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APPENDIX A The NCHS Plan for a National Health Care Survey

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THE NATIONAL HEALTH CARE SURVEY Division of Health Care Statistics National Center for Health Statistics Centers for Disease Control December 1990

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EXECUTIVE SUMMARY During the past decade, notable changes in the organization, financing, and delivery of health care have occurred brought about, in part, by cost containment and medical effectiveness initiatives, aging of the population, and changes in the practice of medicine. Further changes are anticipated in the future. The impact of these changes includes a greater diversity in insurance and benefit programs; development and growth in new or alterna- tive settings of health care; and changes in the medical care received by individuals and in the use of medical care technology. These changes have outpaced the capabilities of existing data systems to provide relevant and timely data, a problem compounded by the periodic nature of many surveys. As a result, the National Center for Health Statis- tics (NCHS) has undertaken a major review of its existing surveys of health This review has evolved into plans for a restructuring of these surveys. Under this plan, four NCHS surveys of health care providers, the Na- tional Ambulatory Medical Care Survey, the National Hospital Discharge Survey, the National Nursing Home Survey, and the National Master Facil- ity Inventory, are being merged and expanded, over time, into an ongoing, integrated National Health Care Survey (NHCS). In part, this is being accomplished by reducing the sample sizes for health care providers cov- ered in existing surveys and by stretching the sample over a number of care providers. years. The primary objectives of the NHCS are: to provide national data for "alternative" sites of health care, such as hospital emergency and outpatient departments, ambulatory surgi-centers, home health agencies, and hospices; to increase the analytical uses of survey data through the use of an integrat- ed cluster sample design; to develop the capability to conduct patient fol- low-up studies to examine issues related to the outcome and subsequent use of medical care; and to survey health care providers on an annual basis, thus eliminating gaps in data and fluctuations in resource requirements. NCHS has requested that the Institute of Medicine and the Committee on National Statistics conduct a panel study to evaluate and make recom- mendations regarding the proposed plans for the National Health Care Sur- vey.

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96 TABLE OF CONTENTS I. Background A. Dynamics of the Health Care Delivery System B. Impact on the Health Care Delivery System C. NCHS Data Systems D. Implications for Health Care Data II. A National Health Care Survey A. Components B. Coverage C. Content D. Features E. Flexibility F. Integrated Survey Design G. Current Status and Schedule APPENDIX A

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NCHS PLAN I. BACKGROUND A. Dynamics of the Health Care Delivery System 97 There have been profound changes in recent years that have reshaped many aspects of the health care delivery system in the United States. Fur- ther changes are expected to take place in the years to come. These changes affect not only the recipients of medical care, but the providers of care and medical insurance and benefit programs as well. Any overview of factors influencing the health care delivery system necessarily involves a degree of oversimplification; however, the following areas are among those frequent- ly discussed: Cost containment Health care expenditures increased from $248 bil- lion in 1980 to $500 billion in 1987, an increase of 102 percent, com- pared with a 66 percent increase in the Gross National Product. In response to these rapidly increasing health care expenditures, public and private purchasers of care have moved to institute reforms in the traditional third-party payment mechanisms, which were widely per- ceived as providing incentives for overutilization of health services. Major reforms by government have included the implementation of the Medicare Prospective Payment System; strengthening of Federally-man- dated utilization review programs; State-initiated reforms in Medicaid programs; and physician payment reform. At the same time, businesses and insurance carriers, individually or through local coalitions, have moved to strengthen claims and utilization review; to institute greater cost sharing with beneficiaries; to offer expanded choices of coverage levels to employees, including capitation arrangements; and to use their market power to enter into preferred provider arrangements with hospi- tals and physician groups. Medical effectiveness Recent legislative and departmental health care initiatives, mirroring the feeling of many health care professionals, have focused on the effectiveness and outcomes of health care. Several activities indicating the importance of this emerging issue have oc- curred in the past year: Congress has enacted legislation to expand the Federal program of medical effectiveness research; and the Department of Health and Human Services, as part of its Medical Treatment Effec- tiveness Program, has awarded approximately $6 million in research grants to study patient outcomes and effectiveness of medical treat- ment. In September 1989, two "Effectiveness" conferences, including one sponsored by the Institute of Medicine, were held to review various aspects of this complex issue, such as the current research and health policy activities, the methods and data necessary for assessment, and the future direction of this effort.

