Antimicrobial drug prescription in ambulatory care settings,United States, 1992-2000

During the 1990s, as antimicrobial resistance increased among pneumococci, many organizations promoted appropriate antimicrobial use to combat resistance. We analyzed data from the National Ambulatory Medical Care Survey, an annual sample survey of visits to office-based physicians, and the National Hospital Ambulatory Medical Care Survey, an annual sample survey of visits to hospital emergency and outpatient departments, to describe trends in antimicrobial prescribing from 1992 to 2000 in the United States. Approximately 1,100-1,900 physicians reported data from 21,000-37,000 visits; 200-300 outpatient departments reported data for 28,000-35,000 visits; approximately 400 emergency departments reported data for 21,000-36,000 visits each year. In that period, the population- and visit-based antimicrobial prescribing rates in ambulatory care settings decreased by 23% and 25%, respectively, driven largely by a decrease in prescribing by office-based physicians. Antimicrobial prescribing rates changed as follows: amoxicillin and ampicillin, -43%; cephalosporins, -28%; erythromycin, -76%; azithromycin and clarithromycin, +388%; quinolones, +78%; and amoxicillin/clavulanate, +69%. This increasing use of azithromycin, clarithromycin, and quinolones warrants concern as macrolide- and fluoroquinolone-resistant pneumococci are increasing.     

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.     

Characteristics of chronic arthritis and other rheumatic condition-related ambulatory care visits, united states, 1997

PURPOSE: To characterize ambulatory medical care visits among persons with arthritis and other rheumatic conditions, the leading cause of disability.METHODS: The 1997 National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) collect annual data on the utilization of ambulatory medical services provided by non-federal office-based physicians and hospital outpatient and emergency departments. Arthritis-related visits were defined using a predetermined set of ICD9-CM diagnostic codes developed by an expert panel and designed to include all potential diagnoses for arthritis and other rheumatic conditions. Visits related to acute conditions such as injuries were not included. National estimates and rates of arthritis-related ambulatory care visits were calculated by age, race, and sex groups.RESULTS: In 1997, there were an estimated 959.3 million ambulatory care visits, of which over 38 million (4.0%) were related to arthritis and other rheumatic conditions. Arthritis-related visits were more likely to be made by females (65.4%), white persons (82.2%), non-Hispanic persons (72.7%) and persons aged 25-64 years (61.9%). More than one-third of arthritis-related visits were for osteoarthritis, rheumatoid arthritis and unspecified myalgia/myositis. About half (50.2%) of the office visits for arthritis were made to general/family physicians or internists, while an additional 16.2% were to rheumatologists. Counseling or education related to exercise, diet/nutrition and injury prevention were provided at 18.9%, 9.2% and 2.2% of office and outpatient department visits respectively.CONCLUSIONS: Arthritis and other rheumatic conditions are common conditions associated with ambulatory medical care. These results suggest missed opportunities for counseling patients regarding public health prevention messages for arthritis, including increasing moderate physical activity, weight management and injury prevention.     

Adverse drug events in U.S. adult ambulatory medical care

Objective. To estimate the incidence of adverse drug events (ADEs) associated with health care visits among U.S. adults across all ambulatory settings. Data Source. We analyzed data from two nationally representative probability sample surveys: the National Ambulatory Medical Care Survey and the National Hospital and Ambulatory Medical Care Survey. From 2005 to 2007, the presence of an ADE was specifically defined, requested, and recorded in these surveys. Study Design. Secondary data analysis. Principal Findings. An estimated 13.5 million ADE‐related visits occurred between 2005 and 2007 (0.5 percent of all visits), the large majority (72 percent) occurring in outpatient practice settings, and the remaining in emergency departments. Older patients (age ≥65 years) had the highest age‐specific ADE rate, 3.8 ADEs per 10,000 persons per year. In adjusted analyses of outpatient visits, there was an increased odds of an ADE‐related visit with increased medication burden (odds ratio [OR] for six to eight medications compared with no medications, OR 3.83 [2.20, 6.65]), and increased odds of ADEs associated with primary care visits compared with specialty visits (OR 2.22 [1.70, 2.89]). Conclusions. Approximately 4.5 million ambulatory visits related to ADEs occur each year, the majority of these in outpatient office practices. A greater focus on ADE prevention and detection is warranted among patients receiving multiple medications in primary care practices.     

