Measuring Multimorbidity: Selecting the Right Instrument for the Purpose and the Data Source.

BACKGROUND: Adults have a higher prevalence of multimorbidity-or having multiple chronic health conditions-than having a single condition in isolation. Researchers, health care providers, and health policymakers find it challenging to decide upon the most appropriate assessment tool from the many available multimorbidity measures. OBJECTIVE: The objective of this study was to describe a broad range of instruments and data sources available to assess multimorbidity and offer guidance about selecting appropriate measures. DESIGN: Instruments were reviewed and guidance developed during a special expert workshop sponsored by the National Institutes of Health on September 25-26, 2018. RESULTS: Workshop participants identified 4 common purposes for multimorbidity measurement as well as the advantages and disadvantages of 5 major data sources: medical records/clinical assessments, administrative claims, public health surveys, patient reports, and electronic health records. Participants surveyed 15 instruments and 2 public health data systems and described characteristics of the measures, validity, and other features that inform tool selection. Guidance on instrument selection includes recommendations to match the purpose of multimorbidity measurement to the measurement approach and instrument, review available data sources, and consider contextual and other related constructs to enhance the overall measurement of multimorbidity. CONCLUSIONS: The accuracy of multimorbidity measurement can be enhanced with appropriate measurement selection, combining data sources and special considerations for fully capturing multimorbidity burden in underrepresented racial/ethnic populations, children, individuals with multiple Adverse Childhood Events and older adults experiencing functional limitations, and other geriatric syndromes. The increased availability of comprehensive electronic health record systems offers new opportunities not available through other data sources.

COVID-19 Pandemic Impact on the National Health Care Surveys.

While underscoring the need for timely, nationally representative data in ambulatory, hospital, and long-term-care settings, the COVID-19 pandemic posed many challenges to traditional methods and mechanisms of data collection. To continue generating data from health care and long-term-care providers and establishments in the midst of the COVID-19 pandemic, the National Center for Health Statistics had to modify survey operations for several of its provider-based National Health Care Surveys, including quickly adding survey questions that captured the experiences of providing care during the pandemic. With the aim of providing information that may be useful to other health care data collection systems, this article presents some key challenges that affected data collection activities for these national provider surveys, as well as the measures taken to minimize the disruption in data collection and to optimize the likelihood of disseminating quality data in a timely manner. (Am J Public Health. 2021;111(12):2141-2148. https://doi.org/10.2105/AJPH.2021.306514).

Antineoplastic drugs prescription during visits by adult cancer patients with comorbidities: findings from the 2010-2016 National Ambulatory Medical Care Survey.

PURPOSE: Cancer treatment may be affected by comorbidities; however, studies are limited. The purpose of this study is to examine the frequency of comorbidities at visits by patients with breast, prostate, colorectal, and lung cancer and to estimate frequency of a prescription for antineoplastic drugs being included in the treatment received at visits by patients with cancer and concomitant comorbidities. METHODS: We used nationally representative data on visits to office-based physicians from the 2010-2016 National Ambulatory Medical Care Survey and selected visits by adults with breast, prostate, colorectal, or lung cancer (n = 4,672). Nineteen comorbid conditions were examined. Descriptive statistics were calculated for visits by cancer patients with 0, 1, and ≥ 2 comorbidities. RESULTS: From 2010-2016, a total of 10.2 million physician office visits were made annually by adult patients with breast, prostate, colorectal, or lung cancer. Among US visits by adult patients with breast, prostate, colorectal, or lung cancer, 56.3% were by patients with ≥ 1 comorbidity. Hypertension was the most frequently observed comorbidity (37.7%), followed by hyperlipidemia (19.0%) and diabetes (12.3%). Antineoplastic drugs were prescribed in 33.5% of the visits and prescribed at a lower percentage among visits by cancer patients with COPD (21.3% versus 34.3% of visits by cancer patients without COPD) and heart disease (22.7% versus 34.2% of visits by cancer patients without heart disease). CONCLUSION: Our study provides information about comorbidities in cancer patients being treated by office-based physicians in an ambulatory setting.

