Medication Data from Nationally Representative Provider- and Population-Based Surveys Lisa L. Dwyer,...

Medication Data from Nationally Medication Data from Nationally Representative Provider- and Representative Provider- and

Population-Based SurveysPopulation-Based Surveys

Lisa L. Dwyer, MPHLisa L. Dwyer, MPH

Saeid Raofi, MS PharmacySaeid Raofi, MS Pharmacy

Karen A. Lees, MPHKaren A. Lees, MPH

Ryne Paulose, PhDRyne Paulose, PhD

National Center for Health StatisticsNational Center for Health Statistics

2006 Data Users Conference (Session #50) 2006 Data Users Conference (Session #50)

Washington, D.C.Washington, D.C.

July 12, 2006July 12, 2006

2

BackgroundBackground

NCHS is the Nation’s principal health statistics NCHS is the Nation’s principal health statistics agencyagency

• compile statistical information to guide actions and compile statistical information to guide actions and policies to improve the health of our peoplepolicies to improve the health of our people

• provide public use files of survey data to the publicprovide public use files of survey data to the public CongressCongress

researchersresearchers

health plannershealth planners

3


Our health statistics allow us to:Our health statistics allow us to:• document the health status of the populationdocument the health status of the population

• monitor trends in health status and health care monitor trends in health status and health care deliverydelivery

• support biomedical and health services researchsupport biomedical and health services research

• provide information to guide and evaluate health provide information to guide and evaluate health policy decisions and programspolicy decisions and programs

4

5

6


NCHS surveys that have collected medication data:NCHS surveys that have collected medication data:• National Health Care Survey (NHCS)National Health Care Survey (NHCS)

National Ambulatory Medical Care Survey National Ambulatory Medical Care Survey (NAMCS)(NAMCS)

National Hospital Ambulatory Medical Care Survey National Hospital Ambulatory Medical Care Survey (NHAMCS)(NHAMCS)

National Nursing Home Survey (NNHS)National Nursing Home Survey (NNHS) National Hospital Discharge Survey (NHDS)National Hospital Discharge Survey (NHDS)

• National Health and Nutrition Examination Survey National Health and Nutrition Examination Survey (NHANES)(NHANES)

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National Health Care SurveyNational Health Care Survey

• family of mostly provider-based surveysfamily of mostly provider-based surveys

• collects information about health care facilities, their collects information about health care facilities, their services, and their patientsservices, and their patients

National Health and Nutrition Examination SurveyNational Health and Nutrition Examination Survey

• population-based surveypopulation-based survey

• consists of a household interview, medical/dental consists of a household interview, medical/dental examinations, and lab testsexaminations, and lab tests

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ObjectivesObjectives

To describe how the National Center for Health To describe how the National Center for Health Statistics (NCHS) collects medication data across Statistics (NCHS) collects medication data across its surveysits surveys

To describe how our data can be used to generate To describe how our data can be used to generate national estimatesnational estimates

To discuss the future direction of NCHS surveysTo discuss the future direction of NCHS surveys

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Prescription MedicationsPrescription Medications

Drugs and their associated costs are at the forefront of Drugs and their associated costs are at the forefront of national health care debates.national health care debates.

According to figures reported by CMS, prescription According to figures reported by CMS, prescription drug expenditures increased at a much faster rate than drug expenditures increased at a much faster rate than the total health care expenditure for most of 1995the total health care expenditure for most of 1995--20042004..

Access to and affordability of drugs for the elderly were Access to and affordability of drugs for the elderly were major drivers behind the Medicare Part D Drug Benefit major drivers behind the Medicare Part D Drug Benefit implementation.implementation.

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Health Care ExpendituresHealth Care Expenditures

02

46

81012

1416

1820

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Year

% in

cre

ase

fro

m p

revi

ou

s ye

ar

Prescription drugexpenditure

Total health careexpenditure

Source: Centers for Medicare & Medicaid Services; www.cms.hhs.gov/NationalHealthExpendData/

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Drug UtilizationDrug Utilization This increase in cost is driven, in part, by an This increase in cost is driven, in part, by an

increase in utilization.increase in utilization.

The national ambulatory health care surveys show The national ambulatory health care surveys show that the number of drugs mentioned per visit that the number of drugs mentioned per visit increased between the 10-year period, 1993/1994 increased between the 10-year period, 1993/1994 and 2003/2004.and 2003/2004.

