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 orinexpensive. The study of trends in health care utilization provides important information on thesephenomena and may spotlight areas that may warrant future indepth studies because of potentialdisparities in access to, or quality of, care. Trends in utilization may also be used as the basis forprojecting future health care needs, to forecast future health care expenditures, or as the basis forprojecting 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. 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 population’s 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”) . 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”)  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 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 events—such as hospitalizations, surgeries, and long-term stays—and 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.

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 how—and to suggest some insights into why—health 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 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  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. root canal therapy or endodontic therapy root canal covington la 

If Health Matters

Conventional public decision-making is reductionist: individual problems are assigned to specialized professions and organizations with narrowly defined responsibilities (Litman 1999). For example, transportation agencies are responsible for improving traffic flow, environmental agencies are responsible for reducing pollution, and health agencies are responsible for public health. This can result in an agency implementing solutions to one problem (those within their mandate) that exacerbate other problems (those outside their mandate), and it undervalues solutions that provide modest but multiple benefits.

This report examines a particular example of this sort of policy disconnect: the lack of coordination between transport and health objectives. It asks, “How would transport policy and planning practices change if transportation agencies considered public health one of their primary responsibilities?”  Many transportation professionals may be offended by this question because they do consider public health an important concern as reflected in their efforts to reduce traffic crashes and pollution emissions. However, as this report points out, current transport planning practices tend to focus on some health impacts but overlook others. For transportation agencies to better address public health objectives they will need to consider a wider range of health impacts and develop better tools for evaluating how particular policy and planning decisions affect public health objectives.

What is Health Information Management?

Health Information Management is a challenging profession involving the application of clinical knowledge, information technology, data base management and administration. Health records are a base for health care planning and management decisions, legal and administrative purposes, research, identifying trends for the treatment of disease and for evaluating the standards and quality of patient care.

What does a Health Information Manager do?

The Health Information Manager is a specialist within the health care team who is responsible for the safekeeping of patient information and ensures that information is properly documented, stored and available.

About our Health Information Management Program

The management of information is critical to ensuring quality care throughout the health system. Health records provide a database for many purposes including health care planning and management, legal and administrative reference, research, trend analysis for the treatment of disease, and for evaluating the standards and quality of patient care. All this must be undertaken with due regard to ethical and legal considerations which emphasise the personal and sensitive nature of the information being collected and processed.

This program, the only one of its kind in Western Australia, combines content from the distinct disciplines of medical science, management, and information technology to ensure you obtain the skills needed to lead the field of health information management. In addition, our staff have strong links with the local health and information professions which will provide you with the opportunity for extensive hands-on experience. Core units include human biology, medical terminology, disease classification systems, epidemiology and biostatistics, management theory, computing and health information systems. Study also includes database management, electronic health information systems and health informatics, health economics, casemix and clinical costing, quality improvement principles, research methodology, human resource management and health services management.

What is a personal health record?

The growing importance of the participation of individuals in their own care and wellness activities is the impetus behind the vision for personal health records. By enabling and encouraging individuals to become more engaged in their health and care, and by providing the means to document, track and evaluate their health conditions, a PHR can lead to more informed health care decisions, improved personal health status, and ultimately, reduced cost and improved quality of health care.

The current and largely rudimentary manifestations of what some call PHRs in electronic form begin to address personal health management objectives by providing some information on health care services and allowing individuals to enter information. Yet, PHRs have the potential to be a robust, better-assembled and more organized source of both clinical and wellness information for an improved level of clinical, health and wellness decisions. The anticipated result is a well-rounded, complete picture of an individual’s health that extends beyond the care provided by the delivery system. Given the longitudinal nature of a PHR, the time period for this information could conceivably be as long as “cradle to grave.”

Though a portion of the information in a PHR may originate from health care providers, health insurers or third party administrators, the control of information transfers to the individual when it becomes part of the PHR. By contrast, current internet-based portals of information on an individual that are hosted and maintained by a provider or payer organization, without transferring access and control and use of the information to the individual, are not considered PHRs based on this definition. 

