National Ambulatory Care Survey Research Articles

Transition to Medicare Does Not Contribute to Rise in Outpatient Visits for Nonmelanoma Skin Cancer, Actinic Keratosis, or Actinic Cheilitis in the US Population.

Outpatient visits for nonmelanoma skin cancer (NMSC) and actinic keratoses (AK) have risen steadily in the United States, notably among Medicare beneficiaries. Individuals may delay seeking care for minimally symptomatic conditions until they qualify for Medicare coverage, indicating potential delay of nonurgent screening interventions for uninsured or underinsured patients younger than 65 years. This study investigates whether an atypical increase in outpatient visits for NMSC, AK, or actinic cheilitis (AC) occurs at the age of Medicare transition by utilizing the National Ambulatory Care Survey from 1993 to 2019. The National Ambulatory Care Survey data were analyzed for patients aged within 5 years of 65 years. Diagnoses were identified using International Classification of Diseases codes. Linear regression and outlier detection were used to identify a relationship between Medicare eligibility and outpatient visits for NMSC and AK/AC. Predicted visits for AK/AC and NMSC increased with age. However, there was no evidence of a disproportionate increase in outpatient visits for NMSC and AK/AC at the age of Medicare eligibility. Outside evidence indicates health care utilization increases after Medicare transition. This study's data do not support a corresponding rise in outpatient visits for NMSC and AK/AC at the age of Medicare eligibility.

Investigation Into Potentially Inappropriate Prescribing Patterns of Loop Diuretics in a Nationally Representative Outpatient Population.

Loop diuretic therapy effectively treats edema related to heart failure, chronic kidney disease, and liver impairment; however, evidence supporting other indications is lacking. For indications such as hypertension or dependent edema or treatment of adverse events associated with other medications, the benefits likely do not outweigh the risks, putting patients at an unacceptably high risk of poor outcomes. What is the proportion of loop diuretic prescribing that occurs in the absence of a diagnosis of heart failure, chronic kidney disease, liver impairment, or other evidence-based indications? This was a national, retrospective, cross-sectional investigation conducted using the National Ambulatory Care Survey from 2013 to 2016. Outpatient visits for patients aged 18 years or older prescribed with loop diuretics were included. The primary end point was the frequency of potentially inappropriate loop diuretic prescribing. The secondary end point was a multivariable regression model that identified predictors of potentially inappropriate loop diuretic utilization. This analysis identified 5261 outpatient visits conducted during the study period in which loop diuretics were prescribed. Of these, 3648 visits (65.8% of weighted visits) were of patients without a history of heart failure, chronic kidney disease, or liver impairment. Positive predictors included age older than 65 years (odds ratio [OR] 1.71; 95% confidence interval [CI] 1.38-2.13), concomitant calcium channel blocker (OR 1.42; 95% CI, 1.09-1.84), sodium-containing medication use (OR 2.78; 95% CI, 1.23-6.25), and office visit with a cardiology specialist (OR 2.84; 95% CI, 2.31-3.50). This analysis identified that loop diuretics are prescribed in the absence of evidence-based indications more frequently than they are prescribed for them. This prescribing pattern creates a unique opportunity for clinicians to optimize patient care. Further study of the outcomes associated with this prescribing pattern is warranted.

Development of a Physicians’ Choice Model Using Mixed Logit with Random Prices for Drugs Case Study on Diabetes Type II

Background: this paper presents a first experiment with random generator of drug prices and a first simulation on physicians’ treatment choices (case on pharmacotherapies) for diabetes type II care. It also aims to compare the effects of the price variables according to public versus private health plans on physicians’ choices (Medicare versus commercial Health Plans). Methods: the base line model used is a Mixed Logit model with Random Price variables. A series of experiments with random parameters generations is designed with various sequences and number of draws. The model is tested on a real analytical dataset, extracted from the CDC physician survey (National Ambulatory Care Survey, NAMCS), for patients with diabetes type II without complications, for previous predictive econometrics with ENDEPUS research, Inc. The model uses a first drug choice set with three alternatives: oral agents only, combined therapies, no drug. The choice models introduce qualitative dependent variables and complement the series of cumulative logistic models per disease. The matlab code for the new specification test on the Independence of Irrelevant Alternatives at individual level is modified to fit this type of medical applications. Results: a mixed logit model is run on Stata to estimate main coefficients associated with price variables and socio demographics of diabetic patients; these parameters are then imported into a modified matlab code, based on first experiments of random generators for price; runs compare main parameters of a full choice set versus reduced choice sets of alternatives. It is planned to design more experiments for extended choice sets and widespread applications, to lead to user friendly tools for medical systems. Conclusions: the collaboration with Professor Jerry Hausman on the US market will help with use of results and new ways to adjust the reliability of the selection of alternatives; it may provide additional guidance to the algorithms used by professionals and for health policies.

