States, 19922000
Rate per 1,000 population1 40
1992 1994 1996 1998 2000 29.0 27.9 25.8
30 20
11.9 20.0
10 0
4.8
7.2
9.1
6.9
4.9
See Appendix 1: Sources and Limitations of the Data for a description of the population estimates used. 2Upward time trend before 1996 is 3 significant (p<0.05). Downward time trend after 1996 is significant (p<0.05). SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Home and Hospice Care Survey (NHHCS).
41
60 40 20 0 1992
1
1994
1996
1998
2000
See Appendix 1: Sources and Limitations of the Data for a description of the population estimates used. NOTE: For all age groups, rates increased significantly through 1996 and decreased significantly from 19962000. SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Home and Hospice Care Survey (NHHCS).
Chart 19B: Current home health patients, by race: United States, 19922000
Rate per 1,000 population1 10 8 6 4 2
1
Black White
1992
1994
1996
1998
2000
See Appendix 1: Sources and Limitations of the Data for a description of the population estimates used.2Difference between black and white populations is significant (p<0.05). NOTE: Time trend differences before and after 1996 for white patients are significant. Time trend differences before and after1994 for black patients are significant (p<0.05). SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Home and Hospice Care Survey (NHHCS).
6.3
5.9
5.9
5.2
Residents2
1
Discharges2
See Appendix 1: Sources and Limitations of the Data for a description of the population estimates used. 2Time trend is significant (p<0.05). SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Nursing Home Survey (NNHS).
e f
1985 estimates were recomputed to include five (instead of six) activities of daily living. In 1999, cases with multiple races are included in the other race category.
50 40 30 20
11.6 14.2 9.7
12.0
10 0
Under 65 years1
6574 years1
7584 years1
Age at interview
1Time
trend is significant (p<0.05). SOURCE: Centers for Disease Control and Prevention, National Center for Health Statisitics, National Nursing Home Survey (NNHS).
Chart 21B: Nursing home residents 65 years and over, by race and sex: United States, 19851999
Rate per 1,000 population 65 years and over1 70 60 50 40 30 20 10 0 1985 1995 1997 1999
Black females2 White females2
1 See Appendix 1: Sources and Limitations of the Data for a description of the population estimates used. 2Time trend is significant (p<0.05). SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Nursing Home Survey (NNHS).
Year
80 69 65
Time trend is significant (p<0.05). 2See Appendix 1: Sources and Limitations of the Data for a description of the population estimates used. NOTE: Injuries include first-listed ICD9CM codes 800909.2, 909.4, 909.9, 910994.9, 995.5995.59, 995.80995.85. SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Ambulatory Medical Care Survey (NAMCS), National Hospital Discharge Survey (NHDS), and National Hospital Ambulatory Medical Care Survey (NHAMCS).
10
8.4
8 6 4 2 0
1
5.2
1985
1997
1999
See Appendix 1: Sources and Limitations of the Data for a description of the population estimates used. 2Time trend is significant (p<0.05). NOTE: Injuries include first-listed ICD9CM codes 800909.2, 909.4, 909.9, 910994.9, 995.5995.59, 995.80995.85. SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Nursing Home Survey (NNHS).
Chart 23B: Home health discharges admitted with injuries: United States,19922000
Rate per 10,000 population1 40
32.7
30
25.0 18.9 13.2
27.4
20
10
0 1992
1
1994
1996
1998
2000
See Appendix 1: Sources and Limitations of the Data for a description of the population estimates used. Time trend difference between 1992 and 1996 is significant (p<0.05). NOTE: Injuries include first-listed ICD9CM codes 800909.2, 909.4, 909.9, 910994.9, 995.5995.59, 995.80995.85. SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Home and Hospice Care Survey (NHHCS).
Year
15 25 29
29 31 44
94 113 119
trend is significant (p<0.05). 2See Appendix 1: Sources and Limitations of the Data for a description of the population estimates used. NOTE: Chronic obstructive pulmonary disease includes any-listed ICD9CM codes 491.0, 491.2, 491.8, 491.9, 492.8, 493.2, 496. SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Ambulatory Medical Care Survey (NAMCS), National Hospital Discharge Survey (NHDS), and National Hospital Ambulatory Medical Care Survey (NHAMCS).