Previous study reports that medication use is Previous study reports that medication use is highest among the institutionalized elderly. This highest among the institutionalized elderly. This population continues to increase.population continues to increase.

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Increase in Drug Mention RatesIncrease in Drug Mention Rates

0 50 100 150 200 250

Emergencydepartments

Outpatientdepartments

Medical specialtyoffices

Surgical specialtyoffices

Primary care offices

Number of mentions per 100 visits

1993-94

2003-04

Source: 1993-1994, 2003-2004 NAMCS and NHAMCS

Collection and Processing of Drug Collection and Processing of Drug Information in National Ambulatory Information in National Ambulatory Medical Care and National Hospital Medical Care and National Hospital Ambulatory Medical Care SurveysAmbulatory Medical Care Surveys

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Drug Data Collection in National Drug Data Collection in National Health Care SurveysHealth Care Surveys

I will focus on the National Ambulatory Health Care I will focus on the National Ambulatory Health Care surveys, NAMCS and NHAMCS, which have collected surveys, NAMCS and NHAMCS, which have collected drug data the longest.drug data the longest.

The system developed for the processing and coding The system developed for the processing and coding of the collected drug data for NAMCS and NHAMCS of the collected drug data for NAMCS and NHAMCS will be used for processing of the data in other surveys will be used for processing of the data in other surveys as well.as well.

I will also give a detailed description of this processing I will also give a detailed description of this processing and coding system.and coding system.

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NAMCS and NHAMCS BackgroundNAMCS and NHAMCS Background

NAMCS NAMCS

• Fielded 1973-1981, 1985, 1989-presentFielded 1973-1981, 1985, 1989-present

• Began collecting drug data in 1980Began collecting drug data in 1980

NHAMCS NHAMCS

• Fielded annually since 1992Fielded annually since 1992

• Began collecting drug data in 1992Began collecting drug data in 1992

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Patient characteristics Patient characteristics

• Age, sex, race, ethnicityAge, sex, race, ethnicity

Visit characteristicsVisit characteristics

• Source of payment, continuity of care, reason for Source of payment, continuity of care, reason for visit, diagnosis, treatment, medications ordered or visit, diagnosis, treatment, medications ordered or providedprovided

Provider characteristicsProvider characteristics

• Physician specialty, hospital ownershipPhysician specialty, hospital ownership

Items CollectedItems Collected

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National probability sample surveysNational probability sample surveys

Complex sample designsComplex sample designs

Common definitions, data items, sampling framesCommon definitions, data items, sampling frames

Medical diagnoses coded to ICD-9-CMMedical diagnoses coded to ICD-9-CM

High response ratesHigh response rates

Data processed by private contractorData processed by private contractor

NCHS Common MethodologyNCHS Common Methodology

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NAMCS NAMCS • 3-stage sample3-stage sample

PSUs – PSUs –

physicians – physicians –

visits during 1 weekvisits during 1 week

NHAMCS NHAMCS • 4-stage sample4-stage sample

PSUs – PSUs –

hospitals – hospitals –

ED/OPD clinics – ED/OPD clinics –

visits during 4 weeksvisits during 4 weeks

NAMCS and NHAMCS Sample DesignNAMCS and NHAMCS Sample Design

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Generating National Estimates Generating National Estimates from Samplesfrom Samples

Statistics from the NAMCS and NHAMCS are derived Statistics from the NAMCS and NHAMCS are derived by a multistage estimation procedures that produce by a multistage estimation procedures that produce essentially unbiased national estimates.essentially unbiased national estimates.

The basic components of estimation are:The basic components of estimation are:• Inflation by reciprocals of the sampling selection Inflation by reciprocals of the sampling selection

probabilitiesprobabilities

• Adjustment for nonresponseAdjustment for nonresponse

• Weight smoothingWeight smoothing

• A calibration ratio adjustmentA calibration ratio adjustment

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Sample WeightSample Weight

The estimation procedure produces a single The estimation procedure produces a single weight, called Patient Visit weight, for each weight, called Patient Visit weight, for each NAMCS, OPD, and ED record.NAMCS, OPD, and ED record.

This weight is used for both visits and drug This weight is used for both visits and drug mentions.mentions.