No racial differences in mortality found among Veterans Health Administration out-patients

OBJECTIVE: Health care delivery systems that offer equal access to ambulatory care may hold promise for preventing and correcting racial disparities that exist in our health care system as a whole. We examined whether racial differences in mortality rates exist among patients receiving outpatient care within the Veterans Health Administration. STUDY DESIGN AND SETTING: This study used data from the 1998 National Survey of Ambulatory Care Patients, a prospective monitoring system of patient outcomes. We used an outpatient care system in the Veterans Health Administration. We followed 25,172 Whites and 3,517 African-Americans for 48 months. The main study outcome measures were unadjusted and adjusted mortality rates over a 48-month period. RESULTS: African-Americans had significantly lower unadjusted 48-month mortality rates than Whites (33 vs. 40 deaths per 1,000 person-year, hazard ratio, 0.84; 95% confidence interval [CI], 0.75-0.95). After risk adjustment, the mortality rates became similar for African-Americans and Whites (hazard ratio, 0.99; 95% CI, 0.89-1.09). These findings were consistent across all time points evaluated during the 48-month follow-up. CONCLUSIONS: The lack of racial differences in mortality in patients receiving ambulatory care in the Veterans Health Administration is reassuring, given the emphasis on equal access within this health care system. This warrants further research to determine whether efforts to improve access in other settings have the potential to reduce racial disparities in health care.     

U.S. adolescents receive suboptimal preventive counseling during ambulatory care

PurposeTo examine U.S. adolescents’ (age 13–18) utilization of ambulatory care and the likelihood of receiving preventive counseling from 1993 through 2000.MethodsThe National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey provided visit-based data on counseling services that occurred in private physician offices and hospital outpatient departments. Main outcome measures included adolescents’ use of outpatient care and their likelihood of being counseled on 3 health promotion topics (i.e., diet, exercise, and growth/development) and 5 risk reduction topics (i.e., tobacco use/exposure, skin cancer prevention, injury prevention, family planning/contraception, and HIV/STD transmission).ResultsAdolescents had the lowest rates of outpatient visits among all age groups, with particularly low rates among boys and ethnic minorities. Most frequently, adolescent visits were for upper respiratory tract conditions, acne, routine medical or physical examinations, and, for girls, prenatal care. In 1997–2000, counseling services were documented for 39% (99% CI: 32–46%) of all adolescent general medical/physical examination (GME) visits. Diet [26% of GME visits (20–32%)] and exercise [22% (17–28%)] were the most frequent counseling topics. The counseling rates of the other six topics ranged from as low as 3 to 20%, with skin cancer prevention, HIV/STD transmission, and family planning/contraception ranking the lowest. These rates represented minimal improvements from 1993–1996 both in absolute term and in relation to the gaps between practices and recommendations.ConclusionsAdolescents underutilize primary care, and even those who do receive care are underserved for their health counseling needs. The noted lack of change over time suggests that satisfactory improvement is unlikely unless substantial interventions are undertaken.     

National Hospital Ambulatory Medical Care Survey: 1998 outpatient department summary

OBJECTIVE: This report describes ambulatory care visits to hospital outpatient departments in the United States. Statistics are presented on selected hospital, clinic, patient, and visit characteristics. METHODS: The data presented in this report were collected from the 1998 National Hospital Ambulatory Medical Care Survey (NHAMCS). NHAMCS is part of the ambulatory care component of the National Health Care Survey that measures health care utilization across various types of providers. NHAMCS is a national probability sample survey of visits to hospital outpatient and emergency departments of non-Federal, short-stay, and general hospitals in the United States. Sample data are weighted to produce annual estimates. RESULTS: During 1998, an estimated 75.4 million visits were made to hospital outpatient departments in the United States, an overall rate of 28.0 per 100 persons. Visit rates did not vary by age except in a comparison of the 15-24 year old group with the 75 years and over age group. Black persons had higher rates of visits than white persons as did women compared with men. Of all visits made to hospital outpatient departments in 1998, 33.8 percent and 25.9 percent, respectively, listed private insurance and Medicaid as the primary expected source of payment, and 21.9 percent were made by patients belonging to a health maintenance organization. There were an estimated 7.1 million injury-related outpatient department visits during 1998.     