Chart 24B: Chronic obstructive pulmonary disease discharges from short-stay hospitals, by age: United States, 19922000
Rate per 10,000 population1 1000
199293 199697 19992000 846.2 875.4
800
681.4
600
455.3 502.7
531.1
400
200
116.6
130.4
132.1
0 4564 years2
1
6574 years2
See Appendix 1: Sources and Limitations of the Data for a description of the population estimates used. 2Time trend is significant (p<0.05). NOTE: Chronic obstructive pulmonary disease includes any-listed ICD9CM codes 491.0, 491.2, 491.8, 491.9, 492.8, 493.2, 496. SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Discharge Survey (NHDS).
Year
84 157 157
33 38 48
Time trend is significant (p<0.05). See Appendix 1: Sources and Limitations of the Data for a description of the population estimates used. NOTE: Diabetes includes any-listed ICD9CM code 250 and excludes gestational and neonatal diabetes. SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Ambulatory Medical Care Survey (NAMCS), National Hospital Discharge Survey (NHDS), and National Hospital Ambulatory Medical Care Survey (NHAMCS).
Chart 25B: Diabetes discharges from short-stay hospitals, by age: United States, 19922000
Rate per 10,000 population1 1000
199293 199697 19992000 791.1 699.8 631.0 828.6
800
576.1
600
536.9
400
208.9 216.7 233.7
200
0 4564 years2
1
6574 years2
See Appendix 1: Sources and Limitations of the Data for a description of the population estimates used. 2Time trend is significant (p<0.05). NOTE: Diabetes includes any-listed ICD9CM code 250 and excludes gestational and neonatal diabetes. SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Discharge Survey (NHDS).
Male
Female
142.0
150.6 133.9
120
92.9 97.2 88.9
80 40 0 199495
41.6 39.2 43.9
63.1
60.4
65.7
199697
199899
2000
1 See Appendix 1: Sources and Limitations of the Data for a description of the population estimates used. 2Time trend is significant (p<0.05). SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS).
Chart 26B: Blood glucose regulator drug mention during physician office and hospital outpatient department visits, by age: United States, 19932000
Visits per 1,000 population1 600 500 400 300 200 100 0 1993
1
4564 years
1844 years
199495
199697
199899
2
2000
See Appendix 1: Sources and Limitations of the Data for a description of the population estimates used. Time trend is significant (p<0.05). SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS).
1844 years2
Under 18 years
199596
199798
19992000
See Appendix 1: Sources and Limitations of the Data for a description of the population estimates used. 2Time trend is significant (p<0.05). SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Ambulatory Medical Care Survey (NAMCS).
Chart 27B: Antidepressant drug mention during outpatient department visits, by age: United States, 19932000
Visits per 1,000 population1 30 25 20
1844 years2 4564 years2 65 years and over2
15 10 5 0 199394
1
Under 18 years
199596
199798
19992000
See Appendix 1: Sources and Limitations of the Data for a description of the population estimates used. 2Time trend is significant (p<0.05). SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Ambulatory Medical Care Survey (NHAMCS).
1993
199495
199697
199899
2000
205.0 182.9 163.9
150
141.7 141.4
127.2
123.8
105.1
116.5
121.5
125.6
96.0
93.9
91.2
100
83.3 69.9
50
0 All ages2
1
59.3
Under 18 years2
1844 years2
63.6 66.1
83.0
4564 years2
2
90.8
See Appendix 1: Sources and Limitations of the Data for a description of the population estimates used. Time trend is significant (p<0.05). SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS).
93.2
101.8
142.8
185.1
200
600
555.5 199495 199697 199899 2000
500
435.8
400
354.2 317.7
300
230.9 230.3
200
146.5
184.5
100
54.0 58.3 64.7
81.1
0
1
1844 years2
4564 years2
2
See Appendix 1: Sources and Limitations of the Data for a description of the population estimates used. Time trend is significant (p<0.05). SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS).
1844 years
1993
199495
199697
199899
2
2000
See Appendix 1: Sources and Limitations of the Data for a description of the population estimates used. Time trend is significant (p<0.05). SOURCE: Centers for Disease Prevention and Control, National Center for Health Statistics, National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS).
Chart 30B: Estrogen/Progestin mentions during physician office visits for women 45 years of age and over, by race: United States, 1993-2000
Visits per 1,000 women1 500
423.6 486.5 418.8 317.7 1993 199697 19992000
400 300
200 100 0
See Appendix 1: Sources and Limitations of the Data for a description of the population estimates used. 2Time trend is significant (p<0.05). SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Ambulatory Medical Care Survey (NAMCS).