Computerized Capability of Office-Based Physicians to Identify Patients Who Need Preventive or Follow-up Care - United States, 2017.

Preventive care or follow-up care have the potential to improve health outcomes, reduce disease in the population, and decrease health care costs in the long-term (1). Approximately one half of persons in the United States receive general recommended preventive services (2,3). Missed physician appointments can hinder the receipt of needed health care (4). With electronic health record (EHR) systems able to improve interaction and communication between patients and providers (5), electronic reminders are used to decrease missed care. These reminders can improve various types of preventive and follow-up care, such as immunizations (6) and cancer screening (7); however, computerized capability must exist to make use of these reminders. To examine this capability among U.S. office-based physicians, data from the National Electronic Health Records Survey (NEHRS) for 2017, the most recent data available, were analyzed. An estimated 64.7% of office-based physicians had computerized capability to identify patients who were due for preventive or follow-up care, with 72.9% of primary care physicians and 71.4% of physicians with an EHR system having this capability compared with surgeons (54.8%), nonprimary care physicians (58.5%), and physicians without an EHR system (23.4%). Having an EHR system is associated with the ability to send electronic reminders to increase receipt of preventive or follow-up care, which has been shown to improve patient health outcomes (8).

Prevalence of Multiple Chronic Conditions Among US Adults, 2018.

This analysis provides prevalence estimates of diagnosed single and multiple (≥2) chronic conditions among the noninstitutionalized, civilian US adult population. Data from the 2018 National Health Interview Survey (NHIS) were used to estimate percentages for US adults by selected demographic characteristics. More than half (51.8%) of adults had at least 1 of 10 selected diagnosed chronic conditions (arthritis, cancer, chronic obstructive pulmonary disease, coronary heart disease, current asthma, diabetes, hepatitis, hypertension, stroke, and weak or failing kidneys), and 27.2% of US adults had multiple chronic conditions.

kg_nchs: A command for Korn-Graubard confidence intervals and National Center for Health Statistics' Data Presentation Standards for Proportions.

In August 2017 the National Center for Health Statistics (NCHS), part of the U.S. Federal Statistical System, published new standards for determining the reliability of proportions estimated using their data. These standards require an individual to take the Korn-Graubard confidence interval (CI), along with CI widths, sample size, and degrees of freedom, to assess reliability of a proportion and determine if it can be presented. The assessment itself involves determining if several conditions are met. This manuscript presents kg_nchs, a postestimation command that is used following svy: proportion. It allows Stata users to (a) calculate the Korn-Graubard CI and associated statistics used in applying the NCHS presentation standards for proportions, and (b) display a series of three dichotomous flags that show if the standards are met. The empirical examples provided show how kg_nchs can be used to easily apply the standards and prevent Stata users from needing to perform manual calculations. While developed for NCHS survey data, this command can also be used with data that stems from any survey with a complex sample design.

National Center for Health Statistics Data Presentation Standards for Proportions.

The National Center for Health Statistics (NCHS) disseminates information on a broad range of health topics through diverse publications. These publications must rely on clear and transparent presentation standards that can be broadly and efficiently applied. Standards are particularly important for large, cross-cutting reports where estimates cannot be individually evaluated and indicators of precision cannot be included alongside the estimates. This report describes the NCHS Data Presentation Standards for Proportions. The multistep NCHS Data Presentation Standards for Proportions are based on a minimum denominator sample size and on the absolute and relative widths of a confidence interval calculated using the Clopper-Pearson method. Proportions (usually multiplied by 100 and expressed as percentages) are the most commonly reported estimates in NCHS reports.

Barriers to Health Care Among Adults Identifying as Sexual Minorities: A US National Study.

