Background of the Generic Clearance

Attachment C:

Background of the Division of Health Care Statistics (DHCS) surveys and detailed original needs and circumstances for the currently-approved generic data collection

Background

The Division of Health Care Statistics (DHCS) is one of four data collection divisions within the National Center for Health Statistics (NCHS). The mission of DHCS is to collect, monitor, analyze, and disseminate data on the use, access, quality, safety, disparity, and cost of health care in the United States and on the healthcare organizations and professionals who deliver that care. DHCS conducts the National Health Care Surveys, a family of nationally representative surveys of encounters and health care providers in inpatient, ambulatory, and long-term care settings. (Note that in earlier submissions some survey settings were referred to as outpatient and others as ambulatory. Both settings are now referred to as ambulatory.)

Some surveys are ongoing; others are periodic. The currently-active surveys include the following:

• National Hospital Discharge Survey (NHDS; 1965-2010); National Hospital Care Survey (NHCS; 2011-present); OMB No. 0920-0212, Exp. Date 03/31/2022

• National Ambulatory Medical Care Survey (NAMCS; 1973-1981, 1985, 1989-present); OMB No. 0920-0234, Exp. Date 05/31/2022

• National Hospital Ambulatory Medical Care Survey (NHAMCS; 1992-present); OMB No. 0920-0278, Exp. Date 06/30/2021

• Data Collection for the Residential Care Community and Adult Day Services Center Components of the National Study of Long-term Care Providers; OMB No. 0920-0943, Exp. Date 05/31/19 Discontinued: 03/12/2019. Currently drafting as a reinstatement with change package.

These surveys share certain design features; each representative national survey samples health care providers and collects data from encounters sampled with each provider. More information is available at DHCS website: www.cdc.gov/nchs/dhcs/dhcs_surveys.htm.

Data from these surveys are used by providers, policy makers and researchers to address important topics of interest, including the quality and disparities of care among populations, epidemiology of medical conditions, diffusion of technologies, effects of policies and practice guidelines, and changes in health care over time.

Needs and circumstances motivating the current request

In recent years, DHCS has experienced tremendous changes in the type and content of data collected, as well as in the manner in which data are collected, in their National Health Care Surveys. Through these survey experiences, DHCS realizes the need to engage in continuous research evaluation and improvement on quality and efficiency in existing and proposed survey operations and data collection. Furthermore, NHCS needs to be poised in their data collection to anticipate, as well as to be responsive to, the ongoing changes happening in health services delivery systems – e.g., the expansion of electronic health record use in all health care settings and the growing number of mid-level, non-physician clinicians delivering health services. Research studies will examine not only ways to improve existing survey design and operations, but also to assess feasibility and address challenges that may arise with future expansions of the National Health Care Surveys. The following highlights several key illustrative, but not exhaustive, examples of needs and circumstances motiving the current request for survey research:

1. Improve and refine existing survey design and procedures

1. The NHDS was replaced in 2011 with the National Hospital Care Survey, which integrates NHDS and NHAMCS into one hospital survey.

• Recruitment efforts for hospitals to partake in the National Hospital Care Survey have proven difficult; to date, about 150 hospitals out of a sample of 598 have agreed to participate. To ensure that National Hospital Care Survey will be successful, studies to collect new data under this generic clearance request are needed to:

• Better understand recruitment problems by identifying barriers to recruitment for field representatives and reasons for non-participation among respondents in order to develop strategies to increase enrollment rate.

• A major change in the National Hospital Care Survey data collection method is the use of administrative Uniform-Bill (UB-04) claims forms to collect data on all inpatient and ambulatory care provided in participating hospitals that have adopted electronic health records. Submitting these claims to NCHS has been challenging for hospitals. For example, some hospitals that process their own claims do not know how to output and submit the data from their systems to NCHS. Administrative data may not include key elements that the National Health Care Surveys traditionally have collected but need (e.g., race and social security number). Further, administrative data retrieval may be complex and costly for hospitals utilizing clearinghouses to process, “clean-up” and submit their UB-04 claims. Studies to collect new data under this generic clearance request are needed to:

• Better understand the feasibility of retrieving administrative data and in turn strategize ways to expedite the retrieval process;

• Determine if accurate billing records are accessible by the key personnel who can then transmit the data to NCHS;

• Determine information that must be obtained from participating hospitals for survey purposes and strategize ways to accommodate data elements that are missing in the claims data; and

• Assess technical difficulties (e.g., data compatibility, sample size, duplication of records) that DHCS may encounter while accepting hospital electronic medical record files through a secure data network.

2. With the expansion of electronic health record (EHR), DHCS initiated two new mail supplements to NAMCS: the EHR Supplement and the now completed Physician Workflow Supplement.