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98 APPENDIX A Aging of the populationRapid growth is occurring in the number and proportion of older persons in the population, as life expectancy at birth has risen to nearly 75 years; more importantly, persons reaching age 65 can expect, on average, to live another 17 years. Improvements in the morbidity status of this population have led to growing numbers that can live relatively independently, and a rise in the demand for health and social services that support independent living. At the same time, those persons that are institutionalized consume a large and growing share of health resources. This demand will expand in future years as the baby boomers age into the 65 years and older group. Medicine and technologyOver the last several decades, investment in basic research, combined with a reimbursement system that encouraged the use of technology, has led to the rapid development and diffusion of new diagnostic and treatment modalities. In many cases, due to reim- bursement incentives, intensity of treatment, and cost, the use of these procedures was limited to inpatient settings. In recent years, as many existing technologies have become more routine and new lower-intensity and less costly procedures have been developed, many procedures are now performed in outpatient and ambulatory settings. A variety of new facilities have emerged and grown to address this health care market. B. Impact on the Health Care Delivery System In the 1970's, the health care system was characterized by heavy reli- ance on inpatient care, fee-for-service physicians, cost- or charge-based reimbursement through third-party insurers, and the insulation of consumers of health care from financial risk. During the 1980's, as a result of some of the factors outlined above, there has been a growing trend toward greater diversification in organization, financing, and delivery of health care. Evi- dence of this diversity includes the proliferation of insurance and benefit alternatives for individuals; new forms of physician group practice; and growth in the number of alternative sites of care, such as surgical centers, walk-in ambulatory care facilities, and home health agencies. Surgery is now provided on an outpatient basis for many procedures for which patients would have been admitted as inpatients previously. The substitution of alternative sites of medical c; ;-- for high-cost inpatient hos- pital care is having a dramatic effect on i-- structure, organization, and finance of surgical care to the point that for some procedures the outpatient and ambulatory settings have become the preferred location for such care. The emphasis placed on the reduction of regulation and promotion of market forces, as well as efforts to contain costs, has led to increased com- petition between providers and insurers of health care. At the Federal level,

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NCHS PLAN 99 health planning programs have been de-emphasized, and other forms of regulation have been eased. At the same time, employers and insurers have facilitated increased competition by offering a greater range of choices, and consumers have responded with a growing acceptance of alternative forms of health care organization, as shown in the growth of enrollment in health maintenance organizations and other types of prepaid plans. Further, pro- viders, in positions of both relative oversupply or underutilization, have sought to more aggressively market their services or enter into "preferred provider" arrangements to protect their market share. One of the many emerging themes in the area of medical effectiveness research is the need for reliable and valid utilization data to measure and assess health care outcomes and medical technology. [discussion of these data needs and the methods for obtaining and analyzing these data is a frequent agenda item, for example, the use of administrative data and regis- tries to assess medical effectiveness was explored at the IOM conference. The aging of the population has led to concerns regarding the adequacy and cost of existing long-term care services, and a growing attention to long-term care insurance, as well as alternatives to institutionalization. The demand for long-term care services is exemplified by the dramatic rise in the number of nursing home beds in the 70s and 80s and an occupancy rate which has remained fairly constant over that time. And while home health care is often promoted as a cost-efficient alternative to institutionalization, there are concerns that more ready access to home health care will increase overall costs as new demand surfaces from individuals not currently receiv- ing such assistance from organized providers. Increasingly, health care institutions are becoming vertically integrated (wherein one firm or facility serves several provider functions, such as hospital, nursing home, and home health care) with greater likelihood of substitution between levels of service as individual patient needs or the availability of reimbursement dictate. Finally, changes in the organization and financing of health care have resulted in significant changes in the practice of medicine and the develop- ment and use of technology. Since the implementation of the Medicare Prospective Payment System, lower inpatient lengths of stay have been observed, stimulating some debate over the extent of inappropriate early discharges; practitioners are placing more emphasis on the efficacy and cost effectiveness of technologies, where in the past any marginal benefit to the patient was sufficient justification for use of a procedure. Lower hospital occupancy rates again reflect the movement from inpatient to outpatient care. Greater emphasis is also being placed on early diagnosis and treat- ment of patients in capitation systems, while the increased employment of case management for Medicaid and privately insured groups has altered the traditional doctor-patient relationship in many settings.

