National impact of 13-valent pneumococcal conjugate vaccine on ambulatory care visits for otitis media in children under 5 years in the United States.

OBJECTIVE: The 7- and 13-valent pneumococcal conjugate vaccines (PCV7 and PCV13) were approved in the US in 2000 and 2010, respectively, for active immunization against invasive disease caused by all vaccine serotypes and otitis media (OM) caused by 7 serotypes common to both vaccines, starting at ∼6 weeks of age. This study assessed the impact of PCV13 on OM by evaluating changes in US ambulatory care visit rates between the period before PCV7 (1997-1999), during PCV7 (2001-2009), and after the introduction of PCV13 (2011-2013) among US children <5 years old. METHODS: This ecological study used US National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey data. Trend analyses using weighted least-squares regression and mean visit rates were calculated for OM and two control endpoints not likely to be related to either vaccine (skin rash and trauma). RESULTS: Among children <5 and < 2 years old, the observed reduction in OM visit rates was 22% (95%CI: 12%-32%) and 24% (95%CI: 13%-35%) when comparing PCV13 to PCV7 periods, and 41% (95%CI: 30%-52%) and 48% (95%CI: 37%-59%) when comparing PCV13 to pre-PCV7 periods. Visit rates for skin rash and trauma remained stable. CONCLUSION: Significant reductions in US ambulatory care visit rates for OM were observed among children aged <5 years after introduction of PCV13 compared to the periods before and during PCV7; reductions were greatest among children <2 years old. The reductions beyond the PCV7 period support the effectiveness of the vaccine's 6 additional serotypes in preventing OM.

Trends in diabetes treatment patterns among primary care providers.

Using data from the National Ambulatory Medical Care Survey, logit models tested for trends in the probability that visits by adult diabetes patients to their primary care providers included recommended treatment measures, such as a prescription for an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin-II receptor blocker (ARB), blood pressure measurement, and diet/nutrition or exercise counseling. Results indicated that the probability that visits included prescription of an ACE or ARB and blood pressure measurement increased significantly over the 1997-2005 period, while the probability that visits documented provision of exercise counseling rose since 2001.

Are there patient disparities when electronic health records are adopted?

Using nationally representative samples of visits from the 2005-2006 National Ambulatory Medical Care Surveys and the National Hospital Ambulatory Medical Care Surveys (N=39,343), this study examines whether electronic health record (EHR) systems have been adopted by primary care physicians or providers (PCPs) for poor minority patients at the same rate as by the PCPs for wealthier non-minority patients. Although we found that electronic health record adoption rates varied primarily by type of practice of the PCP, we also found that uninsured Black and Hispanic or Latino patients, as well as Hispanic or Latino Medicaid patients were less likely to have PCPs using EHRs, compared with privately-insured White patients, after controlling for PCPs' practice type and location, as well as patient characteristics. This finding reflects a mixture of high and low EHR adopters among PCPs for poor minority patients.

National Hospital Ambulatory Medical Care Survey: 2006 emergency department summary.

OBJECTIVE: This report presents the most current (2006) nationally representative data on visits to hospital emergency departments (ED) in the United States. Statistics are presented on selected hospital, patient, and visit characteristics. METHODS: Data are from the 2006 National Hospital Ambulatory Medical Care Survey (NHAMCS), the longest continuously running nationally representative survey of hospital ED utilization. The NHAMCS collects data on visits to emergency and outpatient departments of nonfederal, short-stay, and general hospitals in the United States. Sample data are weighted to produce annual national estimates. RESULTS: In 2006 there were 119.2 million visits to hospital EDs, or 40.5 visits per 100 persons, continuing a long-term rise in both indices. The rate of visits per 100 persons was 36.1 for white persons, 79.9 for black persons, and 35.3 for Hispanic persons. ED occupancy (the count of patients who had arrived, but not yet discharged, transferred, or admitted) varied from 19,000 patients at 6 a.m. to 58,000 at 7 p.m. on an average day nationally. Though overall ED visits increased, the number of visits considered emergent or urgent (15.9 million) did not change significantly from 2005, nor did the number of patients arriving by ambulance (18.4 million). At 3.6 percent of visits, the patient had been seen in the same ED within the previous 72 hours. Median time to see a clinician was 31 minutes. Of all ED visits, 35.6 percent were for an injury. Patients had computerized tomography or magnetic resonance imaging at 12.1 percent of visits, blood drawn at 38.8 percent, an intravenous line started at 24.0 percent, an x ray performed at 34.9 percent, and an electrocardiogram done at 17.1 percent. Patients were admitted to the hospital at 12.8 percent of ED visits in 2006. The ED was the portal of admission for 50.2 percent of all nonobstetric admissions in the United States in 2006, an increase from 36.0 percent in 1996. Patients were admitted to an intensive care unit at 1.9 percent of visits.