White 195.7
Black
229.9
171.4 117.6
19992000
2
See Appendix 1: Sources and Limitations of the Data for a description of the population estimates used. Difference between black and white populations is significant (p<0.05). SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Ambulatory Medical Care Survey (NAMCS).
Chart 31B: Hospital outpatient department visits with mammograms ordered or provided for women 45 years of age and over, by race: United States, 19922000
Visits per 1,000 women1 70 60 50 40 30 20 10 0 1992
1
White 53.5
Black
59.4
22.3 13.7
19992000
See Appendix 1: Sources and Limitations of the Data for a description of the population estimates used. 2Difference between black and white women is significant (p<0.05). SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Ambulatory Medical Care Survey (NHAMCS).
10
Tonsillectomy2 Myringotomy2
0 199091
1
199293
199495
199697
199899
2
2000
See Appendix 1: Sources and Limitations of the Data for a description of the population estimates used. Time trend is significant (p<0.05). NOTES: Tonsillectomy includes any-listed ICD9CM procedure codes 28.2 and 28.3. Myringotomy with tube insertion includes any-listed ICD9CM procedure code 20.01. SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Discharge Survey (NHDS).
2000
See Appendix 1: Sources and Limitations of the Data for a description of the population estimates used. 2Time trend is significant (p<0.05). NOTE: Coronary artery bypass graft includes any-listed ICD9CM procedure code 36.1. SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Discharge Survey (NHDS).
Chart 33B: Percutaneous transluminal coronary angioplasty for discharges from short-stay hospitals, by age: United States, 19902000
Rate per 100,000 population1 1,000 800 600 400 200 0 199091
1
199293
199495
199697
199899
2000
See Appendix 1: Sources and Limitations of the Data for a description of the population estimates used. 2Time trend is significant (p<0.05). NOTE: Percutaneous transluminal coronary angioplasty includes any-listed ICD9CM procedure codes 36.0136.02 and 36.05. SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Discharge Survey (NHDS).
600
531.9
500
400
367.1 323.2
318.5
300
292.7 251.4
200
157.4
188.0
100
0 4564 years2
1
See Appendix 1: Sources and Limitations of the Data for a description of the population estimates used. 2Time trend is significant (p<0.05). NOTE: Stent insertion includes any-listed ICD9CM procedure code 36.06. SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Discharge Survey (NHDS).
6574 years
1991
1
1993
1995
1997
1999
2
2000
See Appendix 1: Sources and Limitations of the Data for a description of the population estimates used. Time trend is significant (p<0.05). NOTE: Hip replacements include any-listed ICD9CM procedure codes 81.51 and 81.52. SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Discharge Survey (NHDS).
Chart 35B: Knee replacements performed in short-stay hospitals, by age: United States, 19912000
Rate per 100,000 population1
700 600 500 400 300 200 100 0
All ages2 Under 65 years2 75 years and over2 6574 years2
1991
1
1993
1995
1997
1999
2
2000
See Appendix 1: Sources and Limitations of the Data for a description of the population estimates used. Time trend is significant (p<0.05). NOTE: Knee replacements include any-listed ICD9CM procedure code 81.54. SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Discharge Survey (NHDS).
Under 65 years2
6574 years2
12.9
6.6
19992000
See Appendix 1: Sources and Limitations of the Data for a description of the population estimates used. 2Time trend is significant (p<0.05). NOTE: Includes any-listed ICD9CM codes- E870E879, E930E949. SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Ambulatory Medical Care Survey (NHAMCS).
Chart 36B: Hospital discharges with diagnoses of adverse effects of medical treatment, by age: United States, 19922000
Discharges per 1,000 population1 35 30 25 20 15 10 5 0 199293
1
Under 65 years2
6574 years2
31.0
18.7 14.8
20.7
2.7
3.7
19992000
2
See Appendix 1: Sources and Limitations of the Data for a description of the population estimates used. Time trend is significant (p<0.05). NOTE: Includes any-listed ICD-9-CM codes E870E879, E930E949. SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Discharge Survey (NHDS).
The HDS Survey Manual defines long-term care institutions as nursing homes, skilled nursing facilities, extended care facilities, intermediate care facilities, and custodial care facilities.