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100 C. NCHS Data Systems APPENDIX A Over its 30-year history the National Center for Health Statistics has developed and maintained, as changing data needs have dictated, a number of surveys of the supply, organization, and utilization of health care in the United States. These surveys have provided data for monitoring changes in the use of health care in these settings, for monitoring specific diseases, and for examining the impact of the introduction of new technologies. Exam- ples include the data to examine the impact of the prospective payment system on the utilization of hospital care. The currently active surveys of health care providers are briefly described below. The National Ambulatory Medical Care Survey (NAMCS), conducted annually from 1973-81, in 1985, and again on a continuous basis begin- ning in 1989, collects inflation about ambulatory medical care pro- vided by office-based physicians. This survey provides statistics on the demographic characteristics of patients, reasons for visit, diagnoses, diagnostic procedures, services provided, drug therapy, and disposition. The National Hospital Discharge Survey (NHDS), which has been con- ducted annually since 1965, is the principal source of information on inpatient utilization of hospitals. This survey obtains data on the char- acteristics of patients, their expected sources of payment, lengths of stay, diagnoses, surgical operations, and patterns of care by hospital bed size, ownership type and geographic region. The National Nursing Home Survey (NNHS), conducted periodically since 1963 and most recently in 1985, provides information on nursing homes from two perspectives - that of the provider of services and that of the recipient. Data about the facilities include characteristics such as size, ownership, staffing patterns, Medicare/Medicaid certification, oc- cupancy rate, days of care provided, and expenses. For residents, data are obtained on demographic characteristics, health status, services re- ceived and (for discharges) the outcome of care. The National Master Facility Inventory (NMFI), conducted on a period- ic basis since 1962, is an important source of national information on the number, type, and geographic distribution of inpatient health care facilities. In addition, the NMFI serves as a sampling frame from which facility samples such as the NNHS are selected. These data systems rely on information from providers of health care, rather than from recipients, because 1) providers have the most accurate and detailed data on diagnosis and treatment, and 2) providers are an extremely cost-effective source for identifying events such as hospitalization, surgery, and long-tenn ~,stitutionalization, which are relatively "rare" events in the