Emergency department visits by persons recently discharged from U.S. hospitals.

BACKGROUND: Emergency department (ED) visits are rarely used as an outcome of prior hospitalization, but could be an indicator of poor inpatient care or follow-up planning. STUDY OBJECTIVE: To examine the rate and characteristics of ED visits of patients recently discharged from any hospital. METHODS: Data from the 2005 and 2006 National Hospital Ambulatory Medical Care Surveys (NHAMCS) and National Hospital Discharge Surveys (NHDS) were used to produce ratios of the numbers of ED visits where patients were discharged from any hospital within the last 7 days to the numbers of hospital discharges. NHAMCS, an annual survey of visits to U.S. hospital EDs, reported data for patients discharged from any hospital within 7 days previous to the ED visit. The NHDS is an annual survey of inpatient discharges from U.S. hospitals. Data from nonnewborn patients were weighted to produce national estimates. RESULTS: About 2.3 million ED visits (2.0 percent of all visits) were made by persons who had been hospitalized within the last 7 days. This corresponds to 68 ED visits per 1000 live hospital discharges. About 10 percent of patients at these ED visits presented with medical or surgical complications that may have been related to their recent hospitalization. Uninsured persons were nearly three times as likely as those privately insured to make an ED visit following hospital discharge. CONCLUSION: A large number of ED visits following recent hospitalization may be related to prior hospitalization. Returning to the ED after hospitalization may be an important measure to help improve inpatient care quality. Disparities in rates of ED visits following hospitalization may be attributed to differential inpatient or follow-up care.

Characteristics of office-based physicians and their medical practices: United States, 2005-2006.

OBJECTIVES: This report describes average annual estimates of nonfederal, office-based physicians who saw patients in the United States during 2005-2006. The report also uses a multiplicity estimator from the physician sample to estimate the number and characteristics of medical practices with which physicians are associated. Selected physician estimates of characteristics obtained only in 2006 are also presented, as well as selected trends in physician practice characteristics between 2001-2002 and 2005-2006. METHODS: Data presented in this report were collected during the induction interview of physicians during the 2005 and 2006 National Ambulatory Medical Care Surveys (NAMCS). NAMCS is a national probability sample survey of nonfederal physicians who see patients in an office setting in the United States. Radiologists, anesthesiologists, and pathologists--as well as physicians who treat patients solely in hospital, institutional, and occupational settings--are excluded. Sample weights for physician data use information on the number of physicians in the sampled physician's practice to produce national estimates of medical practices. RESULTS: During 2005-2006, an average of 308,900 office-based physicians practiced in an estimated 163,800 medical practices in the United States. In 2005-2006, nearly 1 in 10 medical practices were multispecialty groups (8.9 percent) and accounted for 20.3 percent of all physicians. In 2006, 11.5 percent of medical practices employed at least one mid-level provider and about one-third of medical practices performed electrocardiogram (EKG/ECG) tests (33.5 percent) and lab tests (30.2 percent) onsite. Between 2001-2002 and 2005-2006, the percentage of physicians not accepting new Medicaid patients increased by 16 percent and the percentage not accepting new charity cases increased by 23 percent.

Toward vocabulary control for chief complaint.