20 15 10 5 0
4.3 5.5
7.5
All ages1
1Time trend is significant (p<0.05). NOTE: Percentages exclude deaths and unknown disposition. SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Discharge Survey (NHDS).
Chart 37B: Percentage of current residents and discharges from nursing homes who were admitted from hospitals: United States, 19851999
Percent 70
1985 1997 1999 55.2 44.6 37.4 46.3 61.3 65.4
60 50 40 30 20 10 0 Current residents1
Discharges1
1 Time trend is significant (p<0.05). SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Nursing Home Survey (NNHS).
The fatality rate is defined here as the number of deaths in the institution (hospital or nursing home) divided by the total number of discharges in that institution, multiplied by 100.
30
28.1 1985 1999 24.4
25
20
15
10
5
2.7 2.6
0 Hospital
Nursing home1
Difference between 1985 and 1999 is significant (p<0.05). SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Discharge Survey (NHDS) and National Nursing Home Survey (NNHS).
25.7 16.5
Nursing homes1
Difference between 1985 and 1999 is significant (p<0.05). SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Discharge Survey (NHDS), National Nursing Home Survey (NNHS), and National Vital Statistics System.
Chart 39B: Deaths occurring during emergency department visits or while enrolled in home health care or a hospice program: United States, 1992 and 2000
Rate per 100 deaths 25 20
15.8 1992 13.0 10.5 6.9 9.1 2000 22.1
15 10 5 0
Emergency department
1
Home health1
Hospice1
Difference between 1992 and 2000 is significant (p<0.05). SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Ambulatory Medical Care Survey (NHAMCS), National Home and Hospice Care Survey (NHHCS), and National Vital Statistics System.
40
50
Difference between 1985 and 1999 is significant (p<0.05). NOTE: Numerator of rate based on the primary diagnosis at discharge for discharges from hospitals and nursing homes because of death. SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Discharge Survey (NHDS), National Nursing Home Survey (NNHS), and National Vital Statistics System.
Chart 40B: Where cancer and heart disease deaths occur: United States, 1992 and 2000
Hospice/ cancer1 Hospice/ heart disease1 Home health/ cancer1 Home health/ heart disease2 0
1.7 4.9 3.6 8.3 4.7 1992 2000 28.3 55.0
10
20
50
60
70
1 Difference between 1992 and 2000 is significant (p<0.05). 2Rate not provided for 2000 because estimate is based on less than 30 cases. NOTE: Numerator of rate based on the primary diagnosis at discharge for discharges from home health agencies and hospices because of death. SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Home and Hospice Care Survey (NHHCS), and National Vital Statistics System.
20
17.6
15
13.7
10
8.8
7.1
3.9
0 1992
1
1994
1996
1998
2000
See Appendix 1: Sources and Limitations of the Data for a description of the population estimates used. 2Time trend is significant (p<0.05). between black and white populations is significant (p<0.05). SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Home and Hospice Care Survey (NHHCS).
3Difference
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Any use of trade names in this book is for identification purposes only and does not imply endorsement by the Centers for Disease Control and Prevention, U.S. Department of Health and Human Services.
Index
............................................................................... Associated Charts (and Text) Access to care ................................................................................................................ 2 Acute care providers ........................................................................................................ 5 Adverse events ..................................................................................................... 36A, 36B Age groups ....................................................... 11A, 11B, 14B, 15A, 19A, 21A, 24B, 25B, 26B, ............................................................. 27A, 27B, 28, 29, 33A, 33B, 34, 35A, 35B, 36A, 36B Aging population............................................................................................................. 3 Children under 18 years of age ........................................................................................ 32 Chronic Obstructive Pulmonary Disease (COPD) .......................................................... 24A, 24B Deaths ..................................................................................................38, 39A, 40A, 40B Diabetes ..................................................................................................... 25A, 25B, 26B Drugs ........................................................................ 26A, 26B, 27A, 27B, 28, 29, 30A, 30B Duration, length of encounter ............................................................................................ 17 Emergency department .................................................. 9, 14A, 14B, 22, 24A, 25A, 36A, 39B Heart disease .......................................................................... 26A, 33A, 33B, 34, 40A, 40B Home health care ....................................................... 8B, 18A, 18B, 19A, 19B, 23B, 39B, 40B Deaths ........................................................................................................... 39B, 40B Injuries .................................................................................................................. 23B Supply .................................................................................................................... 8B Utilization ................................................................................. 