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NCHS PLAN 101 total population. For example, about 1 person in 10 receives hospital care each year and 1 elderly person in 20 uses nursing home care. Data from these surveys are obtained through a variety of mechanisms, including, for example, abstraction of medical records of institutions, completion of pa- tient encounters by physicians, compilation of data from States and profes- sional associations and purchase of data from private abstract services. Other data systems provide important data on health care utilization, obtained from personal interviews with individuals. For example, the Na- tional Health Interview Survey provides data on physician and dental visits, as well as hospitalizations; and the National Medical Expenditure Survey (conducted by the National Center for Health Services Research) focuses on expenditures and financing of individuals for health care. These popula- tion-based surveys, while providing information on care received by indi- viduals, are limited in their ability to provide accurate detail on diagnoses and treatments, or the characteristics of health care providers. On the other hand, these surveys do have the ability to obtain national estimates on expenditures for health care and insurance coverage, to provide information on persons who do not receive or have access to medical attention during a given period, and to provide socio-economic and health status information about respondents that is not readily available from health care providers. D. Implications for Health Care Data NClIS provider-based surveys have considerable strengths in measur- ing the care provided in traditional settings, including physicians' offices, acute care hospitals, and nursing homes. The NAMCS, NHDS and NNHS were designed to cover the health provider settings where the bulk of medi- cal care was provided in the 60s and 70s. Despite the multitude of changes previously described, these sources of care remain as the key elements of the nation's health care data system. However, these data reflect only part of the medical care provided in the United States and, because of the kinds of changes previously discussed, there is concern that existing national health data sources are unable to fully address a number of areas of health policy interest, and are only partly capable of providing information needed to evaluate changes in the organization, financing, and delivery of health care. Current surveys are weak in two areas: (1) coverage of new and emerging sites of medical care, especially in those areas where new sites of care are substituting for the more traditional sources; and (2) measurement of the impact of change on the effectiveness, quality, and outcome of medical care. Existing data systems are unable to measure the degree of shift from traditional to alternative settings, or to provide national estimates for types of care delivered in these new settings. Examples of these new or growing settings include hospital-based and freestanding ambulatory surgi-centers,

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102 APPENDIX A ambulatory care provided in hospitals and clinics, and community-based long-term care settings. Furthermore, currently available estimates - such as rates for surgical procedures, physician visits and reasons for such visits, and receipt of long-term care - that are obtained from existing surveys may become less definitive as treatments and patients shift to other settings. A prime example of this shift is in the measurement of lens implants, which until recently were performed almost entirely as an inpatient service but are now performed with few exceptions on an outpatient basis. At the same time, data based on claims forms may become less useful as capitation systems gain larger market shares, since these systems require less detailed administrative records for reimbursement. In order to continue to provide basic estimates of the supply and use of health services and health care technology, surveys of health care providers will need to recognize the shift of medical practice to new settings. Existing national data systems are limited in their ability to assess the impact of changes in the practice of medicine, such as the introduction of new technologies, and the resulting change in health outcomes that are brought about by modifications in financing and organization of such care. Important issues in this area include differences in health outcomes between different sites of surgery or other care in terms of subsequent institutional- ization, mortality, or illness; differences in outcomes from alternative treat- ments or technologies employed for the same diagnosis; and the impact of declining inpatient lengths of stay for various diagnoses on subsequent re- admission, other care, and on health outcomes. The NCHS provider-based surveys were originally designed to operate continuously or with short periodicity cycles. Many of the problems of provider coverage described above have been compounded by the periodic schedule of data collection of some NCHS surveys of health care providers, for example, only the NHDS has been conducted on an annual basis during its entire history. Due to resource limitations, the scheduled interval be- tween data collection periods in the NAMCS and NNHS were increased in 1981: the NAMCS from an annual to a triennial survey, the NNHS from triennial to sexennial. Further resource limitations led to the delay of these surveys from even the lengthened intervals. Although these programs are regarded as part of the NCHS base program, their periodic nature required justification of increased funding as each survey cycle approached. Despite the importance of these surveys to health researchers and policy makers, it has been increasingly difficult to obtain such funds. A more stable level of resources for surveys of health care utilization is required. Finally, it is important to recognize the limitations of any analysis of current change in the health care system, and the danger of basing plans for future data collection solely on updating our current assessment of the structure of the delivery system Change will continue to occur - both in reaction to