Health Network Terms

Networks for exchanging health related information are essential to aggregating patient-focused information into EHRs and PHRs as well as to developing a population-based approach to improving care practices and preventing illness. These networks are beginning to take shape in localities and regions around the nation, and there is a need to enable these networks and their participants to exchange health-related information electronically on a widespread, interoperable basis with appropriate privacy, security, and confidentiality safeguards in place.

Nationally recognized interoperability standards are a necessary component of the definitions for the records terms. However, the network terms require interoperability plus an additional set of nationally recognized standards to enable the flow of information reliably, consistently, accurately and securely. This concept is reflected in the definitions.

The terms that facilitate understanding of the concepts closely associated with building health information exchange networks must address two principal components of a network endeavor:

                The process of sharing health-related information using nationally recognized standards.

                The need for an oversight structure to facilitate this sharing of health-related information and to be accountable for its performance.

The two terms under examination for their role in describing information networks—HIE and RHIO—address these two components, but further clarification is needed.

Eliminating Confusion. As an oversight structure, a RHIO describes a certain type of arrangement with distinct attributes relating to governance and geography. But it is not adaptable enough to suffice as a term that can encompass the wide range of organizational forms that an information-sharing structure can take, including forms yet to be envisioned. This shortcoming has led to the increasing usage of the term HIE to represent an oversight structure with the requisite flexibility. However, the term HIE at its core describes the process of sharing information. Continuing its dual meaning as the oversight structure as well as the process perpetuates confusion over the term, which runs counter to the objectives of clearly assigning meaning to each term and distinguishing one term from another in discussions about health information technology.

Proposed new term. Drawing from discussions in the Network Work Group and comments received in public forums and written public comments, two possibilities emerged and were considered; both of them are adaptations of existing health IT terms:

                Health information organization (HIO), identifiable as the root element of RHIO without the boundaries of geography assigned by the use of the modifying word regional.

                Health information exchange organization (HIEO), identifiable as the organizational entity that undertakes the oversight and governance of the HIE process.

Each alternative had significant support. In the final stage of consideration, consensus developed around HIO as more straightforward and distinguishable from HIE. HIO also lends itself to being the overarching term to describe an organization while having the built-in capacity to include a modifier for more specific identity: state-level, pediatric, behavioral, etc. It embraces RHIO as one kind of HIO while opening up the opportunity for other HIOs that are not geographically based.

Health information terms

In 2004, United States President George Bush called for most Americans to have electronic health records by 2014. While few would have imagined what that really could mean to the providers of health care, patients and consumers, and those dependent on gathering health-related information from multiple sources, one thing was certain: he was not referring to electronic versions of the paper records used in most clinical settings at the time.

The types of electronic records that would support the outcomes that were and are still anticipated are part of a health information technology infrastructure that will ultimately allow authorized access to fully comprehensive patient and consumer health related information for multiple appropriate activities: patient care, consumer self-management of health, and a multitude of research, emergency response, and public health initiatives. Another part of that infrastructure is the system of health information exchange networks that can support secure and reliable information exchange within their constituency, and with other similar networks. Both the electronic records and the system of networks must, however, have incorporated recognized standards for interoperability and for the secure and reliable exchange of health information.

As of today, we do not have all the critical pieces in place to realize the vision. They are, however, just around the corner. The Certification Commission for Health Information Technology has incorporated basic interoperability standards for patient care as part of its 2008 certification criteria. Nine sites implementing the core specifications for health information exchange are the first of many that will constitute the Nationwide Health Information Network. We are on the cusp of a cataclysmic change in how health and care will be managed into the future as more and more information becomes available through expanded adoption of interoperable technologies.

Realizing the vision is not, however, just about the enabling technology. It’s also, to quote Secretary Michael Leavitt in his keynote address at the February 2008 HIMSS Annual Conference & Exhibition in Orlando, very much about sociology and culture change. Both clinicians and consumers need to feel that privacy and security needs are addressed appropriately. Everyone must see the value in creating, exchanging, and using electronic health information, and contribute to its investment. And, as in any culture, we need to clearly communicate with one another, so that our health policies are well informed, products can be marketed with transparency, and protections can be applied to well-defined situations.