The chief complaint (CC) is the data element that documents the patient's reason for visiting the emergency department (ED). The need for a CC vocabulary has been acknowledged at national meetings and in multiple publications, but to our knowledge no groups have specifically focused on the requirements and development plans for a CC vocabulary. The national consensus meeting "Towards Vocabulary Control for Chief Complaint" was convened to identify the potential uses for ED CC and to develop the framework for CC vocabulary control. The 10-point consensus recommendations for action were 1) begin to develop a controlled vocabulary for CC, 2) obtain funding, 3) establish an infrastructure, 4) work with standards organizations, 5) address CC vocabulary characteristics for all user communities, 6) create a collection of CC for research, 7) identify the best candidate vocabulary for ED CCs, 8) conduct vocabulary validation studies, 9) establish beta test sites, and 10) plan publicity and marketing for the vocabulary.

Factors associated with ability to treat pediatric emergencies in US hospitals.

OBJECTIVE: The purpose of this analysis is to investigate hospital and community factors associated with the availability of pediatric services, expertise, and supplies in US hospitals for treating pediatric emergencies. METHODS: Data from the Emergency Pediatric Services and Equipment Supplement, a component of the 2002-2003 National Hospital Ambulatory Medical Care Survey, were merged with hospital and community characteristics to model preparedness to treat pediatric emergencies. The National Hospital Ambulatory Medical Care Survey samples nonfederal, short-stay, and general hospitals in the United States. The Emergency Pediatric Services and Equipment Supplement was based on the 2001 guidelines developed by the American Academy of Pediatrics and the American College of Emergency Physicians. Estimates were weighted to produce unbiased national estimates of pediatric services, expertise, and equipment availability in emergency departments. Logistic regression was used to model the probability of being better prepared based on the above guidelines. RESULTS: Bivariate analyses showed that hospital inpatient pediatric structure was linearly related to availability of supplies. However, inpatient structure was not associated with presence of a pediatric trauma service or written transfer agreement. Logistic regressions with each preparedness measure indicated that, after adjusting for hospital and community factors, pediatric volume, teaching hospital status, geographic region, and per capita income of the community were strongly related to being better prepared on each of the preparedness measures. CONCLUSIONS: To meet the 2001 guidelines, emergency departments need to improve their inventory of pediatric supplies, and hospitals that do not have specialized inpatient services need to implement written transfer agreements with other hospitals.

Electronic medical record use by office-based physicians and their practices: United States, 2006.

OBJECTIVES: This report presents the latest information on the use of electronic medical records in physician offices. Percentages of medical practices and physicians within the practices using electronic medical records (EMR) are presented for 2006 by selected physician and practice characteristics. METHODS: Data from the physician induction interviews of the 2006 National Ambulatory Medical Care Survey (NAMCS) are presented. NAMCS includes a national probability sample of nonfederal office-based physicians who saw patients in an office setting. Sample data were weighted to produce national estimates of physicians. Estimates of medical practices were derived from NAMCS physician data by adjusting the weighting scheme using a multiplicity estimator. RESULTS: In 2006, 29.2 percent of office-based physicians reported using full or partial EMR systems, which represented a 22% increase since 2005 and a 60% increase since 2001, when the NAMCS began monitoring this technology. Starting in 2005, the NAMCS included questions about EMR system features that health information technology experts consider minimal for a comprehensive EMR, namely computerized orders for prescriptions, computerized orders for tests, reporting of test results (lab or imaging), and clinical notes. Based on these requirements, 12.4 percent of physicians surveyed used comprehensive EMR systems in 2006, a figure not significantly different from the 9.3 percent reported for 2005. From 2005 to 2006, the percentage of medical practices using full or partial EMR systems increased by 42% (from 18.3 to 25.9 percent), but the percentage of medical practices using a comprehensive EMR system did not change.

Ambulatory medical care utilization estimates for 2005.