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NCHS PLAN 103 the impact of previous changes and in response to forces that will emerge in the future. A critical concern as to future data collection is the flexibility to adapt to these changes as they occur. II. A NATIONAL HEALTH CARE SURVEY As a major initiative in the FY 1988 PHS Planning Process, NCHS examined the changes occurring in the health care delivery system, the impact of these changes, and the implications of these changes for the types of surveys of health care that are needed. The result is a plan for a major restructuring of its current surveys of health care utilization into a National Health Care Survey that is expected to provide a much more realistic pic- ture of the medical care provided in the U.S. As the Center's four existing surveys of providers (the NAMCS, NHDS, NNHS, and NMFI) are fielded according to their projected schedule, they are being modified into compo- nents of the National Health Care Survey. Coverage of these surveys is being expanded to include alternative sites of care, and a greater continuity of resources is being achieved by moving periodic surveys to an annual basis. In part, this is being accomplished by reducing historical levels of sample size for health care providers covered in existing surveys and reduc- ing or modifying the content of each provider component. The capability to conduct routine and specialized patient follow-up studies is being instituted through a patient follow-up component in order to address outcome and quality of care issues and greater analytic utility will be achieved through the use of an integrated cluster sampling approach. In the following sec- tions the approach, features, and schedule for the National Health Care Survey are presented. A. Components The National Health Care Survey is designed to produce annual data on the use of health care and the outcomes of care for the major sectors of the health care delivery system. These data will describe the patient popula- tion, medical care provided, financing, and provider characteristics. The NHCS has five components based on the Center's current health care pro- vider surveys: The Ambulatory Care Component has as its base the National Ambu- latory Medical Care Survey. This component is being expanded initial- ly to include medical care provided in hospital emergency and outpa- tient departments and clinics. When fully implemented, this component will also cover ambulatory care provided in other settings such as neigh- borhood health clinics.

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104 APPENDIX A The Hospital and Surgical Care Component is based on the National Hospital Discharge Survey. This component is being enlarged to in- clude hospital-based and freestanding ambulatory surgery centers. The Long-Term Care Component is based on the National Nursing Home Survey and is being restructured and expanded to include home health agencies and hospices. The Long-Term Care Component will provide data from smaller annual surveys, rather than periodic surveys with larger samples. The Health Provider Inventory Component is based on the National Master Facility Inventory. The NMFI which now provides the sam- pling frame for the NNHS and other facility based surveys is being expanded to include providers of acute ambulatory care and communi- ty-based long-term care. The NMFI has been renamed the National Health Provider Inventory (NHPI). The Patient Follow-up Component is being developed to collect infor- mation from the patient or patient's family about the outcomes of pa- tient care, including subsequent use of medical care and morbidity; hospital readmissions; and changes in health status. In this methodolo- gy periodic contacts (possibly by telephone) are made to follow the long-range outcomes of care and subsequent use of care to produce longitudinal data on quality of care, episodes of care and the dynamics of the use of health care and its financing. The application of this type of methodology in the 1985 NNHS is described in section G. Addition- ally, it is anticipated that these data could be linked with other data sources as the 1985 NNHS is being linked to the NCHS National Death Index to obtain information on mortality status and cause of death for former patients. The patient follow-up component could also focus on other dimensions: a financing mechanism, a diagnosis or procedure; a particular demographic group (e.g., aged, poor, minority); a particular disposition at discharge (e.g., live/dead, admission to long-term institu- tional care). The dimensions could change to address emerging issues and special topics. B. Coverage The National Health Care Survey is designed to cover the three major types of health care and health care providers: Hospital Care: Inpatient Outpatient surgery Outpatient departments and clinics - Emergency departments

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NCHS PLAN Ambulatory Care: - Physicians' offices - Prepaid practice, including HMO's - Freestanding surgi-centers Long-Term Care - Nursing and personal care homes - Home health agencies - Hospices C. Content 105 Determination of the data content of the components of the National Health Care Survey is underway via discussions within the Department about basic data needs and research to develop specific data items. Tradi- tionally, the basic core of data has been defined by an appropriate minimum data set - a common set of data items that meets the needs of a multiplicity of users. Several of these data sets have been designed by the National Committee on Vital and Health Statistics and it is possible that new data sets will need to be developed. D. Features Central to the development of a National Health Care Survey are sever- al technical aspects or features which enhance its analytical capabilities and minimize costs. These features include: Employing an integrated cluster sample design where the health care providers are sampled at the second stage from a first stage sample of geographic areas, rather than selecting the providers at the first stage. Currently, the geographic areas being used in the NHCS are the Prima- ry Sampling Units (actually a subsample of the PSUs) of the National Health Interview Survey. The advantages to this type of design in- clude: the increased analytical utility as health care utilization is exam- ined in relation to health status indicators; the reduced interviewing costs as sample providers are concentrated in specific geographic areas; the increased potential for record-linkage across settings which aids in tracking patients and in differentiating multiple episodes of the same condition; and the possibility of producing local area statistics, at least for some areas or communities. Conducting the components on a continuous annual basis to address seasonality of illness, to maintain a small group of well-trained staff, to reduce the budgeting and scheduling problems associated with periodic surveys, and to minimize recurrent start-up costs for survey compo- nents.

