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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 population—Rapid 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 technology—Over 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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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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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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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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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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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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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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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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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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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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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.
OCR for page 110
110
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Representative terms from entire chapter:
home health