18A, 18B, 19A, 19B, 23B Hospice ................................................................................................... 8A, 39B, 40B, 41 Hospital ............ 9, 15A, 15B, 17, 22, 24B, 25B, 32, 33A, 33B, 34, 35A, 35B, 36B, 38, 39A, 40A Deaths ..................................................................................................... 38, 39A, 40A Length of stay ........................................................................................................... 17 Transfers to nursing homes ......................................................................................... 37A Utilization ............................... 9, 15A, 15B, 22, 24B, 25B, 32, 33A, 33B, 34, 35A, 35B, 36B Hospital outpatient departments.................................... 9, 11B, 12, 17, 22, 23A, 24A, 25A, 31B Duration .................................................................................................................. 17 Utilization ......................................................................... 9, 11B, 12, 22, 24A, 25A, 31B Injuries ......................................................................................................... 22, 23A, 23B Long-term care residences .................................................................................................. 7 Mammograms ..................................................................................................... 31A, 31B Medicaid ....................................................................................................................... 4
Index
............................................................................... Associated Charts (and Text) Medicare ............................................................................................................ 4, 8A, 8B National Ambulatory Medical Care Survey (NAMCS) ........................... 1, 9, 10A, 10B, 11A, 12, 13, 17, 22, ....................................................................... 24A, 25A, 26A, 26B, 27A, 27B, 28, 29, 30A, 30B, 31A National Health Care Survey (NHCS)................................................................................... 1 National Home and Hospice Care Survey (NHHCS) ... 1, 8B, 18A, 18B, 19A, 19B, 23B, 39B, 40B, 41 National Hospital Ambulatory Medical Care Survey (NHAMCS) ....................... 1, 9, 11B, 12, 14A, .................................... 14B, 22, 24A, 25A, 26A, 26B, 27A, 27B, 28, 29, 30A, 31B, 36A, 39B National Hospital Discharge Survey (NHDS) ................................ 1, 9, 15A, 15B, 16, 17, 22, 24A, ....................................... 24B, 25A, 25B, 32, 33A, 33B, 34, 35A, 35B, 36B, 37A, 38, 39A, 40A National Nursing Home Survey (NHHS) ................... 1, 6, 20, 21A, 21B, 23A, 37B, 38, 39A, 40A National Survey of Ambulatory Surgery (NSAS) ............................................................... 1, 16 Nursing homes ........................................................ 6, 20, 21A, 21B, 23A, 37B, 38, 39A, 40A Deaths ......................................................................................................38, 39A,40A Injuries .................................................................................................................. 23A Services .................................................................................................................... 6 Utilization .................................................................................. 20, 21A, 21B, 23A, 37B Older adults 65 years of age and over ...................................................................... 18A, 21B Physicians services .................................... 5, 9, 10A, 10B, 11A, 12, 13, 17, 22, 24A, 25A, 31A Duration of visit ......................................................................................................... 17 Supply ...................................................................................................................... 5 Utilization ..................................................... 9,10A, 10B, 11A, 12, 13, 22, 24A, 25A, 31A Policy initiatives ............................................................................................................... 4 Primary care ........................................................................................................ 10A, 10B Procedures (inpatient) ............................................................. 16, 32, 33A, 33B, 34, 35A, 35B Race ......................................................12, 13, 14A, 14B, 15B, 19B, 21B, 30B, 31A, 31B, 41 Sex ................................................................................................................... 21B, 26A Transfers ............................................................................................................. 37A, 37B Women 45 years of age and over ............................................................. 30A, 30B, 31A, 31B
All estimates presented in this report were weighted to account for the complex sample design of each survey. Standard error estimates and measures of sampling error were computed for all estimates presented in this report using SUDAAN software.1 Because survey results are subject to sampling and nonsampling errors, the total error will be larger than the error due to sampling variability alone. The significance of all trends over time were evaluated using a weighted, least-squares regression analysis at the 0.05 level of significance. The z-test or t-test with a 0.05 level of significance was used for all other comparisons mentioned in this report. For multiple comparisons between subdomains, the Bonferroni test of simultaneous comparisons was used.
Shah BV, Barnwell BG, Hunt PN, LaVange LM. SUDAAN Users Manual, Release 5.50. Research Triangle Park, North Carolina. 1991.