Weight must be applied or estimates of totals, Weight must be applied or estimates of totals, percents and effects will be incorrect.percents and effects will be incorrect.

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Definition of Drug MentionsDefinition of Drug Mentions

A drug mention is the provider’s entry of drugs A drug mention is the provider’s entry of drugs (prescription or over the counter), immunizations, (prescription or over the counter), immunizations, allergy shots, anesthetics, chemotherapy, and allergy shots, anesthetics, chemotherapy, and dietary supplements that were ordered, supplied dietary supplements that were ordered, supplied administered or continued during the visit.administered or continued during the visit.

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Drug Data ProcessingDrug Data Processing

Since 2003, the provider can list up to eight drug Since 2003, the provider can list up to eight drug mentions on the survey form. From 1995 to 2002 mentions on the survey form. From 1995 to 2002 the provider could enter up to six drug mentions the provider could enter up to six drug mentions and before then up to five mentions.and before then up to five mentions.

Each drug mention will be associated with a drug Each drug mention will be associated with a drug code at data entry stage.code at data entry stage.

Drugs not in the database will be assigned a new Drugs not in the database will be assigned a new unique code.unique code.

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Adding Drug CharacteristicsAdding Drug Characteristics

Upon completion of visit files, the following drug Upon completion of visit files, the following drug characteristics are added to visit files for each drug characteristics are added to visit files for each drug mentionmention• Generic nameGeneric name

• Therapeutic classTherapeutic class

• IngredientsIngredients

• CompositionComposition

• Control statusControl status

• Rx or OTCRx or OTC

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Drug Coding and Characterization Drug Coding and Characterization ExampleExample

Drug nameDrug name Generic nameGeneric name Therapeutic Therapeutic classclass

ProzacProzac

MED#=25674MED#=25674

FluoxetineFluoxetine

GEN#=80006GEN#=80006

AntidepressantAntidepressant

DRUGCL=0630DRUGCL=0630


MED#=91079MED#=91079


Gen#=80006Gen#=80006



Fluoxetine HCLFluoxetine HCL

MED#=91079MED#=91079


GEN#=80006GEN#=80006



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Utility of Drug CharacteristicsUtility of Drug Characteristics

Drug characteristics can be used to create Drug characteristics can be used to create summary reports based on therapeutic class, summary reports based on therapeutic class, active ingredients, etc.active ingredients, etc.

They can be used in combination with patient and They can be used in combination with patient and visit characteristics to study pharmacotherapy in visit characteristics to study pharmacotherapy in specific disease areas.specific disease areas.

They can be used in combination with physician They can be used in combination with physician characteristics in studies looking at prescribing characteristics in studies looking at prescribing behavior.behavior.

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Example: Therapeutic classes with the Example: Therapeutic classes with the highest mention rate in 2003-2004highest mention rate in 2003-2004

Therapeutic classificationTherapeutic classification Number of Number of mentions/100 visitsmentions/100 visits

Standard error Standard error of rateof rate

Drugs used for relief of painDrugs used for relief of pain 25.725.7 0.70.7

Cardiovascular-renal drugsCardiovascular-renal drugs 25.225.2 1.21.2

Respiratory tract drugsRespiratory tract drugs 20.720.7 0.80.8

Central nervous system drugsCentral nervous system drugs 17.617.6 0.60.6

Antimicrobial agentsAntimicrobial agents 16.016.0 0.50.5

Metabolic/nutrientMetabolic/nutrient 15.215.2 0.80.8

Hormones and agents affecting Hormones and agents affecting hormonal mechanismshormonal mechanisms 15.215.2 0.60.6

Gastrointestinal agentsGastrointestinal agents 9.19.1 0.40.4

Skin/mucous membrane drugsSkin/mucous membrane drugs 7.17.1 0.20.2

Immunologic agentsImmunologic agents 6.36.3 0.40.4

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Example: Mentions of Example: Mentions of Antihypertensive Drugs for Antihypertensive Drugs for Ages 55-64 from 1999-2002Ages 55-64 from 1999-2002

Probability of Hypertensive Visit having a Specific Drug MentionProbability of Hypertensive Visit having a Specific Drug Mention