Culture change requires a consistent language that can support a system of public policies, private development, and outreach/educational initiatives that will allow the majority of Americans to experience the actual value of an electronic health information infrastructure. Our next step, then, is to assure that this language is in place and represents a consensus on how terminology and definitions should be used as we move toward the 2014 goal. I am pleased that The National Alliance for Health Information Technology has convened this public dialogue and presents here the results.

Costs and Benefits of Health Information Technology

The United States health care system is at risk due to increasing demand, spiraling costs,  inconsistent and poor quality of care, and inefficient, poorly coordinated care systems. Some  evidence suggests that health information technology (HIT) can improve the efficiency, costeffectiveness, quality, and safety of medical care delivery by making best practice guidelines and evidence databases immediately available to clinicians, and by making computerized patient records available throughout a health care network. However, much of the evidence is based on a small number of systems developed at academic medical centers, and little is known about the organizational changes, costs, and time required for community practices to successfully implement off-the-shelf systems. An analysis of the usefulness of implementing HIT must take into consideration several

factors: 

• ·         The potential of this technology to improve health care quality, safety, and patient satisfactionand how this potential has been demonstrated.The cost-effectiveness of the technology—the business case for adoption of the technology including the total costs of implementation (both financial and in terms of resources) and any cost savings that accrue. Concerns exist that those who bear the greatest share of such costs are not able to recoup those costs.  

• ·         The ability to generalize the effects of an HIT intervention on costs and benefits in existing systems (using published experience with or research on these systems) to the technology’s use by other health care organizations. The Leap Frog Group and a number of components of the U.S. Department of Health and Human Services (HHS)—the Centers for Medicare & Medicaid Services (CMS), the Office of the Assistant Secretary for Planning and Evaluation (ASPE), the Office of Disease Prevention and Health Promotion (ODPHP), and the Agency for Healthcare Research and Quality (AHRQ)—requested a review of the research on HIT to compile and evaluate the evidence regarding the value of discrete HIT functions and systems in various health care settings. This  Evidence-based Practice Report on the costs and benefits of health information technology systems, along with an accompanying interactive database that catalogs and assesses the existing evidence was prepared by the Southern California Evidence-based Practice Center (EPC). This report systematically reviews the literature on the implementation of HIT systems in all care settings and assesses the evidence in four specific circumstances: 

1.  The costs and benefits of HIT for pediatric care.
2.  The ability of one aspect of HIT, the electronic health record (EHR), to improve the quality of care in ambulatory care settings.
3. The costs and cost-effectiveness of implementing HER.
4. The effect of HIT on making care more patient-centered.

Pharmacology and formulation

Buprenorphine acts as a partial opioid agonist by attaching tightly to the same receptors in the brain as other opioids, such as oxycodone, heroin, or methadone, blocking their effects and preventing withdrawal symptoms. Buprenorphine produces only weak morphinelike effects, without the euphoria triggered by full opioid agonists in opioiddependent individuals. Buprenorphine carries a lower risk of abuse, dependence, and overdose compared to full opioid agonists.However, a fatal overdose is still possible if patients combine buprenorphine with other central nervous system (CNS) depressants, such as sedative-hypnotics (e.g., benzodiazepines) or alcohol.

Effectiveness of Buprenorphine office-based treatment 

A 2006 evaluation of buprenorphine office-based treatment showed it to be effective. Most physicians surveyed (74%) found one or more months of buprenorphine treatment to be effective for their patients, with 60% of patients abstaining from all drugs and 84% from opioids (except buprenorphine) after a one-month period.

Slightly more than half the physicians (53%) had no previous experience with medication-assisted treatment (MAT) for opioids. (MAT is the use of medications, in combination with counseling and behavioral therapies, to treat substance-use disorders). At a six-month follow-up, 81% of patients said they had abstained from opioids, and 59% said they had abstained from all drugs.