OBJECTIVES: To assess the extent to which lesbian, gay, and bisexual (LGB) adults aged 18 to 64 years experience barriers to health care. METHODS: We used 2013 National Health Interview Survey data on 521 gay or lesbian (291 men, 230 women), 215 bisexual (66 men, 149 women), and 25 149 straight (11 525 men, 13 624 women) adults. Five barrier-to-care outcomes were assessed (delayed or did not receive care because of cost, did not receive specific services because of cost, delayed care for noncost reasons, trouble finding a provider, and no usual source of care). RESULTS: Relative to straight adults, gay or lesbian and bisexual adults had higher odds of delaying or not receiving care because of cost. Bisexual adults had higher odds of delaying care for noncost reasons, and gay men had higher odds than straight men of reporting trouble finding a provider. By contrast, gay or lesbian women had lower odds of delaying care for noncost reasons than straight women. Bisexual women had higher odds than gay or lesbian women of reporting 3 of the 5 barriers investigated. CONCLUSIONS: Members of sexual minority groups, especially bisexual women, are more likely to encounter barriers to care than their straight counterparts.

State and Regional Prevalence of Diagnosed Multiple Chronic Conditions Among Adults Aged ≥18 Years - United States, 2014.

The prevalence and care management of multiple (two or more) chronic conditions (MCC) are important public health concerns (1). Approximately 25% of U.S. adults have diagnoses of MCC (2). Care management of MCC presents a challenge to both patients and providers because of the substantial costs associated with treating more than one condition and the traditional care strategies that focus on single conditions as opposed to enhanced care coordination (3,4). Maintaining surveillance, targeting service delivery, and projecting resources are all important to meet this challenge, and these actions can be informed by identifying state and other regional variations in MCC prevalence (5,6). Data from the 2014 National Health Interview Survey (NHIS) were used to estimate prevalence of MCC (defined as two or more of 10 diagnosed chronic conditions) for each U.S. state and region by age and sex. Significant state and regional variation in MCC prevalence was found, with state-level estimates ranging from 19.0% in Colorado to 38.2% in Kentucky. MCC prevalence also varied by region, ranging from 21.4% in the Pacific region to 34.5% in the East South Central region. The prevalence of MCC was higher among women than among men within certain U.S. regions, and was higher in older persons in all regions. Such findings further the research and surveillance objectives stated in the U.S. Department of Health and Human Services (HHS) publication, Multiple Chronic Conditions: A Strategic Framework (1). Furthermore, geographic disparities in MCC prevalence can inform state-level surveillance programs and groups targeting service delivery or allocating resources for MCC prevention activities.

Prevalence of Inflammatory Bowel Disease Among Adults Aged ≥18 Years - United States, 2015.

Crohn's disease and ulcerative colitis, collectively known as inflammatory bowel disease (IBD), are characterized by chronic inflammation of the gastrointestinal tract (1). IBD has been associated with poor quality of life and extensive morbidity and often results in complications requiring hospitalizations and surgical procedures (2-4). Most previous studies of IBD have used administrative claims data or data collected from limited geographic areas to demonstrate increases in estimated prevalence of IBD within the United States (5,6). Few national prevalence estimates of IBD among adults based on large, nationally representative data sources exist, and those that do tend to be based on older data. For example, the most recent national study used 1999 National Health Interview Survey (NHIS) data and estimated that 1.8 million (0.9%) U.S. adults had IBD (7). To examine the prevalence of IBD among the civilian, noninstitutionalized U.S. adult population, data from the 2015 NHIS were analyzed. Overall, an estimated 3.1 million, or 1.3%, of U.S. adults have received a diagnosis of IBD. Within population subgroups, a higher prevalence of IBD was identified among adults aged ≥45 years, Hispanics, non-Hispanic whites, and adults with less than a high school level of education, not currently employed, born in the United States, living in poverty, or living in suburban areas. The use of a nationally representative data source such as the NHIS to estimate the prevalence of IBD overall and by population subgroups is important to understand the burden of IBD on the U.S. health care system.

Multiple chronic conditions and labor force outcomes: A population study of U.S. adults.