Predicted ProbabilitiesPredicted Probabilities

Insurance StatusInsurance Status

VariableVariable MeanMean InsuredInsured UninsuredUninsured p-valuep-value

ACE InhibitorsACE Inhibitors 0.2570.257 0.2600.260 0.2000.200 0.1350.135

Beta BlockersBeta Blockers 0.1530.153 0.1600.160 0.1100.110 0.2060.206

Calcium Channel BlockersCalcium Channel Blockers 0.2100.210 0.2100.210 0.2400.240 0.4540.454

DiureticsDiuretics 0.1320.132 0.1300.130 0.1000.100 0.2710.271

AspirinAspirin 0.0700.070 0.0700.070 0.0400.040 0.0620.062

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Therapeutic Classification System Therapeutic Classification System Through 2004Through 2004

Since 1985, the FDA’s NDC therapeutic Since 1985, the FDA’s NDC therapeutic classification has been used classification has been used

Limitations of this system:Limitations of this system:

• Only has one level of sub-classificationOnly has one level of sub-classification

• FDA has discontinued this productFDA has discontinued this product

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Adoption of Multum Lexicon as the Adoption of Multum Lexicon as the Therapeutic Classification SystemTherapeutic Classification System

Starting with 2005 data, Multum therapeutic Starting with 2005 data, Multum therapeutic classification system will be used for classifying classification system will be used for classifying NAMCS and NHAMCS drug data.NAMCS and NHAMCS drug data.

This system has two level of sub-classification.This system has two level of sub-classification.

It is regularly updated.It is regularly updated.

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Example: Classification of Paroxetine Example: Classification of Paroxetine by the two classification systemsby the two classification systems

NDC systemNDC system

• 0600 central nervous system0600 central nervous system 0630 antidepressants0630 antidepressants

Multum Lexicon systemMultum Lexicon system

• 242 psychotherapeutic agents242 psychotherapeutic agents 249 antidepressants249 antidepressants

208 SSRI antidepressants208 SSRI antidepressants

Using NAMCS/NHAMCS public use Using NAMCS/NHAMCS public use files for analyzing drug datafiles for analyzing drug data

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Ambulatory Care Data StructureAmbulatory Care Data Structure

Provider provider info practice info

geographic info

Visit patient & visit info

treatment & outcome infomedications

Visit Visit

Medcode 1 …Medcode 8

Class 1 Ingredient 1 ..ingredient 5

…Class 3

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File StructureFile Structure

Flat ASCII files for each setting and yearFlat ASCII files for each setting and year

Use file layout to read the dataUse file layout to read the data

Input and format code available for:Input and format code available for:

• SASSAS

• STATASTATA

• SPSSSPSS

Can use SETS (but no sampling variance Can use SETS (but no sampling variance estimates)estimates)

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Visit File LayoutVisit File Layout

Setting&

Year

Patient Info:Age, Sex,

Race, Ethnicity

Visit Info:Date, Reason

for Visit, Payment source,

Diagnosis, Patient Weight

Treatment Info:

Diagnostic services,

Counseling/education,

Therapeutic services

Medication Info:

Drug Name, Generic Name,

Ingredients,Therapeutic

class

Outcome Measures:

No follow up planned,

Return, Refer,Admit to Hospital

Provider Info:

Specialty, Region,

Urban, SoloPractice,

Ownership

35

http://www.cdc.gov/nchs/about/major/ahcd/ahcd1.htm

Ambulatory Health Care DataAmbulatory Health Care Data

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Drug Database SystemDrug Database System

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Example of Drug Lookup FunctionExample of Drug Lookup Function

By brand name PAXIL

BY GENERIC NAME PAROXETINE

http://www2.cdc.gov/drugs/

38

39

40

41

42

For more information on the NAMCS and NHAMCS, For more information on the NAMCS and NHAMCS, please visitplease visit

http://www.cdc.gov/nchs/about/major/ahcd/ahcd1.htmhttp://www.cdc.gov/nchs/about/major/ahcd/ahcd1.htm

Medication Data Collected Medication Data Collected

in thein the

2004 National Nursing Home Survey2004 National Nursing Home Survey

44


Nationally representative sample survey of U.S. Nationally representative sample survey of U.S. nursing homesnursing homes

services/programsservices/programs

staffstaff

residentsresidents

Conducted periodically since 1973-74Conducted periodically since 1973-74 1977, 1985, 1995, 1997, 1999, 20041977, 1985, 1995, 1997, 1999, 2004

45


Taken out of the field after the 1999 survey for a Taken out of the field after the 1999 survey for a major redesign.major redesign.

