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

In 2016, mental illness affected about 45 million U.S. adults (1). Although mental health-related office visits are often made to psychiatrists (2), primary care physicians can serve as the main source of treatment for patients with mental health issues (3); however, availability of provider type may vary by geographic region (3,4). This report uses data from the 2012-2014 National Ambulatory Medical Care Survey (NAMCS) to examine adult mental healthrelated physician office visits by specialty and selected patient characteristics.

Emergency Department Visits for Injury and Illness Among Adults Aged 65 and Over: United States, 2012-2013.

KEY FINDINGS: Data from the National Hospital Ambulatory Medical Care Survey ● During 2012-2013, adults aged 65 and over had an emergency department (ED) visit rate of 12 per 100 persons for injury and 36 per 100 persons for illness. ● Among adults aged 65 and over, women had a higher ED visit rate for injury (14 per 100 women) compared with men (10 per 100 men).There was no difference between women and men in the visit rate for illness. ● The percentage of injury visits resulting in hospital admission (17%) was lower than for illness visits (32%) among adults aged 65 and over. The same pattern held for critical care admissions (2% compared with 5%). ● Imaging was ordered at 75% of injury visits among adults aged 65 and over, which was higher than for illness visits (63%).

Toward a More Complete Picture of Outpatient, Office-Based Health Care in the U.S.

The healthcare system in the U.S., particularly outpatient, office-based care, has been shifting toward service delivery by advanced practice providers, particularly nurse practitioners (NPs) and physician assistants (PAs). The National Ambulatory Medical Care Survey (NAMCS), conducted by the National Center for Health Statistics (NCHS) at the Centers for Disease Control and Prevention, is the leading source of nationally representative data on care delivered by office-based physicians. This paper first describes NAMCS, then discusses key NAMCS expansion efforts, and finally presents major findings from two exploratory studies that assess the feasibility of collecting data from NPs and PAs as sampled providers in NAMCS. The first NAMCS expansion effort began in 2006 when the NAMCS sample was expanded to include community health centers and started collecting and disseminating data on physicians, NPs, PAs, and nurse midwives in these settings. Then, in 2013, NCHS included workforce questions in NAMCS on the composition and clinical tasks of all healthcare staff in physician offices. Finally, in 2013-2014, NCHS conducted two exploratory studies and found that collecting data from NPs and PAs as sampled providers in NAMCS is feasible. However, modifications to the current NAMCS procedures may be necessary, for example, changing recruitment strategies, visit sampling procedures, and physician-centric survey items. Collectively, these NCHS initiatives are important for healthcare research, practice, and policy communities in their efforts toward providing a more complete picture of the changing outpatient, office-based workforce, team-based care approach, and service utilization in the U.S.

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

ED care is important for the treatment of acute presentations of schizophrenia and may serve as a safety net for schizophrenic patients not otherwise receiving care (4,5). This analysis of National Hospital Ambulatory Medical Care Survey (NHAMCS) data indicates that during 2009-2011, an average of 382,000 ED visits related to schizophrenia occurred each year among adults aged 18-64, corresponding to an overall visit rate of 20.1 per 10,000 adults. A visit having a first-, second-, or third-listed diagnosis of schizophrenia (i.e., whether the visit was directly or indirectly related to schizophrenia) was included in the analysis to provide a broader description of ED use by these patients. The distribution of the primary diagnosis of visits related to schizophrenia was: schizophrenia (58.8%), another mental disorder (15.4%), and a nonmental health disorder (25.7%) (data not shown). Among adults aged 18-64, the rate for ED visits related to schizophrenia was about twice as high for men as for women. Public insurance (Medicaid, Medicare, or dual Medicare and Medicaid) was more frequently the primary expected source of payment for ED visits related to schizophrenia compared with ED visits not related to schizophrenia. ED visits related to schizophrenia were more frequently made by patients who were homeless compared with ED visits not related to schizophrenia. About one-third of ED visits related to schizophrenia resulted in a hospital admission, and another 16.7% resulted in a transfer to a psychiatric hospital--both higher than the percentages for ED visits not related to schizophrenia. One of the goals of Healthy People 2020 is to improve mental health through prevention and by ensuring access to appropriate, quality mental health services (6). National data on the rates and characteristics of ED visits related to schizophrenia will help policymakers and practitioners address disparities and meet this goal.