Development of a Physicians’ Choice Model Using Mixed Logit with Random Prices for Drugs Case Study on Diabetes Type II

Abstract Background: this paper presents a first experiment with random generator of drug prices and a first simulation on physicians’ treatment choices (case on pharmacotherapies) for diabetes type II care. It also aims to compare the effects of the price variables according to public versus private health plans on physicians’ choices (Medicare versus commercial Health Plans). Methods: the base line model used is a Mixed Logit model with Random Price variables. A series of experiments with random parameters generations is designed with various sequences and number of draws. The model is tested on a real analytical dataset, extracted from the CDC physician survey (National Ambulatory Care Survey, NAMCS), for patients with diabetes type II without complications, for previous predictive econometrics with ENDEPUS research, Inc. The model uses a first drug choice set with three alternatives: oral agents only, combined therapies, no drug. The choice models introduce qualitative dependent variables and complement the series of cumulative logistic models per disease. The matlab code for the new specification test on the Independence of Irrelevant Alternatives at individual level is modified to fit this type of medical applications.

A vote for the full ticket.

Based on data from the 1997-2016 National Ambulatory Care Surveys, dramatic changes have occurred in the treatment practices of psychiatrists caring for patients with bipolar disorder (1). These trends include an increase in the prescription of antipsychotics from 19.1% to 52.7% and a concomitant decrease in the prescription of mood stabilizers, including a decrease in the use of lithium from 30.4% to 17.6%. Despite equivocal evidence for efficacy together with evidence for potential harm, prescribing of antidepressants rose from 47.0% to 57.5%. And in spite of growing evidence for efficacy, use of psychotherapy fell from 50.9% to 35.7%.

Vaccinating to Prevent Antibiotic Use: Potential Impact of a Group A Streptococcus Vaccine on Acute Respiratory Infections

