Office-related antibiotic prescribing for persons aged ≤ 14 years--United States, 1993-1994 to 2007-2008

In 2003, the Institute of Medicine identified antibiotic resistance as a key microbial threat to health in the United States and recommended promoting appropriate antibiotic use as an important strategy to address this threat. Antibiotic use contributes to development of antibiotic resistance on both the individual and country level. To examine trends in pediatric antibiotic prescribing in physician offices, CDC analyzed data from the National Ambulatory Medical Care Survey (NAMCS) for the period 1993-1994 to 2007-2008. This report summarizes the results of that analysis, which found that antibiotic prescribing rates for persons aged ≤ 14 years who had visited physician offices decreased 24% from 300 antibiotic courses per 1,000 office visits in 1993-1994 to 229 antibiotic courses per 1,000 office visits in 2007-2008. Among the five acute respiratory infections (ARIs) examined, antibiotic prescribing rates decreased 26% for pharyngitis and 19% for nonspecific upper respiratory infection (common cold); prescribing rates for otitis media, bronchitis, and sinusitis did not change significantly. Although the overall antibiotic prescribing rate for persons aged ≤ 14 years has decreased, the rate remains inappropriately high. Further efforts are needed to decrease inappropriate antibiotic prescribing for persons aged ≤ 14 years.     

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.     

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.     

Ambulatory visit groups: a framework for measuring productivity in ambulatory care.

This article describes Ambulatory Visit Groups (AVGs) and the process by which they were defined. An approach to the analysis of physician productivity in the ambulatory setting is then demonstrated, with data derived from the National Ambulatory Medical Care Survey [1]. Finally, recommendations for future work are presented to make this approach more effective in designing and managing ambulatory care delivery organizations.     

Hospitalization for ambulatory care-sensitive conditions: a method for comparative access and quality studies using routinely collected statistics

BACKGROUND: Appropriate and timely provision of ambulatory care is an important factor in maintaining population health and in avoiding unneccessary hospital use. This article describes conditions for which hospitalization rates have a strong and inverse relationship to access to high-quality ambulatory care. METHODS: Three panels of Canadian physicians following different consensus techniques selected conditions for which the relative risk of hospitalization is inversely related to ambulatory care access. PRINCIPAL FINDINGS: All panels identified asthma, angina pectoris, congestive heart failure, otitis media, gastric ulcer, pelvic inflammatory disease, malignant hypertension, and immunization-preventable infections as ambulatory care-sensitive admissions. These conditions strongly overlap with lists developed for similar purposes in the U.S. and England. INTERPRETATION: Ambulatory care-sensitive conditions represent an intermediate health outcome. They are distinct from inappropriate hospitalizations. They may be useful for measuring the impact of health care policy, and for performance measurement or audit.     

PHB6 Health Care Use in Women Age 45 and Older

Key components of preventive health care for middleaged and older women include evaluating the risk for osteoporosis and coronary artery disease, considering hormone replacement therapy (HRT), and cancer screening. HRT is effective for treating the symptoms of acute menopause, and it may prevent some chronic health problems associated with growing older. However, HRT may increase the risks for other diseases.
OBJECTIVE: The purpose of this study was to estimate the level of health care use and costs incurred by post-menopausal women for conditions that have been associated with HRT.
METHODS: National health care survey and discharge data were used to estimate health care use by women age 45 and older for cardiovascular disease, osteoporosis, breast cancer, uterine cancer, and deep-vein thrombosis/ pulmonary embolism. The databases used were the Healthcare Utilization Project-3, National Ambulatory Medical Care Survey, National Hospital Ambulatory Medical Care Survey, National Nursing Home Survey, and National Home and Hospice Care Survey. Clinical Classification for Health Policy Research codes were used to identify patients whose primary diagnosis or procedure corresponded with the above conditions. National weights were used to estimate resource use. Treatment costs were estimated using cost-to-charge ratios or Medicare Fee Schedule to calculate costs of individual procedures.
RESULTS: For each of the five conditions, resource use and costs are reported for hospitalization, outpatient, nursing home, and home health care services. Resource use and costs are also reported by age and race/ethnicity.
CONCLUSION: Results of the study may be used to estimate the burden of disease for conditions commonly affecting postmenopausal women and to provide data for cost-effectiveness models comparing newly developed drugs to existing HRTs.     

Adequacy of two ambulatory care surveillance systems for tracking childhood obesity practice patterns