Emergency department visits for drug poisoning: United States, 2008-2011.

Poisoning is the leading cause of injury-related mortality in the United States, with more than 40,000 deaths annually. Drugs account for 90% of poisoning deaths, and the number of deaths from drug poisoning has increased substantially in recent years. The emergency department (ED) plays an important role in the treatment of poisoning. This report describes nationally representative data on ED visits for drug poisoning during 2008-2011.

Emergency department visits for motor vehicle traffic injuries: United States, 2010-2011.

Data from the National Hospital Ambulatory Medical Care Survey, 2010-2011. In 2010-2011, the emergency department (ED) visit rate for motor vehicle traffic injuries was highest among persons aged 16-24 years. The rates declined with age after 16-24, with rates for those aged 0-15 similar to those 65 and over. The overall ED visit rate for motor vehicle traffic injuries was higher among non-Hispanic black persons compared with non-Hispanic white and Hispanic persons. Imaging services were ordered or provided at 70.2% of ED visits for motor vehicle traffic injuries, which was higher than for other injury-related ED visits (55.9%). About one-half of ED visits for motor vehicle traffic injuries had a primary diagnosis of sprains and strains of the neck and back, contusion with intact skin surface, or spinal disorders. In spite of improvements in motor vehicle safety in recent years, motor vehicle crashes remain a major source of morbidity and mortality in the United States (1-3). Motor vehicle-related deaths and injuries also result in substantial economic and societal costs related to medical care and lost productivity (4). This report describes the rates and characteristics of emergency department (ED) visits for motor vehicle traffic injuries during 2010-2011 based on nationally representative data from the National Hospital Ambulatory Medical Care Survey (NHAMCS).

Injury-related emergency department visits by children and adolescents: United States, 2009-2010.

KEY FINDINGS: Key findings Data from the National Hospital Ambulatory Medical Care Survey, 2009-2010 In 2009-2010, an annual average of 11.9 million injury-related emergency department (ED) visits were made by children and adolescents aged 18 years and under in the United States. The injury-related ED visit rate was 151 per 1,000 persons aged 18 years and under, and rates were higher for males than for females for all age groups (0-4 years, 5-12 years, and 13-18 years). The injury-related ED visit rates among persons aged 5-12 years and 13-18 years were higher for non-Hispanic black persons than for other race and ethnicity groups. Leading causes of injury-related ED visits among both males and females included falls and striking against or being struck unintentionally by objects or persons. Visit rates were higher for males than for females for both of these causes. Injury is the leading cause of death and a major source of morbidity among children and adolescents in the United States (1,2). The emergency department (ED) plays an important role in the care of injuries, and these visits often represent the initial contact with a provider for the injury (3). This report examines nationally representative data on injury-related ED visits by children and adolescents aged 18 years and under in the United States during 2009-2010. Injury-related ED visit rates were also compared for the age groups 0-4, 5-12, and 13-18 years, as these correspond to the preschool, school-age, and teen life periods respectively.

Emergency department visits by persons aged 65 and over: United States, 2009-2010.

KEY FINDINGS: Data from the National Hospital Ambulatory Medical Care Survey, 2009-2010. In 2009-2010, a total of 19.6 million emergency department (ED) visits in the United States were made by persons aged 65 and over. The visit rate for this age group was 511 per 1,000 persons and increased with age. The percentage of ED visits made by nursing home residents, patients arriving by ambulance, and patients admitted to the hospital increased with age. Twenty-nine percent of ED visits by persons aged 65 and over were related to injury, and the percentage was higher among those aged 85 and over than among those aged 65-74 or 75-84. The percentage of ED visits caused by falls increased with age.