Background: Group A Streptococcus (GAS) causes acute upper respiratory tract infections that are frequently treated with antibiotics. GAS vaccines in development may prevent both disease and outpatient antibiotic prescribing. We estimated (1) the incidences of GAS-attributable pharyngitis, sinusitis, and acute otitis media (AOM) infections in the United States; (2) the proportion of these infections resulting in antibiotic prescriptions; and (3) the incidence of infection and antibiotic prescribing potentially preventable by vaccination against GAS. Methods: We estimated annual rates of US outpatient visits and antibiotic prescriptions for pharyngitis, sinusitis, and AOM using physician office and emergency department visit data in the National Ambulatory Care Survey and National Hospital Ambulatory Medical Care Survey from 2012 to 2015. We supplemented this with visits to other outpatient settings (eg, urgent care) from the 2016 IBM MarketScan Commercial Database. We estimated the proportion of episodes attributable to GAS and to GAS emm types targeted by a 30-valent vaccine in development using data from previously conducted etiology studies. We estimated the incidence of disease and antibiotic prescribing preventable by a vaccine meeting the WHO 80% efficacy target for preventing noninvasive GAS disease, with doses administered during infancy and at age 4 years. We estimated the proportion of outpatient antibiotic prescribing preventable by vaccination by dividing estimates by total antibiotic dispensations, estimated from the IQVIA TM dataset. Results: Among individuals aged 0–64 years, GAS causes 27.3 (95% CI, 24.6–30.6) ambulatory care visits and 16.4 (95% CI, 14.5–18.6) outpatient antibiotic prescriptions per 1,000 population annually for pharyngitis, sinusitis, and AOM combined, representing 2.1% (95% CI, 1.8%–2.4%) of all outpatient antibiotic prescriptions. Among children aged 3–9 years, GAS-attributable incidence includes 124.4 (95% CI, 109.0–142.1) visits and 77.1 (95% CI, 65.7–90.6) antibiotic prescriptions per 1,000 population annually, representing 8.6% (95% CI, 7.3%–10.1%) of antibiotic prescriptions in this age group. Individual-level direct protection from a 30-valent vaccine meeting the WHO target could prevent 26.0% (95% CI, 24.0%–28.1%) of pharyngitis visits; 17.3% (95% CI, 15.5%–19.5%) of pharyngitis, sinusitis, and AOM visits; and 5.5% (95% CI, 4.7%–6.4%) of outpatient antibiotic prescriptions among children aged 3–9 years. If vaccination eliminated the need for antibiotic treatment of pharyngitis (for which GAS is the only etiology warranting antibiotic treatment), the total effects of vaccination could include the prevention of up to 17.2% (95% CI, 15.0%–19.6%) and 6.8% (95% CI, 6.3%–7.3%) of antibiotic prescriptions among persons 3–9 years and 0–64 years of age, respectively. Conclusions: In addition to preventing infections and healthcare visits, an efficacious GAS vaccine could prevent a substantial volume of outpatient antibiotic prescribing in the United States.Funding: This work was supported by the Centers for Disease Control and Prevention. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.Disclosures: Laura M. King is a contractor employed by Northrop Grumman Corporation to fulfill research needs at the Centers for Disease Control and Prevention as part of a contract covering many positions and tasks. All other authors declare no conflicts.

Changes in Proportions of Emergency Department Patients with Mental Illness Noted in the National Hospital Ambulatory Medical Care Survey, 2012-2015.

The primary objective of this study was to determine whether there was a change in the rate and types of patients with psychiatric illnesses being seen in the emergency department (ED) from 2012 to 2015 using the National Ambulatory Care Survey. A secondary objective was to determine what if any changes occurred in the resources available to care for these patients. Our study used 2012-2015 data from the National Hospital Ambulatory Medical Care Survey and the State Mental Health Agency Per Capita Mental Health Services Expenditures, and expenditures data from 2012-2015 to examine whether there was a significant change in the rate and type of mental illness ED visits. Additional data on the number of beds per region from the National Mental Health Services Survey, 2012-2015 were used. A t test was used to look for significant (P = 0.05) changes in the rate and types of patients, ED dispositions, ED reimbursement types, region and community level income, sex, age, state mental health funding, and psychiatric beds from 2012 to 2015. There was an 8% increase in the rate of patients who presented with a diagnosed mental health disorder (P = 0.03, 95% confidence interval [CI] 5.32-5.96) and substance use disorders (P = 0.03, 95% CI 0.564-0.122). The reimbursement for these visits did change (P = 0.01, 95% CI 0.245-0.685); however, there was no significant increase (P = 0.07, 95% CI-214 to 101) in state mental health budgets and the number of psychiatric and detox hospital beds from 2012 to 2015. The rate and types of mental health patients coming to the ED are still on the rise. This is coupled with a lack of mental health infrastructure to address the needs and diagnoses that continue to be seen in the ED. States may need increased, targeted funding for mental health outside the increase in coverage via the Patient Protection and Affordable Care Act to slow the rate of mental health patients seen in the ED.

Recommendation Rates for Physical Therapy, Lifestyle Counseling, and Pain Medications for Managing Knee Osteoarthritis in Ambulatory Care Settings: A Cross-Sectional Analysis of the National Ambulatory Care Survey (2007-2015).

