Health Care Disparities Research: Using the National Health Care Surveys

1. Health Care Disparities Research:Using 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

2. 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 2008;374-382.

3. 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

4. Examples of Data Provider Organizations Setting Sources of revenue Ownership/staffing Technologies Electronic medical records Clinicians Specialty and training Visits Region Gender 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

5. New Patients Whom Physicians WereNot Accepting , 2001-2006 1/Trend is statistically significant (p<0.05). Source: National Ambulatory Medical Care Survey, 2001-2006 Hing et al. National Health and Vital Statistics Series 13 2008; no 266

6. 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

7. Ambulatory Visits by Setting, 2005 Asian White Black/African-American Sources: National Ambulatory and National Hospital Ambulatory Medical Care Surveys, 2005. Burt C. et al. Advance Data 2007;388.

8. Ambulatory Visits in Different Settings by Poverty in Patient Zip Code, 2001-2005 40% or more Poverty 30-39% Poverty 20-29% Poverty < 20% Poverty Sources: National Ambulatory and National Hospital Ambulatory Medical Care Surveys, 2001-2005.

9. Emergency Department Waiting Times, 1997-2004 *Chi-square test among categories; p < .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):27:w84-95.

10. Appropriate Medication Therapy*Adult Visits with Atrial Fibrillation (AF) Prominent Measure Denominator Numerator Exclusions Antithrombotic AF visits AF visits with AF visits with GI therapywarfarin, bleeding, dicumarol,duodenitis, anisindione, alcoholism, drug or aspirin abuse, Alzheimer’s, gait abnormality, cerebral hemorrhage, seizure disorder, CNS tumors, renal insufficiency, or thrombocytopenia 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 2005;165:1354-1361.

11. 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 AF51 52 60 Diuretic + β-blocker, HTN57 63 54 IC, asthma, adults38 36 30 ACE inhibitor, CHF32§ 45§ 20 IC, asthma, children23 27 20 β-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 2005;165:1354-1361.

12. 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/fig6.htm

13. Adult VaccinationsNursing Home Residents, 2004 Source: 2004 National Nursing Home Survey

14. Methodological Challenges • Encounter, not person-based • Limited sample size • Missing data • Clustering

15. 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

16. 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

17. For More Informationhttp://www.cdc.gov/nchs/nhcs.htm E-mail nsonnenfeld@cdc.gov