Emergency department visits for chest pain and abdominal pain: United States, 1999-2008.

KEY FINDINGS: The number of noninjury emergency department (ED) visits in which abdominal pain was the primary reason for the visit increased 31.8%. The percentage of ED visits for which chest pain was the primary reason decreased 10.0%. Use of advanced medical imaging increased strongly for ED visits related to abdominal pain (122.6%) and chest pain (367.6%). The percentage of ED visits for chest pain that resulted in a diagnosis of acute coronary syndrome decreased 44.9%. Chest and abdominal pain are the most common reasons that persons aged 15 years and over visit the emergency department (ED). Because EDs provide both emergency and nonemergency care, visits for these symptoms may vary in their acuity. Advanced medical imaging is often ordered to assist in both diagnosing and ruling out serious illness associated with these symptoms. This report describes trends in visits for chest and abdominal pain in adults and the seriousness of illness and use of imaging in these visits. All data shown are for persons aged 18 and over whose visit was not injury related.

Ambulatory care visits for Pap tests, abnormal Pap test results, and cervical cancer procedures in the United States.

OBJECTIVES: To establish current estimates and project potential reductions in the volume and cost of annual Pap tests administered at visits to physician office and hospital outpatient departments in light of cervical cancer screening changes and HPV vaccination. STUDY DESIGN: Assessment of baseline national administrative data and future projection. METHODS: We used data from the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS) to analyze physician office and hospital outpatient department visits made by female subjects 15 years and older from 2003 through 2005. RESULTS: Pap tests were ordered annually at 30.2 million physician office and hospital outpatient department visits in the United States from 2003 through 2005. Among visits by young women aged 15 to 26 years, Pap tests were ordered at 5.8 million visits each year, representing 19.3% of all Pap tests ordered. Among visits made by women of childbearing age that included Pap tests, 76.0% occurred in obstetrics and gynecology offices or clinics. Using a simple projection model, we estimated an overall annual decrease of 1.2 million Pap tests for young women aged 15 to 26 years and a corresponding cost reduction of $77.6 million after routine HPV vaccination and HPV DNA testing. Among female subjects 15 years and older, the estimated potential decrease in Pap tests was 6.3 million, with an estimated $403.8 million in cost reduction. CONCLUSIONS: The NAMCS and NHAMCS provide baseline data to estimate the effects of HPV vaccination and HPV DNA testing on cervical cancer screening policy. These future technologies may result in changes to cervical cancer screening policies and, when fully accepted and implemented, may reduce economic costs associated with cervical cancer in the United States.

Research using emergency department-related data sets: current status and future directions.

The 2009 Academic Emergency Medicine consensus conference focused on "Public Health in the ED: Surveillance, Screening and Intervention." One conference breakout session discussed the significant research value of health-related data sets. This article represents the proceedings from that session, primarily focusing on emergency department (ED)-related data sets and includes examples of the use of a data set based on ED visits for research purposes. It discusses types of ED-related data sets available, highlights barriers to research use of ED-related data sets, and notes limitations of these data sets. The paper highlights future directions and challenges to using these important sources of data for research, including identification of five main needs related to enhancing the use of ED-related data sets. These are 1) electronic linkage of initial and follow-up ED visits and linkage of information about ED visits to other outcomes, including costs of care, while maintaining de-identification of the data; 2) timely data access with minimal barriers; 3) complete data collection for clinically relevant and/or historical data elements, such as the external cause-of-injury code; 4) easy access to data that can be parsed into smaller jurisdictions (such as states) for policy and/or research purposes, while maintaining confidentiality; and 5) linkages between health survey data and health claims data. ED-related data sets contain much data collected directly from health care facilities, individual patient records, and multiple other sources that have significant potential impact for studying and improving the health of individuals and the population.

