Mental Health-related Physician Office Visits by Adults Aged 18 and Over: United States, 2012-2014

June 6, 2018

Donald Cherry, M.S., Health Statistician

Questions for Donald Cherry, M.S., Health Statistician, and Lead Author of “Mental Health-related Physician Office Visits by Adults Aged 18 and Over: United States, 2012-2014

Q:  Was there a result in your study that you hadn’t expected and that really surprised you?

DC:  Most of the results confirmed what we’ve seen in current research, so there really was not a finding in this study that surprised me. But confirming existing knowledge is an important finding! Specifically, the results examining urban-rural visit differences are exactly in the expected direction; that is, in large metropolitan areas, psychiatrists are more concentrated (as suggested by prior research), and we would expect to see a higher percentage of visits to them for mental health-related issues. Rural areas have less psychiatrists and more primary care physicians (PCPs) (as suggested by prior research), and seeing 54% of mental health-related visits occurring at primary care physician offices suggests that in these rural areas, availability of provider type for outpatient mental health treatment might be limited.

Also, the results show no difference in a couple of areas. One area where you can see this is in the percent of health-related visits to psychiatrists vs. PCPs when Medicare is the expected source of payment. We see this too, in the rate of visits when the patient age is 65 years and older – which is interesting for its possible implications.  These results together may indicate that older adults, who are also assumed more likely to use Medicare, are as inclined to visit a primary care physician as they are a psychiatrist for mental health-related issues.


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

DC:  I think the real take-home message of this report is that continued monitoring of the utilization of mental health services is important in identifying the present and future needs of the U.S. adult population. As one might expect, the composite of mental health-related visits occur in psychiatrists’ offices; however, this does not seem to be a phenomenon that is always consistent. Differences in mental health-related visits by physician specialty did vary by age, payment type, and within patient sex. The most interesting difference is in large metropolitan areas where a higher percentage of mental health-related office visits are to psychiatrists compared to primary care physicians (PCPs). In rural areas, an opposite trend is observed. This is consistent with past research and further suggests that a greater supply of, and access to, primary care physicians vs. psychiatrists occurs in rural areas.


Q:  What made you decide to conduct this study on mental health-related doctor’s office visits?

DC:  My background is in psychology, and I’m very interested in mental health issues, so mental-health related doctor’s office visits is a natural topic for me to explore. Having access to the National Ambulatory Medical Care Survey (NAMCS) data has given me the opportunity to examine different research topics. In the past, I have also been privileged to collaborate with prominent researchers in the field who have used NAMCS data. I have specifically been interested in where people are going to get treatment for mental health issues. Data accessibility in NAMCS is especially useful becauses it collects visit details on both primary care physicians and psychiatrists in the same survey sample design.


Q:  What differences or similarities did you see between or among various demographic groups in this analysis?

DC:  We did note some differences among different age groups, between sexes, and between rural and urban areas of the United States. When examining age, the mental health-related office visit rate to psychiatrists is higher compared with the rate to primary care physicians among all adults, and among adults in age groups 18–34, 35–49, and 50–64. But there was no significant difference among adults aged 65 and over. Not seeing a difference in rates for the oldest patients is interesting, and some researchers indicate that psychiatrists have a proportionately smaller role in office-based mental health care among older adults — than younger — perhaps due to age-related attitudinal differences toward psychiatric services.

Looking at sex, mental health-related office visit rates to psychiatrists are higher compared with primary care physicians for both men and women, but the visit rate is higher for women compared to men (1,380 vs. 1,111 visits per 10,000 adults).  Within-sex differences were expected given the overall premise of where adults as a group are getting their care. Within-sex differences follow 2016 data presented by The National Institutes of Mental Health that show the prevalence of any mental health illness is higher in women (21.7%) vs. men (14.5%).

Large metropolitan areas experienced a higher percentage of mental health-related office visits to psychiatrists compared to PCPs. In rural areas, an opposite trend was observed. This is consistent with past research and further suggests that a greater supply of, and access to, primary care physicians vs. psychiatrists occurs in rural areas. In medium to small metropolitan areas there was no difference in the percent of visits to either physician specialty, suggesting a possible absence of a supply-demand issue.


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

DC:  Although we did not examine mental health-related office visits across years for this analysis, we certainly have the ability to examine the same characteristics in future research. An interesting finding in our current report is that mental health-related office visit rates to psychiatrists are higher compared with primary care physician visit rates in all age groups — except for adults aged 65 and over, and as a percentage of visits among all primary expected payment types except Medicare. These results together may indicate that older adults, who are assumed more likely to use Medicare, are as inclined to visit a primary care physician as they are a psychiatrist for mental health-related issues.


Q:  What information do you have on the differences between or among the different types of physicians that are visited for mental health, e.g. what do patients get at a psychiatrist’s office visit that they may not receive at a primary care physician’s – and vice versa?