BACKGROUND: Although 1-in-5 adults have multiple (≥ 2) chronic conditions, limited attention has been given to the association between multiple chronic conditions and employment. METHODS: Cross-sectional data (2011 National Health Interview Survey) and multivariate regression analyses were used to examine the association among multiple chronic conditions, employment, and labor force outcomes for U.S. adults aged 18-64 years, controlling for covariates. RESULTS: Among U.S. adults aged 18-64 years (unweighted, n = 25,458), having multiple chronic conditions reduced employment probability by 11-29%. Some individual chronic conditions decreased employment probability. Among employed adults (unweighted, n = 16,096), having multiple chronic conditions increased the average number of work days missed due to injury/illness in the past year by 3-9 days. CONCLUSIONS: Multiple chronic conditions are a barrier to employment and increase the number of work days missed, placing affected individuals at a financial disadvantage. Researchers interested in examining consequences of multiple chronic conditions should give consideration to labor force outcomes.

Selected Diagnosed Chronic Conditions by Sexual Orientation: A National Study of US Adults, 2013.

INTRODUCTION: Research is needed on chronic health conditions among lesbian, gay, and bisexual populations. The objective of this study was to examine 10 diagnosed chronic conditions, and multiple (≥2) chronic conditions (MCC), by sexual orientation among US adults. METHODS: The 2013 National Health Interview Survey was used to generate age-adjusted prevalence rates and adjusted odds ratios of diagnosed chronic conditions and MCC for civilian, noninstitutionalized US adults who identified as gay/lesbian, straight, or bisexual, and separately for men and women. Chronic conditions were selected for this study on the basis of previous research. RESULTS: Hypertension and arthritis were the most prevalent conditions for all groups. Gay/lesbian adults had a 4.7 percentage-point higher prevalence of cancer than bisexual adults, and a 5.6 percentage-point higher prevalence of arthritis and a 2.9 percentage point higher prevalence of hepatitis than straight adults. The prevalence of chronic obstructive pulmonary disease was 8.1 percentage points higher among bisexual adults than among gay/lesbian adults and 7.0 percentage points higher than among straight adults. These differences remained in the multivariate analyses. Additional differences were found in the sex-stratified analyses. No significant differences were found in MCC by sexual orientation. CONCLUSION: After age adjustment and controlling for sociodemographic characteristics, only a few significant health disparities for diagnosed chronic conditions were found by sexual orientation, and none for MCC. However, for conditions where differences were found, magnitudes were relatively large. Further examination of these differences among gay/lesbian and bisexual adults could yield a better understanding of why these disparities exist.

Sexual orientation in the 2013 national health interview survey: a quality assessment.

Objective-This report presents a set of quality analyses of sexual orientation data collected in the 2013 National Health Interview Survey (NHIS). NHIS sexual orientation estimates are compared with those from the National Survey of Family Growth (NSFG) and the National Health and Nutrition Examination Survey (NHANES). Selected health outcomes by sexual orientation are compared between NHIS and NSFG. Assessments of item nonresponse, item response times, and responses to follow-up questions to the sexual orientation question are also presented. Methods-NHIS is a multipurpose health survey conducted continuously throughout the year by the Centers for Disease Control and Prevention's National Center for Health Statistics. Analyses in this report were based on NHIS data collected in 2013 from 34,557 adults aged 18 and over. Sampling weights were used to produce national estimates that are representative of the civilian noninstitutionalized U.S. adult population. Data from the 2006-2010 NSFG and 2009-2012 NHANES were used for the comparisons. Results-Based on the 2013 NHIS data, 96.6% of adults identified as straight, 1.6% identified as gay/lesbian, and 0.7% identified as bisexual. The remaining 1.1% of adults identified as ''something else,'' stated ''I don't know the answer,'' or refused to answer. Responses to follow-up questions suggest that the sexual orientation question is producing little classification error. In addition, largely similar patterns of association between sexual orientation and health were observed for NHIS and NSFG. Analyses of item nonresponse rates revealed few data quality issues, although item response times suggest possible shortcutting of the question and comprehension problems for select respondents.

Multiple chronic conditions among US adults: a 2012 update.

