Last data update: Oct 28, 2024. (Total: 48004 publications since 2009)
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Quickstats: Rate* of emergency department visits,(†) by homeless status(§) - National Hospital Ambulatory Medical Care Survey, United States, 2010-2021
Schappert SM , Santo L . MMWR Morb Mortal Wkly Rep 2023 72 (42) 1153 The rate of visits to hospital emergency departments by persons experiencing homelessness increased from an estimated 141 visits per 100 persons per year during 2010–2011 to 310 during 2020–2021. Rates increased during 2016–2017 compared with 2014–2015, and again during 2020–2021 compared with 2018–2019. Visit rates for persons not experiencing homelessness did not vary significantly across years, ranging from 42 visits per 100 persons per year during 2010–2011 to 40 during 2020–2021. Visit rates for persons experiencing homelessness were higher than rates for persons not experiencing homelessness in all years. |
QuickStats: Percentage of emergency department visits* with Medicaid as the primary expected source of payment among persons aged <65 years, by race and ethnicity(†) - National Hospital Ambulatory Medical Care Survey, United States, 2011-2021
Santo L , Schappert SM , Ashman JJ . MMWR Morb Mortal Wkly Rep 2023 72 (31) 853 During 2011–2021, the percentage of ED visits among persons aged <65 years with Medicaid as the primary expected source of payment increased from 34.0% to 45.3%. This pattern was consistent irrespective of race and Hispanic or Latino (Hispanic) origin. ED visits among Hispanic persons increased the most, from 46.3% in 2011 to 62.7% in 2021. The percentage of ED visits among persons with Medicaid as their primary expected source of payment increased from 40.9% in 2011 to 53.4% in 2021 among Black or African American (Black) persons, and from 27.8% to 35.5% among White persons. During the study period, the percentages of ED visits by Black and Hispanic persons with Medicaid as the primary expected source of payment were higher than the percentages of visits by White persons. |
NHAMCS has been a trusted source of data for healthcare disparities research since 1992
Schappert SM , Santo L , Ward BW , Ashman JJ , DeFrances CJ . Public Health Nurs 2023 40 (6) 811-812 The National Center for Health Statistics (NCHS) conducts the National Hospital Ambulatory Medical Care Survey (NHAMCS), a national probability sample survey of visits to U.S. hospital emergency departments (EDs). NCHS staff recently became aware of a Brief Report published in the July 2022 issue of Public Health Nursing (Marye, 2022) which claimed that healthcare disparities research was limited with NHAMCS data; however, the report included inaccuracies about the survey and its data that should be clarified. NHAMCS has been conducted annually since 1992 and has been used for decades to understand the provision of ambulatory medical care at hospitals, as well as disparities in this care. A brief search in the PubMed® database returns hundreds of peer-reviewed research manuscripts using NHAMCS data, with at least 40 focusing on healthcare disparities. Furthermore, NHAMCS continues to be used in various U.S. government reports that focus on health care and health disparities (Agency for Healthcare Research and Quality, 2022; National Center for Health Statistics, 2023). |
Trends in office visits during which opioids were prescribed for adults with arthritis: United States, 2006-2015
Santo L , Schappert SM , Hootman JM , Helmick CG . Arthritis Care Res (Hoboken) 2020 73 (10) 1430-1435 OBJECTIVE: To analyze trends in opioid prescriptions during visits to office-based physicians made by adults with arthritis in the US from 2006 to 2015. METHODS: We analyzed nationally representative data on patient visits to office-based physicians from the National Ambulatory Medical Care Survey (NAMCS) 2006-2015. Visit percentages for first- and any-listed diagnosis of arthritis by age groups and sex are reported. Time points were grouped into 2-year intervals to increase the reliability of estimates. Annual percentage point change and 95% CI were reported from linear regression models. RESULTS: During 2006-2015, the percentage of visits to office-based physicians by adults with a first-listed diagnosis of arthritis increased from 4.1% (95%CI: 3.5%-4.7%) in 2006-2007 to 5.1% (95% CI: 3.9%-6.6%) in 2014-2015 (p=.033). Among these visits, the percentage of visits with opioids prescribed increased from 16.5% (95%CI: 13.1%-20.5%) in 2006-2007 to 25.6% (95%CI: 17.9%-34.6%) in 2014-2015 (p=.017). The percentage of visits with any-listed diagnosis of arthritis increased from 6.6% (95%CI: 5.9%-7.4%) in 2006-2007 to 8.4% (95%CI: 7.0%-10.0%) in 2014-2015 (p=.001). Among these visits the percentage of visits with opioids prescribed increased from 17.4% (95%CI: 14.6%-20.4%) in 2006-2007 to 25.0% (95%CI: 19.7%-30.8%) in 2014-2015 (p=.004). CONCLUSION: During 2006-2015, the percentage of arthritis visits by adults to office-based physicians increased and the percentage of opioids prescribed at these visits increased as well. NAMCS data will allow continued monitoring of these trends after guidelines were implemented. |