DC:  There is information available about the type of care patients receive for mental health from different types of physicians. We do have the ability to determine some components of care which patients receive at mental health-related visits; for example, did the patient receive psychotherapy, health education/counseling, psychotropic medications, etc. However, this topic has been examined before as researchers outside The National Center for Health Statistics (NCHS) have studied care received at psychiatrist vs. PCP offices, so this data brief did not explore these factors extensively. Perhaps in a future NCHS study! The uniqueness of this research in how we define a mental health-related office visit should be recognized – and will be very useful in future studies. By using the patient’s reason for a visit, and not a physician’s diagnosis, we attempt to control that at least the initial reason for the visit was for a mental health issue.

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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.


Emergency Department Visits by Patients aged 45 and over with Diabetes: United States, 2015

February 8, 2018

Questions for Pinyao Rui, Statistician and Author of, “Emergency Department Visits by Patients aged 45 and over with Diabetes: United States, 2015.”

Q: Why did you decide to examine emergency department (ED) visits made by patients aged 45 years older with diabetes?

PR: We decided to examine emergency department visits made by patients aged 45 years and older because we wanted to focus on visits made by older patients who are at higher risk of developing or having diabetes and who comprise a majority of all diabetes cases in the U.S.  Additionally, we wanted to use more recent data not currently available in the literature to examine characteristics of an ED visit for a condition that is projected to rise and contribute to increasing burden of medical care systems.


Q: How did the rate of emergency department visits by patients aged 45 and over with diabetes change with age?

PR: The rate of emergency department visits by patients aged 45 and over increased with age. The rate increased from 69 per 1,000 persons for those aged 45-64 years and more than doubled to 164 per 1,000 persons for those aged 75 years and over.


Q: Were there differences in the percentage of visits that ended in inpatient hospital admission by diabetes status?

PR: Yes, the percentage of ED visits with diabetes that ended in inpatient hospital admission was significantly higher than the percentage of ED visits without diabetes among visits made by patients aged 45-64 and 65 and over.


Q: Are there any findings that surprised you from this report?

PR: One finding from the report that surprised me was that among ED visits made by 45-64 year olds, a higher proportion of diabetes visits were paid by Medicare compared with visits made by patients without diabetes (24% versus 14%).


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

PR: I think the take home message is that the percentage of ED visits by older patients with diabetes reported in the medical record has been increasing in recent years with the highest proportion observed in patients aged 65-74 (32% in 2015).


QuickStats: Percentage of Emergency Department Visits for Acute Viral Upper Respiratory Tract Infection That Had an Antimicrobial Ordered or Prescribed, by Metropolitan Statistical Area — United States, 2008–2015

January 29, 2018

From 2008–2011 to 2012–2015, the percentage of visits for acute viral upper respiratory tract infection that had an antimicrobial ordered or prescribed decreased from 37.1% to 25.5% among emergency departments (EDs) located in nonmetropolitan statistical areas, but this decline was not seen among EDs in metropolitan statistical areas.

In 2008–2011, the percentage was higher among nonmetropolitan EDs than metropolitan EDs, but there was no difference in 2012–2015.

Source: National Hospital Ambulatory Medical Care Survey, 2008–2015
https://www.cdc.gov/mmwr/volumes/67/wr/mm6703a7.htm


Ambulatory Surgery Data From Hospitals and Ambulatory Surgery Centers: United States, 2010

February 28, 2017

Questions for Margaret J. Hall, Health Statistician and Lead Author of “Ambulatory Surgery Data From Hospitals and Ambulatory Surgery Centers: United States, 2010.”

Q: Why did you decide to do a report on national estimates of surgical and nonsurgical ambulatory procedures performed in hospitals and ambulatory surgery centers?

MH: The National Center for Health Statistics (NCHS), Division of Health Care Statistics, gathers national data on health care utilization. Included are surveys of inpatient care, physicians’ office care, and emergency department and outpatient department care. From 1994 to 1996, and again in 2006, NCHS gathered ambulatory surgery data through the National Survey of Ambulatory Surgery. Ambulatory surgery, also called outpatient surgery, refers to surgical and nonsurgical procedures that are nonemergency, scheduled in advance, and generally do not result in an overnight hospital stay. The nationally representative data from our inpatient and ambulatory surgery surveys showed that ambulatory surgery procedures made up a large part of the total surgery performed in the United States. In 2010, we were able to expand the National Hospital Ambulatory Medical Care Survey (NHAMCS), which has gathered data on hospital emergency and outpatient department utilization since 1992, to also gather data on ambulatory surgery in hospitals and in ambulatory surgery centers. This meant that we could provide more recent estimates of this important component of health care utilization.

Data were gathered on patient characteristics including age, sex, expected payment source, duration of surgery, and discharge disposition, as well as on the number and types of procedures performed in these settings. As is the case in our other health care surveys, sample data are collected and are then weighted to produce nationally representative estimates.