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106 APPENDIX A Using the same samples of providers over time, where possible, for better quality of data and reduced sample induction costs. Using available data for developing sampling frames, e.g., for hospitals - the American Hospital Association; for physicians - the American Medical Association; and for certified home health agencies - the Health Care Financing Administration; and using the National Master Facility Inventory mechanism to complete or compile the sampling frames, e.g., surgi-centers, hospices and noncertified home health agencies. Aggregating estimates across years to produce data on sub-populations, "rare" diagnoses and treatments, to produce greater geographic detail, and to compensate for smaller sample sizes. As an example of other features which are being considered is the possibility of using the same sample of providers for several components of the NHCS, e.g., the same sample of hospitals might be used for surveys of inpatient, outpatient and emergency department care. E. Flexibility The National Health Care Survey is being designed for maximum flexi- bility, providing a basic framework which can be expanded in several di- mensions as data needs change. This flexibility in an on-going national survey is important for providing data on changes in health care delivery such as new technologies, new procedures, and new approaches to organiza- tion or payment for care. Dimensions for expansion include: Provider coverage Coverage of health care providers can be expanded to include additional ambulatory and long-term care providers of inter- est, e.g., community health centers, walk-in acute care centers, adult day care centers, mental health facilities, or institutions for the mentally retarded. One the of general limitations for expansion is the availabili- ty and adequacy of a sampling frame. Financing arrangements In addition to source of payment, type of payment mechanism (fee for service, capitation, discounted fee, etc.) can be determined. As new payment mechanisms are implemented, the impact on the various sectors of the health care delivery system can be exam- ined. Special topics The provider components and the patient follow-up com- ponent can be expanded to address special topics or emerging issues and can continue for several years if the issue warrants. Of current inter- est are the FY 1992 AIDS Initiatives which contain a concept proposal for the development and testing of a patient follow-up methodology.

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NCHS PLAN 107 Other applications of this longitudinal methodology include tracking the morbidity experience and subsequent use of services for patients hospitalized with stroke, or for patients in nursing homes with Alzhei- mer's Disease or hip fracture. And questions such as the following could be addressed: Do decreases in length of hospital stay for certain diagnoses result in greater use of long-term care or higher readmission rates to hospitals? What are the differences in morbidity and subse- quent use of care when inpatient and outpatient surgery are compared for the same procedure? F. Integrated Survey Design As mentioned earlier, the components of the NHCS are being fielded in a subsample of the Primary Sampling Units selected for the National Health Interview Survey (NHIS). This linkage with the NHIS is consistent with the decision to base the NCHS Integrated Survey Design Program on the NHIS sample and to establish survey linkages to the other NCHS popula- tion surveys. The next cycle of NHIS redesign research is currently under- way. Factors and design options now being explored include not only the issues related to the NCHS population surveys, but also the particular re- quirements of the NCHS provider and establishment surveys, e.g., the effect of conducting the NHCS in the NITS PSU's and the analytical utility of such a design. G. Current Status and Schedule The current status and plans for the initial expansion of each NHCS component are described below and presented in Table 1. Also described are significant research and development activities previously completed. Ambulatory Care The 1989 NAMCS was redesigned based on the integrated cluster sam- ple design (NHIS PSUs) and data collection began in March 1989. The 1989 and 1990 NAMCS samples include approximately 2,500 physicians in office-based practice. Data items will remain constant over the two-year period so that data can be aggregated to produce approximately the same level of detail as in 1985 when 5,000 physicians were sampled. Induction interview questions about health maintenance organizations and other pre- paid practice arrangements have been incorporated into the 1989-90 NAMCS. Based on the results of research conducted in two previous contracts which provided information on the availability of data items, appropriate data collection procedures, and construction of sampling frames, a contract