Put back into the field in 2004Put back into the field in 2004

• computerized data collectioncomputerized data collection

• many new content items, including collection of many new content items, including collection of medication datamedication data

• supplemental survey on nursing assistants, NNAS supplemental survey on nursing assistants, NNAS

46


Two-stage probability survey designTwo-stage probability survey design

• nursing home facilitynursing home facility

• residents (up to 12 current residents)residents (up to 12 current residents)

47


Sampling frameSampling frame

• Centers for Medicare and Medicaid Services Centers for Medicare and Medicaid Services Provider of Services file of U.S. nursing homesProvider of Services file of U.S. nursing homes

• state licensing lists compiled by private state licensing lists compiled by private organizationorganization

• total of 16,628 nursing homes in frame total of 16,628 nursing homes in frame

48


Eligibility criteriaEligibility criteria

• licensed by State as a nursing facilitylicensed by State as a nursing facility

• certified and non-certified facilitiescertified and non-certified facilities

• three or more bedsthree or more beds

49


Survey itemsSurvey items

• medications taken 24 hrs before facility interviewmedications taken 24 hrs before facility interview standing or routine medications, or PRNsstanding or routine medications, or PRNs

up to 25 medicationsup to 25 medications

• medications taken regularly but not 24 hrs medications taken regularly but not 24 hrs before facility interviewbefore facility interview up to 25 medicationsup to 25 medications

• reason medications were prescribedreason medications were prescribed

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Medication dataMedication data

• found in medication administration recordsfound in medication administration records

did not collect dosage, frequency, routedid not collect dosage, frequency, route

• collected during in-person interview at facilitycollected during in-person interview at facility

• entered into CAPI system by interviewerentered into CAPI system by interviewer

• processed like NAMCS/NHAMCS dataprocessed like NAMCS/NHAMCS data

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Medication data collectedMedication data collected

• prescription and nonprescription medicationsprescription and nonprescription medications

• genericsgenerics

• supplementssupplements

vitamin/mineral, herbal, nutritionalvitamin/mineral, herbal, nutritional

52


Drug characteristics appendedDrug characteristics appended

• generic namegeneric name

• ingredientsingredients

• therapeutic classestherapeutic classes

• composition statuscomposition status

• prescription statusprescription status

• DEA statusDEA status

53


Data collected in 2004 NNHS are organized Data collected in 2004 NNHS are organized into three independent files:into three independent files:

• Facility Facility

• ResidentResident

• Prescribed medicationPrescribed medication

54

2004 National Nursing Home Survey2004 National Nursing Home Survey Resident FileResident File

• ageage• sexsex• racerace• marital statusmarital status• admission diagnosisadmission diagnosis• current primary and secondary current primary and secondary

diagnosesdiagnoses• services/treatments receivedservices/treatments received• activities of daily living (ADLs)activities of daily living (ADLs)• vaccination statusvaccination status• expected source(s) of paymentexpected source(s) of payment

Facility FileFacility File

• bed sizebed size

• ownershipownership

• servicesservices

• per diem ratesper diem rates

• special programsspecial programs

• staffingstaffing

55


The Prescribed Medications (PM) file includes:The Prescribed Medications (PM) file includes:

• medication codesmedication codes

• ICD-9 codesICD-9 codes

• drug characteristicsdrug characteristics

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PMPMData FileData File ++

Resident Resident Data FileData File

==AnalyticAnalytic

FileFile

Warning: Great analytic potential but very large file with Warning: Great analytic potential but very large file with over 13,000 records and over 1000 variables per record.over 13,000 records and over 1000 variables per record.

(164,000 KB)(164,000 KB) (13,000 KB)(13,000 KB)

Link data files using a randomly assigned ID #Link data files using a randomly assigned ID #

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2004 National Nursing Home Survey 2004 National Nursing Home Survey

New data set provides information on: New data set provides information on:

• 1.5 million current residents (weighted estimate)1.5 million current residents (weighted estimate)

71% female, 29% male71% female, 29% male

mean age = 81 (standard error = 0.24)mean age = 81 (standard error = 0.24)

86% White, 12% Black, 2% Other86% White, 12% Black, 2% Other

Preliminary Results.