OBJECTIVE: 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 2005. Ambulatory medical care utilization is described in terms of patient, practice, facility, and visit characteristics. METHODS: Data from the 2005 National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS) were combined to produce averaged 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 4.0 visits per person annually. Between 1995 and 2005, population visit rates increased by about 20% in primary care offices, surgical care offices, and OPDs; 37% in medical specialty offices; and 7% in EDs. The aging of the population has contributed to increased volume of visits because older patients have higher visit rates. Visits by patients 40-59 years of age represented about 28.5 percent in 2005, compared with 23.9 percent in 1995. Black persons had higher visit rates than white persons to hospital OPDs and EDs, but lower visit rates to office-based primary care and to surgical and medical specialists. In the ED, the visit rate for patients with no insurance was about twice that of those with private insurance; whereas for all types of office-based care, the visit rates were higher for privately insured persons than for uninsured persons. About 29.4 percent of all ambulatory care visits were for chronic diseases and 25.2 percent were for preventive care, including checkups, prenatal care, and postsurgical care. The leading treatment provided at ambulatory care visits was medicinal with 71.3 percent of all visits having one or more medications prescribed, up by 10% since 1995 when encounters with drug therapy represented 64.9 percent of all visits. In 2005, 2.4 billion medications were prescribed or administered at these visits.

Emergency response planning in hospitals, United States: 2003-2004.

OBJECTIVE: This study presents baseline data to determine which hospital characteristics are associated with preparedness for terrorism and natural disaster in the areas of emergency response planning and availability of equipment and specialized care units. METHODS: Information from the Bioterrorism and Mass Casualty Preparedness Supplements to the 2003 and 2004 National Hospital Ambulatory Medical Care Surveys was used to provide national estimates of variations in hospital emergency response plans and resources by residency and medical school affiliation, hospital size, ownership, metropolitan statistical area status, and Joint Commission accreditation. Of 874 sampled hospitals with emergency or outpatient departments, 739 responded for an 84.6 percent response rate. Estimates are presented with 95 percent confidence intervals. RESULTS: About 92 percent of hospitals had revised their emergency response plans since September 11, 2001, but only about 63 percent had addressed natural disasters and biological, chemical, radiological, and explosive terrorism in those plans. Only about 9 percent of hospitals had provided for all 10 of the response plan components studied. Hospitals had a mean of about 14 personal protective suits, 21 critical care beds, 12 mechanical ventilators, 7 negative pressure isolation rooms, and 2 decontamination showers each. Hospital bed capacity was the factor most consistently associated with emergency response planning and availability of resources.

National Ambulatory Medical Care Survey: terrorism preparedness among office-based physicians, United States, 2003-2004.

OBJECTIVES: This investigation describes terrorism preparedness among U.S. office-based physicians and their staffs in identification and diagnosis of terrorism-related conditions, training methods and sources, and assistance with diagnosis and reporting. METHODS: The National Ambulatory Medical Care Survey (NAMCS) is an annual national probability survey of approximately 3,000 U.S. nonfederal, office-based physicians. Terrorism preparedness items were added in 2003 and 2004. RESULTS: About 40 percent of physicians or their staffs received training for anthrax or smallpox, but less than one-third received training for any of the other exposures. About 42.2 percent of physicians, 13.5 percent of nurses, and 9.4 percent of physician assistants and nurse practitioners received training in at least one exposure. Approximately 56.2 percent of physicians indicated that they would contact state or local public health officials for diagnostic assistance more frequently than federal agencies and other sources. About 67.1 percent of physicians indicated that they would report a suspected terrorism-related condition to the state or local health department, 50.9 percent to the Centers for Disease Control and Prevention (CDC), 27.5 percent to the local hospital, and 1.8 percent to a local elected official's office. Approximately 78.8 percent of physicians had contact information for the local health department readily available. About 53.7 percent had reviewed the diseases reportable to health departments since September 2001, 11.3 percent had reviewed them before that month, and 35 percent had never reviewed them.

Terrorism preparedness: have office-based physicians been trained?