To describe and compare triennial rates of physicians' recommendations for physical therapy (PT), lifestyle counseling, and pain medication for knee osteoarthritis (OA) and to identify patient, physician, and practice factors associated with each treatment recommendation. We conducted a cross-sectional analysis examining data between 2007 and 2015 from the National Ambulatory Medical Care Survey. Visits to orthopedists and primary care physicians for knee OA were identified and assessed for the following: PT referral, lifestyle counseling, nonsteroidal antiinflammatory drug (NSAID) prescriptions, and narcotics prescriptions. Triennial rates for each treatment were calculated. We examined associations between patient (e.g., race, insurance), physician, and practice factors (e.g., ownership, location) and treatments prescribed using multivariate logistic regression that accounted for complex sampling design. A total of 2,297 physician visits related to knee OA (~67 [±4] million weighted visits) were identified. For visits to orthopedists, PT and lifestyle recommendation rates declined (158 to 88 of 1,000 visits and 184 to 86 of 1,000 visits, respectively), while NSAID and narcotics prescriptions increased (132 to 278 of 1,000 visits and 77 to 236 of 1,000 visits, respectively) over time (P < 0.05). For visits to primary care physicians, there were no significant changes in rates of PT, lifestyle counseling, and narcotics prescriptions over time, while NSAIDs prescriptions increased (221 to 498 of 1,000 visits; P < 0.05). Treatment recommendations were associated with nonclinical factors, including practice type, location, and type of provider. In patients with knee OA, PT and lifestyle counseling seem underutilized, while pain medication prescriptions increased during the investigated timeframe. Variation in treatment choices were associated with nonclinical factors. Future research is necessary to examine ways to improve PT and lifestyle utilization and reduce variation in care for knee OA.

Adherence to clinical guidelines for monitoring diabetes in primary care settings

Objective Adherence to clinical guidelines is key to improving diabetes care. Contemporary knowledge of guideline adherence is lacking. This study sought to produce a national snapshot of primary care physicians’ (PCPs) adherence to the American Diabetes Association guidelines for monitoring diabetes and determine whether continuity of care promotes adherence. Methods Using the 2013 National Ambulatory Medical Care Survey, we examined adherence to ordering hemoglobin A1c (HbA1c) and lipid profile tests as recommended by the American Diabetes Association for monitoring diabetes in 2379 primary care visits of patient with diabetes. Results In the preceding 12 months, less than 60.0% of the patients were given a test recommended for monitoring diabetes (58.0% for HbA1c and 57.0% for lipid profile). Continuity of care with PCPs increased the odds of adhering to diabetes monitoring guidelines by 36.0% for the HbA1c test (P=0.06) and by 76.0% for the lipid profile test (P=0.0006). Conclusion A substantial gap exists in achieving optimal monitoring for diabetes in primary care settings in the United States. While PCPs are ideally positioned to ensure that guidelines are closely followed, we found that even in primary care settings, patient-provider continuity of care was associated with guideline adherence. Significance statement Adherence to clinical guidelines is an integral part of the World Health Organization’s Global Action Plan to reduce the impact of diabetes. In this study, we used the 2013 National Ambulatory Care Survey to assess US physicians’ adherence to the American Diabetes Association’s guidelines for monitoring diabetes. We found a substantial gap between what was done in primary care settings and what is recommended for optimal diabetes management. Our findings support the positive effect of continuity of care on improving diabetes quality of care.

PIH47 - Racial Trends in Non-Vitamin/Non-Mineral Medication Use During Pregnancy or Puerperium in the Ambulatory Care Setting

The objective of this study was to evaluate racial trends in the prescribing of non-vitamin/non-mineral medications within office-based ambulatory care visits occurring during pregnancy or puerperium. A cross-sectional analysis of office-based ambulatory care visits occuring during pregnancy or puerperium was conducted using the National Ambulatory Care Survey (NAMCS) from 2005 to 2011. Descriptive statistics for all study variables by racial subgroups were estimated. Weighted bivariable analyses were used to examine statistical differences in the prescribing of non-vitamin/non-mineral medications by race. Annual trends in use by therapeutic class were also evaluated by racial subgroup. All analyses were performed using SAS 9.3 at an alpha of 0.05. A total of 5,850 office-based ambulatory care visits (213.7 million weighted visits) occurring during pregnancy or puerperium were included. Of them, 78.8%, 14.0%, and 7.1% were from pregnant women who were of White, Black and Other race respectively. Medication use findings showed that at least half of all included study visits had a non-vitamin/non-mineral medication prescribed. Racial differences in the prescribing of non-vitamin/non-mineral medications were also observed with visits from Black women having a higher proportion of prescribing (p<0.05). Higher proportions of medications for cardiovascular-related conditions were also reported. Racial differences in non-vitamin/non-mineral prescribing during pregnancy or puerperium overall and for cardiovascular-related conditions were observed.