Diet and physical activity counseling during ambulatory care visits in the United States

BACKGROUND: Research is limited regarding national patterns of behavioral counseling during ambulatory care. We examined time trends and independent correlates of diet and physical activity counseling for American adults with an elevated cardiovascular risk during their outpatient visits. METHODS: The National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) provided 1992-2000 national estimates of counseling practices in private physician offices and hospital outpatient departments. RESULTS: Rates of diet and physical activity counseling among visits by at-risk adults exhibited a modest ascending trend from 1992 to 2000, with the biggest growth found between 1996 and 1997. Throughout the 1990s, however, diet counseling was provided in <45% and physical activity counseling in < or = 30% of visits by adults with hyperlipidemia, hypertension, obesity, or diabetes mellitus. Lower likelihood of either counseling was significantly associated with patients who were > or = 75 years of age, seen by generalists, and those with fewer risk factors. Also, diet counseling was less frequently provided during visits by whites vs. ethnic minorities and by men vs. women. CONCLUSIONS: Despite available national guidelines, diet and physical activity counseling remain below expectations during outpatient visits by adults with an elevated cardiovascular risk. Given recent trends, immediate, satisfactory improvement is unlikely without future innovative interventions.     

US Provider-Reported Diet and Physical Activity Counseling to Pregnant and Non-pregnant Women of Childbearing Age During Preventive Care Visits

Healthy diet, physical activity and appropriate weight gain during pregnancy contribute to healthy birth outcomes. The Institute of Medicine recommends that women receive counseling about diet and exercise during preconception, pregnancy and postpartum periods. We sought to determine how often healthcare providers report counseling women of childbearing age about diet or exercise and if such rates vary by pregnancy, overweight/obesity status or physician specialty. We combined the 2005–2010 National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey to obtain nationally representative estimates of outpatient preventive care visits for women of child-bearing age (15–44 years). Accounting for survey design, we compared proportions of preventive visits that included diet/exercise counseling for pregnant women versus non-pregnant women and performed multivariable logistic regression models to estimate odds ratios. Providers reported counseling pregnant women about diet/exercise during 17.9 % of preventive care visits compared to 22.6 % of visits for non-pregnant women (P < 0.01, adj. OR 0.8, 95 % CI 0.7, 1.0). Overweight/obese pregnant (vs. non-pregnant) women were significantly less likely to receive diet/exercise counseling (adj. OR 0.7, CI 0.5, 0.9) as were women seen by OB/GYNs versus non-OB/GYNs (adj. OR 0.4, CI 0.3, 0.5). Our findings suggest that provider-reported diet/exercise counseling rates during preventive care visits for women of childbearing age vary by overweight/obesity and pregnancy statuses, as well as by provider specialty. Our data suggest that there may be missed opportunities to provide diet/exercise counseling and that increasing rates of counseling could result in improved maternal and infant health outcomes.     

National Hospital Ambulatory Medical Care Survey: 1998 emergency department summary

OBJECTIVES: This report describes ambulatory care visits to hospital emergency departments in the United States. Statistics are presented on selected patient and visit characteristics. METHODS: The data presented in this report were collected from the 1998 National Hospital Ambulatory Medical Care Survey (NHAMCS). NHAMCS is part of the ambulatory care component of the National Health Care Survey that measures health care utilization across various types of providers. NHAMCS is a national probability survey of visits to hospital emergency and outpatient departments of non-Federal, short-stay, and general hospitals in the United States. Sample data are weighted to produce annual national estimates. RESULTS: During 1998, an estimated 100.4 million visits were made to hospital emergency departments (ED's) in the United States, about 37.3 visits per 100 persons. Persons 75 years and over had the highest rate of ED visits. There were an estimated 37.1 million injury-related ED visits during 1998, or 13.8 visits per 100 persons. Seventy-four percent of injury-related ED visits were made by persons under 45 years of age. Injury visit rates were higher for males than females in each age group under 45 years. According to ICD-9-CM classification, 77.2 percent of injury visits were unintentional. About 71 percent of the ED visits involved medication therapy, with pain relief drugs accounting for 31.5 percent of the medications mentioned. Acute upper respiratory infection was the leading illness-related diagnosis at ED visits.     

