Characteristics of Asthma Visits to Physician Offices in the United States: 2012–2015 National Ambulatory Medical Care Survey

September 20, 2019

Questions for Lead Author Lara Akinbami, Health Statistician, of “Characteristics of Asthma Visits to Physician Offices in the United States: 2012–2015 National Ambulatory Medical Care Survey.”

Q: Why did you decide to do a report on asthma visits to physician offices?

LK: Asthma is a common chronic condition in the United States: in 2016 8.3% of the population had asthma.  Each year, there are nearly 2 million emergency department visits, over 300,000 hospitalizations and more than 3.500 deaths in the United States due to asthma.

These adverse outcomes arise when episodic asthma attacks become severe.  A key part of preventing these adverse asthma outcomes is the prevention of attacks, and early recognition and management of symptoms.  Physicians in non-emergent community settings have a key role in partnering with people with asthma in identifying and monitoring symptoms, and developing a plan to avoid things that trigger attacks, and providing a medication plan to reduce symptoms when they do arise.  There are evidence-based national asthma guidelines that provide recommendations on how to best manage asthma that are directed toward care in physician offices (https://www.ncbi.nlm.nih.gov/books/NBK7232/).  Furthermore, asthma is now increasingly recognized as a risk factor for chronic obstructive pulmonary disease, the fourth leading cause of death in the US, and diagnosis and management of asthma is as an important part of monitoring lung health through the lifespan.

For all these reasons, assessing trends in visits to physician offices is useful in tracking the characteristics of asthma patients, the reasons asthma patients seek care (routine monitoring or acute care), and the services provided in these visits.  These help answer questions that can direct interventions, for example, “Are certain groups less likely to seek care in office settings?” Or “Are guideline recommendations being followed?”


Q: How did the data vary by age, sex and race?

LK: Asthma visit rates tend to reflect the prevalence of asthma in the population, but with some notable exceptions.  Asthma prevalence is higher in children than in adults, and children have higher asthma physician office visit rates than adults.  However, although asthma prevalence peaks in mid-childhood, we see high rates of asthma visits among children 0-4 years of age.  This is because these very young children have smaller airways.  They are more likely to show symptoms with any conditions that further narrows the airways, such as respiratory infections.

Another interesting pattern is that asthma prevalence is higher among boys than girls, in contrast to among adults in whom women have higher asthma prevalence than men.  Asthma visit rates also reflect this pattern with boys having higher visit rates than girls, and women having higher visit rates than men.  However, once the differences in prevalence are accounted for by looking at just people who have asthma, boys with asthma have similar asthma visit rates as girls with asthma, and the same is true for men and women with asthma.  The one exception is that very young boys ages 0-4 yeas with asthma still have higher rates of asthma visits than 0-4 year old girls with asthma.

By race and Hispanic origin, asthma visit rates are similar between groups with no differences seen between asthma visits rates for non-Hispanic white, non-Hispanic black and Hispanic persons.  Asthma visit rates were lower for persons of non-Hispanic other race.  However, this pattern does not reflect asthma prevalence which is higher for non-Hispanic black persons than non-Hispanic white and Hispanic persons.


Q: Is this the first time you have published a report on this topic?

LK: The Centers for Disease Control and Prevention publishes regular asthma surveillance reports on asthma that provide analysis of trends and estimates of the most recent data for asthma prevalence, health care utilization and death.  The CDC also provides a web page with the most recent asthma data: https://www.cdc.gov/asthma/most_recent_national_asthma_data.htm.  However, this report is only the second since 1996 to analyze asthma visits to physician offices in depth, including the degree to which services in asthma visits reflect recommendations in the national asthma guidelines.  These guidelines were originally released in 1991 with the most recent update in 2007.  When findings of this report which analyzed data from 2012-2015 is compared to the 1996 report that analyzed data from 1993-1994, we found that despite an increase in asthma prevalence over this period, the annual average number of asthma visits declined from 11 million in 1993-1994 to 10.2 million in 2012-2015.  Medications in 2012-2015 included newer medications that target airway inflammation.  A similar percentage of asthma visits were seen by primary care physicians as opposed to asthma specialists, 65% in 1993-1994 and 60% in 2012-2015.  However, there was less progress in increasing the implementation of national asthma guidelines than would be expected given the effort to increase uptake of key recommendations such as providing an asthma action plan and documenting asthma severity and control.