BACKGROUND: The National Ambulatory Medical Care Surveys (NAMCS) and National Hospital Ambulatory Medical Care Surveys (NHAMCS) are surveillance systems in the USA that track provider practice patterns at ambulatory care visits. This study investigated the adequacy of the NAMCS/NHAMCS for surveillance of childhood obesity practice patterns. METHODS: The frequency of obesity visits in the 1997-2000 NAMCS/NHAMCS (outpatient component) was compared with obesity prevalence among children who reported a physician visit in the preceding 12 months in the National Health and Nutrition Examination Survey (NHANES) 1999-2000. Obesity was identified using the International Classification of Diseases 9th revision clinical modification code ICD-9-278.0 in the NAMCS/NHAMCS. For the NHANES, age- and gender-specific body mass index >95th percentile was used. RESULTS: Between 1997 and 2000, obesity was identified in 4.1 million (0.8%) of 516 million ambulatory care visits. With an obesity prevalence of 14.2% from the NHANES survey, NAMCS/NHAMCS only identified 5.6% of all children aged 2-17 years >95th percentile. Of those identified, the rate of obesity visits in the NAMCS/NHAMCS was lowest for non-Hispanic Whites (3.9%) compared with non-Hispanic Blacks (6.9%) and Hispanics (10.2%). CONCLUSION: The very infrequent reporting of obesity in the NAMCS/NHAMCS suggests that these surveillance systems do not reflect how healthcare providers identify and care for overweight children. Collecting weight and height measures would improve their utility in tracking identification and management of overweight children.     

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

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

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.     

Improving quality or shifting diagnoses? What happens when antibiotic prescribing is reduced for acute bronchitis?

BACKGROUND: A quality improvement project in an academic practice demonstrated a reduction in antibiotic prescribing for acute bronchitis. However, it was unclear whether this represented a reduction in antibiotic use or whether physicians assigned new diagnoses to the same patients to avoid scrutiny and continue to use antibiotic therapy. OBJECTIVE: To examine whether a substantial amount of diagnostic shifting occurred while antibiotic prescribing for acute bronchitis decreased during a 14-month period (from January 1, 1996, to February 28, 1997). METHODS: All patient diagnoses of acute bronchitis, acute sinusitis, upper respiratory tract infection, and pneumonia were determined for the 14 months of the acute bronchitis intervention. The relative distribution of patients among these 4 diagnostic categories was compared to determine if the percentage of patients with acute bronchitis decreased while those with acute sinusitis and pneumonia increased during the acute bronchitis intervention. RESULTS: The percentage of patients with the diagnosis of acute bronchitis remained unchanged during the 14-month period while antibiotic use for this condition decreased from 66% of cases to less than 21% of cases. Instead of the patients being assigned a different diagnosis such as acute sinusitis so that antibiotic prescribing would not be scrutinized, as we hypothesized, the relative number of diagnoses for acute sinusitis compared with acute bronchitis actually declined during the 14 months. No change was noted in the relative frequency of acute bronchitis cases compared with pneumonia cases. CONCLUSION: During a 14-month period when an intervention was successful at reducing antibiotic use for acute bronchitis, there was no evidence that physicians shifted patients from the diagnosis of acute bronchitis to other diagnoses.     

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.     

Provision of health counseling in office-based practices and hospital outpatient clinics

OBJECTIVE: To compare the rates of health counseling provided during primary care visits in two different types of ambulatory care settings. METHODS: Secondary analysis of the 2000 National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS). RESULTS: Of the estimated 722 million adult ambulatory care visits during 2000, 90.8% were made to office-based physician practice settings and 9.2% to hospital-based outpatient departments. Consistent with previous reports, the demographic profile of patients who seek primary care in hospital outpatient departments differs from those seen in office-based practices. Provision of health counseling for exercise [OR = 1.4; 95% confidence intervals (CI): 1-1.8], diet (OR = 1.6; 95% CI: 1.2-2.3), breast self-exam (OR = 2; 95% CI: 1.1-3.6) and stress management (OR = 1.7; 95% CI: 1-2.7) during patient visits was more likely to be reported in the office-based practices than in hospital outpatient clinics. The visit-based rates of health counseling for HIV/STD prevention, tobacco use, mental health or injury prevention were low in both settings. CONCLUSIONS: There is opportunity to improve rates of preventive counseling in primary care settings and to reduce disparities that exist. Identifying the reasons for these disparities and effective interventions will be important steps in providing equitable care in the area of preventive health counseling.     

National Hospital Ambulatory Medical Care Survey: 2002 emergency department summary

OBJECTIVES: This report describes ambulatory care visits to hospital emergency departments (EDs) in the United States. Statistics are presented on selected hospital, patient, and visit characteristics. Selected trends in ED utilization from 1992 through 2002 are also presented. METHODS: The data presented in this report were collected from the 2002 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. RESULTS: During 2002, an estimated 110.2 million visits were made to hospital EDs, about 38.9 visits per 100 persons. From 1992 through 2002, an increasing trend in the ED utilization rate was observed for persons over 44 years of age. In 2002, abdominal pain, chest pain, fever, and cough were the leading patient complaints accounting for nearly one-fifth of all visits. Acute upper respiratory infection was the leading illness-related diagnosis at ED visits. From 1992 through 2002, decreases in ED visit rates were observed for intracranial injuries in children, and increases were found for depression in young adults and arthropathies among middle-aged and elderly patients. There were an estimated 39.2 million injury-related visits during 2002, or 13.8 visits per 100 persons. Diagnostic/screening services, procedures, and medications were provided at 86.8 percent, 43.2 percent, and 75.8 percent of visits, respectively. In 2002, approximately 12 percent of ED visits resulted in hospital admission. On average, patients spent 3.2 hours in the ED.     

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.