The objective of this research was to update earlier estimates of prevalence rates of single chronic conditions and multiple (>2) chronic conditions (MCC) among the noninstitutionalized, civilian US adult population. Data from the 2012 National Health Interview Survey (NHIS) were used to generate estimates of MCC for US adults and by select demographic characteristics. Approximately half (117 million) of US adults have at least one of the 10 chronic conditions examined (ie, hypertension, coronary heart disease, stroke, diabetes, cancer, arthritis, hepatitis, weak or failing kidneys, current asthma, or chronic obstructive pulmonary disease [COPD]). Furthermore, 1 in 4 adults has MCC.

Mortality risks associated with average drinking level and episodic heavy drinking.

Data from the 1997 to 2004 National Health Interview Survey Sample Adult questionnaires were linked to the National Death Index (N = 242,397) to examine mortality risks associated with average and episodic heavy drinking. Cox proportional hazard models (Stata 12.0) revealed that (average) heavier drinkers and episodic heavy drinkers (5+ in a day) had increased mortality risks but when examined together, episodic heavy drinking added only modestly to the mortality risks of light and moderate drinkers. Limitations and implications of results for survey measurement of potentially harmful levels of alcohol use are noted. This was a Federal study that received no outside funding.

Racial/ethnic differences in the relationship among cigarette use, religiosity, and social norms for U.S. adolescents.

This study investigated the racial/ethnic differences in the role of social norms in the protective relationship between religiosity and cigarette smoking. The 2009 National Survey on Drug Use and Health was used to investigate the relationships between smoking, religiosity, and social norms of U.S. adolescents (N = 13,278). Significant indirect effects between religiosity and smoking were found through social norms for non-Hispanic White adolescents. Findings were mixed for non-Hispanic Black adolescents. Mechanisms driving the religiosity-smoking association differ across subpopulations. Smoking prevention efforts and messaging campaigns that include partnerships with religious communities may require consideration of these racial/ethnic differences when planning prevention strategies.

Prevalence rates of work organization characteristics among workers in the U.S.: data from the 2010 National Health Interview Survey.

BACKGROUND: Surveillance is needed to capture work organization characteristics and to identify their trends. METHODS: Data from the 2010 National Health Interview Survey (NHIS) were used to calculate prevalence rates for four work organization characteristics (long work hours, non-standard work arrangements, temporary positions, and alternative shifts) overall, and by demographic characteristics, and industry and occupation of current/recent employment. RESULTS: Data were available for 27,157 adults, of which 65% were current/recent workers. Among adults who worked in the past 12 months, 18.7% worked 48 hr or more per week, 7.2% worked 60 hr or more per week, 18.7% had non-standard work arrangements, 7.2% were in temporary positions, and 28.7% worked an alternative shift. CONCLUSIONS: Prevalence rates of work organization characteristics are provided. These national estimates can be used to help occupational health professionals and employers to identify emerging occupational safety and health risks, allow researchers to examine associations with health, and use the data for benchmarking.

The prevalence of selected potentially hazardous workplace exposures in the US: findings from the 2010 National Health Interview Survey.

OBJECTIVE: Assess the national prevalence of current workplace exposure to potential skin hazards, secondhand smoke (SHS), and outdoor work among various industry and occupation groups. Also, assess the national prevalence of chronic workplace exposure to vapors, gas, dust, and fumes (VGDF) among these groups. METHODS: Data were obtained from the 2010 National Health Interview Survey (NHIS). NHIS is a multistage probability sample survey of the civilian non-institutionalized population of the US. Prevalence rates and their variances were calculated using SUDAAN to account for the complex NHIS sample design. RESULTS: The data for 2010 were available for 17,524 adults who worked in the 12 months that preceded interview. The highest prevalence rates of hazardous workplace exposures were typically in agriculture, mining, and construction. The prevalence rate of frequent handling of or skin contact with chemicals, and of non-smokers frequently exposed to SHS at work was highest in mining and construction. Outdoor work was most common in agriculture (85%), construction (73%), and mining (65%). Finally, frequent occupational exposure to VGDF was most common among mining (67%), agriculture (53%), and construction workers (51%). CONCLUSION: We identified industries and occupations with the highest prevalence of potentially hazardous workplace exposures, and provided targets for investigation and intervention activities.