Recognizing opioid abuse and dependence 

Clinicians should be alert to potential signs of substance abuse during routine and urgent visits, or while taking the patient history. Asking nonjudgmental, open-ended questions about a patient’s functioning with his or her family, at work or school, and in social situations may reveal a drug problem. It is important to avoid stigmatization. Primary care physicians can use screening tools such as the CAGEAID (Table 2), which are effective in identifying substance abuse problems. If the substance abuse screen is positive, be aware of signs associated with opioid intoxication such as drowsiness, slurred speech, memory impairment, and pupillary constriction.

After a thorough assessment, a formal diagnosis of either opioid dependence or abuse should be made. Substance dependence or abuse is based on a cluster of behaviors and physiological effects occurring within a specific time frame. The diagnosis of dependence is more severe and therefore supersedes one of abuse if the person meets the criteria for both abuse and dependence listed in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR).

City Health Information

A ddiction to narcotic pain relievers and heroin (opioids) is a major health problem in the United States (US). Rates of abuse and dependence for opioid pain relievers such as Vicodin® (hydrocodone bitartrate and acetaminophen) and OxyContin® (oxycodone HCl controlled-release) have increased during the past several years, and opioids are now second only to marijuana as drugs of abuse.

However, fewer than 20% of Americans who are dependent on opioids (narcotic pain relievers and heroin used intravenously and intranasally) are in drug treatment programs. Drug overdose is one of the leading causes of death in New York City (NYC). In 2006, more than 900 people died of drug overdoses in NYC; heroin and other opioids were involved in the majority of these deaths. Buprenorphine is the only approved officebased treatment for opioid dependence. Buprenorphine makes treatment for opioid dependence more readily available, and patients can have their buprenorphine prescriptions filled at a pharmacy. Opioid addiction treatment in a primary care setting also allows for increased clinical attention to other health conditions amongopioid-dependent individuals.

Framework and Standards for Country Health Information System

The Health Metrics Network (HMN) was launched in 2005 to help countries and other partners improve global health by strengthening the systems that generate health-related information for evidence-based decision-making. HMN is grateful for funding support from the Bill and Melinda Gates Foundation, the Uk Department for International Development (DFID), the Danish International Development Agency (DANIDA), the Netherlands Ministry of Foreign Affairs, the United States Agency for International Development (USAID), the European Commission (EC) and the World Health Organization (WHO), which also serves as host to HMN.

HMN is the first global health partnership that focuses on two core requirements of health system strengthening in low and low-middle income countries. First, the need to enhance entire health information and statistical systems, rather than focus only upon specific diseases. Second, to concentrate efforts on strengthening country leadership for health information production and use. In order to help meet these requirements and advance global health, it has become clear that there is an urgent need to coordinate and align partners around an agreed-upon “framework” for the development and strengthening of health information systems.

It is therefore intended that by 2011, this Framework and Standards for Country Health Information Systems (the “HMN Framework”) will be the universally accepted standard for guiding the collection, reporting and use of health information by all developing countries and global agencies. This will only be achieved by fostering agreement on the goals and coordinated investments now needed by country health information systems.

The HMN Framework will serve two broad purposes. Firstly, at country level, it will focus investment and technical assistance on standardizing health information system development, and serve as a benchmark for baseline system assessments. As part of this, a roadmap is described for strengthening health information systems, and putting in place on going monitoring and evaluation. Second, the HMN Framework will permit access to and better use of improved health information at the country and global levels.

The HMN Framework is not intended to replace existing guidelines that provide detailed information on health information system elements. Instead it will seek to identify appropriate and existing standards and promote them. This dynamic approach is expected to evolve over time as it incorporates new developments, country experiences and partner inputs. This second edition has already been informed by a wealth of input on different aspects of health information systems obtained through consultative meetings and country visits. Its adaptation is intended to be iterative as HMN progresses and country health information systems mature. It is intended that the HMN Framework will be instrumental in forging consensus around the vision, standards and processes required of a health information system.