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Resources available to data users:Resources available to data users:

Tab delimited ASCII file of PM dataTab delimited ASCII file of PM data

Long-term Care Drug DatabaseLong-term Care Drug Database

Data dictionary documentData dictionary document

User’s manual User’s manual

SAS, SPSS, and STATA input statementsSAS, SPSS, and STATA input statements

59


Things to consider when analyzing NNHS data:Things to consider when analyzing NNHS data:

• complex sample survey designcomplex sample survey design multiple stages of selectionmultiple stages of selection

• sampling weights are requiredsampling weights are required point estimatepoint estimate

standard errorstandard error

• statistical software that takes the sample design statistical software that takes the sample design into accountinto account

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Guidelines for Reporting EstimatesGuidelines for Reporting Estimates

Check Check samplesample sizesize and and standard error.standard error.

Calculate the relative standard error (RSE).Calculate the relative standard error (RSE).

If sample size < 30, then the value of the estimate should not be reported.If sample size < 30, then the value of the estimate should not be reported.

If sample size is 30If sample size is 3059, or greater than 59 and the RSE 59, or greater than 59 and the RSE 30%, then the 30%, then the estimate can be reported but should not be considered reliable.estimate can be reported but should not be considered reliable.

If sample size If sample size 60 and the RSE < 30, then the estimate is considered 60 and the RSE < 30, then the estimate is considered reliable.reliable.

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Example: Mean number of medications per residentExample: Mean number of medications per resident

Total population: Mean = 8.73, SE Mean = 0.07Total population: Mean = 8.73, SE Mean = 0.07

Male population: Mean = 8.52, SE Mean = 0.11Male population: Mean = 8.52, SE Mean = 0.11

Female population: Mean = 8.81, SE Mean = 0.07Female population: Mean = 8.81, SE Mean = 0.07


62


RSE = (S.E. of point estimate/point estimate) * 100RSE = (S.E. of point estimate/point estimate) * 100

RSE for Total population = (0.07/8.73) * 100 = 0.80

RSE for Male population = (0.11/8.52) * 100 = 1.29

RSE for Female population = (0.07/8.81) * 100 = 0.79


63


Other examples of how data can be used:Other examples of how data can be used:

to analyze how medications are used and if used for off-to analyze how medications are used and if used for off-label indicationslabel indications

to examine the differences in medication use among to examine the differences in medication use among subpopulationssubpopulations

to explore which medications were taken by residents to explore which medications were taken by residents receiving hospice/palliative/end-of-life carereceiving hospice/palliative/end-of-life care

to determine the top therapeutic classes taken by nursing to determine the top therapeutic classes taken by nursing home residentshome residents

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Therapeutic ClassTherapeutic Class % of residents % of residents (n=1,492,207)(n=1,492,207)

% ther. classes % ther. classes (n=12,979,578)(n=12,979,578)

Vitamins or minerals Vitamins or minerals 57.257.2 6.66.6

LaxativesLaxatives 48.048.0 5.55.5

AntidepressantsAntidepressants 46.246.2 5.35.3

Non-narcotic analgesicsNon-narcotic analgesics 44.044.0 5.15.1

Acid or peptic disorder drugsAcid or peptic disorder drugs 43.143.1 5.05.0

AntipyreticsAntipyretics 41.741.7 4.84.8

DiureticsDiuretics 35.235.2 4.14.1

Replenishers/regulators of electrolytesReplenishers/regulators of electrolytes 31.231.2 3.63.6

AntiarthriticsAntiarthritics 31.131.1 3.63.6

Antipsychotics or antimanicsAntipsychotics or antimanics 25.925.9 3.03.0

Top Therapeutic Classes Taken by ResidentsTop Therapeutic Classes Taken by Residents


65

For more information on the NNHS, please visitFor more information on the NNHS, please visit

http://www.cdc.gov/nchs/nnhs.htmhttp://www.cdc.gov/nchs/nnhs.htm

Collecting Medication Data in the Collecting Medication Data in the National Hospital Discharge National Hospital Discharge Survey: Results from a Pilot Survey: Results from a Pilot

StudyStudy

67

National Hospital Discharge SurveyNational Hospital Discharge Survey

Conducted annually since 1965Conducted annually since 1965

Produces nationally representative data on Produces nationally representative data on characteristics of patients discharged from Non-characteristics of patients discharged from Non-Federal, short-stay hospitalsFederal, short-stay hospitals