Staphylococcus aureus-associated skin and soft tissue infections in ambulatory care

To describe the number and treatment of skin and soft tissue infections likely caused by Staphylococcus aureus in the United States, we analyzed data from the 1992-1994 and 2001-2003 National Ambulatory Medical Care Surveys and National Hospital Ambulatory Medical Care Surveys. Each year, data were reported by an average of 1,400 physicians, 230 outpatient departments, and 390 emergency departments for 30,000, 33,000, and 34,000 visits, respectively. During 2001-2003, the number of annual ambulatory care visits for skin and soft tissue infections was 11.6 million; the visit rate was 410.7 per 10,000 persons. During the study period, rates of overall and physician office visits did not differ; however, rates of visits to outpatient and emergency departments increased by 59% and 31%, respectively. This increase may reflect the emergence of community-acquired methicillin-resistant S. aureus infections.     

Autonomous ambulatory care by nurse practitioners and physician assistants in office-based settings

Data from the 1997 National Ambulatory Medical Care Survey were used to examine the autonomous provision of ambulatory medical care by nurse practitioners (NPs) and physician assistants (PAs) in physician-managed office-based settings. An estimated 6.81 million office visits involved autonomous care by NPs and PAs, for an overall rate of 2.55 visits per 100 persons. The visit rates were greatest for patients over 64 years of age, females, blacks, and patients from the Northeast. The visits encompassed a broad range of acute and chronic problems, with a greater proportion of non-illness care visits when compared with visits to physicians. While NPs and PAs provided diagnostic services and pharmacotherapy, there was more emphasis on therapeutic or preventive services in their practices than among physicians' practices. Predisposing, enabling, and need factors were differentially associated with visits to NPs and PAs. Utilization of NPs and PAs as autonomous providers in office-based settings appears limited. Public policy and educational initiatives can focus on predisposing, enabling, and need factors to increase access to autonomous practice of NPs and PAs in ambulatory care.     

Differences in obesity management among physicians

Abstract Despite the strong recommendations of guidelines, intensive obesity management is not offered to all obese patients. This study aimed to examine differences in obesity management between primary care physicians (PCPs) and non-PCPs. A cross-sectional study was performed using the 2006-2007 National Ambulatory Medical Care Survey. Adults (age ≥20 years) with obesity (body mass index (BMI)≥30?kg/m(2) or obesity diagnosis using International Classification of Diseases, Ninth Revision, Clinical Modification code 278) were included in the study cohort. A multivariate logistic regression model was constructed to examine differences between PCPs and non-PCPs (primary independent variable) for obesity management (dependent variable) while controlling for predisposing, enabling, and need characteristics per Anderson's behavioral model. In all, 32.66% of 214 million visits by obese patients in 2006-2007 resulted in obesity management. PCPs were 2.38 times more likely to provide obesity management compared to non-PCPs (odds ratio [OR]=2.37; 95% confidence interval [CI]: 1.69, 3.36). Patients who had preventive visits (OR=2.23; 95% CI: 1.50, 3.32) and chronic visits (OR=1.93; 95% CI: 1.46, 2.55) were more likely to receive obesity management than patients who had acute visits. More time spent with physician, more comorbid conditions, and BMI ≥ 40 significantly increased the likelihood of receiving obesity management, while older age and smoking reduced the likelihood of receiving obesity management. Only one third of ambulatory care visits in 2006-2007 resulted in obesity management. A difference in obesity management was noted between PCPs and non-PCPs. Future research should aim to identify the reasons for these observed differences, ensure equitable access, and address the undertreatment of obesity. (Population Health Management 2012;15:287-292).     

National Hospital Ambulatory Medical Care Survey: 2004 outpatient department summary

OBJECTIVES: This report describes ambulatory care visits to hospital OPDs in the United States. Statistics are presented on selected hospital, patient, and visit characteristics. Selected trends in OPD utilization from 1994 through 2004 are also presented. METHODS: The data presented in this report were collected in the 2004 NHAMCS, a national probability sample survey of visits to emergency and outpatient departments of nonfederal, short-stay, and general hospitals in the United States. Selected comparisons are also made with data from the 2004 National Ambulatory Medical Care Survey (NAMCS), a national probability sample survey of visits to office-based physicians in the United States. Sample data are weighted to produce annual national estimates. RESULTS: During 2004, an estimated 85.0 million visits were made to hospital OPDs in the United States, about 29.5 visits per 100 persons. Females (35.1 per 100 persons) had higher OPD visit rates than males (23.6 per 100 persons), and black or African American persons (50.3 per 100 persons) had higher OPD visit rates than white persons (27.0 visits per 100 persons). The overwhelming majority of visits to hospital OPDs were made by established patients (85.4 percent). Females made 75.5 percent of preventive care visits. The preventive care visit rate by Hispanic or Latino patients was twice the rate of non-Hispanic patients. Diagnostic and screening services were ordered at 90.3 percent of visits, therapeutic and preventive services were ordered at 50.0 percent of visits, and medications were ordered at 67.4 percent of visits. The proportion of visits involving only midlevel providers increased from 5.9 in 1993-94 to 11.4 percent of visits in 2003-04.     