HIV Testing at Visits to Physicians’ Offices in the U.S., 2009–2012

HIV testing serves as an entry point for HIV care services for those who test HIV positive, and prevention services for those who test HIV negative. The Centers for Disease Control and Prevention recommends routine testing of adults and adolescents in healthcare settings. To identify missed opportunities for HIV testing at U.S. physicians' offices, data from the National Ambulatory Care Surveys from 2009 to 2012 were analyzed. The mean annual number and percentage of visits with an HIV test among HIV-uninfected nonpregnant females and males aged 15-65 years was estimated using weighted survey data. Factors associated with HIV testing at visits to physicians' offices were identified. The mean annual number of U.S. physicians' office visits with an HIV test conducted was 1,396,736 (0.4% of all visits) among nonpregnant females and 986,891 (0.5% of all visits) among males. For both nonpregnant females and males, HIV testing prevalence was highest among those aged 20-29 years (1.3% of all visits by nonpregnant females; 1.7% of all visits by males) and non-Hispanic blacks (1.1% of all visits by nonpregnant females; 1.0% of all visits by males). An HIV test was not conducted at 98.5% of visits at which venipuncture was performed for both nonpregnant females and males. Important opportunities exist to increase HIV testing coverage at U.S. physicians' offices. Structural interventions, such as routine opt-out testing policies, electronic medical record notifications, and use of non-clinical staff for testing could be implemented to increase HIV testing in these settings.

Adherence to treatment guidelines: the association between stroke risk stratified comparing CHADS2 and CHA2DS2-VASc score levels and warfarin prescription for adult patients with atrial fibrillation

BackgroundIschemic stroke is a risk associated with atrial fibrillation (AF) and is estimated to occur five times more often in afflicted patients than in those without AF. Anti-thrombotic therapy is recommended for the prevention of ischemic stroke. Risk stratification tools, such as the CHADS2, and more recently the CHA2DS2-VASc, for predicting stroke in patients with AF have been developed to determine the level of stroke risk and assist clinicians in the selection of antithrombotic therapy. Warfarin, for stroke prevention in AF, is the most commonly prescribed anticoagulant in North America. The purpose of this study was to examine the utility of using the CHADS2 score levels (low and high) in contrast to the CHA2DS2-VASc when examining the outcome of warfarin prescriptions for adult patients with AF. The CHA2DS2-VASc tool was not widely used in 2010, when the data analyzed were collected. It has only been since 2014 that CHA2DS2-VASc criteria has been recommended to guide anticoagulant treatment in updated AF treatment guidelines.MethodsBivariate and multivariate data analysis strategies were used to analyze 2010 National Ambulatory Care Survey (NAMCS) data. NAMCS is designed to collect data on the use and provision of ambulatory care services nationwide. The study population for this research was US adults with a diagnosis of AF. Warfarin prescription was the dependent variable for this study. The study population was 7,669,844 AF patients.ResultsBivariate analysis revealed that of those AF patients with a high CHADS2 score, 25.1% had received a warfarin prescription and 18.8 for those with a high CHA2DS2-VASc score. Logistic regression analysis yielded that patients with AF had higher odds of having a warfarin prescription if they had a high CHADS2 score, were Caucasian, lived in a zip code where < 20% of the population had a university education, and lived in a zip code where < 10% of the population were living in households with incomes below the federal poverty level. Further, the analysis yielded that patients with AF had lesser odds of having a warfarin prescription if they were ≥ 65 years of age, female, or had health insurance.ConclusionsOverall, warfarin appears to be under-prescribed for patients with AF regardless of the risk stratification system used. Based on the key findings of our study opportunities for interventions are present to improve guideline adherence in alignment with risk stratification for stroke prevention. Interprofessional health care teams can provide improved medical management of stroke prevention for patients with AF. These interprofessional health care teams should be constituted of primary care providers (physicians, physician assistants, and nurse practitioners), nurses (RN, LPN), and pharmacists (PharmD, RPh).