68


National probability sample:National probability sample:

• Short-stay, non-Federal hospitalsShort-stay, non-Federal hospitals

Three stage design:Three stage design:

• Geographic units (PSUs)Geographic units (PSUs)

• HospitalsHospitals

• DischargesDischarges

69


Hospitals included:Hospitals included:

• General hospitalsGeneral hospitals

• Children’s general hospitalsChildren’s general hospitals

• Hospitals with an average length of stay of less than 30 daysHospitals with an average length of stay of less than 30 days

Hospitals excluded:Hospitals excluded:

• Federal hospitalsFederal hospitals

• Military and VA hospitalsMilitary and VA hospitals

• Hospitals in institutions (such as prisons)Hospitals in institutions (such as prisons)

• Hospitals with fewer than 6 bedsHospitals with fewer than 6 beds

70


Sample SizeSample Size

• Approximately 500 hospitals sampled per yearApproximately 500 hospitals sampled per year

• Over 300,000 discharges sampled per yearOver 300,000 discharges sampled per year

Data CollectionData Collection

• 55% manual55% manual

• 45% automated45% automated

States, commercial firms, individual hospitalsStates, commercial firms, individual hospitals

71


Data are abstracted from Data are abstracted from the patient’s medical the patient’s medical recordrecord

Data are edited and Data are edited and weighted to produce weighted to produce national estimatesnational estimates

0

0.5

1

1.5

2

2.5

3

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

Year

Nu

mb

er in

Mill

ion

s

72


Patient DataPatient Data

• AgeAge

• SexSex

• RaceRace

• Expected source of Expected source of paymentpayment

• Admission source and Admission source and typetype

• Discharge statusDischarge status

Hospital DataHospital Data

• Bed sizeBed size

• OwnershipOwnership

• Geographic regionGeographic region

73


Medical DataMedical Data

• DiagnosesDiagnoses – principal and up to six secondary – principal and up to six secondary

• Surgical, diagnostic, or therapeutic Surgical, diagnostic, or therapeutic proceduresprocedures – – up to fourup to four

Coded according to the International Classification Coded according to the International Classification of Diseases (ICD-9-CM)of Diseases (ICD-9-CM)

74


Weight:Weight:

• Inverse of the probability of selectionInverse of the probability of selection

• Adjustments for non-responseAdjustments for non-response

• Population weighting ratio adjustmentPopulation weighting ratio adjustment

75

National Hospital Discharge Survey National Hospital Discharge Survey and Uniform Bill-92 (UB-92)and Uniform Bill-92 (UB-92)

Objective of UB-92Objective of UB-92

• To standardize and increase the submission of To standardize and increase the submission of electronic claimselectronic claims

UB-92 limits the information available for the UB-92 limits the information available for the NHDS to that which is necessary for billingNHDS to that which is necessary for billing

Unable to modify the variables collected in the Unable to modify the variables collected in the NHDSNHDS

76

NHDS Pilot StudyNHDS Pilot Study

To examine whether pharmaceutical data can be To examine whether pharmaceutical data can be added to the manual or primary data collection part of added to the manual or primary data collection part of NHDSNHDS

Two-phase study conducted in 34 hospitals in three Two-phase study conducted in 34 hospitals in three areas of the countryareas of the country

• 791 discharges from 2003791 discharges from 2003

• Registered Health Information Technicians (RHIT) Registered Health Information Technicians (RHIT) collected datacollected data

• Collected the names of all medications listed as Collected the names of all medications listed as administered in the medical record for that dischargeadministered in the medical record for that discharge

77

NHDS Pilot StudyNHDS Pilot Study

MedicationsMedications

• Total of 10,839 medications collectedTotal of 10,839 medications collected 74 were illegible or indeterminate (<1%)74 were illegible or indeterminate (<1%)

• Range: 0 to 63Range: 0 to 63

• Mean: 13.61, Median: 13.00Mean: 13.61, Median: 13.00

• 3% had no medications listed3% had no medications listed

78

Average number of medications Average number of medications overall and by genderoverall and by gender