Emergency department visits by persons recently discharged from U.S. hospitals.

BACKGROUND: Emergency department (ED) visits are rarely used as an outcome of prior hospitalization, but could be an indicator of poor inpatient care or follow-up planning. STUDY OBJECTIVE: To examine the rate and characteristics of ED visits of patients recently discharged from any hospital. METHODS: Data from the 2005 and 2006 National Hospital Ambulatory Medical Care Surveys (NHAMCS) and National Hospital Discharge Surveys (NHDS) were used to produce ratios of the numbers of ED visits where patients were discharged from any hospital within the last 7 days to the numbers of hospital discharges. NHAMCS, an annual survey of visits to U.S. hospital EDs, reported data for patients discharged from any hospital within 7 days previous to the ED visit. The NHDS is an annual survey of inpatient discharges from U.S. hospitals. Data from nonnewborn patients were weighted to produce national estimates. RESULTS: About 2.3 million ED visits (2.0 percent of all visits) were made by persons who had been hospitalized within the last 7 days. This corresponds to 68 ED visits per 1000 live hospital discharges. About 10 percent of patients at these ED visits presented with medical or surgical complications that may have been related to their recent hospitalization. Uninsured persons were nearly three times as likely as those privately insured to make an ED visit following hospital discharge. CONCLUSION: A large number of ED visits following recent hospitalization may be related to prior hospitalization. Returning to the ED after hospitalization may be an important measure to help improve inpatient care quality. Disparities in rates of ED visits following hospitalization may be attributed to differential inpatient or follow-up care.

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.

Increasing blood culture use at US hospital emergency department visits, 2001 to 2004.

STUDY OBJECTIVE: We describe emergency department (ED) visits in which patients had blood cultured and examine changes in blood culture use. METHODS: Data from the 2001 to 2004 National Hospital Ambulatory Medical Care Survey, an annual sample survey of visits to US hospital EDs, were analyzed. About 400 EDs reported data for approximately 37,000 visits each year. Trends in blood culture use were examined among persons 3 months of age and older. Visits by admitted/transferred patients were compared to those released. RESULTS: About 3.1 million blood cultures were ordered annually in US EDs; blood cultures were ordered at 2.8% of all visits. From 2001 through 2004, the proportion of visits where a blood culture was ordered increased by 33%, particularly in adults. The proportion of visits with a pneumonia diagnosis where a blood culture was ordered rose by 23% during the study period; these visits accounted for 22% of the increase in blood culture use among admitted patients. Almost half of blood cultures were ordered at visits in which the patient was released from the ED. For visits by released patients 3 years of age and older who had blood cultured, 43% had neither fever nor antibiotic prescriptions. CONCLUSION: There is an increasing national trend in the use of blood cultures at adult patient ED visits; a large proportion of these cultures were for released patients without apparent indicators for bacteremia, such as fever or antibiotic prescriptions. Factors and impact associated with this dynamically changing practice need further evaluation.

Staffing, capacity, and ambulance diversion in emergency departments: United States, 2003-04.