BACKGROUND AND OBJECTIVES: Terrorism may have a severe impact on physicians' practices. We examined terrorism preparedness training of office-based physicians. METHODS: The National Ambulatory Medical Care Survey uses a nationally representative multi-stage sampling design. In 2003 and 2004, physicians were asked if they had received training in six Category-A viral and bacterial diseases and chemical and radiological exposures. Differences were examined by age, degree, specialty, region, urbanicity, and managed care involvement. Chi-squares, t tests, and logistic regressions were performed in SUDAAN-9.0, with univariate significance at P<.05 and multivariate significance within 95% confidence intervals. RESULTS: Of 3,968 physicians, 56.3% responded. Forty-two percent were trained in at least one exposure. Primary care specialists were more likely than surgeons to be trained for all exposures. Medical specialists were more likely than surgeons to be trained for smallpox, anthrax, and plague. Physicians ages 55-69 years were less likely than those in their 30s to be trained for smallpox, anthrax, and chemical exposures. Managed care physicians were more likely to be trained for all exposures except botulism, tularemia, and hemorrhagic fever. CONCLUSIONS: Terrorism training frequencies were low, although primary care and managed care physicians reported more training than their counterparts.

Office-based medical practices: methods and estimates from the national ambulatory medical care survey.

OBJECTIVES: The report uses a multiplicity estimator from a sample of office-based physicians to estimate the number and characteristics of medical practices in the United States. Practice estimates are presented by characteristics of the practice (solo or group, single, or multi-specialty group, size of practice, ownership, location, number of managed care contracts, use of electronic medical records, and use of computerized physician order entry systems). METHODS: Data presented in this report were collected during physician induction interviews for the 2003-04 National Ambulatory Medical Care Survey (NAMCS). The NAMCS is a national probability sample survey of nonfederal physicians who see patients in an office setting in the United States. Radiologists, anesthesiologists, and pathologists-as well as physicians who treat patients solely in hospital, institutional, or occupational settings-are excluded. Sample weights for physician data use information on the number of physicians in the sampled physician's practice to produce annual national estimates of medical practices. RESULTS: During 2003-04, an average of 311,200 office-based physicians practiced in an estimated 161,200 medical practices in the United States. Medical practice characteristics differed from physician characteristics. Although 35.8 percent of office-based physicians were in solo practice, 69.2 percent of medical practices consisted of solo practitioners. The one-fifth of medical practices with three or more physicians (19.5 percent) contains about one-half of all office-based physicians (52.4 percent). About 8.4 percent of medical practices involved multiple specialties. Fifteen percent of medical practices, consisting of 19.0 percent of physicians, used electronic medical records. Similarly, 6.5 percent of medical practices, consisting of 9.2 percent of physicians, used computerized prescription order entry systems.

Characteristics of office-based physicians and their practices: United States, 2003-04.

OBJECTIVE: This report presents demographic and practice characteristics of nonfederal physicians who were primarily engaged in office-based patient care in the United States during 2003-04. METHODS: The data in this report were collected during the physician induction interview for the 2003 and 2004 National Ambulatory Medical Care Surveys (NAMCS). NAMCS includes a national probability sample of nonfederal office-based physicians who saw patients in an office setting. It excludes physicians in the specialties of anesthesiology, radiology, and pathology, as well as physicians practicing in hospitals, institutions, and occupational settings. Sample data were weighted to produce national estimates of the number of physicians and characteristics of their practices. RESULTS: During 2003-04, an average annual of 311,200 office-based physicians provided patient care in the United States, an overall rate of 108.4 physicians per 100,000 persons. Approximately three-fourths of office-based physicians owned or were part owner of their practice, two-thirds of physicians worked in group practices with two or more physicians, and one-half of office-based physicians were primary care specialists. Physicians with 10 or more managed care contracts spent less time per patient visit, but had more weekly visits compared with physicians with fewer than three managed care contracts. The average total weekly number of encounters (consults or visits) and the average number of office visits per physician were greater among primary care specialists compared with other specialty types. About one-fourth of physicians (25.5 percent), reported that they did not accept new Medicaid patients and 13.9 percent did not accept new Medicare patients-similar to previous years.

Making patient-level estimates from medical encounter records using a multiplicity estimator.