The Immediate Impact of the 2009 USPSTF Screening Guideline Change on Physician Recommendation of a Screening Mammogram: Findings from a National Ambulatory and Medical Care Survey-Based Study.

Regular screening is considered the most effective method to reduce the mortality and morbidity associated with breast cancer. Nevertheless, contradictory evidence about screening mammograms has led to periodic changes and considerable variations among different screening guidelines. This study is the first to examine the immediate impact of the 2009 US Preventive Services Task Force (USPSTF) guideline modification on physician recommendation of mammograms. The study included visits by women aged 40 years and older without prior breast cancer from the National Ambulatory and Medical Care Survey 2008-2010. Bivariate and multiple logistic regressions were used to determine the factors associated with mammography recommendation. Approximately 29,395 visits were included and mammography was recommended during 1350 visits; 50-64-year-old women had 72% higher odds, and 65-74-year-old women had twice the odds of getting a mammogram recommendation compared with 40-49-year-old women in 2009. However, there was no difference in recommendation by age groups in 2008 and 2010. Obstetricians and gynecologists did not modify their recommendation behavior in 2009, unlike all other specialists who reduced their recommendation for 40-49-year-old women in 2009. Other characteristics associated with mammogram recommendations were certain patient comorbidities, physician specialty and primary care physician status, health maintenance organization status of the clinic, and certain visit characteristics. This study demonstrated a temporary effect of the USPSTF screening guideline change on mammogram recommendation. However, in light of conflicting recommendations by different guidelines, the physicians erred toward the more rigorous guidelines and did not permanently reduce their mammogram recommendation for women aged 40-49 years.

Comparing Care Given by Primary Care Physicians and Advanced Practice Clinicians

In a study of data from two national ambulatory care surveys, researchers evaluated quality of primary care by assessing use of low-value and guideline-discordant tests and treatments that were provided during care of patients who had one of three common outpatient conditions (upper respiratory infection, headache, or back …

Are Discrepancies in Waiting Time for Chest Pain at Emergency Departments between African Americans and Whites Improving Over Time?

BackgroundOne of the Healthy People 2010 goals was to eliminate racial disparities in the U.S health system. To date, we have limited knowledge about the impact of Healthy People on racial disparities at emergency departments (EDs). ObjectiveWe sought to investigate whether there has been an improvement in ED waiting time to see a physician for African Americans (AAs) compared to whites with chest pain symptoms that suggest acute coronary syndrome (ACS). MethodsA retrospective analysis of the National Hospital and Ambulatory Care Survey data from 2004 to 2011 was conducted in adults with visits related to ACS. We compared covariate-adjusted odds ratios for race for each study year and 2011. In addition, adjusted average differences in waiting times (i.e., time to see a physician) for AAs and whites for each study year were compared. ResultsA total of 15,438 visits related to ACS symptoms were made during the study period. The waiting time for AAs (median, 33 min) was statistically longer compared to whites (median, 21 min). In addition, the adjusted waiting time for AAs was 30% longer compared to whites (95% confidence interval, 24–36%). Pairwise comparison of adjusted odds ratios between the year 2011 and other years was not significantly different (all p values = 0.32), suggesting no change in the difference in waiting times during the study period. ConclusionAmong patients presenting to the ED with symptoms suggesting ACS, AA compared to whites waited longer to receive care. In addition, this difference in waiting time persisted during the study period, even after the implementation of the Healthy People 2010 initiative. Additional research is warranted to investigate the underlying reasons for unequal care offered to AAs at EDs and the implications on disease outcome.