14.213.113.6

0

2

4

6

8

10

12

14

16

18

20

Overall Male Female

Av

era

ge

nu

mb

er

of

me

dic

ati

on

s

79

Average number of medications Average number of medications administered by ageadministered by age

0

2

4

6

8

10

12

14

16

18

20

Newborn <1 1-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75+

Age (years)

Nu

mb

er o

f m

edic

atio

ns

Overall: 13.6 medicationsOverall: 13.6 medications

80

Average number of medications by Average number of medications by length of staylength of stay

18.4

17.3

14.4

9.5

0

2

4

6

8

10

12

14

16

18

20

1-2 days 3-4 days 5-10 days 11+ days

Length of stay

Av

era

ge

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s Overall: 13.6 medicationsOverall: 13.6 medications

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Top Therapeutic ClassesTop Therapeutic Classes

Therapeutic ClassTherapeutic Class

Medication Medication FrequencyFrequency

(n=10,839)(n=10,839)

Patient Patient FrequencyFrequency

(n=791)(n=791)Narcotic analgesicsNarcotic analgesics 8.9%8.9% 21.6%21.6%

LaxativesLaxatives 4.9%4.9% 12.4%12.4%

Non-narcotic analgesicsNon-narcotic analgesics 4.8%4.8% 16.2%16.2%

AntipyreticsAntipyretics 4.6%4.6% 10.1%10.1%

Acid or peptic disordersAcid or peptic disorders 3.8%3.8% 9.6%9.6%

AntihistaminesAntihistamines 3.7%3.7% 8.5%8.5%

Replenishers or regulators of electrolytesReplenishers or regulators of electrolytes 3.6%3.6% 8.3%8.3%

Vertigo or motion sickness or vomitingVertigo or motion sickness or vomiting 3.5%3.5% 9.0%9.0%

Sedatives or hypnoticsSedatives or hypnotics 2.9%2.9% 10.1%10.1%

NSAIDsNSAIDs 2.8%2.8% 11.1%11.1%

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Top Generic Drugs AdministeredTop Generic Drugs Administered

Therapeutic ClassTherapeutic Class

Medication Medication FrequencyFrequency

(n=10,839)(n=10,839)

Patient Patient FrequencyFrequency

(n=791)(n=791)AcetaminophenAcetaminophen 7.2%7.2% 66.2%66.2%

MorphineMorphine 2.2%2.2% 25.7%25.7%

HydrocodoneHydrocodone 2.1%2.1% 25.0%25.0%

DocusateDocusate 1.9%1.9% 24.5%24.5%

Magnesium antacidsMagnesium antacids 1.8%1.8% 24.9%24.9%

PromethazinePromethazine 1.7%1.7% 22.0%22.0%

Potassium replacement solutionsPotassium replacement solutions 1.6%1.6% 18.6%18.6%

Sodium chlorideSodium chloride 1.5%1.5% 16.6%16.6%

DiphenhydramineDiphenhydramine 1.4%1.4% 18.6%18.6%

Ondansetron hydrochlorideOndansetron hydrochloride 1.4%1.4% 18.8%18.8%

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For more information on the NHDS, please visit For more information on the NHDS, please visit our webpage:our webpage:

http://www.cdc.gov/nchs/nhds.htmhttp://www.cdc.gov/nchs/nhds.htm

For more information on the pilot study or the For more information on the pilot study or the NHDS redesign, please contact me at:NHDS redesign, please contact me at:

Karen Lees, MPHKaren Lees, MPH

Email: [email protected]: [email protected]

Phone: (301) 458-4518Phone: (301) 458-4518

84

NHCS Future StepsNHCS Future Steps

Adoption of Multum therapeutic classification system Adoption of Multum therapeutic classification system beginning with 2005 databeginning with 2005 data

2007 National Home and Hospice Care Survey2007 National Home and Hospice Care Survey

2008 National Survey of Residential Care Facilities2008 National Survey of Residential Care Facilities

2006 National Survey of Ambulatory Surgery2006 National Survey of Ambulatory Surgery

NHDS RedesignNHDS Redesign

• Contract currently let with RANDContract currently let with RAND

• Options being evaluated currentlyOptions being evaluated currently

• Anticipate new NHDS collecting data in 2010Anticipate new NHDS collecting data in 2010

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Medication Data from Nationally Representative Provider- and Population-Based Surveys Lisa L. Dwyer,...

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