The National Ambulatory Medical Care Survey (NAMCS) is a nationally representative survey of medical encounters in physician offices in the United States. Data from this survey and its counterpart in hospitals, the National Hospital Ambulatory Medical Care Survey (NHAMCS), have been used to investigate physician treatment and prescribing patterns. A limitation of these data, however, is that they represent visits rather than patients. Starting in 2001, the survey questionnaires began collecting information on the number of past visits the patient had to the sample provider during the one-year period prior to the sampled visit. This information was used to estimate number of patients from the NAMCS and NHAMCS visit data using a multiplicity estimator. The resulting distribution of patients by the number of annual visits is similar to the distribution of persons in the U.S. making ambulatory care visits from a population-based survey. This estimation technique may be useful in estimating patients with clinical characteristics that are difficult to collect from a population-based survey. Published in 2007 by John Wiley & Sons, Ltd.

Staffing, capacity, and ambulance diversion in emergency departments: United States, 2003-04.

OBJECTIVE: The increased demand for emergency department (ED) services over the past decade has resulted in crowding. This report presents estimates of structure and process characteristics of hospital EDs related to their capacity to treat medical and surgical emergencies. Estimates of EDs experiencing crowded conditions are also presented. METHODS: Several facility supplements were added to the 2003-04 National Hospital Ambulatory Medical Care Survey (NHAMCS), which were completed by hospital staff. NHAMCS samples nonfederal, short-stay, and general hospitals in the United States. Of all sample hospitals that operated 24-hour EDs, 83 percent completed the supplemental questionnaires. Data from 467 hospitals were weighted to produce national annual estimates of ED characteristics. RESULTS: There was an annual average of 4,500 EDs operating in the United States during 2003 and 2004. Over one-half of EDs saw less than 20,000 patients annually, but 1 out of 10 had an annual visit volume of more than 50,000 patients. Although 16.1 percent of hospitals expanded their ED physical space within the last 2 years, approximately one-third of others planned to do so within the next 2 years. Most EDs used outside contracts to provide physicians (64.7 percent). One-half of EDs in metropolitan statistical areas (MSAs) had more than 5 percent of their nursing positions vacant. Of all on-call specialists, the services of plastic and hand surgeons were most frequently reported as somewhat or very difficult to obtain (49.4 percent). Approximately one-third of U.S. hospitals reported going on ambulance diversion sometime in the previous year. About 12 percent of hospitals in MSAs reported having spent between 5 and 19 percent of their operating time in diversion status. Between 40 and 50 percent of U.S. hospitals experienced crowded conditions in the ED with almost two-thirds of metropolitan EDs experiencing crowding.

Analysis of ambulance transports and diversions among US emergency departments.

STUDY OBJECTIVE: We describe emergency department (ED) visits in which the patient arrived by ambulance and estimate the frequency of and reasons for ambulance diversion. Using information on volume of transports and probabilities of being in diversion status, we estimate the number of patients for whom ED care was delayed because of diversion practices. METHODS: Data from the 2003 ED component of the National Hospital Ambulatory Medical Care Survey, an annual sample survey of visits to US hospital EDs, were used for the analysis. Data were provided by 405 participating EDs on 40,253 visits. Data from supplemental questionnaires to the hospital staff were used to describe volume and frequency of ambulance diversions. RESULTS: In 2003, patients arrived by ambulance for 16.2 million ED visits (14.2%). About 31 ambulances arrived at a US ED every minute. Of ambulance-related visits, 39% were made by seniors, 68% were triaged as emergent or urgent, and 37% resulted in hospital-admission. About 45% of EDs reported diverting ambulances at some point during the previous year. Among EDs that had any diversion, approximately 3% of operating time was spent in diversion status. In 2003, an estimated 501,000 ambulances were diverted, ie, 1 ambulance diversion per minute. Large EDs represent 12% of all EDs, 35% of all ambulance arrivals, 18% of all EDs that went on diversion, 47% of all hours spent in diversion status, and 70% of all ambulances diverted to another ED. CONCLUSION: Description of current use of ED ambulance transports and likelihood of diversions should help policymakers plan for demographic changes in the population during the next 15 years.