PD51-05 THE BURDEN OF KIDNEY STONES IN PRIMARY CARE

You have accessJournal of UrologyStone Disease: Evaluation III1 Apr 2015PD51-05 THE BURDEN OF KIDNEY STONES IN PRIMARY CARE Melissa Mendez, Michael Lipkin, Glenn Preminger, and Charles Scales Melissa MendezMelissa Mendez More articles by this author , Michael LipkinMichael Lipkin More articles by this author , Glenn PremingerGlenn Preminger More articles by this author , and Charles ScalesCharles Scales More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1765AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Urinary lithiasis is a highly prevalent condition in the United States, affecting nearly 1 in 11 persons in their lifetime. Many stones pass without requiring surgical intervention, and uneven workforce distribution reduces access to urologic care in many areas. Patients may be initially evaluated or managed by primary care physicians. Given this context, we sought to characterize the utilization of primary care visits for patients with urinary stones in the United States. METHODS We performed a cross-sectional analysis of ambulatory visits for patients with upper tract stones between 2008 and 2010 using the National Ambulatory Care Survey (NAMCS). NAMCS is a multistage probability survey of non-hospital-based outpatient visits in the United States. It is specifically designed to provide nationally representative estimates of healthcare utilization. The survey includes information regarding patient demographics, health conditions, services and physician specialty. Visits were identified using ICD-9-CM diagnostic codes. National estimates were compared using the Rao-Scott chi square test or univariate linear regression, as appropriate. All analyses accounted for the complex sampling structure of the NAMCS. RESULTS During the study period, an estimated 10.6 million ambulatory visits for patients with upper tract stones occurred. Urologists provided care at just more than half of these visits (56%), and primary care physicians provided care during 33% of visits. Patients seen in primary care were younger (46.4 vs. 53.0 years, p = 0.01) and more likely to be of non-white ethnicity (26% vs 11%, p = 0.007) than those seen by a urologist. There were no differences in visits to primary care versus urology by patient sex or metropolitan location. Most visits (61%) to primary care were for a new presentation of a stone, with a smaller proportion for a recurrence of chronic stone disease (16%). In contrast, only about one-third of visit to urologists represented new presentation of a stone (p<0.001 vs primary care). CONCLUSIONS A substantial portion of ambulatory visits for patients with kidney stones occurs in the primary care setting. Many of these visits are for new onset of a symptomatic stone. Further research is required to gain a better understanding of utilization, variation, and outcomes of care for these patients. For patients not requiring surgical intervention, treatment in a primary care setting may provide a lever to reduce the overall cost of care for kidney stones in the United States. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e1110 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Melissa Mendez More articles by this author Michael Lipkin More articles by this author Glenn Preminger More articles by this author Charles Scales More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

The Prevalence, Burden, and Treatment of Severe, Frequent, and Migraine Headaches in US Minority Populations: Statistics From National Survey Studies

The prevalence and burden of migraine and other severe headaches in the US population as a whole is well documented. Prevalence and treatment patterns in US racial and ethnic minorities, however, have received less attention. We sought to assemble and compare this information as identified in large, nationally representative studies. We searched for summary statistics from studies performed in the United States between 1989 and 2014. Included studies had to provide population-based, nationally or broadly representative information on the prevalence, burden, or treatment of severe or frequent headache or migraine in adult US Blacks, Hispanics, Native Americans, or Asians. Nine studies were included in the review. Prevalence data from the National Health Interview Survey (NHIS) provide the most comprehensive information for major racial and ethnic groups. The average prevalence of severe headache or migraine from 2005 to 2012 NHIS was 17.7% for Native Americans, 15.5% for Whites, 14.5% for Hispanics, 14.45% for Blacks, and 9.2% for Asians. Severe headache or migraine prevalence was higher in females of all races and ethnic groups compared with males and across all included studies. Female to male prevalence ratios from the 2005-2012 NHIS were 2.1 for Whites, 2.5 for Hispanics, 2.1 for Blacks, and 2.0 for Asians. Among those with chronic migraine (≥15 days of headache per month), prevalence data from the American Migraine Prevalence and Prevention study showed that the prevalence of chronic migraine was highest in Hispanic women (2.26% compared with 1.2% for White females), whereas White males had the lowest prevalence at 0.46%. Data from the National Hospital Ambulatory Care Survey and National Ambulatory Care Survey show that Hispanics make only 89.5 annual ambulatory care visits per 10,000 population at which they receive a diagnosis of migraine, compared with 176.3 for Whites and 133.2 for Blacks. In contrast, visit rates resulting in a diagnosis of nonspecific headache were more comparable across all groups. Only one study obtained information on selected subgroups within Hispanic and Asian populations. This showed that differences among these subgroups, which suggest composite prevalence estimates for broadly defined racial and ethnic groups such as Asians, may conceal meaningful differences in subgroups, such as Vietnamese or Filipinos. In the United States, migraine prevalence is highest among Native Americans, then Whites, followed closely by Hispanics and Blacks. Asians have the lowest prevalence of severe, frequent headache or migraine of the major racial or ethnic groups. Differences in diagnosis and treatment of headache and migraine may indicate racial and ethnic disparities in access and quality of care for minority patients.