Q: Was there a specific finding in your report that surprised you?

LK: Given the emphasis on the importance of assessing and documenting asthma control, only 40.9% of asthma visits to physician offices had a level of asthma control documented.  The distribution between levels of asthma control was expected with 29.1% of patients with well controlled asthma, 10.5% with not well controlled asthma and 1.3% of patients with very poorly controlled asthma.  However, that 59.1% of asthma patients had no level of control documented was surprising given the concerted efforts to have asthma control assessed and documented.  These efforts included quality of care measurements, physician continuing education, a Guideline Implementation Report (https://www.nhlbi.nih.gov/files/docs/guidelines/gip_rpt.pdf), and local quality improvement projects.


Q: What is the take home message for this report?

LK: Asthma is a common chronic condition and a common reason for physician office visits.  Given its high burden in morbidity, health care use, and mortality, it is important to assess the content of asthma physician office visits given that physicians are the on the “front line” of asthma care and provide the majority of asthma care.  Rates for asthma visits to physician offices started to decline before total office visit rates declined.  Asthma education, objective monitoring (pulmonary function  testing) and level of asthma control were documented in a minority of visits.  Quick-acting relief medication remained the most frequently mentioned medication class.  Additional research can explore the underlying reasons for trends, and future policy can target low implementation rates of guideline recommendations.


Characteristics of Office-based Physician Visits, 2016

January 24, 2019

A new NCHS report examines visit rates by age and sex. It also examines visit characteristics—including insurance status, reason for visit, and services—by age. Estimates use data from the 2016 National Ambulatory Medical Care Survey.

Key Findings:

  • In 2016, there were an estimated 278 office-based physician visits per 100 persons.
  • The visit rate among females exceeded the rate for males, and the rates for both infants and older adults exceeded the rates for those aged 1–64 years.
  • Private insurance was the primary expected source of payment for the majority of visits by children under age 18 and adults aged 18–64, whereas Medicare was the primary expected source of payment for the majority of visits by adults aged 65 and over.
  • Compared with adults, a larger percentage of visits by children were for either preventive care or a new problem.
  • Compared with children, a larger percentage of visits by adults included an imaging service that was ordered or provided.

Characteristics of Office-based Physician Visits, 2015

June 5, 2018

Jill Ashman, Ph.D., Health Statistician

Questions for Jill Ashman, Ph.D., Health Statistician, and Lead Author of “Characteristics of Office-based Physician Visits, 2015

Q: What made you write this report on doctors’ office visits?

JA: Our intent in producing this data brief is to provide the annual summary of National Ambulatory Medical Care Survey (NAMCS) data. Last year we created the format for this NAMCS summary report using 2014 data, and we are currently working on the 2016 summary. These summary reports provide a snapshot of the care provided at office-based physician offices.


Q: Was there a result in your study that surprised you?

JA:  While there is a notable finding in the report, generally the patterns are what we expected to find and are consistent with a similar report looking at office visits in 2014. One notable finding is the relatively low percentage of visits for preventive care among adults 18 years or older (21% for ages 18-64 and 13% for those aged 65 years or older).


Q: What differences or similarities did you see between or among various demographic groups, such as age and sex, in this analysis?

JA:  We noted a number of differences among various groups examined in this report. In terms of visit rates, we found that females visited the doctor’s office at a higher rate than males. We also found that the visit rate for infants and older adults exceeded the rates for those aged 1-64 years.

We also found age variation with primary expected sources of payment, the major reason for a doctor’s office visit, and for the services provided at the physician visit. Medicaid was the primary expected source of payment at a higher percentage of visits by children (38%) than adults, and Medicare was the primary expected source of payment at a higher percentage of visits by adults aged 65 and older (79%) compared with patients under 65 years. Having no insurance at all was at a higher percentage of visits by adults aged 18-64 (9%) than those aged 65 and over (2%). Also, compared with adults, a larger percentage of office visits by children were for either preventive care (33%) or a new problem (41%). Additionally, visits by children (compared with adults) were less likely to include a laboratory test, imaging service, or procedure that was ordered or provided. No variation by age was observed for office visits for an injury or that included an examination or screening service.


Q:  What is new in this report that has not already been published?