Is it necessary that some patients come to see us so often? Factors associated with primary care use in pediatrics

OBJECTIVES: To analyze the relationship between pediatric patients morbidity and their level of primary health care services use; and to establish if the patients level of use affects the health promotion and immunization schedule completion. METHODS: All patients assigned to a pediatric practice of the Basque National Health Service in Astrabudua (Bizkaia, Spain) over a 6-year period were categorized into different utilization patterns according to their age and number of primary care visits (whose principal reason for encounter was different from health promotion activities). Bivariate and multivariate analyses were performed comparing three groups of subjects: 116 consistently high users, 115 consistently low users and 123 patients classified as consistently medium or erratic users. Ambulatory care Groups (ACGs) case-mix system was used to manage pathologies. RESULTS: High use patients experienced several morbidity types most frequently than low use ones: asthma (OR = 44.7; 95% CI = 5.5-206.1), diseases likely to recurr (OR = 33.5; 95% CI = 8.5-131.6), specialty unstable chronic conditions (OR = 10.8; 95% CI = 2.2-52.8), psychosocial conditions (OR = 5.7; 95% CI = 2.1-15.2), chronic medical stable conditions (OR = 4.0; 95% CI = 1.9-8.6), eye/dental diseases (OR = 3.5; 95% CI = 1.5-8.1). On the other hand, low users were more likely to be lacking completion of the immunization (OR = 3.0; 95% CI = 1.1-8.8) and the well-child care program visits schedules (OR = 4.3; 95% CI = 2.3-8.0). CONCLUSION: Our data confirm that high utilization, far from being inadequate behavior, is an adequate response to the higher health care needs showed by such patients. Primary care pediatricians should assess preventive care needs of the children who consult them infrequently.     

National Hospital Ambulatory Medical Care Survey: 2000 outpatient department summary

OBJECTIVES: This report describes ambulatory care visits to hospital outpatient departments (OPDs) in the United States. Statistics are presented on selected hospital, clinic, patient, and visit characteristics. Highlights of trends in OPD utilization from 1997 through 2000 are also presented. METHODS: The data presented in this report were collected from the 2000 National Hospital Ambulatory Medical Care Survey (NHAMCS). NHAMCS is part of the ambulatory care component of the National Health Care Survey that measures health care utilization across various types of providers. NHAMCS is a national probability sample survey of visits to emergency and outpatient departments of non-Federal, short-stay, and general hospitals in the United States. Sample data are weighted to produce annual national estimates. Trends are based on NHAMCS data from 1997 through 2000. RESULTS: During 2000, an estimated 83.3 million visits were made to hospital OPDs in the United States, about 30.4 visits per 100 persons. Females had higher OPD visit rates than males (35.3 versus 25.2 visits per 100 persons). The OPD utilization rate for black persons was higher than for white persons (48.3 versus 28.0 visits per 100 persons). Of all visits made to hospital OPDs in 2000, private insurance (38.5 percent), Medicaid (22.1 percent), and Medicare (16.9 percent) were listed as the leading primary expected source of payment. Approximately 21 percent of OPD visits reported that patients belonged to an HMO. There were an estimated 9.5 million injury-related OPD visits in 2000. Since 1997, the percent of OPD visits that were for injuries increased by 24% (from 9.2 percent to 1.4 percent). Most of these visits were for unintentional injuries (57.6 percent), including those caused by falls (12.9 percent). Medications were prescribed at 64.0 percent of visits. On average, 1.6 medications were ordered at each OPD visit. In 2000, patients saw one or more physicians (i.e., staff physician, resident/intern, or other physician) at approximately 79 percent of visits. Most patients were given an appointment to return to the clinic (57.2 percent).