A note on the effect of data clustering on the multiple-imputation variance estimator: a theoretical addendum to the Lewis et al. article in JOS 2014
He Y , Shimizu I , Schappert S , Xu J , Beresovsky V , Khan D , Valverde R , Schenker N . J Off Stat 2016 32 (1) 147-164 Multiple imputation is a popular approach to handling missing data. Although it was originally motivated by survey nonresponse problems, it has been readily applied to other data settings. However, its general behavior still remains unclear when applied to survey data with complex sample designs, including clustering. Recently, Lewis et al. (2014) compared single-and multiple-imputation analyses for certain incomplete variables in the 2008 National Ambulatory Medicare Care Survey, which has a nationally representative, multistage, and clustered sampling design. Their study results suggested that the increase of the variance estimate due to multiple imputation compared with single imputation largely disappears for estimates with large design effects. We complement their empirical research by providing some theoretical reasoning. We consider data sampled from an equally weighted, single-stage cluster design and characterize the process using a balanced, one-way normal random-effects model. Assuming that the missingness is completely at random, we derive analytic expressions for the within-and between-multiple-imputation variance estimators for the mean estimator, and thus conveniently reveal the impact of design effects on these variance estimators. We propose approximations for the fraction of missing information in clustered samples, extending previous results for simple random samples. We discuss some generalizations of this research and its practical implications for data release by statistical agencies. © Statistics Sweden. |
NHAMCS: does it hold up to scrutiny?
McCaig LF , Burt CW , Schappert SM , Albert M , Uddin S , Brown C , Madans J . Ann Emerg Med 2013 62 (5) 549-51 The Centers for Disease Control and Prevention's (CDC's) National Center for Health Statistics (NCHS) is committed to collecting and disseminating high-quality data that meet the information needs of a wide range of users. We take issue with the unfavorable assessment of National Hospital Ambulatory Medical Care Survey (NHAMCS) data in a recent editorial by Cooper1 and appreciate the opportunity to respond to her comments. | We agree with Cooper1 that research findings need to be critically assessed, and we appreciate the guidelines she provides for potential authors using NHAMCS data, which are consistent with our recent article.2 We are troubled, however, by her sweeping indictment of the NHAMCS data-gathering process and her concern that medical practice or policy may have changed based on “the false assumption that the data were valid.”1 In fact, the authors cited by Cooper1 appropriately assessed the limitations of using NHAMCS data3, 4, 5, 6 and reported that their findings3, 4, 5 were consistent with previous research. In cases in which findings from studies diverge, it is important to consider the methodology of each study. A particular strength of NHAMCS is that it includes hospitals other than academic medical centers, which commonly serve as the settings for research studies, thereby giving a more complete picture of health care use patterns. When comparing data from NHAMCS with other studies, one should always be careful to keep such methodological differences in mind before making conclusions about validity. |
Emergency department volume and racial and ethnic differences in waiting times in the United States
Sonnenfeld N , Pitts SR , Schappert SM , Decker SL . Med Care 2012 50 (4) 335-41 BACKGROUND: Racial and ethnic differences in emergency department (ED) waiting times have been observed previously. OBJECTIVES: We explored how adjusting for ED attributes, particularly visit volume, affected racial/ethnic differences in waiting time. RESEARCH DESIGN: We constructed linear models using generalized estimating equations with 2007-2008 National Hospital Ambulatory Medical Care Survey data. SUBJECTS: We analyzed data from 54,819 visits to 431 US EDs. MEASURES: Our dependent variable was waiting time, measured from arrival to time seen by physician, and was log transformed because it was skewed. Primary independent variables were individual race/ethnicity (Hispanic and non-Hispanic white, black, other) and ED race/ethnicity composition (covariates for percentages of Hispanics, blacks, and others). Covariates included patient age, triage assessment, arrival by ambulance, payment source, volume, region, and teaching hospital. RESULTS: Geometric mean waiting times were 27.3, 37.7, and 32.7 minutes for visits by white, black, and Hispanic patients. Patients waited significantly longer at EDs serving higher percentages of black patients; per 25 point increase in percent black patients served, waiting times increased by 23% (unadjusted) and 13% (adjusted). Within EDs, black patients waited 9% (unadjusted) and 4% (adjusted) longer than whites. The ED attribute most strongly associated with waiting times was visit volume. Waiting times were about half as long at low-volume compared with high-volume EDs (P<0.001). For Hispanic patients, differences were smaller and less robust to model choice. CONCLUSIONS: Non-Hispanic black patients wait longer for ED care than whites primarily because of where they receive that care. ED volume may explain some across-ED differences. |