NAMCS and NHAMCS surveys use various imputation methods to adjust for missing values, including race, and others present data separately for unknown race. Potential underreporting bias associated with this variable should be considered when using some health-related DHCS estimates by race. Plans for revisions of future National Health Care Survey components As the health care infrastructure evolves, so too does the need to obtain information on new and different providers, to address current policy and research issues, and to take advantage of new survey technologies and methodologies. Although NHCS surveys facilities and providers who account for the majority of health care in the United States, technological advances and other factors increasingly are shifting care to new and different places, such as ambulatory surgical centers, community radiology centers, urgent care centers, and new types of long-term care such as assisted living facilities. In addition, NHCS does not survey dentists, psychologists, or other independent health practitioners. Thus, NHCS tells only part of the total health care utilization story in the United States. To address issues related to utilization in new types of health care facilities and to keep up with current and emerging policy and research topics, NHCS is undergoing ongoing re-evaluation and modification. However, extensive revisions to existing surveys can undermine the ability to produce meaningful trend data. NHCS is attempting to balance the need for new information with the ability to continue presenting important trends in health care utilization, given available resources.
2 Kozak L J. Underreporting of race in the National Hospital Discharge Survey. Advance data from vital and health statistics; no 265. Hyattsville, Maryland: National Center for Health Statistics. 1995.
Active (or professionally active) physicians are currently practicing medicine for a minimum of 20 hours per week. Excluded are physicians who are not practicing, practice medicine for less than 20 hours per week, have unknown addresses, or specialties not classified (when specialty information is presented). Federal physicians are employed by the Federal Government; non-Federal or civilian physicians are not. Hospital-based physicians spend the plurality of their time as salaried physicians in hospitals. Office-based physicians spend the plurality of their time working in practices based in private offices.
Physician officeIn the National Ambulatory Medical Care Survey, any location for a physicians ambulatory practice other than hospitals, nursing homes, other extended care facilities, patients homes, industrial clinics, college clinics, and family planning clinics. Offices in health maintenance organizations and private offices in hospitals are included. See Physician office visit; Outpatient visit; Physician. Physician office visitIn the National Ambulatory Medical Care Survey (NAMCS), any direct personal exchange between an ambulatory patient and a physician or members of his or her staff for the purposes of seeking care and rendering health services. These visits may occur in offices of nonfederally employed physicians classified by the American Medical Association (AMA) or American Osteopathic Association (AOA) as office-based, patient care physicians. Patient encounters with physicians engaged in prepaid practices (including health maintenance organizations (HMOs), independent practice organization (IPAs), and other prepaid practices) are included in NAMCS. Excluded are visits to hospital-based outpatient departments; visits to specialists in anesthesiology, pathology, and radiology; and visits to physicians who are principally engaged in teaching, research, or administration. Telephone contacts and visits that do not occur in a physicians office are also excluded. See Outpatient visit.
Total population is the population of the United States, including all members of the Armed Forces living in foreign countries, Puerto Rico, Guam, and the U.S. Virgin Islands. Other Americans abroad (for example, civilian Federal employees and dependants of members of the Armed Forces or other Federal employees) are not included. Resident population includes persons whose usual place of residence (that is, the place where one usually lives and sleeps) is in one of the 50 States or the District of Columbia. It includes members of the Armed Forces stationed in the United States and their families. It excludes international military, naval, and diplomatic personnel and their families located here and residing in embassies or similar quarters. Also excluded are international workers and international students in this country and Americans living abroad. The resident population is usually the denominator when calculating birth and death rates and incidence of disease. Civilian population is the resident population excluding members of the Armed Forces. However, families of members of the Armed Forces are included. This population is the denominator in rates calculated for the National Hospital Discharge Survey, the National Home and Hospice Care Survey, the National Nursing Home Survey, and the National Survey of Ambulatory Surgery. Civilian noninstitutionalized population is the civilian population not residing in institutions. Institutions include correctional institutions, detention homes, and training schools for juvenile delinquents; homes for the aged and dependent (for example, nursing homes and convalescent homes); homes for dependent and neglected children; homes and schools for the mentally or physically handicapped; homes for unwed mothers; psychiatric, tuberculosis, and chronic disease hospitals; and residential treatment centers. U.S. Census Bureau estimates of the civilian noninstitutionalized population are used to calculate rates using National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey data.
Primary careAccording to a report by the Institute of Medicine, the provision of integrated, accessible, health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of the family and the community.3
Institute of Medicine. Primary Care: Americas Health in a New Era. Washington DC: National Academy Press. 1996.