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

MH: NCHS has published ambulatory surgery data for 1994 through 1996 and again for 2006. This report primarily contains 2010 data but it does note that the estimated number of ambulatory surgery visits decreased from 34.7 million to 28.6 million from 2006 to 2010. This 18% drop was statistically significant. But the 48.3 million ambulatory surgery procedures estimated using 2010 NHAMCS data was not significantly different from the 53.3 million ambulatory surgery procedures estimated using 2006 NSAS data.


Q: How do ambulatory surgery procedures by sex and age break down?

MH: For both males and females, 39% of procedures were performed on those aged 45–64. For females, about 24% of procedures were performed on those aged 15–44 compared with 18% for males, whereas the percentage of procedures performed on those under 15 was lower for females than for males (4% compared with 9%). About 19% of procedures were performed on those aged 65–74, with about 14% performed on those aged 75 and over. For the latter two age groups, there was no significant difference between males and females.


Q: What types of ambulatory surgery procedures are most patients getting?

MH: Seventy percent of the 48.3 million ambulatory surgery procedures were in the following clinical categories: operations on the digestive system (10 million or 21%), operations on the eye (7.9 million or 16%), operations on the musculoskeletal system (7.1 million or 15%), operations on the integumentary system (4.3 million or 9%), and operations on the nervous system (4.2 million or 9%). These procedure categories made up 72% of procedures performed on females and 67% of those performed on males.

  • Examples of operations on the digestive system include endoscopy of large intestine—which included colonoscopies—which was performed 4.0 million times; endoscopy of small intestine which was performed 2.2 million times; and endoscopic polypectomy of large intestine which was performed an estimated 1.1 million times.
  • Eye operations included extraction of lens, performed 2.9 million times, and insertion of lens, performed 2.6 million times, both for cataracts; and operations on eyelids, performed 1.0 million times.
  • Musculoskeletal procedures included operations on muscle, tendon, fascia, and bursa, performed 1.3 million times.
  • Operations on the integumentary system included excision or destruction of lesion or tissue of skin and subcutaneous tissue, performed 1.2 million times.
  • Operations on the nervous system included injection of agent into spinal canal, performed 2.9 million times, including injections for pain relief.

Q: Were there any findings that surprised you?

MH: It was surprising that the number of ambulatory surgery visits and procedures performed did not increase from 2006 to 2010. Instead our 2010 data showed that there was a significant decrease of 18% in the number of ambulatory surgery visits since 2006. The number of procedures performed during 2010 did not differ significantly from the number performed in 2006.

One reason for these findings could be an under count in the survey in 2010. There were some problems in hospitals identifying in-scope ambulatory surgery visits since they were more dispersed throughout the hospitals in 2010 than they had been in 2006. Another reason that ambulatory surgery visit estimates could have decreased could be the deep economic recession that began in 2007. By 2010, when our survey began gathering ambulatory surgery data in both hospitals and Ambulatory Service Centers, the economy had not fully recovered and, due to this, some patients may have decided not to schedule ambulatory surgery. Some ambulatory surgery procedures are elective.


Emergency Department Visits Related to Schizophrenia Among Adults Aged 18–64: United States, 2009–2011

September 23, 2015

Schizophrenia is a severe brain disorder with clinical manifestations that may include hallucinations, delusions, and thought and movement disorders.

A new NCHS report describes the rate and characteristics of emergency department (ED) visits related to schizophrenia among adults aged 18–64.

Key Findings from the Report:

  • During 2009–2011, an estimated 382,000 ED visits related to schizophrenia occurred each year among adults aged 18–64, with an overall ED visit rate of 20.1 per 10,000 adults.
  • The overall rate for ED visits related to schizophrenia for men (26.5 per 10,000) was approximately double the rate for women (13.8 per 10,000).
  • Public insurance (Medicaid, Medicare, or dual Medicare and Medicaid) was used more frequently at ED visits related to schizophrenia compared with ED visits not related to schizophrenia.
  • About one-half of ED visits related to schizophrenia led to either a hospital admission (32.7%) or a transfer to a psychiatric hospital (16.7%); these percentages were higher than for ED visits not related to schizophrenia.

 


Progress With Electronic Health Record Adoption

February 19, 2015

The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 provides incentive payments to eligible hospitals and providers that demonstrate the meaningful use of a certified electronic health record (EHR) system.

A new report describes the adoption of EHRs in hospital emergency departments (EDs) and outpatient departments (OPDs) from 2006 through 2011 using the National Hospital Ambulatory Medical Care Survey.

Key Findings from the Report:

  • In 2011, 84% of hospital emergency departments used an electronic health record system.
  • Adoption of a basic EHR system with a specific set of functionalities by EDs increased from 19% in 2007 to 54% in 2011.
  • In 2011, 73% of hospital outpatient departments used an EHR system, up from 29% in 2006.
  • Adoption of a basic EHR system with a specific set of functionalities by OPDs increased from 9% in 2007 to 57% in 2011.
  • From 2007 through 2011, adoption of Stage 1 Meaningful Use objectives by EDs and OPDs increased.
  • In 2011, 14% of EDs and 16% of OPDs had EHR technology able to support nine Stage 1 Meaningful Use objectives.