JA: This report provides the most recent nationally representative estimates of office-based physician visits in the United States. To our knowledge, age differences in the selected characteristics of patients accessing the doctor’s office in 2015 have not already been published.


Q: What sort of trend data do you have on this topic that will help us see how doctor’s office visits have evolved over time?

JA: With a number of years of data, we can look at trends over time by examining other National Center for Health Statistics reports. We released a similar report last year that looked at age variation in the same selected characteristics of office-based physician visits made in 2014. Comparing the results of both reports shows little change in the patterns of selected characteristics from 2014 to 2015. However, one notable change was an observed increase from 2014 to 2015 in the percentage of health education and counseling services ordered or provided overall and among the three age groups examined.

For older years of data, we provide detailed summary tables on our website going back as far as 2008 that can be used to help see how office-based physician visits have evolved over time. The summary tables can be found here.


Q: What would you say is the take-home message of this report?

JA: The take-home message from this report is that there is a wide variation by age in the characteristics of visits to office-based physicians in the United States in 2015. Larger differences were observed in the services ordered or provided and in the major reason for the office visit between children under 18 years and adults aged 18 or older.


Characteristics of Office-based Physician Visits, 2014

December 12, 2017

In 2014, most Americans had a usual place to receive health care (86% of adults and 97% of children). A majority of children and adults listed a doctor’s office as the usual place they received care. In 2014, there were an estimated 885 million office-based physician visits in the United States.

A new NCHS report examines office-based physician visit rates by age and sex. It also examines visit characteristics, including insurance status, reason for visit, and services, by age. Estimates use data from the 2014 National Ambulatory Medical Care Survey (NAMCS).

Findings:

  • In 2014, there were an estimated 282 office-based physician visits per 100 persons.
  • The visit rate among females exceeded the rate for males, and the rates for both infants and older adults exceeded the rates for those aged 1–64 years.
  • Compared with other age groups, a higher percentage of visits by adults aged 18–64 indicated no insurance.
  • A larger percentage of visits by children under age 18 years were for either preventive care or a new problem, compared with adults aged 18 and over.
  • Compared with children, a larger percentage of visits by adults included a laboratory test, imaging service, or a procedure being ordered or provided.

Characteristics of Primary Care Physicians in Patient-centered Medical Home Practices: United States, 2013

February 17, 2017

Questions for Esther Hing, Survey Statistician and Lead Author on “Characteristics of Primary Care Physicians in Patient-Centered Medical Home Practices: United States, 2013

Q: Can you define what a patient-centered medical home (PCMH) practice is?

EH: One of several PCMH definitions is that PCMHs provide care that is: comprehensive care provided by a team of providers, patient-centered care, coordinated care, has accessible services, and care focused on quality and safety.


Q: Why did you decide to do a report on PCMH practices?

EH: Although the PCMH has been advocated by the “primary care community” for more than a decade, there are no national estimates that describe characteristics of this model of care delivery. “Primary care community” includes primary care physicians as well as other primary care providers and associated professional societies. The report, based on questions funded by the Assistant Secretary for Planning and Evaluation (ASPE), will inform policy makers of the prevalence of certified PCMH practices in the United States, as well as care attributes of these practices (compared with non-PCMH practices).

Estimates not only serve as benchmark estimates for this model of primary care, but adds to the knowledge base about this type of practice. Payers and the federal government have increasingly funded PCMH demonstrations, and certain payers and states have also increased funding to practitioners in PCMH practices.


Q: Is the first time NCHS has published a report on this topic?

EH: Yes, this is the first year that the PCMH questions have been reported.


Q: What did your report find on primary care physicians in PCMH practices?

EH: The report found that primary care physicians in PCMH practices tended to be in larger practices, and located in urban areas. These findings may be attributed to infrastructure requirements needed for PCMH care delivery. It may also reflect that in 2013, the Centers for Medicare and Medicaid Service (CMS) demonstrations and payment policy supporting chronic care was not yet implemented or was in early stages of development.


Q: Were there any findings that surprised you?

EH: The finding that a substantial percentage of non-PCMH practices have non- physician clinicians and Electronic Health Records suggests that there is untapped potential for a greater number of primary care practices to become PCMHs.