• The EHR Supplement began in 2008 with an annual supplemental sample of 2,000 physicians, increasing to 10,302 physicians in 2010 and continuing annually. The Physician Workflow Supplement, an annual follow-up data collection initiative to better understand the effect of EHR adoption on physician practices, has for its base sample the respondents to the 2011 EHR Supplement. Because of the increased volume of participating physicians and the ongoing changes to items on the EHR Supplement to monitor “meaningful use” adoption of health information technology, DHCS is faced with the need to explore and develop new ways to continuously improve recruitment strategies, cognitively test newly proposed survey items and response categories, and alleviate respondent burden. Pilot studies to collect new data under this clearance request are needed to:

  • Explore the use of monetary and non-monetary token incentives to improve response rates for hard-to-reach physician populations;

  • Compare different modalities of survey administration (e.g., internet, post-mail, and telephone) to increase respondent’s convenience to complete the survey;

  • Cognitively test survey instructions, items and response categories that are newly developed or are undergoing continuous updating to assess their level of comprehensibility, completeness, reliability, and burden on respondents;

  • Triangulate different sources of data (e.g., administrative data, interviews with different staff within the same office) to validate survey responses especially those that are self-reported; and

  • Experiment with different aspects of the survey (e.g., mode, length, format, flow, and response categories) to determine the most significant factors in reducing non-response or recall bias, and alleviating respondent burden.

2. Explore and evaluate alternative approaches to data collection

1. The advent of significant nationwide EHR adoption allows for new ways for DHCS to collect, aggregate, and store clinical health data more effectively and efficiently. In 2012, DHCS conducted a small pilot study in 9 study sites with the Palo Alto Medical Research Institute (PAMFRI) to evaluate alternative approaches to collecting NAMCS data from office-based physician practices.

• Moving toward greater collection of health care data by electronic means, DHCS intends for all of its National Health Care Surveys to be poised to accept electronic files from medical records as they become available in sampled sites. Because this will be a significant overhaul to current DHCS survey operations and data collection, large pilot studies to collect new data under this generic clearance request are needed to:

  • Further investigate the feasibility of data retrieval/management and impact on the completeness, quality, and reliability of data using data extraction from an EHR using computer code and/or data export utilities, and data transmission using continuity of care documents.

  • Compare the impact of electronic data extraction and transmission to traditional data abstraction by Census field representatives.

  • Assess the feasibility and impact of collecting/managing electronic data in a variety of settings including mid-size/large provider and hospital networks, managed care health plans, and other inpatient, ambulatory, and long-term care settings that are either in-scope or out-of-scope from the National Health Care Surveys.

2. Motivated by the rapid growth of mid-level, non-physician clinicians in health services delivery, ongoing changes in major sectors of the U.S. healthcare delivery systems, and expected future interagency agreements with other federal agencies to expand healthcare data collection beyond the current scope of the National Health Care Surveys, DHCS will need to collect new data under this generic clearance request to:

   • Develop new sample frames for providers that are currently out-of-scope from the National Health Care Surveys, including:

• Specialty clinicians – e.g., dentists, psychologists, podiatrists, chiropractors, optometrists, among others;

• Mid-level providers – e.g., physician assistants, advanced practice nurses, nurse practitioners, certified nurse midwives, among others; and

• Allied-health professionals – e.g., certified nursing aides, medical assistants, radiology technicians, laboratory technicians, pharmacists, dieticians/ nutritionists, among others.

• Develop new sample frames of currently out-of-scope health care settings, including:

• Mid-size/large provider and hospital networks, managed care health plans, prison-hospitals, long-term care hospitals, home care agencies, facilities exclusively serving individuals with intellectual/developmental disability, among others.

Appropriate for a generic clearance request

The OMB document “Questions and Answers When Designing Surveys for Information Collections,” describes generic surveys: “A generic clearance is considered only when the agency is able to demonstrate that there is a need for multiple, similar collections, but that the specifics of each collection cannot be determined until shortly before the data are to be collected… Individual collections should not raise any substantive or policy issues or go beyond the methods specified in the generic ICR.” See the following website for further information: www.whitehouse.gov/sites/default/files/omb/inforeg/pmc_survey_guidance_2006.pdf.

This generic clearance request is in accordance with this description because the pilot studies covered in this clearance are intended to be broad with research aims designed to: (1) explore ways to refine and improve upon existing survey designs and procedures; and (2) explore and evaluate proposed survey designs and alternative approaches to data collection. Therefore, specifics cannot be determined for any particular tests until shortly before the data are to be collected. Additionally, DHCS believes that each data collection under this clearance request would be non-controversial in nature and each would not raise any substantive policy issues.

Proposed data collection fitting into CDC's broader research agenda

The DHCS National Health Care Surveys have and will continue to provide policy-relevant national and sub-national data that directly address the mission, research agenda, and 21^st Century vision for the CDC ¹ and NCHS. The NCHS mission is “to provide statistical information as the Nation’s principal health statistics agency that will guide actions and policies to improve the health of the American people.”

1 Centers for Disease Control and Prevention (CDC) website, written by CDC’s Office of Enterprise Communication. Available at http://www.cdc.gov/about/mission.htm.

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