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108 APPENDIX A is currently underway to develop the national sample design and conduct a field test to refine the data forms and collection procedures for the survey of hospital emergency and outpatient departments. This survey is sched- uled to begin in mid-l991 and it is anticipated that the Bureau of the Census will be the data collection agent for the national effort. lIosp~tal and Surgical Care The National Hospital Discharge Survey was redesigned based on the integrated cluster sample design and fielded in 1988. The redesigned NHDS sample contains 542 hospitals and emphasizes the purchase of discharge data from hospital abstract services as a method of data collection. Approx- imately 75 percent of the sampled discharges for the 1988 NtIDS are col- lected via hospital abstract services. The design includes a nationally repre- sentative subsarnple of 128 hospitals which provide data on hard copy abstracts. This feature reduces the dependence on abstract services and provides nar- rative, as opposed to coded, diagnoses and procedures for special studies. Research is currently underway via contract to develop a survey of ambulatory surgery centers. Among the technical and methodological is- sues being addressed in this research are the development of a data set and data collection procedures and the investigation of potential sampling frames. This survey would sample patients receiving surgical, diagnostic or thera- peutic procedures in both hospital-based and freestanding ambulatory surgi- centers. Implementation of this survey is currently scheduled for 1993. Long-Term Care Contract research is ongoing to develop a survey of clients of home health agencies and hospices. Data content and data collection procedures are being developed and a field test is currently underway. This work follows earlier work on the evaluation of the Long-Term Care Minimum Data Set which provided information on the establishment of sampling frames and on the content and availability of minimum data set items in agency records. Contingent upon the results of the current project, the home health agency/hospice client survey is scheduled to be pretested in late 1991 and fielded in 1992. The schedule for the next National Nursing Home Survey has recently been accelerated so that the next NNHS will be fielded in 1992. It is anticipated that the Bureau of the Census will be the data collection agent. Health Provider Inventory Mailing lists of facilities for the 1991 National Health Provider Inven- tory are currently being prepared and in early 1991 the NHPI will be field-

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NCHS PLAN 109 ed. This mail survey will concentrate on compiling current and complete listings of home health care agencies, hospices, nursing homes, personal care homes and licensed board and care homes. The information collected will be used to construct sampling frames for the 1992 home health agency/ hospice client survey and the 1992 National Nursing Home Survey. Rec- ommendations from a 1983-85 evaluation of the NMFI which addressed issues of definition, content, and data collection procedures for nursing homes and the experience from the centralized collection activities used in the 1986 Inventory of Long-Term Care Places conducted by NCHS are being incorporated in the 1991 NHPI. Patient Follow-up The 1985 NNHS included a survey of the current and discharged resi- dent's "next-of-kin." This survey provided experience in obtaining release of information to identify the patient and in contacting the "next of kin" in order to collect longitudinal information not readily available in the medical record. This included information on the resident's health and functional status prior to admission, the reason for admission and a history of previous nursing home admissions. Two follow-up cycles have been conducted - one in 1987 (August-November) and the second in 1988 (July-October) - to determine the resident's current functional status, living arrangements, use of medical care and sources of payment since the last contact. A third follow-up cycle began in January 1990. Future studies will rely on such work as the National Academy of Sciences evaluation of data needed for health policy analysis for an aging population which provides guidelines for the content of data items on qual- ity and use of care.

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