OBJECTIVE: The increased demand for emergency department (ED) services over the past decade has resulted in crowding. This report presents estimates of structure and process characteristics of hospital EDs related to their capacity to treat medical and surgical emergencies. Estimates of EDs experiencing crowded conditions are also presented. METHODS: Several facility supplements were added to the 2003-04 National Hospital Ambulatory Medical Care Survey (NHAMCS), which were completed by hospital staff. NHAMCS samples nonfederal, short-stay, and general hospitals in the United States. Of all sample hospitals that operated 24-hour EDs, 83 percent completed the supplemental questionnaires. Data from 467 hospitals were weighted to produce national annual estimates of ED characteristics. RESULTS: There was an annual average of 4,500 EDs operating in the United States during 2003 and 2004. Over one-half of EDs saw less than 20,000 patients annually, but 1 out of 10 had an annual visit volume of more than 50,000 patients. Although 16.1 percent of hospitals expanded their ED physical space within the last 2 years, approximately one-third of others planned to do so within the next 2 years. Most EDs used outside contracts to provide physicians (64.7 percent). One-half of EDs in metropolitan statistical areas (MSAs) had more than 5 percent of their nursing positions vacant. Of all on-call specialists, the services of plastic and hand surgeons were most frequently reported as somewhat or very difficult to obtain (49.4 percent). Approximately one-third of U.S. hospitals reported going on ambulance diversion sometime in the previous year. About 12 percent of hospitals in MSAs reported having spent between 5 and 19 percent of their operating time in diversion status. Between 40 and 50 percent of U.S. hospitals experienced crowded conditions in the ED with almost two-thirds of metropolitan EDs experiencing crowding.

National Hospital Ambulatory Medical Care Survey: 2004 emergency department summary.

OBJECTIVES: This report describes ambulatory care visits to hospital emergency departments (EDs) in the United States in 2004. Statistics are presented on selected hospital, patient, and visit characteristics. Selected trends in ED utilization from 1994 through 2004 are also presented. METHODS: The data presented in this report were collected in the 2004 National Hospital Ambulatory Medical Care Survey (NHAMCS), 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 2004, an estimated 110.2 million visits were made to hospital EDs, about 38.2 visits per 100 persons. Visit rates have shown an increasing trend since 1994 for persons aged 22-49 years, 50-64 years, and 65 years and over. In 2004, more than 16 million patients arrived by ambulance (15.1 percent). At approximately 3 percent of visits, the patient had been seen in the ED within the last 72 hours. Abdominal pain, chest pain, fever, and back symptoms were the leading patient complaints, accounting for nearly one-fifth of all visits. Abdominal pain was the leading illness-related diagnosis at ED visits. There were an estimated 41.4 million injury-related visits or 14.4 visits per 100 persons. Diagnostic and screening services were provided at 89.9 percent of ED visits. Procedures were performed at 47.7 percent, and medications were prescribed at 78.4 percent of ED visits. Approximately 13 percent of ED visits resulted in hospital admission. On average, patients spent 3.3 hours in the ED, of which 47.4 minutes were spent waiting to see a physician.

Analysis of ambulance transports and diversions among US emergency departments.

STUDY OBJECTIVE: We describe emergency department (ED) visits in which the patient arrived by ambulance and estimate the frequency of and reasons for ambulance diversion. Using information on volume of transports and probabilities of being in diversion status, we estimate the number of patients for whom ED care was delayed because of diversion practices. METHODS: Data from the 2003 ED component of the National Hospital Ambulatory Medical Care Survey, an annual sample survey of visits to US hospital EDs, were used for the analysis. Data were provided by 405 participating EDs on 40,253 visits. Data from supplemental questionnaires to the hospital staff were used to describe volume and frequency of ambulance diversions. RESULTS: In 2003, patients arrived by ambulance for 16.2 million ED visits (14.2%). About 31 ambulances arrived at a US ED every minute. Of ambulance-related visits, 39% were made by seniors, 68% were triaged as emergent or urgent, and 37% resulted in hospital-admission. About 45% of EDs reported diverting ambulances at some point during the previous year. Among EDs that had any diversion, approximately 3% of operating time was spent in diversion status. In 2003, an estimated 501,000 ambulances were diverted, ie, 1 ambulance diversion per minute. Large EDs represent 12% of all EDs, 35% of all ambulance arrivals, 18% of all EDs that went on diversion, 47% of all hours spent in diversion status, and 70% of all ambulances diverted to another ED. CONCLUSION: Description of current use of ED ambulance transports and likelihood of diversions should help policymakers plan for demographic changes in the population during the next 15 years.

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.