Rates of Psychiatrists’ Participation in Health Insurance Networks

Rates of Psychiatrists’ Participation in Health Insurance Networks

Variation in antimicrobial prescribing for otitis media by race: different wrinkle in disparity?

* Abbreviation: AOM — : acute otitis media Acute otitis media (AOM) is an almost universal occurrence during childhood, with at least 90% experiencing ≥1 episode by age 7 years.1 Multiple studies through the early 2000s noted a lower frequency of AOM among black children compared with white children.2,3 Other studies suggested that rates of middle ear effusion4,5 and clinical diagnoses of AOM3 did not differ between black and white children. The apparent rate difference in many studies more likely reflected differences in access to care and possibly differences in diagnosis and management by health care providers, rather than differences in genetic predisposition. In a recent study in the Philadelphia area, primary care physicians were less likely to diagnose AOM in black children versus non-black children; they were more likely, however, to prescribe recommended narrow-spectrum amoxicillin than broader-spectrum antimicrobial agents when they diagnosed AOM in black children versus non-black children.6 In this issue of Pediatrics , Fleming-Dutra et al7 present their results on this topic from analyses of the National Ambulatory Care Survey and National Hospital Ambulatory Care Survey databases from 2008–2010. AOM diagnoses in these databases were assigned by the treating physician, although not necessarily confirmed with the level of rigor required of a prospective clinical trial. The sample size … Address correspondence to Charles R. Woods, MD, MS, Pediatric Infectious Diseases, 571 S. Floyd St, Suite 321, Louisville, KY 40202. E-mail: charles.woods{at}louisville.edu

PMS76 - Drug Utilization Patterns For Rheumatoid Arthritis

Various medications are commonly used to manage Rheumatoid Arthritis (RA). This study examined drug utilization patterns and factors associated with the use of medications by RA patients. Data from the 2006-2010 National Ambulatory Care Survey (NAMCS) and the outpatient department component of the National Hospital Ambulatory Medical Care Survey (NHAMCS) were used to examine the RA related ambulatory visits. RA medications were classified as NSAIDS and analgesics, corticosteroids, and disease modifying Anti-rheumatic drugs (DMARDs). Bivariate chi-square analysis and multiple logistic regression analysis were performed to evaluate the factors associated with prescribing of RA medications. SAS survey procedures that adjust for the complex sampling procedure of national surveys were used to conduct bivariate and multivariate analyses. An average of 3.57 million (0.33%) visits was made by patients with RA from 2006 to 2010. Majority of these visits were made by females (76.75%), Whites (88.50%) and individuals aged 18-64 years old (61.53%). More than two third of the RA patients were prescribed anti-rheumatic drugs (70.75%). The most commonly prescribed anti-rheumatic drugs were NSAIDs and Analgesics (75.60%), DMARDs (20.40%) and Corticosteroids (4.00%). Multiple logistic regression analysis showed that females (OR: 0.55; 95% CI: 0.32-0.95), individuals aged group 18 to 64 years (OR: 0.48; 95% CI: 0.29-0.78) were less likely to receive anti-rheumatic drugs, whereas those seeking care from rheumatologists (OR: 4.38; 95% CI: 2.19-8.77) and those with multiple previous visits (OR: 1.43; 95% CI: 1.26-1.62) were more likely to receive anti rheumatic drugs. Most (7 out of 10) visits for the RA involved use of anti-rheumatic drugs. Drug use patterns varied across age, gender, physician specialty, and previous use of health care. Further research is needed to evaluate the variation across drug classes for RA.