Health Care Disparities Research: Using the National Health Care Surveys

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Health Care Disparities ResearchUsing the
National Health Care Surveys

• Jane E. Sisk and Nancy Sonnenfeld
• AcademyHealth Annual Research Meeting
• June 8, 2008

Division of Health Care Statistics National
Center for Health Statistics Centers for Disease
Control and Prevention
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Concept of Disparity

• Defining a disparity
• lies along a causal pathway through which
  race/ethnicity affects health care or health
• has roots in injustice
• Identifying a disparity differs from analyzing
  its causes

Hebert P, Sisk JE, Howell EA. Health Affairs
2008374-382.
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The National Health Care Surveys

• Physicians in offices
• Hospital emergency and outpatient departments
• Hospital inpatient departments
• Ambulatory surgery facilities
• Nursing homes
• Home and hospice care agencies
• Residential care facilities

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Examples of Data
Provider Organizations Setting Sources of
revenue Ownership/staffing Technologies Electronic
medical records
Clinicians Specialty and training Visits Region Ge
nder Race/ethnicity
Patients Demographics, including
race/ethnicity Medical conditions Continuity Vital
signs Insurance status Residential zip code
Clinical Management Medications Services
provided/ordered Duration of visit Disease
Management Counseling Disposition
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New Patients Whom Physicians WereNot Accepting ,
2001-2006
1/Trend is statistically significant
(plt0.05). Source National Ambulatory Medical
Care Survey, 2001-2006 Hing et al. National
Health and Vital Statistics Series 13 2008 no 266
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Difficulty Referring PatientsFor Specialty
Consultation, 2005-2006
Source National Ambulatory Medical Care Survey,
2005-2006 Hing et al. National Health and Vital
Statistics Series 13 2008 no 266
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Ambulatory Visits by Setting, 2005
White
Black/African-American
Sources National Ambulatory and National
Hospital Ambulatory Medical Care Surveys,
2005. Burt C. et al. Advance Data 2007388.
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Ambulatory Visits in Different Settings by
Poverty in Patient Zip Code, 2001-2005
40 or more Poverty
30-39 Poverty
20-29 Poverty
lt 20 Poverty
Sources National Ambulatory and National
Hospital Ambulatory Medical Care Surveys,
2001-2005.
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Emergency Department Waiting Times, 1997-2004
Chi-square test among categories p lt .0001.
Significant differences remained after adjusting
for age, gender, payment source, initial triage
assessment, presenting complaint of chest pain,
admitted, and ultimate ED diagnosis of
AMI. Source National Hospital Ambulatory Medical
Care Survey, 1997-2004. Adapted from Wilper, et
al. Health Affairs 2008(2)27w84-95.
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Appropriate Medication TherapyAdult Visits with
Atrial Fibrillation (AF)
Prominent Measure
Denominator Numerator Exclusions Antithr
ombotic AF visits AF visits with
AF visits with GI therapy
warfarin, bleeding,
dicumarol, duodenitis,
anisindione, alcoholism, drug or
aspirin abuse, Alzheimers, gait
abnormality, cerebral hemorrhage,
seizure disorder, CNS tumors,
renal insufficiency, or thromboc
ytopenia
CNS Central Nervous System Guidelines from
American College of Cardiology/American Heart
Association/European Society of Cardiology
Excerpted from Ma J, et al. Arch Intern Med
20051651354-1361.
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Appropriate Medication Therapy,
1995-2002Percent of Visits
Non-Hispanic Non-Hispanic Measure White
Black Hispanic No benzodiazepine
for depression 84
87 77 Antithrombotic therapy for AF 51
52 60 Diuretic ß-blocker, HTN 57
63 54 IC, asthma, adults 38
36 30 ACE inhibitor, CHF 32
45 20 IC, asthma, children 23
27 20 ß-blocker, CAD 29 25 28
significant differences AF atrial
fibrillation CHF congestive heart failure
HTN hypertension CAD coronary artery
disease ACE angiotensin converting enzyme IC
inhaled corticosteroid
Sources National Ambulatory Medical Care Survey
and National Hospital Ambulatory Medical Care
Survey, 1995-2002 Excerpted from Ma J, et al.
Arch Intern Med 20051651354-1361.
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Hospitalizations For Diabetes
Sources National Hospital Discharge Survey,
National Health Interview Survey Statistics
computed by CDC/Division of Diabetes Translation,
http//www.cdc.gov/diabetes/statistics/dmfirst/fig
6.htm
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Adult VaccinationsNursing Home Residents, 2004
Source 2004 National Nursing Home Survey
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Methodological Challenges

• Encounter, not person-based
• Limited sample size
• Missing data
• Clustering

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Recent Improvements

• Increase sample size
• Community Health Centers, NAMCS from 2006
• Oncologists, NAMCS 2006-07
• Expand providers covered
• Ambulatory surgery facilities, 2006
• Improve methods
• Imputation of race/ethnicity, NAMCS, 2006
• Add information on providers, patients, and care
• Electronic medical records, NAMCS/NHAMCS, 2006
• Screening for cervical cancer, NAMCS/NHAMCS
  2006-10
• Prior contacts, NHAMCS ED and NAMCS from 2006
• Cancer stage, radiation therapy, NAMCS 2006-07
• Link to external data sets
• National Nursing Home Survey linked to Medicare
  MDS files, 2004
• Patient ZIP linked to Census data on income,
  education, poverty levels, NAMCS/NHAMCS from 2006

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Improvements Underway

• Laboratory results to be pilot tested, NAMCS,
  2009
• Routine coverage of ambulatory surgery in NHAMCS
• Hospital-based facilities from 2009
• Free-standing facilities from 2010
• Redesigned National Hospital Discharge Survey,
  2010
• - Clinical depth (medications, tests) -
  Better race data
• - Resource use/billings/payments - Prior and
  later admissions
• - Added facility characteristics - Link to
  National Death Index
• National Survey of Residential Care Facilities,
  2010
• Update samples, NAMCS/NHAMCS, 2011
• National Nursing Home Survey, 2011

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For More Informationhttp//www.cdc.gov/nchs/nhcs.
htm
E-mail nsonnenfeld_at_cdc.gov