Suzanne E. Proctor, MSPH Richard J. Klein, MPH NCHS Data User’s Conference July 12, 2004

1. Methodological Issues in Producing CDC Data for the National Healthcare Quality and Disparities Reports Suzanne E. Proctor, MSPH Richard J. Klein, MPH NCHS Data User’s Conference July 12, 2004

2. Background • Preliminary set of measures for the 1st National Healthcare Quality Report (NHQR) and National Healthcare Disparities Report (NHDR) presented to NCHS in summer 2002 • High degree of overlap between measures in two reports (same Quality of Care measures) • Majority of requested measures were Healthy People 2010 measures • Measures already gone through consensus process • Established national data source • Measures widely recognized & used at Federal & State levels

3. Background • Inclusion of HP2010 measures simplified the project • Operational definitions developed • Technical issues (e.g., age adjustment) resolved • SAS/SUDAAN programs written • Some baseline & update data available for most measures • However… • Definitions for some measures differed slightly from HP2010 • Population subgroup data and cross-tabulations requested beyond what is regularly programmed for HP2010 • Additional analytic issues arose during the production of data

4. Scope of NCHS Contribution

5. Summary of Measures Provided for the 2003-2004 Reports

6. Summary of Measures Provided for the 2003-2004 Reports

7. Distribution of Measures by Healthy People 2010 Focus Area 1. Access to Quality Health Services 3. Cancer 5. Diabetes 12. Heart Disease & Stoke 13. HIV 14. Immunization & Infectious Diseases 16. Maternal, Infant & Child Health 18. Mental Health 21. Oral Health 24. Respiratory Diseases Number of measures (both reports) Not a HP2010 measure

8. Distribution of Measures by National Data Source National Health Interview Survey National Ambulatory Medical Care Surveys National Vital Statistics System National Health and Nutrition Examination Survey National Immunization Survey Children with Special Healthcare Needs National Hospital Discharge Survey National Home and Hospice Care Survey National Nursing Home Survey National Nosocomial Infections Surveillance System Number of measures (both reports) Behavioral Risk Factor Surveillance System Adult Spectrum of Disease Surveillance Project HIV/AIDS Reporting System

9. Types of Measures Provided

10. Selected NHQR measures Effectiveness • Percent of women (40 and over) who report they had a mammogram in the past 2 years • Hospital admissions for pediatric asthma per 10,000 population under 18 years • HIV-infection deaths per 100,000 population Safety • Central line-associated bloodstream infection in Intensive Care Unit patients

11. Selected NHQR measures Timeliness • Percent of persons who have a usual source of medical care, by place of care • Percent of patients who wait 1 or more hours to be seen by a physician, by urgency of needed care Patient Centeredness (No measures provided)

12. Selected NHDR measures Quality of Care • Effectiveness:Hospital admissions for lower extremity amputations in patients with diabetes per 1,000 population • Safety:(No measures provided) • Timeliness:Percent of persons in fair or poor health who have a specific source of on-going care • Patient centeredness:(No measures provided)

13. Selected NHDR measures Access to Care • Entry barriers:Percent of persons < 65 years with public health insurance only • Structural barriers:(No measures provided) • Patients’ perceptions:(No measures provided) • Use:Emergency department visits per population

14. Depth of Data Provided

15. Data Templates • Specific tabulations requested by AHRQ differed for the NHQR and NHDR

16. Typical NHQR Data Template for Population-Based Objectives Gender Female Male Socioeconomic Status Family Income Level Poor Near poor Middle/high income or Education Level Less than high school High school graduate At least some college Total Age Race American Indian or Alaska Native Asian or Pacific Islander Asian Native Hawaiian or Other Pacific Islander Black or African American White Hispanic origin and race Hispanic or Latino Not Hispanic or Latino Black or African American White

18. NHDR Data Templates for Population-Based Objectives • Race x NHQR variables • Ethnicity x NHQR variables • Socioeconomic status x NHQR variables

20. Data Templates • Specific tabulations requested by AHRQ differed for the NHQR and NHDR • Availability of data to complete templates varied by data source • SES and health insurance information not available from all data sources • Collection & tabulation of race/ethnic data differed by data source • Data quality/small number issues limited ability to provide data for some cross-tabulations in the NHDR

21. Tracking Trends

22. Tracking Trends – Key Issues • Change in Federal standards for collecting and tabulating race/ethnicity data • Change in Census population denominators • National/State data comparability • Periodicity of data collection • Sample size and data quality issues

23. Population Denominators • For the 2003 reports, NCHS provided 1999 and 2000 data from NVSS • Denominators for these data were post-censal estimates (based on the 1990 Census) • For the 2004 reports, NCHS reran the 1999 and 2000 NVSS data using 2000 census data and revised 1999 inter-censal estimates

26. National/State Data Comparability • National andState data provided for 25 measures • In general, the national and State data were comparable • NVSS national and State data based on same source reports • NIS national and State data based on same source reports • NHIS (national) and BRFSS (state) surveys – compare cautiously • However, not all of the BRFSS questions were asked by all States each year • Some BRFSS questions contained in optional modules

29. Periodicity of Data • For most measures, NCHS was able to provide a new data point for each data year shown • However … • Some surveys are fielded on a periodic basis (e.g. NNHS) • Questions used to track some measures were not included in the survey each year (e.g. NHIS, BRFSS) • For some measures, needed to combine 2 or more years of data to obtain reliable estimates (e.g. NHANES)

30. Periodicity of Data - Example • NHIS measure: 12-12. Percent of adults (18 years and over) who have had a blood pressure measurement within the past 2 years and can state whether it was normal or high Data available in 1998, 2003 • BRFSS measure: 12-15. Percent of adults (18 years and over) who have had their blood cholesterol checked within the past 5 years 2001: 50 States + D.C. 2002: 12 States + D.C.

32. Sample Size/Data Quality Issues • Data for smaller subpopulation groups may be statistically unreliable due to small sample size • Even when the subpopulation groups size is sufficient for univariate analysis, cross-tabulation with other variables in the template can spread the data too thin • For some data sources, the sample design does not produce representative estimates for some sub-population groups • Large number of missing responses • DSU – data are suppressed

38. Summary • Reports provided an opportunity for intra-agency and cross-agency collaboration on two major Federal public health reports • Reports provided a rich source of additional data for HP2010 (e.g. Progress Reviews) • Excellent example of how the existing Federal data infrastructure can be readily used for in-depth examination of critical public health issues