However, the relatively lower participation by solo and small practices as PCMHs suggests the need for assistance or coaching to make this transformation. The ongoing implementation of payment incentives from CMS and elsewhere has encouraged growth of PCMHs. This is a trend that the National Ambulatory Medical Care Survey (NAMCS) can be used to examine for the next few years and beyond.


Physician Office Visits for ADHD in Children and Adolescents Aged 4–17 Years: United States, 2012–2013

January 25, 2017

Questions for Michael Albert, Medical Officer and Lead Author on “Physician Office Visits for Attention-deficit/Hyperactivity Disorder in Children and Adolescents Aged 4–17 Years: United States, 2012–2013

Q: Did we learn anything new from this new report about the problem of Attention-deficit/Hyperactivity Disorder (ADHD) among children?

MA: Yes, this report provides a snapshot of health care utilization related to ADHD among children aged 4-17 years. Specifically, it looks at visits to physician offices and uses nationally representative data from the 2012-13 National Ambulatory Medical Care Survey.  Based on a sample of 946 visits by children aged 4-17 years with a primary diagnosis of ADHD, an estimated annual average of 6.1 million physician office visits were made by this age group during 2012-13, corresponding to a visit rate of 105 visits per 1,000 children.


Q:  Does your research back up the notion that boys are more commonly afflicted with ADHD than girls?

MA: Our analysis did find that among children aged 4-17 years with a primary diagnosis of ADHD, the visit rate was more than twice as high for boys as girls.


Q: Is it true that medication is very often involved in the treatment of ADHD?

MA: Central nervous system stimulant medications were provided, prescribed, or continued at approximately 80% of these ADHD visits.  A total of 29% of ADHD visits included a diagnostic code for an additional mental health disorder.  In terms of what specialty of physician provided care at these visits, it was a pediatrician at 48%, psychiatrist at 36%, and general and family medicine physician at 12%.


Q: Was it surprising that 80% of office visits for ADHD involve medication?

MA: It is important to interpret this finding carefully.  Because the National Ambulatory Medical Care Survey is a visit-based survey, as opposed to population based, estimates of persons cannot be made.  Thus, the finding should not be interpreted as indicating that 80% of children aged 4-17 years with ADHD are taking CNS stimulant medications. It is possible that patients taking CNS stimulant medications tend to make more physician office visits than those not taking these medications.  This might be in order to monitor the medication, or for other reasons such as differences in the severity of disease between those who take medication and those who do not.  Although the use of medication in children with ADHD in our survey cannot be directly compared with population-based surveys, there is evidence from the latter that medication is frequently used.  An analysis of parent-reported data from the National Survey of Children’s Health found that among children aged 4-17 years, 69% of children with current ADHD were taking medication for their ADHD (the specific medication was not identified).


Q: Anything else you’d like to address about the report?

MA: Again, we think the significance of this report lies in providing a snapshot of health care utilization related to ADHD in children that is nationally representative.  We chose to investigate several variables to in our analysis that are of interest and provide important information.


State Variation in Preventive Care Visits, by Patient Characteristics, 2012

January 25, 2016

Preventive care visits such as general medical examinations, prenatal visits, and well-baby visits give physicians and other health professionals the opportunity to screen for diseases or conditions, as well as to promote healthy behaviors that may delay or prevent these conditions and reduce subsequent use of emergency or inpatient care.

In an NCHS report, the rate of preventive care visits to office-based physicians is examined by state, patient demographics, and physician specialty. Estimates are based on data from the National Ambulatory Medical Care Survey, a nationally representative survey of visits to office-based physicians.

Findings:

  • In 2012, 61.4 preventive care visits were made to office-based physicians per 100 persons. The female rate (76.6 visits per 100 females) exceeded the male rate (45.4 visits per 100 males) by 69%.
  • Among the 34 most populous states, the rate of preventive care visits exceeded the national rate in 1 state (Connecticut) and was lower than the national rate in 11 states (Arkansas, Indiana, Iowa, Michigan, Missouri, North Carolina, Oklahoma, Oregon, Pennsylvania, South Carolina, and Washington).
  • The rate of preventive care visits to primary care physicians in the 34 most populous states exceeded the national rate in 1 state (Connecticut) and was lower than the national rate in 7 states (Arkansas, Indiana, Iowa, Missouri, North Carolina, Pennsylvania, and Washington).