Trends in emergency department visits among Medicaid patients
Sonnenfeld N , Decker SL , Schappert SM . JAMA 2011 306 (11) 1202-3; author reply 1203 Dr Tang and colleagues1 concluded that emergency department (ED) visit rates have been increasing most among Medicaid patients. We believe this conclusion may be unwarranted. The analysis does not appear to have incorporated changes that occurred over the years in the coding of the variable “primary expected source of payment” in the data source used by the authors, the National Hospital Ambulatory Medical Care Survey (NHAMCS) conducted by the National Center for Health Statistics (NCHS). The only information on payment sources that NHAMCS collected from 1997 through 2004 was the primary expected source of payment.2 Starting in 2005, hospital respondents could indicate multiple expected sources of payment per visit and did not designate a primary source. From 2005 through 2007, the data files included separate variables for each expected payment source plus a variable that assigned the primary expected source using a hierarchy with Medicaid first, followed by Medicare, private insurance, worker's compensation, self-payment, and no charge. | We suspect that many hospital respondents from 1997 through 2004 reported Medicare as the primary expected payment source for patients dually eligible for Medicare and Medicaid. It appears that for 2007, Tang et al used NHAMCS’ hierarchical payment variable that classified dual eligibles as having Medicaid. This approach led to a report of ED visit rates between 1997 and 2007 that increased by 36.5% for adult patients with Medicaid and decreased by 2.5% for Medicare (Table in the article). We recomputed the number of visits by coding the primary payment source for dually eligible patients as Medicare instead of Medicaid for 2007. Using information in the Table1 to generate denominators for the visit rate, the estimated number of ED visits for Medicaid patients would be 14.2 million and the visit rate 759.9 per 1000; for Medicare, the number of visits would be 19.9 million and the visit rate 485.9 per 1000. Therefore, the visit rate for adults from 1997 through 2007 would increase 9.5% for Medicaid and 17.6% for Medicare. These latter estimates may be more realistic than those presented by Tang et al. |
Ambulatory medical care utilization estimates for 2007
Schappert SM , Rechtsteiner EA . Vital Health Stat 13 2011 (169) 1-38 OBJECTIVES: This report presents statistics on ambulatory care visits to physician offices, hospital outpatient departments (OPDs), and hospital emergency departments (EDs) in the United States in 2007. Ambulatory medical care utilization is described in terms of patient, provider, and visit characteristics. METHODS: Data from the 2007 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey were combined to produce annual estimates of ambulatory medical care utilization. RESULTS: Patients in the United States made an estimated 1.2 billion visits to physician offices and hospital OPDs and EDs, a rate of 405.0 visits per 100 persons annually. This was not significantly different than the rate of 381.9 visits per 100 persons in 2006, neither were significant differences found in overall visit rates by age, sex, or geographic region. Visit distribution by ambulatory care setting differed by poverty level in the patient's ZIP Code of residence, with higher proportions of visits to hospital OPDs and EDs as poverty levels increased. Between 1997 and 2007, the age-adjusted visit rate increased by 11 percent, fueled mainly by a 29 percent increase in the visit rate to medical specialty offices. Nonillness and noninjury conditions, such as general and prenatal exams, accounted for the largest percentage of ambulatory care diagnoses in 2007, about 19 per 100 visits. Seven of 10 ambulatory care visits had at least one medication provided, prescribed, or continued in 2007, for a total of 2.7 billion drugs overall. These were not significantly different than 2006 figures. Analgesics were the most common therapeutic category, accounting for 13.1 drugs per 100 drugs reported, and were most often utilized at primary care and ED visits. The number of viral vaccines that were ordered or provided increased by 79 percent, from 33.2 million occurrences in 2006 to 59.3 million in 2007; significant increases were also noted for anticonvulsants and antiemetics. |
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